Research Review By Dr. Joshua Plener©

Audio:

Download MP3

Date Posted:

February 2022

Study Title:

Non-Surgical Interventions for Lumbar Spinal Stenosis Leading to Neurogenic Claudication: A Clinical Practice Guideline

Authors:

Bussières A, Cancelliere C, Ammendolia C et al.

Author's Affiliations:

School of Physical Medicine & Occupational Therapy, McGill University. Quebec, Canada; Department Chiropractique, Université du Quebec à Trois-Rivières; Faculty of Health Sciences, University of Ontario Institute of Technology; Faculty of Medicine, University of Toronto and Mount Sinai Hospital, Toronto, Canada

Publication Information:

The Journal of Pain 2021; 22: 1015-39.

Background Information:

Lumbar spinal stenosis is a frequent cause of low back and leg pain, leading to significant disability and functional limitations. The mean prevalence of lumbar spinal stenosis based on clinical and/or radiographical diagnoses vary between 11% and 38% in the general population, with an average patient age of 62 (1).

Lumbar spinal stenosis is most commonly a result of degenerative changes causing narrowing of the central spinal canal, lateral recesses, or intervertebral foramen, leading to compression of the neurovascular structures. Neurogenic claudication is characterized by unilateral or bilateral buttock, thigh or calf symptoms such as achiness, cramping, pain or sensory/balance problems with paresthesia, numbness, and weakness, aggravated by prolonged standing or walking and relieved by sitting, lumbar flexion and lying down (2, 3).

Clinical classification criteria to identify lumbar spinal stenosis causing neurogenic claudication includes (4):
  • age over 60 years
  • positive 30-second extension test (reproduction of symptoms)
  • negative straight leg test
  • pain in both legs
  • leg pain relieved by sitting, leaning forward or flexing the spine
Mild to moderate degenerative lumbar spinal stenosis causing neurogenic claudication tends to have a favorable natural history in approximately 60% of patients, however, 30% of patients are expected to worsen (5-8). A referral for special investigations and/or surgical consultation is recommended when patients report severe intermittent claudication when walking less than 100 meters, new or progressive lower limb weakness (9), and failure to respond to an appropriate course of nonsurgical care determined by the patient’s quality of life and expectations.

As a result of the lack of high-quality evidence for the effectiveness of interventions addressed in previous clinical guidelines, new trials are likely to impact subsequent recommendations. Therefore, this guideline aims to provide an updated, evidence-based understanding to inform the nonsurgical management of lumbar spinal stenosis causing neurogenic claudication.

Summary:

6 PICO questions (population, intervention, comparator, outcome) were answered primarily based on RCTs, while 5 others were based on expert consensus supported by systematic reviews, observational studies, or indirect evidence from systematic reviews or RCTs where available.

For patients with lumbar spinal stenosis causing neurogenic claudication, the recommendations are primarily based on low to moderate quality of evidence or consensus from the multidisciplinary working group.

The results of this review suggest that a multimodal rehabilitation intervention should be offered, consisting of a combination of education, sedentary and nutrition life-style modifications, behavioral change techniques in conjunction with manual therapy (manipulation, mobilization and massage) to the thoracic and lumbar spine, pelvis, and lower extremities, individually tailored supervised and home exercise programs, a trial of acupuncture or antidepressants, and in cases where surgery was performed, post-operative rehabilitation with cognitive behavioural therapy (CBT). The authors do NOT recommend the use of NSAIDs, analgesics or opioids as first-line treatments, nor muscle relaxants, antiseizure neuropathic medication, or epidural steroidal injections in general.

There is inconclusive evidence regarding the moderate to long term effectiveness of surgical interventions for people with lumbar spinal stenosis causing neurogenic claudication. Therefore, because of the higher risks of adverse events of surgical compared to non-surgical interventions, and evidence that delaying surgery is not detrimental to surgical outcomes (10), a reasonable trial of multimodal rehabilitation intervention with or without selected medications is warranted for most symptomatic lumbar spinal stenosis patients prior to recommending more invasive treatments.

Clinical Application & Conclusions:

Symptomatic lumbar spinal stenosis impacts an individual’s emotional state, quality of life, and physical function – including walking, recreational activities such as sports and exercise, standing, social activities, household activities, managing comorbid health conditions, working, sleeping, and lifting (11-13). As a result, health care providers need to address the negative emotions that patients may have as a result of this condition and provide advice and education about lumbar spinal stenosis to facilitate lifestyle change. Engaging older adults in their health and increasing their physical activity is essential when dealing with this condition.

Future research should work towards identifying and validating lumbar spinal stenosis clinical phenotypes, such as neurogenic claudication pain symptoms versus sensory/balance symptoms, and the associated severity of symptoms in relationship to the severity of structural anatomical changes. This could assist in determining who may be more likely to benefit from conservative versus surgical treatment approaches. In addition, high quality RCTs testing a variety of combinations of nonpharmacological and pharmacological treatments and dosages should be conducted – this certainly includes the integration of chiropractic manual techniques!

