Exploring Conservative Management and Postoperative Rehabilitation for Patients with Spinal Stenosis

Overview:

Melancia, J.L., et al defines spinal stenosis as the narrowing of the spinal canal causing clinical symptoms secondary to spinal cord or radicular compromise.

Briefly, lumbar spinal stenosis is characterised by compression of neural tissue either at the central canal, foramen or lateral recess, there are multiple mechanisms of which spinal stenosis can occur these include disc herniation, facet joint hypertrophy or slippage of adjacent vertebral bodies, all narrowing the space for neural tissue to pass through.

Aetiology:

Cases in earlier life are more likely due to congenital causes such as achondroplasia however acquired Lumbar spinal stenosis is generally due to natural degenerative changes . Rarely cancer around the spine can be the cause of spinal stenosis.

several other conditions can display similar symptomology, some common differential diagnoses include, vascular claudication, peripheral neuropathy, lumbar spondylosis and many more.

Epidemiology:

5/1000 people over the age of 50 are projected to develop some level of spinal stenosis, only 9% of cases are ever of congenital cause highlighting how common lumbar stenosis is as a degenerative disease

Diagnosis

When considering diagnosis, imaging is a powerful tool to confidently identify what is causing the patients problem, confirming a lumbar stenosis or perhaps a differential diagnosis. X -ray will show the vertebra and may show disc or facet degeneration, fractures, or calcification. MRI can offer more insight into surrounding soft tissues useful for identifying ligamental changes, neural changes or potential tumours , finally CT uses computer software to generate 3d images of the lumbar structures, CT is especially useful for investigating potential fractures or arthritic changes. Note that Imaging is useful for identifying stenotic changes however does not determine whether the stenosed spine requires direct treatment, systematic review by Jensen et al reported that 21-33% of people who demonstrated radiological signs of LSS did not have symptoms and Haig et al determined that impression of LSS on MRI does not necessarily determine if LSS is the cause of pain.

To ensure a confident diagnosis of LSS symptoms and signs should match with Imaging findings, a spinal canal diameter of 10mm is characterised as absolute stenosis and can be supported by signs such as the bicycle stress test, the patient rides a stationary bicycle in an upright position and the distance is recorded, this is repeated with a flexed forward position, if the distance is greater this time, LSS is indicated.

Surgical options:

Decompression by laminectomy can be used if the central canal is compromised by ligament changes for example, removal of spinal laminae and spinal process and/or soft tissues can relieve pressure on neural tissue

Spondylosyndesis is a type of spinal fusion which is commonly completed post decompression when instability of the spine is suspected. This type of fusion is followed by implants of a metal brace to support the two vertebra together.

Discectomy and fusion – if a disc herniates or degrades it may reduce the compress the central canal or the foraminal space, if the disc is sufficiently degraded it may be removed and the adjacent vertebra fused

Foraminotomy – in cases where the foraminal space is compromised by bony spur or disc herniation, etc, intrusive material will be removed widening the foraminal space to relieve symptoms.

Finally if disc degeneration is severe enough, a disc arthroplasty may be suitable, the damaged intervertebral disc is completely removed, an artificial disc is then place as substitution.

The most suitable surgery is not a physiotherapists responsibility rather other members of the multidisciplinary team such as radiologists and consultant surgeons will decide, however the wide range of surgical options makes lumbar spinal stenosis very treatable should conservative treatment be ineffective.

Pros and cons

Pros and cons of each approach differ, conservative treatment is preferred in early stages as this prevents the need to recover from a large operation, operations that carry risks like infections, decreased function post op and mental health challenges pre and post op. Some cons of the conservative approach are as follows, recovery time is generally longer as you are facilitating the natural healing process, problems from larger issues are unlikely to resolve completely without surgery and certain medical conditions will need to be considered prior to treatment and acted on accordingly by the MDT such as diabetes.

On the other hand surgery can resolve pain quicker as the route cause is dealt with, however spinal surgery is somewhat traumatic to the body so naturally a post op rehabilitation plan is needed which can be lengthy.

