Lumbar spinal stenosis with radiating leg pain

Ninety percent of the population will experience some form of low back pain.  Fortunately, these symptoms are often self-limited and resolve with simple treatment such as exercise, anti-inflammatory medications, and time.  However, many experience back pain that is progressive over time and can include symptoms that radiate into the legs. Common in older patients, these symptoms can be caused by stenosis – or narrowing – around the nerves in the spinal canal.

Studies have shown that many people over the age of fifty have some degree of age-related changes in the spine.  Arthritis in the spinal joints, bulging of the cartilage discs, and thickening of the spinal ligaments may eventually cause enough nerve compression to produce symptoms.  In some patients, these symptoms are mild may improve with nonsurgical treatment.  In other patients, stenosis can cause severe pain and dysfunction that is better treated with surgery.

SYMPTOMS & DIAGNOSIS

The symptoms of spinal stenosis can vary depending upon the location of the problem.  In the lumbar spine, spinal stenosis most commonly results in pain, numbness, and/or weakness in the legs.  Symptoms are usually worsened with walking or standing, and improved with sitting.  The classic “shopping cart sign” is a function of opening of the spinal canal when leaning forward, allowing otherwise symptomatic patients to walk farther distances.

In addition to a good history and physical examination, other radiographic tests are usually necessary to confirm the diagnosis and guide treatment.  Upright x-rays of the spine can reveal arthritis, wear of the discs, and abnormal spinal alignment or motion.  To confirm the diagnosis, however, an MRI can best visualize thickened ligaments, bulging discs, or bone spurs causing compression of nerves or the spinal cord.  Patients with a pacemaker or other implanted metallic devices may be unable to get an MRI, in which case a CT-myelogram is the study of choice.

TREATMENT

Depending on the severity of symptoms and subsequent effect on quality of life, treatment can range from giving it time and activity modification to surgical decompression of the spinal canal in the affected region.

Non-Surgical

First line nonsurgical options include over-the-counter anti-inflammatory medication as well as exercises guided by a physical therapist.  Specifically, patients may benefit from flexion-based exercises, such as riding a stationary bike, which are better tolerated than standing exercises.  Other medications might include an anti-seizure medication such as gabapentin or pregabalin to help relieve pain from nerve compression.

In addition to medications and an exercise program, some patients may benefit from an injection of steroid.  These injections, performed under x-ray guidance, can reduce inflammation and swelling of targeted nerves, often resulting in good pain relief.  However, this relief is often temporary and may not be a “cure” of the symptoms.

Surgical

For patients who fail to respond to medications, exercise, and injections, surgery may be indicated.  Surgical treatment typically involves a laminectomy — the removal of bone, ligament, and/or disc material as needed to relieve nerve compression.  Patients often report immediate improvement in symptoms, and surgical outcomes overall are quite good, noting improved pain, function, and quality of life.

Research and outcomes from the Maine Lumbar Spine Study and the SPORT trial indicates that patients treated with surgery – compared with nonsurgical options – had better long-term function and less pain.  And more recent evidence continues to support improved quality of life following surgical treatment, with cost-per-quality of life years gained comparable with a total knee replacement.

For more information, please visit OrthoInfo, the patient-education site from the American Academy of Orthopedic Surgeons.