Lumbar Spinal Stenosis is a condition we know well. Often tied up with age-related spinal degeneration, it occurs when we see a narrowing of the spinal canal in the lower part of the spine. Given the rich innervation throughout the spinal canal (obviously), this can lead to nerve compression which in turn can lead to back and leg pain, numbness or weakness in the feet and legs, difficulty walking or keeping balance, and in severe cases even bowel or bladder dysfunction. Of course it can also be asymptomatic, but these aren’t usually the cases that come through our doors.
It’s not just age-related degeneration that can cause it though: herniated discs, tumours, genetic factors or spinal injury and trauma can cause it. It is thought to affect 8-9% of the population above the age of 60, but this can vary according to region or particular subgroups of people.
In terms of interventions, conservative treatment usually involves a combination of pharmaceutical interventions (potentially including epidural steroid injections), as well as physical therapy and lifestyle changes. Canes or walkers are often used by sufferers as part of these modifications. Laminectomies, which are surgical interventions to remove portions of bone or tissue, or the use of laser techniques to aid decompression are thought of as minimally invasive. Spinal fusions are also used in more severe cases to fuse segments of the spine together in efforts to stabilise it.
All in all, we can see that lumbar spinal stenosis is no joke. But what role can chiropractic have in the care and management of lumbar spinal stenosis? Of course, larger studies are needed in order for us to make any large claims. But a recent case report took a look at the condition when a 73-year-old female presented for chiropractic care with chronic low back pain and leg pain.
The patient in question had survived a motor vehicle accident some 12 years prior to her presentation at a chiropractic clinic, and she reported that her symptoms may have stemmed from that incident. An MRI conducted following the accident showed marked central canal and mild neuro-foraminal stenosis at L4-L5 (where the nerve roots exit the spine in the lower back). This was due to a Grade 1 spondylolisthesis (where the lumbar spine had moved forward off the sacrum), disc bulging, facet arthropathy, and degenerative disc disease. She was told that her ongoing symptoms were due to spinal stenosis.
At the time of her chiropractic presentation (the commencement of the case report), her low back pain was rated a 5/10 at rest and a 9/10 with physical activity. Previously she had experienced pain in both legs, but at the time of presentation the pain was only in the left leg.
Symptoms were intermittent, daily, and worsening throughout the day. She described the pain as stabbing and heavy, which worsened with walking, standing, and general activity.
Previous to her presentation, she had been advised that rest, medications (NSAIDs), and spinal manipulative therapy were all factors that might temporarily relieve her pain. The daily activities of her life were greatly impacted by the pain, affecting her overall quality of life.
The chiropractor undertook a thorough examination of the patient’s history, which revealed she also suffered from significant lower extremity edema (swelling), musculoskeletal pain, hypertension, and hypothyroidism – all of which were managed with medication. There was also significant shortness of breath noted.
Chiropractic testing revealed:
- Left-sided axial back pain and gluteal pain
- Nerve tension
- Thoracolumbar range of motion was reduced in extension
- Hyperesthesia in both lower legs (although these findings appeared to be related to the significant lower extremity edema)
- Motor testing revealed losses in hip flexion on both sides, knee extension, and knee flexion.
- Segmental and somatic dysfunction was identified in the thoracic and lumbar regions.
The chiropractor provided a provisional diagnosis of lumbar discogenic pain, with significant deconditioning and concomitant lumbar spinal stenosis.
Care involved prone end-range loading exercises into lumbar extension and high-velocity low-amplitude (HVLA) spinal manipulative therapy of the thoracic and lumbar spine. When the patient returned for her second visit, she reported a significant reduction in low back pain and leg symptoms while performing the lumbar extension. However, the exercises had provoked a prior shoulder injury. As such, the exercises were adapted to be performed standing. The patient had good compliance with the high frequency of the exercises (10 repetitions every 2 hours), and after 6 sessions of spinal manipulative therapy, a walking regimen was added to the care plan.
The patient was seen once a week for 8 weeks, after which she continued with the exercises at home as a form of self-management. At that time she was able to ascend 3 flights of stairs without stopping and was regularly walking in intervals of 5-7 minutes, which was previously unachievable. The patient’s Back Bournemouth Questionnaire (an outcome measure for patients with low back pain) findings improved from 33/70 to 11/70. At a 7 month follow up, the patient was still experiencing therapeutic benefit with the standing extension exercises and maintained a Back Bournemouth finding of 11/70.
This case report presents some interesting questions – most of which only further time and research can answer. We most often think of spinal degeneration as a one-way street. But such an improvement in symptoms and function in a relatively short amount of time raises the question – what would happen if spinal stenosis patients were given long term chiropractic care? What would the results be on an MRI, in addition to the possibility of pain reducing, quality of life improving and function returning? We don’t know the answer to this yet. We do know that, in this case, the results were strong and it certainly presents a case for further research. We can’t wait to see what emerges.
REFERENCE
- Percuoco, K., Dunaj-Compo, M., & Olson, M. (2023). EXTENSION END-RANGE LOADING FOR LUMBAR SPINAL STENOSIS: A CASE REPORT. Journal of Contemporary Chiropractic, 6(1), 56–61