Conservative management

Conservative management is usually the first line of treatment to patients with spinal stenosis who present with mild to moderate symptoms. The treatment options are vast, ranging from strengthening and stretching, non-steroidal anti-inflammatory drugs, epidural steroid injections, pelvic traction, hydrotherapy or aquatic therapy to flexion exercises and more, however, these options are commonly recommended (Gunzburg and Szpalski, 2003), (Spinal Stenosis Treatment & Management: Approach Considerations, Non-steroidal Pharmacologic Therapy, Epidural Steroid Injection, 2022).

Some of the many benefits of conservative treatment options for LSS include; reduced risk of infection in comparison to surgical interventions, minimises invasive interventions and the patients generally report better outcome measures (inception, 2014).

• Lumbar flexion prescription - Lumbar flexion is promoted by several authors rather than lumber extension exercises due to the neuroforaminal narrowing and the narrowing of the spinal canal that is produced in lumbar extension. In ‘normal’ spines, during lumbar extension the cross-sectional area of the lumbar spinal canal and lateral recesses reduces by 9%, with lumbar stenotic patients, this reduction increases to 67%. This reduction in the area of space the spinal cord and exiting nerve roots can move around would likely reproduce the patients symptoms and risk further nerve damage. 'Rule of progressive narrowing' (Penning, 1992)
• Hydrotherapy - Aquatic treatments have proven to provide benefits to patients such as increasing muscle strength (paraspinal, trunk, glutes and other lower limb muscles), improving flexibility and also the balance of the patients, with the natural buoyancy of the water if a patient slips who has fear of falling it has been observed to reduce their fear. Along with the warmth of the water providing further pain relief effects.
• Epidural/steroid injections - These are commonly used for pain relief although the evidence for the management of LS is Level II for long-term improvement for caudal and lumbar intraforaminal injections and with transforaminal injections there is Level III (expert opinions) for short-term improvement only. Injections also coincide with an increased risk of infection due to the needle breaking the protective skin barrier. Epidural or steroid injections also come with further risks to patients with diabetes and/or glaucoma, these need to be taken into consideration for patients considering this line of treatment (Cleveland Clinic, n.d.).
• Pelvic/lumbar manual traction - This is used to stretch the para-spinal muscles, reducing the pressure they exert on the nerve roots and also to temporarily widen the joint space to alleviate the patient's symptoms which has been proven to be beneficial with lumbar stenotic patients (Schneider et al., 2019).
• Stretching and strengthening exercises - Having been used for several years in the lines of management for back pain, stretching exercises to lengthen muscles have been proven to temporarily alleviate patients' symptoms by relaxing the muscles and reducing the pressure exerted onto the exiting nerve roots and increasing the central canal space encasing the spinal cord. Strengthening exercises have also been proven to reduce the patients' pain levels and decrease disability levels (Slater et al., 2015).

Examples of exercises

• Single-leg knee to chest in supine
• Child's pose
• Forward flexion
• The 'cat' portion of the 'cat, cow' exercise
• Single-leg straight-leg raise
• Cobra pose
• Glute bridge
• Superman on all 4's

Surgery - Exploring the Literature

There are various surgical interventions available that can be used to treat lumbar spinal stenosis. The most common surgery is spinal decompression but these vary mostly due to location and type of deformity of the stenosis as well presence of instability. Surgical options are only considered for patients who do not improve with conservative management (Lurie and Tomkins-Lane, 2016). Patients with lumbar stenosis and predominant leg pain have better surgical outcomes as surgery is particularly effective in decompressing the nerve (Pearson et al, 2011) fusion of vertebra may also be considered if instability is also suspected as a cause of pain (Katz et al. 2022). spinal stenosis is now one of the most common indications for spinal surgery in those older than 65 years, with an overall increasing rate of these surgeries being linked to an increasingly aging population (Deyo, 2010). Regarding age, surgery still provided a significant benefit for patients 80 or over with no significant differences in complications or mortality rates compared to younger patients, so surgery is still a viable option. However, pain levels were not as reduced as much compared to the younger population (Rihn et al. 2015).

When is surgery considered?

