4 Prognosticators for Lumbar Stenosis
The reported incidence of lumbar spinal stenosis (LSS) in patients with low back pain is 3-14%. As with many other structural diagnoses, patients with anatomic lumbar spine stenosis fall somewhat unpredictably on a spectrum between asymptomatic and severely disabled. The course of symptomatic individuals continues on a variable course with 50-70% of patients remaining stable, while the remainder are divided fairly equally into groups that inconsistently improve or worsen. (1-3)
Conservative care, including spinal manipulation, is a viable option for many patients with degenerative disc disease and LSS. (4-6) A new study (7) has identified four factors that help identify LSS patients who are most likely to respond to conservative manual therapy. Improved outcomes are more likely in patients with:
- Lower initial VAS and disability scores
- Relatively younger age
- Radicular symptoms described as “pain”, as opposed to paresthesia or weakness
- Higher body mass index (BMI)
Although LSS is characteristically unpredictable, this JMPT study has armed conservative providers with new information. Here are five more clinical pearls for managing stenosis patients:
- A spinal canal diameter between 10 and 12 mm is defined as “relative stenosis,” and a diameter of less than 10 mm defines “absolute stenosis.”
- Stenosis is rare before age 50, but is the most common reason for spinal surgery in those above 65.
- The intervertebral foramina undergoes a 15% decrease surface area in extension and a 12% increase surface area in flexion.
- Lower extremity symptoms are bilateral in almost 7 out of 10 patients.
- Clinicians should be cautious to rule out vascular claudication, which is characterized by five Ps: pulselessness, paralysis, paresthesia, palor, and pain.
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1. Johnsson KE, Rosen I, Uden I. The natural course of lumbar spinal stenosis. Clin Orthop. 1992;279:82-86.
2. Herno A. Spinal Stenosis without deformity: Nonoperative treatment. In: Herkowitz HH, Dvorak JJ, Bell G, Nordin M, Grob DD, editors. The Lumbar Spine. Philadelphia: Lippincott Williams & Wilkins; 2004. pp. 490-4.
3. Jenis LG, An HS. Lumbar foraminal stenosis. Spine. 2000;25:389-394.
4. Stern PJ, Cote P, Cassidy JD. A series of consecutive cases of low back pain with radiating leg pain treated by chiropractors. J Manipulative Physiol Ther. 1995;18:335-342.
5. Cox JM. Low back pain: mechanisms, diagnosis and treatment. 6th. Baltimore, Williams and Wilkens; 1999.
6. Vieira-Pellenz F et al. Short-Term Effect of Spinal Manipulation on Pain Perception, Spinal Mobility, and Full Height Recovery in Male Subjects with Degenerative Disc Disease: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2014 May 23.
7. Exploratory analysis of clinical predictors of outcomes of nonsurgical treatment in patients with lumbar spinal stenosis. Schneider MJ, et al. J Manipulative Physiol Ther. 2016 Feb;39(2):88-94.