This month I would like to discuss "conservative" treatment of lumbar spinal stenosis, a condition that we are seeing more of as the population ages. Incidence is difficult to evaluate but spine surgeons are now finding that spinal stenosis is the most frequent condition for which they operate.
How spinal stenosis presents:
Typically patients are elderly, although some may present in their 50's or 60's. Patients stand with lumbar spines and hips flexed and experience pain in the low back and/or leg(s) with lumbar extension. Walking more than a limited distance provokes pain. Sitting gives almost immediate relief.
The onset of the pain is usually gradual. Without treatment, the condition typically persists for many years. Because the mechanism of pain is encroachment on the cauda equina or a lumbar nerve root by narrowing of a canal, the definitive treatment has been considered (in some quarters) to be surgery.
For a more general discussion of spinal stenosis see: www.spinalstenosis.org.
What exactly is "conservative" treatment of spinal stenosis?
The list (by most medical authorities) is usually limited to anti-inflammatory medication, physiotherapy (whatever that means), corsets and caudal epidural steroids. In my experience, these are palliative treatments, although caudal epidurals (of procaine with or without steroids) may give months of relief in certain cases.
However things get interesting when we start looking at less conventional treatments. Among these I include manipulation, prolotherapy and neural therapy. None of these treatments directly addresss the narrowing of the canal. All target the conditions associated with the stenosis, e.g. poor mechanics, intervertebral instability, local inflammation and autonomic nervous system dysregulation.
I had already begun writing this article when the current edition of the American Academy of Osteopathy Journal (December 2006) arrived with an article entitled "Non-operative management of spinal stenosis" by Phil Greenman. He reports on 15 patients with moderately severe symptoms who responded very well to a program of manipulation and intensive physiotherapy which included proprioceptive balance training, muscle stretching, muscle strengthening and aerobic conditioning. I personally have had some success treating spinal stenosis patients with manipulation and attention to muscle balance, but certainly not with results like this. Professor Greenman's report is a challenge to the fatalistic mind‐set that so often surrounds conservative treatment of spinal stenosis.
Prolotherapy (or ligament‐tightening injections) has been used in treating spinal stenosis for many years and the internet abounds with claims of its efficacy. However no scholarly reports have been published to my knowledge. My own results of treating spinal stenosis with prolotherapy (over 28 years) is mixed, with perhaps less than half of patients responding. Whether this reflects my skill level or my patient population is hard to say, but prolotherapy certainly should in my opinion be considered for spinal stenosis. A relatively safe treatment that provides relief is always worth trying in any condition that does not improve spontaneously, even when the failure rate is high.
Neural therapy: There appears to be even less written about the use of neural therapy for spinal stenosis, at least in the English literature. Dosch's 1984 textbook does not mention it. However, if we consider manipulation to be a form of neural therapy in that it involves the autonomic nervous system, Greenman's report suggests that interference fields could indeed contribute to the spinal stenosis sydrome.
A recent case in my practice confirms this. A vigorous, otherwise healthy 65 year old man presented with four years of bilateral low back pain extending into his buttocks when standing for more than 20 minutes or walking for more than a few minutes. Sitting provided immediate relief. Sleep was disturbed by pain and narcotics were needed. A MRI demonstrated "significant central canal and foraminal stenosis". Previous osteopathic manipulation was ineffective, but an exercise program had helped. Apart from pain on lumbar extension and mild hamstring tightness, his musculoskeletal examination appeared non-contributory. Autonomic response testing indicated bilateral pre-vertebral sympathetic ganglion interference fields at the L3 level.
Both ganglia were treated for a little over a minute each using a Tenscam device. (For more information see tenscam.com). Immediate relief (less than 50% of the pre-existing pain) was obtained lasting about a week. At the next visit three weeks later, an interference field was detected on the left side only. Tenscam treatment resulted this time in more than two weeks relief, and a lower level of pain on relapse. Narcotic usage had declined significantly. On the third visit, an interference field was again found on the left side and was treated in the same way. On the fourth visit, this time after three weeks relief, an interference field was found in the right L3 sympathetic ganglion. It also was treated with the Tenscam.
A cure has not yet been obtained, although I am reasonably sure that it is on its way. However the point of this story is that the autonomic nervous system's involvement in spinal stenosis pain can be important. A variety of mechanisms could explain neural therapy's effect: e.g. alteration of local perfusion, improvement of intervertebral mechanics through optimization of muscle balance, regulation of local nociception, or perhaps some other mechanism.
All this is good news for patients with spinal stenosis. However it does require more effort and vigilance on the part of their physicians. Spinal stenosis is more treatable than we used to think.
Robert F. Kidd, MD, CM