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Lumbar Spinal Stenosis
Outpatient Treatment Guidlines
David C. Urquia, MD, Augusta Orthopaedic Associates/Waterville Orthopedics
Assumes a neurologically intact patient. Patients with new or evolving deficits should be referred for immediate ortho-spineconsultation.
Patients with very chronic neurological symptoms can be referred for spine surgical consultation without further delay. Unlikechronic radiculopathy patients, the results of surgery for spinal stenosis patients are usually not time-dependent.
Your initial visit will be used to do a good neurological exam and to screen for “red flags” and vascular insufficiency. Lowerextremity arterial insufficiency can be ruled out prior to any spine consultation. If there are no palpable pedal pulses and thepatient has claudication symptoms, send for arterial dopler studies prior to spinal scans.
Initial acute symptom management consists of rest/recumbency and anti-inflammatory medication, usually for 4-6 weeks.
Physical therapy is generally ineffective for spinal stenosis unless the goal is to treat only the mechanical (arthritic) symptoms.
These patients usually can control their neurological symptoms with rest/recumbency, so it is even more important for thisgroup of patients to not initiate narcotic therapy or complex polypharmacy.
Oral or parenteral (IM, IV) steroids have little proven efficacy for stenosis, but a single Medrol Dose Pack for the acute onsetof neurological symptoms is not unreasonable.
In neurologically intact patients, MRI scanning usually is unnecessary in the first 4-6 weeks from onset of acute neurologicalsymptoms. If very chronic symptoms exist and the patient has no contraindication to future ESI or spinal surgery, MRI can beordered at the patient’s initial visit.
Usually you are not going to order a lumbar ESI unless a relatively recent MRI has first been performed.
The standard for ESI is for X-ray-directed procedures, rather than “blind” office injections. Although not recommended basedon evidence-based data, my observation is that transforaminal injection technique is superior to interlaminar procedures.
If a patient does not respond meaningfully to the first 1-2 ESI attempts, additional injections are not recommended.
Patients with anatomic spinal stenosis by CT/MRI but with no neurological signs/symptoms (i.e., mechanical back pain only)usually will not respond to injection therapy and will not require surgical management unless some other co-existing spinalinstability exists.
Surgical consultation is recommend for patients with no resolution of acutesymptoms after 4-6 weeks, or any patient with chronic spinal neurologicalsymptoms.
EMG/NCV studies usually are not helpful in the work-up of stenosis patients.
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They may be useful to rule out peripheral neuropathy in select patients, although
neuropathy symptoms are fundamentally different from the classic claudication
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