Facet joint syndrome may cause symptoms that mimic lumbar spinal stenosis. These patients have back pain with extension of the spine. Pain in the buttock and posterior thigh may develop with prolonged compression associated with standing. Patients may walk in the flexed posture for extended distances without pain. Facet syndrome is unassociated with any neurologic abnormalities.
Management
Lumbar spinal stenosis management requires judgment that matches the severity of functional impairment with benefits and risks of the interventions.11 The options range from education, to weight loss, to exercises, to drugs, to injections, to surgical decompression. No one therapy works for all patients. Some therapies are not worth the risks. Other patients have no choice but surgical decompression if genitourinary or gastrointestinal dysfunction is imminent.
When advising the elderly spinal stenosis patient, I try to gauge the impact of their functional impairment in standing and walking with their general medical condition. I tell my patients, “You are only as young as your oldest part.” For example, most patients have co-morbidities, including cardiovascular disease, pulmonary insufficiency, and diabetes. In many of these individuals, spinal stenosis does not limit their function. Instead, they are limited because of angina after walking two blocks, or dyspnea after three blocks. These individuals have cardiovascular or pulmonary disease that limits activity before leg pain causes them to take a seat. The non-musculoskeletal systems are their oldest parts. In these patients, I attempt to relieve pain with the simplest of therapies. In other patients, spinal stenosis is their only major health problem. These individuals are treated intensively to reverse neurogenic claudication. In these individuals, the spine is their oldest part.
Non-surgical
The recommendations I make for patients with spinal stenosis are based upon the few outcomes trials that are in the literature and the knowledge of the pathogenesis of the disease. Space-occupying tissues compress the neural elements when the volume in the canal is diminished. The goal of therapy is to maximize the space in the canal by flexing the spine and reversing swelling of any inflamed soft tissues.
I recommend the following for initial therapy:
1 The patient should make an effort to achieve an ideal body weight. Weight loss places less strain on the spine and decreases the effort needed to walk any distance.
2 Riding a stationary bicycle is a way to obtain aerobic exercise and increase calorie utilization without stressing the lumbar spine.
