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Research Review By Dr. Kent Stuber©

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Date Posted:

September 2014

Study Title:

An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update)

Authors:

Kreiner S, Shaffer WO, Baisden JL, et al.

Author's Affiliations:

Ahwatukee Sports and Spine, Phoenix, AZ; Northwest Iowa Bone, Joint & Sports Surgeons, IA; Medical College of Wisconsin, Tuft’s Medical Center, MA, USA.

Publication Information:

The Spine Journal 2013; 13: 734-743.

Background Information:

Degenerative lumbar spinal stenosis (LSS) is a difficult clinical entity, both in terms of diagnosis and management. The purpose of this evidence-based clinical guideline is to assist health professionals in improving the quality and efficiency of care delivered to patients with this condition.

This clinical guideline on the diagnosis and treatment of symptomatic degenerative LSS was developed by the North American Spine Society (NASS) and is an update of their prior guideline, published in 2006.

Guideline Summary:

There were 16 clinical questions assessed, with recommendations made and graded based on the strength of the literature on those particular topics. They are summarized below.

Definition of Degenerative Lumbar Spinal Stenosis

Consensus Statement:
“Degenerative lumbar spinal stenosis describes a condition in which there is diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes in the spinal canal. When symptomatic, this causes a variable clinical syndrome of gluteal and/or lower extremity pain and/or fatigue that may occur with or without back pain. Symptomatic lumbar spinal stenosis has certain characteristic provocative and palliative features. Provocative features include upright exercise such as walking or positionally induced neurogenic claudication. Palliative features commonly include symptomatic relief with forward flexion, sitting, and/or recumbency.”

Natural History of LSS:

There were no Grade A, B, C, or I recommendations made with respect to natural history of LSS. Consensus Statements:
  • “The natural history of patients with clinically mild to moderately symptomatic degenerative lumbar stenosis can be favorable in about one-third to one-half of patients.”
  • “In patients with mild or moderately symptomatic degenerative lumbar stenosis, rapid or catastrophic neurologic decline is rare.”
  • “Information in the literature is insufficient to define the natural history of clinically or radiographically severe degenerative lumbar stenosis.”
Diagnosis of LSS:
  • There was no Grade A recommendation for diagnosis of degenerative lumbar spinal stenosis (LSS).
  • Grade B recommendation: For patients with history and examination findings consistent with degenerative LSS, the suggested order of preference for imaging to confirm the presence of narrowing of the spinal canal or nerve root impingement is magnetic resonance imaging (MRI), followed by CT myelography, followed by CT without myelography.
  • Grade C recommendation: Degenerative LSS may be considered in older patients presenting with a history of gluteal or lower extremity symptoms exacerbated by walking or standing which improves with sitting or bending forward (flexion). Degenerative LSS is unlikely in those whose pain is not exacerbated by walking.
  • Grade I recommendations: There is insufficient evidence to make recommendations for or against the use of questionnaires in the diagnosis of spinal stenosis, as well as several physical diagnostic findings such as an abnormal Romberg test, thigh pain exacerbated with extension, sensorimotor deficits, leg cramps, and abnormal Achilles tendon reflexes. There is also insufficient evidence to make a recommendation for or against the reliability of dominance of lower extremity pain and low back pain or correlation between clinical symptoms or function with the presence of anatomic narrowing of the spinal canal on MRI, CT with myelography, or CT alone.
Consensus Statement:
“Imaging studies [should] be considered as a first-line diagnostic test in the diagnosis of degenerative lumbar spinal stenosis.”

