Literature reviewChiropractic treatment of lumbar spinal stenosis: a review of the literature☆
Introduction
Lower back pain can be a disabling condition and has become the second most common reason that patients visit a physician.1 Recent research has attempted to segregate the lower back pain population into specific subcategories in an attempt to match the most appropriate treatments with conditions and improve outcomes.2 Lumbar spinal stenosis (LSS) is a clinical pathology categorized as a lower back pain condition and is often encountered in older adults. An increased capability of clinicians to diagnose this condition over the past decade has been brought about by improvements in imaging technology.3 The first definition of this disorder can be attributed to Verbiest4; and that has since evolved into what the Spinal Stenosis Work Group of the North American Spine Society Clinical Guidelines Committee defines as a “clinical syndrome of buttock or lower extremity pain, which may occur with or without back pain, associated with diminished space available for the neural and vascular elements in the lumbar spine.”5
Lumbar spinal stenosis can be classified in several ways based on the specific etiology or on the anatomical location and tissues involved in the narrowing. The etiology can be divided into developmental (or congenital) and acquired types, although both can occur in the same patient (Fig 1 for a list of potential causes).6, 7, 8 With respect to the anatomical location and tissues involved in the narrowing, LSS can be classified as either central or lateral stenosis. Central LSS involves the narrowing of the spinal canal around the nerve roots of the cauda equina within the dural sac due to facet joint arthrosis and hypertrophy, thickening and bulging of the ligamentum flavum into the spinal canal, encroachment or bulging of a intervertebral disk herniation, or spondylolisthesis.9, 10, 11 Lateral LSS typically occurs when the nerve root becomes encroached upon in the nerve root canal and/or the intervertebral foramen as a result of an intervertebral disk herniation, hypertrophy of the facet joints, loss of intervertebral disk height, or spondylolisthesis.6, 12, 13 Several of the aforementioned causes of stenosis are degenerative processes that may lead to the most common type of LSS: degenerative LSS. It is important for clinicians to understand the pathogenesis of LSS so that they can correlate this with patient symptoms, physical examination findings, and advanced imaging when considering this diagnosis for their patients.
Although the incidence and prevalence of LSS have not been well established, Fraser et al10 suggested that the prevalence was between 1.7% and 8% in the general population, whereas a report from the United States Agency for Healthcare Research and Quality suggested that 13% to 14% of patients who sought out a spinal specialist for a lower back complaint may have had severe bony stenosis.14 The incidence of lateral root entrapment has been reported at 8% to 11%.15 In the Spine Patient Outcomes Research Trial (SPORT), among 368 patients with spinal stenosis, 40% were female, the average age was 63.9 years, 20% had college degrees, and 8% were receiving workers' compensation for their condition.16
Amundsen et al12 determined through a prospective randomized study that the clinical symptoms of LSS, besides usually being insidious in nature, include leg pain (present in 100% of their subjects; bilateral in 42%, unilateral in 58%), lower back pain (95%), sensory disturbances in the leg (70%), and weakness (33%). In addition, this group observed that claudication was present in approximately 91% of their subjects.12 Patients can describe the leg symptoms as pain, paresthesia, numbness, and/or weakness. These symptoms are due to the entrapment of lumbosacral nerve roots in the constricted neural canal and foramina. Experimental studies have postulated that the pathogenesis of radiculopathy during neurogenic claudication could be due to the reduction of blood flow and impulse conduction in the compressed nerve roots, but this theory remains speculative. In the SPORT study, the duration of symptoms for patients with LSS at the time of enrollment was 7 to 12 weeks for 3% of the subjects, 3 to 6 months for 39%, 7 to 12 months for 25%, and greater than 1 year for 33% of the subjects.16
One of the hallmark signs or symptoms of LSS is the appearance of the leg pain with standing; this leg pain is exacerbated by prolonged walking (more specifically, lumbar extension) and relieved by resting in a flexed lumbar spine position.17, 18 Katz et al18 assessed the value of the history and physical examination findings in the diagnosis of 93 symptomatic degenerative LSS subjects. The most important history and physical findings were age (>65 years), reporting no pain when seated, exhibiting a wide-based gait, and thigh pain within 30 seconds of performing lumbar extension.18 Other authors have suggested that tension signs such as a positive Straight Leg Raise test result are not typical, but that sensory findings may follow specific dermatomal distributions in the L5 (91%), S1 (63%), and L1 through L4 areas (28%).12 More recently, Adamova et al19 investigated the contributions and limits of the exercise treadmill test and electrophysiogic examination in 92 patients with mild LSS. These authors concluded that the electrophysiologic examination may aid with discriminating between mild LSS and diabetic polyneuropathy, but that its contribution in the verification of neurogenic claudication in LSS patients is limited.19 The authors also reported that the exercise treadmill test was useful in the confirmation of neurogenic claudication and walking capacity verification, but that caution should be used with restriction of walking capacity due to other medical reasons (dyspnea, vascular claudication, joint complaints, etc).19
It is important when conducting the history and physical examination of patients with low back pain that chiropractors recognize certain symptoms or patient characteristics that could be indicative of a serious underlying spinal condition or are considered “red flags.” These include, but are not limited to, the following20, 21, 22, 23, 24:
- 1.
