3 Water exercises with or without flotation devices are an alternative for those individuals who have difficulty walking short distances.
4 Abdominal strengthening exercises allow a patient to place their spine in a pelvic tilt, maximizing volume in the canal. Strengthening buttock and thigh muscles is also beneficial. Physical therapy programs that include these exercises have documented improved function.12
5 Smoking cessation is important. Lowering levels of bloodstream carbon monoxide can only be helpful to nerve roots starved for oxygen.
6 Education is key. Information empowers patients to be active in their own care. Understanding the purpose of therapy gets patients to participate to a greater degree.13
Drug therapies are effective in improving physical function and decreasing pain.11,14 I prefer anti-inflammatory drugs over pure analgesics for the initial therapy of spinal stenosis. The theoretical ability of NSAIDs to decrease soft tissue swelling specifically addresses the goal of therapy to maximize the volume in the spinal canal. No NSAID is more effective than another for spinal stenosis. In elderly patients, use the smallest effective dose. The toxicities of NSAIDs (gastrointestinal ulcers, hypertension, and peripheral edema, among others) are greater risks for an elderly population. I offer concomitant medications to reduce side effects in susceptible patients.
Consider opioid analgesics for patients with severe, incapacitating pain who are not good candidates for NSAID therapy, or who have found non-narcotic analgesics to be ineffective. Short-acting opioids can be used when patients are planning an activity that may cause radicular pain. I recommend taking the analgesic prior to the physical activity. I limit the use of long-acting opioids to individuals with persistent pain who are poor surgical candidates.
I utilize low-dose corticosteroid (5 mg to 10 mg QD) in patients who have difficulties with NSAIDs and opioids. No clinical trials have shown the benefits of steroids for spinal stenosis, but my clinical experience has included a group of patients taking low-dose steroids who are able to function with decreased leg pain. Theoretically, the anti-inflammatory effects of steroids may decrease swelling in the spinal canal. I also use steroids in patients who have a good response to epidural corticosteroid injections but are unable to receive additional injections.
I recommend epidural corticosteroid injections to patients with only partial benefit from exercise and NSAID therapy.15 Epidural injections are usually given in a series of three. Injections for herniated discs are given over a six-week period to alter acutely swollen tissues. I order epidurals at a different interval for spinal stenosis because of the different pathology. Injections are limited to three over a six-month period, so I order injections every two months or later and delay subsequent injections until symptoms recur. I have patients who have repeated epidural injections for years without needing surgical decompression.
