When patients talk to me about spinal stenosis they are often confused about the diagnosis and about the treatment options. There is good reason for the confusion: spinal stenosis is a broad description of what can be a complex situation. What has worked for a friend may not have much to do with what is likely to work for you. A patient of mine asked me to write simply about this condition. After several weeks of attempts, this is my simplest explanation. Skip to the ending summary if you don't want the details.
Stenosis means narrowing. Spinal stenosis describes a narrowed nerve canal which may occur in one or more parts of the spine. The narrowing may irritate nerves intermittently or continually. The symptoms of spinal stenosis depend on which nerves or spinal cord components are involved and the degree of impairment to the nerve tissue. Symptoms frequently include numbness, weakness,tiredness or pain in the legs and balance problems. They sometimes include concentration problems, headaches or migraines, and may include sensory or strength changes in the arms. Spinal pain may be present. I notice that people with nerve compression often feel irritable or overwhelmed even when they do not perceive pain. They report feeling more calm and that their ability to focus returns when the nerves have been decompressed and their nervous system is relieved.
Causes of spinal stenosis vary. While an acute injury may cause a stenosis, often it is the result of long standing spinal conditions or old injuries which have become arthritic or worn; of disc and spinal degeneration, which may include disc bulges and herniations; of progressive changes in a scoliosis; or it may result from a reaction to previous spinal surgery. Some combination of thickened ligaments, bone spurs, damaged discs, misaligned vertebrae, scar tissue and soft tissue contraction narrows the nerve passageways, causing pain and interfering with nerve signals. The abnormal wear on the joints can result in swelling or edema, which further irritates the nerves and joints.
The goal of treatment is to provide the best relief at the best price with the fewest risks and side effects. While this condition can be complex, chronic and difficult, most people obtain good results from chiropractic care. Research demonstrates the effectiveness of flexion-distraction treatment with specific spinal joint adjustments as needed. (1) My patients report that when I add meningeal release therapy to their protocol they feel even better. Swelling goes down as the joint and disc health improves, further reducing pain. These treatments give the nerves more space, allowing them to heal. As healing progresses, the treatment frequency can be reduced. For many patients, this safe, non-invasive, non-addictive care is effective at providing both short and long term management and relief. There are no significant risks for most people. Occasionally patients report a temporary increase in inflammation as painful tissues are being addressed, or spinal muscles may feel tired because of improved posture. For most patients, relief becomes evident fairly quickly. The goal of chiropractic treatment is to achieve at least 50% relief within the first 30 days of care. If progress is not adequate a medical or surgical referral will be made. Statistics show that fewer than 4% of people treated with flexion distraction care are candidates for surgery afterwards. (2)
While physical therapy is also a conservative form of care, research demonstrates that chiropractic flexion distraction is better for spinal stenosis patients. People with chronic back pain and people with nerve pain or pressure originating from the spine have significantly better relief from chiropractic flexion distraction care than from physical therapy alone. (3)
Patients with cauda equina syndrome are not good candidates for conservative care and are referred for a neurosurgical consultation immediately. Cauda equina syndrome results from intense pressure on the group of nerves within the lower spinal canal. Symptoms include bladder or bowel dysfunction, causing either an inability to “go” or a loss of control. This degree of nerve pressure requires immediate decompression or the damage may become permanent.
Spinal steroid injections provide some relief to about 50% of people with back and nerve pain for 4-12 weeks. This treatment can be repeated only about 3 times in a year as it may weaken the bone, increasing the risk of fracture. It has no effect on pain that is not caused by inflammation. It has not been shown to reduce the number of people who will require surgery. Side effects can include weight gain, irritability and heart palpitations and there is a small risk of damage to the nerves. It can be used concurrently with chiropractic care to break a cycle of chronic inflammation. I believe that it is best considered only after an anti-inflammatory diet has been established and the spinal joints are being decompressed with flexion distraction and adjusted as needed. The cost of a single injection ranges from $600- $2500.
For the most severe cases, spinal surgery can be an appropriate consideration. A common surgical approach to stenosis is to perform a decompression laminectomy. This procedure removes part of the “roof” of the nerve canal, creating more space below. Research shows that this surgery is good at providing pain relief within a few months. However, a majority of patients report that their symptoms have returned to nearly pre-surgical levels at the five year mark. (4) The outcomes for spinal fusion as a treatment for stenosis are controversial and unclear. The question of spinal fusion should be carefully considered on a case by case basis with an experienced neurosurgeon. Fusions increase the stress on the adjacent joints and may accelerate degeneration further along the spine, in a domino effect. Continued consistent chiropractic care following surgery may help maintain the health of the remaining mobile joints, reducing the need for a series of spinal surgeries.
To summarize, spinal stenosis describes a condition that has many variables. The safest, least expensive and most effective way to address it is usually with chiropractic flexion distraction, accompanied by other chiropractic care as indicated. A one month trial of care, including 10-16 treatments, will demonstrate whether this approach is providing effective relief. Treatment frequency reduces as the tissues heal. Physical therapy is not as effective for stenosis. Spinal steroid injections are helpful for only half of patients, reducing pain for 4-12 weeks. Injection use is declining due to the expense, risks and limitations. While surgery may sometimes be necessary, the relief it provides may be temporary and it may cause a cascade of increased spinal problems in the future. Some of these post surgical problems can be addressed with chiropractic flexion-distraction treatment. So, the treatment order is: try chiropractic first, think twice about spinal injections, and turn to surgery last.
References:
Choi et al: Journal of Physical Therapy Science2015;27(6) 1937-39
Topics in Clinical Chiropractic; vol.3, no.3
European Spine Journal, 2006 July
European Spine Journal, 2007 Nov; 16(11): 1842–1847