Lumbar Spinal Stenosis - a Chiropractor's perspective by Hans Bottesch II, D.C.

by Hans Bottesch, D.C. on Saturday March 13, 2010

Lumbar Spinal Stenosis – from a Chiropractor’s perspective

As a chiropractor, a good majority of the patients we see and treat are several decades into life. A painful condition that commonly presents itself later in life is degenerative lumbar spinal stenosis (LSS). Lets take a closer look into what the name of the condition means:

The word lumbar indicates involvement of the low back, and more specifically the lowest 5 vertebrae of the spinal column. Although in many cases of LSS it isn’t uncommon to find involvement of other tissues such as ligaments along the spine and the discs between the vertebrae that are contributing to the pain and stenosis.
Spinal, in this case, refers to your spine (the bony column holding you upright) and your spinal canal (the long narrow tube that runs from the base of your skull down to your pelvis that houses your spinal cord and its nerves). In some patients, the stenosis may actually be located at the intervertebral foramen (the holes on the side of the spinal column through which the nerves exit) instead of the spinal canal itself.
The definition of stenosis comes from the Greek for “choking”. However, in the case of LSS, it would be better to describe the “choking” more in terms of a reduction of the comfortable space that our spinal cord and its nerve enjoy so much. [1]

Lumbar spinal stenosis can be classified the two types of stenosis: acquired and congenital. Acquired stenosis means that some injury or process in your life caused the reduction in space around your cord and nerves. Degenerative LSS, termed as bony stenosis, is due to "bony spurs" building around the vertebra in response to altered biomechanics. Some acquired stenosis can also be due to soft tissue injuries, like a disc herniations. However just because you have a bulging disc does not mean you WILL have LSS.

Congenital stenosis occurs when there are malfunctions in spinal development. This type of stenosis may present at an earlier age than degenerative LSS. A perfect example of this condition is seen in Achondoplastic Dwarfism. Part of their spine, called pedicles, are found to develop shorted than what is seen in a normal spine. In turn, the shorter pedicle means that there is less space for the spinal cord right from the start.

Degenerative lumbar spinal stenosis is acquired in most cases, meaning that it is a process that came on usually slowly and over a long period of time. The most common culprits are the degenerative changes involving the disc, facet joints, and associated ligaments and muscles that occur as we age. Other possible causes of LSS include disc bulges and herniations, congenital malformations, trauma, and spondylolisthesis, but those causes will not be discussed today. In degenerative LSS, as the disc ages and begins to lose height, the delicate balance of stress that is normally fairly well displaced over the joints of the low back begins to unevenly displace the weight of our body and daily activities over the smaller posterior joints. With time, the bone around the disc and smaller joints may develop bone spurs that can crowd the space around the spinal cord and nerves. As the uneven weight distribution continues, it can also cause spinal ligaments to buckle and with certain positions contribute to the stenosis. [1] Please note that every single patient with LSS is different. Some patients may have a moderate degree of degenerative changes but show no signs or symptoms of LSS.

Lumbar spinal stenosis remains the leading preoperative diagnosis for adults over the age of 65 who undergo spine surgery. [3] At the moment, there are no links between LSS and different ethnicities. Demographically, LSS patients are typically males over the age of 50.

Common symptoms of LSS can include: [1], [3]

Low back pain, buttock pain, and leg pain (or commonly a combination of all the above).
Accompanying numbness and tingling in one or both legs that is made worse with certain activities (such as walking, standing upright for long periods of time, and leaning backwards).
Cramping, leg weakness, and difficulty walking.
Depending on the degree of the numbness and tingling in the legs and feet, clumsiness and in-coordination may be present due to the lack of sensation to the feet.
Patients with LSS due to a reduction of the space in their spinal canal will often find that their symptoms are at least partially relieved when they perform activities or postures that flex the torso forward at the waist.
Walking or shopping while leaning forward over a shopping cart will alleviate some of the pain associated with walking.

An explanation of why flexing forward at the waist relieves some of the symptoms of LSS can be achieved by looking into the biomechanics of the low back. Due to the natural curve of the lumbar spine, standing places the lumbar spine into an extended position, which will in turn further reduce the space around the spinal cord and its nerves. By sitting and flexing forward at the waist the patient is placing the lumbar spine into a flexed position. Someone with LSS is opening and increasing the space around the spinal canal when they sit or flex forward at the waist. Unfortunately, these patients will find their symptoms returning when they return to an upright posture. [1]

So now that you have a little better understanding of Lumbar Spinal Stenosis, you are probably wondering how a doctor will go about formally diagnosing this condition.

Your physician should perform a thorough orthopedic and neurological evaluation of your complaint, which commonly includes different stress tests (orthopedic tests) that are designed to be painful because it gives the physician valuable information to aid in forming a diagnosis.
A neurological evaluation, which tests the integrity of the nerves from your low back that supply the muscles and skin of the legs, will be performed as well. These neurological tests typically include muscle strength tests, skin sensation, the response of your reflexes, vibratory sense, and a quick scan for pathological reflexes.
After the physical exam, the doctor will likely order different diagnostic imaging tests to be performed. This will give the physician a look at the spine, the space in the spinal canal, and the associated structures around the spinal canal that may also be contributing to the pain. These tests will usually include plain film radiographs, magnetic resonance imaging (MRI), and computed tomography (CT) scans.