Cancer (risk factors include age >50 years, a previous history of cancer, unexplained weight loss, no relief of pain with bedrest, pain at rest, and pain that is worse at night)
- 2.
Infection (risk factors include immunocompromised states, persistent fever, intravenous drug use, urinary tract infection, skin infections, and increasing age)
- 3.
Cauda equina syndrome (risk factors include progressive neurologic deficit, urinary incontinence or retention, saddle anesthesia, anal sphincter tone decreased or fecal incontinence, and bilateral lower extremity weakness or numbness)
- 4.
Compression fractures (risk factors include increased age, history of trauma, prolonged corticosteroid use, and a history of osteoporosis)
- 5.
Abdominal aortic aneurysm (risk factors include atherosclerotic vascular disease, abdominal pulsating mass, pain at rest, and age >60 years)
For many patients with LSS, particularly atypical or nonclassic cases, diagnosis from history and physical examination alone may prove difficult; so clinicians will often turn to advanced imaging to determine and confirm diagnosis and to help establish prognosis. Radiographic studies may provide useful information that can aid in the diagnosis of complex LSS, in addition to demonstrating the presence of degenerative changes and spondylolisthesis; but in uncomplicated cases, radiographic findings are highly unspecific.25 Radiographs provide health practitioners with a means to assess or visualize the bony elements of the spine.26 Specifically, radiographs may show osteophytes (associated with disk and joint space narrowing) that can produce spinal canal and intervertebral foraminal stenosis, a decreased interpedicular diameter (which can increase the diagnostic sensitivity for intervertebral foraminal stenosis), and spondylolisthesis that can be a common predisposing lesion.26 However, the ability to determine the degree of LSS from radiographs has not been well established; and therefore, clinical guidelines have not been formulated to aid the clinician.26
It is often suggested that, for best neural foramina visualization, a sagittal magnetic resonance imaging (MRI) should be used and that both axial computed tomography (CT) and MRI images are sufficient to visualize the central canal. Bony findings such as facet arthropathy are better visualized on CT, whereas soft tissue pathologies that can cause LSS such as a disk bulge/herniation, ligamentum flavum buckling and/or hypertrophy, and cysts of the facet capsule and ligamentum flavum are best seen on MRI.27 Both CT and MRI can provide information that can be indicative of LSS such as a measurement of the midsagittal canal diameter of less than 10 mm, a transverse area of the dural sac of less than 100 mm, a height of the lateral recess not exceeding 3 mm, and a foraminal height not exceeding 15 mm.26 Recently, it has been suggested that the sensitivities of CT and MRI for lumbar stenosis exceed 70%; but this can be misleading considering that more than 20% of asymptomatic and limitation-free individuals older than 60 years may have findings of spinal stenosis on these diagnostic modalities.7, 28
The natural history of spinal stenosis generally indicates that, once symptoms have developed, they rarely ameliorate or deteriorate.29 However, symptoms may progress as the etiologic process advances, be that degenerative change or iatrogenic or endogenous causes. Johnsson et al30 followed the course of 32 untreated patients with LSS over an average of 49 months and found that 70% of the patients reported no change in their symptoms, 15% showed improvement, and the remaining 15% reported that their symptoms worsened.
Spinal stenosis is a condition commonly seen by chiropractors. In a large multicenter observational cohort study, as part of the SPORT study, 33% of the 368 subjects with spinal stenosis indicated having chiropractic treatment in the past.16 The National Board of Chiropractic Examiners reported in their 2005 Job Analysis that, among 2167 American chiropractors surveyed, spinal stenosis/neurogenic claudication was seen at a calculated average rate of 1.6 of 4.31 This meant that the average chiropractor surveyed reportedly sees a patient with this condition “sometimes,” equivalent to 1 to 3 patients with this condition per month. Of the respondents, 7.0% indicated that, in most such cases, they do not treat spinal stenosis patients, whereas 19.2% treat most patients with this condition by themselves, and 73.8% of the respondents comanage such patients most of the time.31 Among these chiropractors, 49.3% indicated providing a referral for most patients with this diagnosis.31 The objective of this review was to review the literature on the use of chiropractic in the treatment of LSS.