A systematic review of five RCTs by Kovacs, Urrútia and Alarcón in 2011 with high quality evidence compared general conservative therapy with decompression surgery. Generally, there were improvements with all non-surgical interventions but results of all studies favored decompression studies for improvement of pain, function and quality of life as assessed with the SF-36 questionnaire. Therefore, decompression surgery has better outcomes for patients. However, it is important to consider that this study grouped patients that are already candidates for surgery and who had found no improvements with three to six months of conservative treatment. Therefore, non-conservative management should be trialed first in order to assess whether surgery is or is not required, as surgery is a high cost intervention with potential risks such as infection, hemorrhage and associated anesthetic risks (Ogihara et al, 2018). This systematic review concluded that surgery should be considered if conservative treatment has failed for 3-6 months. However, this is based on participants that only had short-term conservative treatment and so the effects of longer term conservative treatment is unclear. Progression of neurological symptoms and their severity are also taken into account, with guidelines and professional opinions also varying among when surgery is considered for each patient (Liang et al. 2022). It is important to note that it has been reported that only 60-70% of patients were satisfied with their symptoms following surgery (Weinstein et al. 2010). Therefore, it is important for patients to understand that surgery may not alleviate all symptoms and that a discussion around what non-conservative treatment can do compared to surgery is required. Additionally, a study that looked at longer term outcomes of surgery at eight years after operation concluded that there is evidence to suggest that the surgical group had diminishing benefits of their surgery. This should be considered but could also indicate the importance of long term self-management management/ rehabilitation following surgery (Lurie et al. 2015).

How effective is rehabilitation following surgery for spinal stenosis?

A Cochrane review from 2014 of postoperative rehabilitation in lumbar spinal stenosis compared active rehabilitation to usual care. Rehabilitation included all forms of active rehabilitation that aimed to restore or improve function, including exercise or stabilization training involving strength training, flexibility training as well as education and encouraging activity. (McGregor et al. 2014). Low back/disease specific measures of functional or disability status were used as primary outcome measures, for example the Oswestry Disability Index, with global health and pain severity of low back and leg as secondary outcomes.

Short Term (less than 6 months) Moderate quality evidence shows a 20% improvement for functional status and a 16% improvement in low back pain favouring active rehabilitation.

Long-Term (12 months) Moderate quality evidence shows a 23% improvement for functional status and a 18% improvement in low back pain. Unlike short term, there is significant improvement of leg pain with an improvement of 21%.

What makes an effective postoperative rehabilitation program?

Early Postoperative Rehabilitation:

Intensive physiotherapy is not recommended until the surgical wound following decompression surgery has completely healed. This will take approximately three weeks and building up exercise gradually is encouraged (Cambridge University Hospitals, 2023). Therefore, rehabilitation from the studies in the Cochrane review started from six weeks (at the earliest) and three months (at the latest), this active rehabilitation will be explored later. Immediately post-operation, an NHS exercise program recommends 7 simple exercises that focus on moving the joints and neural tissue of the lumbar spine. These exercises are as follows (Cambridge University Hospitals, 2022):

Plantar and dorsiflexion to help improve circulation, reducing chances of DVTs and to help glide the nerves.

Knee rolls, this exercise aims to increase movement in the hips and encourages the small rotational abilities of the lumbar spine .

Hip and knee bends, helps to gently glide the nerves and encourages slight lumbar flexion in a comfortable position.

Back arches on all fours, lengthens the spinal erectors preventing tightness and lumbar restriction.

Lumbar side flexion, the last exercise targeting the different range of motion at the lumbar spine.

Bent Knee dropout, more of a focus on strengthening the hips in a comfortable lying position.

Bridging, strengthening mainly the glutes but also stabilizing and strengthening the muscles surrounding the lumbar spine.

Patients are encouraged to move regularly, with walks recommended as a great way to increase activity level. Sitting for long periods may be uncomfortable so if this occurs movement is needed. Returning to hobbies and sport is recommended to be gradual and guided by levels of pain (Cambridge University Hospitals, 2022).

One study found that patients with more fear avoidance behaviours and reduced physical activity had higher levels of pain and disability (Donnarumma et al. 2016). It is also found that many patients engage in very low levels of physical activity during the early postoperative periods. Even with physiotherapy input and general physical improvements, activity levels did not change from six weeks to six months (Coronado et al. 2020). This suggests that a priority of rehabilitation should be to encourage movement and reduce fear avoidance, particularly in the early stages.