Study Methods:

The guideline panel included 19 individuals representing chiropractors, physiotherapists, general physicians, acupuncture, kinesiology, orthopedic surgery, neurosurgery, clinical epidemiology, motor control and learning, health services and clinical research, methodologists, decision makers, and consumer representatives to ensure stakeholder and patients’ values and preferences were considered.

The target population assessed was adults aged 18 years and older with lumbar spinal stenosis leading to neurogenic claudication with or without associated spondylolisthesis. Populations excluded from this guideline include adults presenting with radicular symptoms not relieved by sitting or lumbar flexion. This guideline assessed non-surgical interventions including non-pharmaceutical and pharmaceutical treatments alone or in combination, and perisurgical rehabilitation.

The following data bases were searched from July 1, 2010 to December 31, 2017: MEDLNE, ACP Journal Club, Cochrane Database of Systematic reviews, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, and US and International Trials registries. The search was updated on June 6th, 2019 in MEDLINE and Cochrane Central Register of Controlled Trials.

Eligible studies were critically appraised using the AMSTAR 2, Cochrane ROB 2 tool for RCTs, and SIGN checklists for observational studies. GRADE was used to appraise the body of evidence for each outcome.

The strength rating of a given recommendation was made based on the extent to which the desirable consequences of an intervention outweigh its undesirable consequences. In the absence of scientific evidence from admissible RCTs, the panel considered other available studies such as low quality RCTs and observational studies before producing consensus-based recommendations. These “good practice” recommendations are based on professional consensus among the multidisciplinary members of the working group.

Regarding the modified Delphi technique, to achieve consensus each recommendation had to have at least 80% agreement with a response rate of at least 75% of eligible panel members.

Study Strengths / Weaknesses:

Strengths:
  • The GRADE approach was used to provide a clear link between the recommendations provided and the level of evidence.
  • An international group of experts provided detailed comments prior to the release of the final report.
Weaknesses:
  • Only English articles were included in this guideline.
  • When the authors updated their search, only 2 of the original databases were searched.
  • The scope of this guideline focused on selected outcomes such as pain, disability, and function. However, included studies assessed additional patient outcomes that may have been important to report on.
  • The articles included were mainly lower quality evidence and therefore new higher quality trials are (still) likely to impact the recommendations in future guidelines.

Additional References:

  1. Jensen RK, Jensen TS, Koes B et al. Prevalence of lumbar spinal stenosis in general and clinical populations: A systematic review and meta-analysis. Eur Spine J 2020; 29: 2143-2163.
  2. Katz JN, Harris MB: Lumbar spinal stenosis. N Engl J Med 2008; 358: 818-825.
  3. Suri P, Rainville J, Kalichman L, et al. Does this older adult with lower extremity pain have the clinical syndrome of lumbar spinal stenosis? JAMA 2010; 304: 2628-2636.
  4. Genevay S, Courvoisier DS, Konstantinou K, et al. Clinical classification criteria for neurogenic claudication caused by lumbar spinal stenosis. The N-CLASS criteria. Spine J 2018; 18: 941-947.
  5. Kreiner S, Baisden J, Gilbert T, et al. North American Spine Society (NASS). Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and treatment of degenerative lumbar spinal stenosis. North American Spine Society Technical report, 2011.
  6. Minamide A, Yoshida M, Maio K: The natural clinical course of lumbar spinal stenosis: A longitudinal cohort study over a minimum of 10 years. J Orthop Sci 2013; 18: 693-698.
  7. Wessberg P, Frennered K: Central lumbar spinal stenosis: Natural history of non-surgical patients. Eur Spine J 2017; 26: 2536-2542.
  8. Costa F, Alves OL, Anania CD, et al. Decompressive surgery for lumbar spinal stenosis: WFNS spine committee recommendations. World Neurosurg 2020; X 7: 100076.
  9. Tsubosaka M, Kaneyama S, Yano T, et al. The factors of deterioration in long-term clinical course of lumbar spinal canal stenosis after successful conservative treatment. J Orthop Surg Res 2018; 13: 239.
  10. Zweig T, Enke J, Mannion AF, et al. Is the duration of pre-operative conservative treatment associated with the clinical outcome following surgical decompression for lumbar spinal stenosis? A study based on the Spine Tango Registry. Eur Spine J 2017; 26: 488-500.
  11. Ammendolia C, Schneider M, Williams K, et al. The physical and psychological impact of neurogenic claudication: The patients' perspectives. J Can Chiroprac Assoc 2017; 61: 18-31.
  12. Lynch AD, Bove AM, Ammendolia C, et al. Individuals with lumbar spinal stenosis seek education and care focused on self-management - results of focus groups among participants enrolled in a randomized controlled trial. Spine J 2018; 18: 1303-1312.
  13. Otani K, Kikuchi S, Yabuki S, et al. Lumbar spinal stenosis has a negative impact on quality of life compared with other comorbidities: An epidemiological cross-sectional study of 1862 community-dwelling individuals. Sci World J 2013 590652-590652.