07/18/2025
📃📝"Diagnosis and Management of Lumbar Spinal Stenosis"
👉Lumbar spinal stenosis is a condition where the spinal canal in the lower back narrows, putting pressure on the spinal cord and nerves that travel down the legs. This narrowing can cause pain, numbness, and weakness in the lower back, buttocks, and legs, especially with walking or prolonged standing. It's a common condition, particularly in older adults, and is often associated with age-related wear and tear on the spine.
🧠 Prevalence & Importance
Lumbar spinal stenosis affects approximately 103 million persons worldwide.
The prevalence in US adults is ~11%, increasing with age.
Most patients are treated nonoperatively, though 600,000+ surgeries are done yearly in the US.
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🧪 Diagnosis
History: Back and lower extremity pain worsened by extension, relieved by flexion.
Confirmed with MRI or CT.
Common signs: Pain relieved by sitting, worse when standing or walking, improved when leaning on shopping cart.
Imaging is crucial if surgery or injections are considered.
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🔍 Clinical Features
Pain radiates from low back to buttocks and legs, may include numbness/paresthesia.
Neurogenic claudication: pain with walking or standing, relieved by sitting.
Wide-based gait, Romberg sign, and vibration sense deficits in L4-S1 regions.
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📉 Pathophysiology
Caused by degenerative changes: disk protrusion, facet joint hypertrophy, ligamentum flavum thickening, and spondylolisthesis.
Leads to compression of nerve roots in central canal or neural foramina.
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⚕️ Treatment – Nonoperative
Education about posture and symptom relief.
Physical therapy including manual therapy, cycling, aquatic therapy, and flexion-based exercises.
NSAIDs show modest benefits but with potential GI/renal risks.
Gabapentin shows benefit but with drowsiness/dizziness (40% incidence).
Duloxetine helps chronic low back pain; not studied specifically in stenosis.
Epidural steroid injections: offer short-term relief only, with small infection risk.
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🛌 Prognosis (Nonoperative)
~33% improve, 50% remain unchanged, and 10-20% worsen over 3 years without surgery.
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🛠️ Surgical Options
Decompressive laminectomy improves symptoms in carefully selected patients.
In patients with spondylolisthesis, the addition of fusion showed mixed results:
One study: Fusion better (5.7-point SF-36 improvement).
Other studies: Decompression alone noninferior.
Fusion carries higher risks: infection, blood loss, hospital stay, cost.
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📊 Guidelines Summary
First-line: activity modification, analgesia, physical therapy.
Epidural steroids: short-term relief, no long-term benefit.
Surgery for persistent symptoms unresponsive to nonoperative care.
Indications for fusion in spinal stenosis with instability remain unclear.
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