Treatment of LSS:
  • It could not be determined if medical or interventional treatments improve outcome over simple natural history. To date, no study has specifically compared natural history with any treatment.
  • Grade A recommendation: Only one methodological recommendation was made, that being that contrast-enhanced fluoroscopy was recommended to guide epidural steroid injections to aid with the accuracy of medication delivery.
  • Grade B recommendation: Only two non-surgical and one surgical treatment were suggested, those being interlaminar epidural steroid injections for short term symptomatic relief (short-term being 2 weeks to 6 months) and lumbosacral corset to aid with pain and improving walking distance. Decompressive surgery was suggested to improve outcomes in patients with moderate to severe symptoms of lumbar spinal stenosis.
  • Grade C recommendation: Several treatments were found to be worthy of consideration by clinicians. In general (non-surgical) medical or interventional treatment may be considered for those with moderate LSS symptoms and may be considered to provide long-term improvement. Radiographically-guided transforaminal epidural steroid injection or caudal injections may be considered to produce medium-term pain relief of radiculopathy or neurogenic intermittent claudication from LSS. Surgical decompression may be considered in patients 75 years or older with LSS and surgery may be considered to provide long-term improvement in patients with degenerative LSS.
  • Grade I recommendation: There was insufficient evidence to make a recommendation for or against the use of several treatments including pharmacological treatment, physical therapy or exercise as standalone treatments, spinal manipulation, traction, electrical stimulation, TENS, acupuncture, or the placement of interspinous process spacing devices.
Consensus Statements:
  • “A limited course of active physical therapy is an option for patients with lumbar spinal stenosis.”
  • “Medical/interventional treatment (should) be considered for patients with mild symptoms of lumbar spinal stenosis.

Clinical Application & Conclusions:

This was an update to the clinical guideline for the diagnosis and management of degenerative lumbar spinal stenosis. The diagnostic procedures given the highest recommendations in patients with symptoms and examination consistent with LSS were MRI, followed by CT myelography, followed by CT without myelography.

The treatments given the highest recommendations were interlaminar epidural steroid injections and lumbosacral corsets, as well as decompressive surgery in patients with moderate to severe symptoms. However, with respect to treatment, several more recent reviews have indicated conflicting or insufficient evidence to guide clinical decision-making in patients with LSS (1, 2). The authors do provide a consensus statement that a limited course of active physical therapy is an option for patients with LSS, while spinal manipulation / manual therapy, standalone exercise, acupuncture, and most electrical modalities were found to have insufficient evidence to support or refute their use.

Study Methods:

NASS’s Evidence-Based Clinical Guideline Development Committee formed a multidisciplinary working group. This group composed an original guideline that was published in 2006 using a 12-step process. An updated literature search was conducted on several databases to address each of the clinical questions to be answered. Three reviewers independently rated all retrieved articles to levels of evidence, included articles were graded from levels I to V with I being the highest rated level of evidence and V being the lowest. A working group discussion process was employed to answer the guideline questions and make recommendations with grades assigned to levels of recommendation. The working group also produced several consensus statements. Recommendations were graded either A, B, C, or I:
  • Grade A recommendations were assigned to those treatments or diagnostic procedures that could be recommended by the working group as they were supported by two or more consistent level I studies.
  • Grade B recommendation meant that a treatment or diagnostic procedure was suggested by the working group based on support from 1 Level I study supported by other lower level studies; or two or more consistent level II or III studies.
  • Grade C recommendations meant that a diagnostic procedure or treatment may be considered as an option as suggested by the working group based on support from higher to mid-level studies (I-III) with support from level IV studies; or two or more consistent level IV studies.
  • A Grade I recommendation indicated insufficient research to either support or refute the use of a treatment or diagnostic procedure as determined by the working group, based on either a single study of any level or multiple studies with conflicting findings.

Study Strengths / Weaknesses:

The authors described no weaknesses or limitations in their guideline development process. However, the literature was only searched in English and up to July 2010. As this article was published in 2013, an updated literature search may have been desirable, as would a multilingual literature search. Finally, the authors of this article were all medical doctors, so it is undetermined how multidisciplinary these guidelines may be.

Additional References:

  1. Ammendolia C, Stuber K, Tomkins-Lane C et al. What interventions improve walking ability in neurogenic claudication with lumbar spinal stenosis? A systematic review. Eur Spine J 2014; DOI 10.1007/s00586-014-3262-6.
  2. Ammendolia C, Stuber KJ, Rok E et al. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD010712. DOI: 10.1002/14651858.CD010712.

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