Later Stage Postoperative Rehabilitation

It is established that postoperative rehabilitation provides better outcomes than no active rehabilitation. However, studies that look at the effect rehabilitation has, often provide only a limited discussion of the actual rehabilitation process. This makes it hard to identify what is most effective from a rehabilitation program. From the studies included in the Cochrane review: Aalto et al. 2011 utilized strengthening exercises 3-5 times a week with stretching every day. McGreggor et al. 2010 had participants attend one hour classes twice a week which included general aerobic fitness, stretching, stability exercises, strengthening and endurance training, advice on lifting, setting targets and self-motivation. Mannion et al. 2007 also compared spine stabilization physiotherapy to non-standardized physiotherapy that used a mix of techniques. There was no statistically significant difference between these groups but the physiotherapy focussing on stabilization exercises did show a slight improvement in reducing disability based off the Roland Morris scores. Looking at the interventions used in the Cochrane review all studies used strengthening exercises, two of these incorporated core stabilisation exercises as well as stretching and endurance training. The individual effect each of these interventions has cannot be determined and there is a lack of this literature however, stabilisation exercises showed a slight improvement in reducing disability. Therefore, there is a need for more research to look at what specific rehabilitation principles are most effective post op.

Postural Control

Worsened postural control and timing of postural reactions is observed in spinal stenosis patients potentially due to stenosis caused afferent dysfunctions. Post surgery, patients still showed postural alterations, but these were significantly improved compared to the control group. Therefore, post-surgical rehabilitation should include a form of balance and proprioception training. This paper suggested the use of unstable surfaces with a component of reduced visual input (Kneis et al. 2019). This study did not explore what impact this training might have in terms on improvements to disability or pain, but this could have links to the idea that addressing core stabilization is important for rehab of these patients.

Example Exercises and Ideas:

Walking – aerobic exercise that is an easy way to increase overall activity levels. Any exercise that patients enjoy should be promoted

Sit to Stand Training – Strengthens the lower limb and can be adjusted to bias one leg, useful if leg strength is unequal due to radicular leg symptoms.

Deadlifts – Isometrically strengthening the spinal erectors which may be weaker after surgery this exercise also helps to build overall strength.

Woodchops/exercises involving spinal movement – This strengthens the ‘core’ muscles but incorporating spinal movement also helps to potentially reduce any fear avoidance.

Wobble Board Training – This could involve balancing with or without eyes closed or incorporating strength and functional movements such as a squat. This is to train postural control and stability.

Suitcase Marches – Core stability and balance for late-stage rehabilitation. We can use the Cochrane recommended outcome measures for our patients to assess if improvements are being made.

Conclusion/Key Learning Points

-Surgery is effective for reducing pain, increasing function and improving quality of life.

-Surgery is particularly effective at reducing leg symptoms, however it is not guaranteed to reduce all symptoms experienced.  

-Patients are encouraged to do what pain allows following surgery, reducing inactivity is important.

-At around 2 months following surgery, more intensive physiotherapy can start.

-There is limited evidence about the most effective form of rehabilitation post operation but evidence that shows the benefits of rehabilitation revolve around strength training.

References:

‌Aalto, T.J., Leinonen, V., Herno, A., Alen, M., Kröger, H., Turunen, V., Savolainen, S., Saari, T. and Airaksinen, O. (2011). Postoperative rehabilitation does not improve functional outcome in lumbar spinal stenosis: a prospective study with 2-year postoperative follow-up. European Spine Journal, 20(8), pp.1331–1340. doi:https://doi.org/10.1007/s00586-011-1781-y.

Cambridge University Hospitals. (2023). Post-operative recovery following lumbar decompression surgery. [online] Available at: https://www.cuh.nhs.uk/patient-information/post-operative-recovery-following-lumbar-decompression-surgery/ [Accessed 16 Mar. 2024].

Cambridge University Hospitals. (n.d.). Exercise programme following surgery of the lumbar spine. [online] Available at: https://www.cuh.nhs.uk/patient-information/exercise-programme-following-surgery-of-the-lumbar-spine/. [Accessed 16 Mar. 2024].

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