Section snippets
Methods
A literature search was conducted on 4 electronic databases (Medline, Index to Chiropractic Literature, Cumulative Index to Nursing and Allied Health Literature, and Allied and Complementary Medicine Database) for clinical research pertaining to chiropractic treatment of LSS. Medical Subject Headings terms were used in the search, consisting of the term spinal stenosis in combination with each of the following: chiropractic, spinal manipulation, chiropractic manipulation, and musculoskeletal
Results
Four single case studies32, 33, 34, 35 met the inclusion criteria for this review, as did 1 case series36 and an observational cohort study37 (details on the included studies in Table 1). Two articles deemed eligible for inclusion33, 38 appeared to pertain to the same case report; and as such, only one33 was included in the analysis because it represented a complete article, whereas the other38 was an abstract from a platform presentation. There were no randomized controlled trials identified
Discussion
Dupriest32 reported on a 76-year–old man with low back and leg pain with moderate to severe lumbar stenosis. Twelve treatments consisting of flexion-distraction manipulation; manual stretching of the thoracolumbar fascia; exercises for the low back, pelvis, and lower extremities; bicycling; progressive ambulation; ultrasound; and a 9-mm heel lift were provided over a 3-week period. Visual analog scale results were reduced from 7.4 of 10 initially to 0. Ranges of motion also demonstrated
Conclusions
To date, only 6 studies—4 case reports, a case series, and an observational cohort study—could be identified pertaining to chiropractic treatment of LSS. These preliminary studies all demonstrated positive results, but the low quality of the designs used precludes definitive conclusions from being made. Further clinical trials using improved research methods are much needed at this point in time.
References (40)
- et al.
Degenerative lumbar spinal stenosis: an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis
Spine J
(2008) - et al.
Lumbar spinal stenosis: a review of current concepts in evaluation, management, and outcome measurements
Arch Phys Med Rehabil
(1998) Spinal stenosis: history and physical examination
Phys Med Rehabil Clin N Am
(2003)- et al.
Lumbar spinal stenosis: anatomy and pathogenesis
Phys Med Rehabil Clin N Am
(2003) Pathophysiology of inflammatory, degenerative, and compressive radiculopathies
Phys Med Rehabil Clin N Am
(2002)What diagnostic tests are useful for low back pain?
Best Pract Res Clin Rheumatol
(2005)- et al.
Imaging lumbar spinal stenosis
Radiol Clin North Am
(2001) The natural history of lumbar degenerative spinal stenosis
Joint Bone Spine
(2002)Chiropractic management of a patient with lumbar spinal stenosis
J Manipulative Physiol Ther
(2001)- et al.
Low back pain. a primary care challenge
Spine
(1996)
A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study
Ann Intern Med
Rates of advanced spinal imaging and spine surgery
Spine
The natural history of spinal disorders
Lumbar spinal stenosis
N Engl J Med
Pathogenesis, presentation, and treatment of lumbar stenosis associated with coronal or sagittal spinal deformities
Neurosurg Focus
Lumbar spinal stenosis. Clinical and radiologic features
Spine
Posture-dependent bilateral compression of L4 or L5 nerve root in facet hypertrophy. a dynamic CT-myelographic study
Spine
Treatment of degenerative lumbar spinal stenosis
Lumbar foraminal stenosis
Spine
Descriptive epidemiology and prior healthcare utilization of patients in the Spine Patient Outcomes Research Trial's (SPORT) three observational cohorts
Spine
Cited by (17)
The influence of flexion distraction spinal manipulation on patients with lumbar spinal stenosis: A prospective, open-label, single-arm, pilot study
2022, Journal of Bodywork and Movement TherapiesCitation Excerpt :A conservative approach is reasonable both from a health care cost perspective and because 30–50% of patients with mild to moderate symptoms experience spontaneous improvement in pain and are able to walk greater distances (Jensen et al., 2021). Chiropractors provide manual therapy and the chiropractic treatment of LSS most often includes flexion distraction type spinal manipulation (Stuber et al., 2009). Flexion distraction manipulation appears not only to be an effective intervention for pain but also disability among patients with LSS (Ammendolia and Chow 2015; Choi et al., 2015).
Exploratory Analysis of Clinical Predictors of Outcomes of Nonsurgical Treatment in Patients with Lumbar Spinal Stenosis
2016, Journal of Manipulative and Physiological TherapeuticsClinical outcomes for neurogenic claudication using a multimodal program for lumbar spinal stenosis: A retrospective study
2015, Journal of Manipulative and Physiological TherapeuticsCitation Excerpt :A systematic review of manual therapy for spinal stenosis concluded there is preliminary evidence for potential benefit, but higher-quality evidence is needed.40 Similar conclusions were drawn from a review of the literature assessing chiropractic treatment of spinal stenosis.41 This review could not identify any RCTs evaluating chiropractic treatment of lumbar spinal stenosis.
Lumbar spinal stenosis and lower extremity motor control: The impact of walking-induced strain on a performance-based outcome measure
2014, Journal of Manipulative and Physiological TherapeuticsA pilot randomized controlled trial of flexion-distraction dosage for chiropractic treatment of lumbar spinal stenosis
2014, Journal of Manipulative and Physiological Therapeutics
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None of the authors received any funding in preparing this manuscript. The authors declare that they have no conflicts of interest to report.