Before we tackle treatment options, let us quickly discuss something that is vitally important to the management of this condition and its symptoms. As a patient, you have to understand that this is a chronic (long-standing) condition and that all the treatment options involved are palliative and preventative in nature. There is no real “cure” for LSS, it is a condition that you must learn to live and cope with. Learn what you can do on your own to help minimize the symptoms. Learn what activities and movements provoke your pain. Taking a proactive approach to the management of your condition may allow you to avoid more serious surgery for the condition (though in some cases surgical decompression will be necessary).

So, what are the treatment options?

Medical care will likely include but is not limited to: [1], [3]
Advice to remain as active as possible.
Spinal stenosis exercises from a physical therapist.
Activity modification; changes to and awareness of your daily activities.
Anti-inflammatory medications and pain relievers.
Epidural injections.
Surgery (see below for more information).

*As always, the type of treatment prescribed by your physician will likely be based on the degree/severity of the disability and pain associated with LSS*

Chiropractic care will likely include but is not limited to: [4]
Flexion distraction therapy; because we know that flexion of the lumbar spine may provide partial relief of symptoms, some LSS patients may respond favorably to this treatment. In relation to this type of therapy, Decompression tables commonly seen in many Chiropractor's offices have been shown with very limited research to improve symptoms of LSS, however it should be noted that the evidence backing this type of therapy is lacking and is not "peer reviewed".
Drop table therapy; a technique in which the chiropractor proceeds to gently impart the proper motion into a restricted joint by leaning into the table until it releases and gives way. While this therapy isn't targeted directly at treating the stenosis, it will address pain and restrictions in your sacroiliac joints, which may be compensatory due to the pain of LSS.
Manual soft tissue manipulation (therapeutic muscle work) may also be performed to the muscles of the low back.
In the absence of contraindications (surgical hardware, tumors, etc), the Chiropractor may also elect to use different physical modalities in the relaxation and treatment of the associated musculature in the area. These therapies may include hot, moist packs, electric muscle stimulation (claimed to be used for pain control), and therapeutic ultrasound.
Depending on the severity of the disability and pain, some Chiropractors may elect to utilize different therapeutic stretches to attempt to length and relax some of the muscles in the area.
Some Chiropractors may elect to use supplements and herbs to treat the inflammatory aspects of the pain, much like a M.D. or D.O. may use anti-inflammatory medication and pain killers.

*A review of the available evidence indicates that there is not a large body of evidence backing chiropractic care for the treatment of LSS, however the limited body of evidence indicates that chiropractic care may be potentially beneficial for patients suffering from LSS* [2]

If and when will surgery be necessary? Your medical professional, whether he/she is a medical doctor or a chiropractor, should inform you that there are certain signs to be aware of as a patient.

Loss of bowel and bladder function.
Saddle anesthesia or numbness in your groin / inner thighs and/or buttocks.
Progressive worsening of your pain and loss of function of your lower extremities.
Unrelenting, persistent pain remaining after a 4 week trial of conservative care.

Conservative management is generally encouraged over surgical options, but in the event that a LSS patient begins to exhibit the above symptoms, surgery will likely be considered the next course of action. [1]

What are the surgical options? Here are just a few, an orthopedic surgeon will be able to provide you with all the options and a full explanation for each. [1], [3]

Laminotomy – a small piece of bone is removed to give the spinal cord and its nerves more space.
Laminectomy – more bone is removed, again to provide more space for the cord and the nerves.
Interspinous Process Devices (X-Stop Device) – a device that is meant to keep that particular segment in a flexed position and increase space around the cord and nerves.
Spinal fusion procedures; are meant to stabilize the area and hopefully prevent further progression of the condition.
Facet Replacement; an investigative type of surgery still being studied for its effectiveness that looks to replace the arthritic smaller joints of the spine, which in some cases of spinal stenosis may be contributing to the stenosis.

*This is just meant to be informational, a qualified surgeon would be able to make all the necessary determinations about which surgical option would best suit your particular case, in the event that you would need surgery*

*As always, there are risks associated with every surgical procedure. Make sure to ask your surgeon about all the possible risks involved with the surgery itself and the post-operative care*

It is the author’s opinion that all conservative care options (ranging from chiropractic care to injections and medication to exercise) should be exhausted before proceeding with more aggressive forms of treatment (surgery). Under certain circumstances, surgery may be the best and only option, however good patient/doctor communication and closely monitoring a patient’s signs and symptoms can determine at what point surgery should be considered.

I hope this has been helpful in providing some information about the leading cause of spinal surgery in older adults. This is the first installment of Dr. Bottesch’s condition of the month discussions. Keep your eyes open in the coming weeks for information on other spinal conditions and how a Chiropractor may potentially manage a similar case. Thank you for reading this and if you have any questions regarding this or any other topic, please feel free to email me I’ll leave you with two very important words.

Take care,

Dr. Hans W. Bottesch II, D.C.
Bloomin Health Chiropractic Clinic
214 Center St
Bloomsburg PA 17815
Ph: (570) 204-9302
Fax: (570) 317-2594

Posted in Condition of the Month    Tagged with Chiropractic, Chiropractor, Lumbar Spinal Stenosis


spinal decompression - June 29th, 2011 at 1:33 AM
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spinal decompression - August 25th, 2011 at 7:31 AM
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Spinal Decompression - August 26th, 2011 at 5:54 AM
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Spinal Decompression - November 24th, 2011 at 4:45 AM
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