Lower back pain and sciatic pain from narrowed spinal canal in the elderly can also be improved by medical treatment. Recourse to surgery is therefore not compulsory.
Nearly 1 in 3 older people have pain when walking due to a degenerative condition of the spine called ‘shrunk lumbar canal’ or ‘narrow canal’. It is a stenosis of the bony lumbar canal which contains the nerve roots. This is manifested by lumbar and sciatic pain that appears when walking and requires stopping, with the risk of disability and falling.
A scientific study demonstrates for the first time that medical treatment is effective and allows us to weigh the therapeutic effect of different types of non-surgical strategies. It thus appears that medical treatment is not cheap treatment and that surgical intervention is not compulsory. This study is published in JAMA Open Network.
A controlled study
Researchers at the University of Pittsburgh randomized 259 patients with narrowed lumbar spinal cord into 3 treatment groups with evidence of spinal stenosis (central or lateral) on MRI and an objective clinical manifestation of narrow canal (sciatica on walking with relief when sitting or leaning forward).
The 3 treatment groups compared were treatment with drugs and/or epidural injections, group rehabilitation treatment and personalized rehabilitation treatment with stretching, mobilization and muscle strengthening.
If the results are comparable at 6 months (50% of patients with an improvement of at least 30% in walking distance), rehabilitation gives the best results at 2 months with 60% of patients having a improvement of at least 30% in walking distance.
Very common surgery
The narrowed lumbar canal is the main cause of surgical operation of the spine in the elderly with sometimes heavy interventions at the key: opening of the canal (laminectomy), arthrodesis by plate with bone grafts.
Health expenditure devoted to this intervention has not ceased to increase in recent years (+137% in the USA between 1998 and 2008), with a clinical and functional benefit which nevertheless remains modest and little differentiated according to the techniques: on average, a reduction of 30% to 50% of lumbar and sciatic pain and a 30% increase in walking distance (Forsth, Ghogawala).
A study that clarifies treatments
In France, the treatment of low back pain related to a narrowed lumbar canal calls for first-line medical treatment and it is only in the event of failure or insufficient functional results that surgical treatment is considered.
This study therefore validates this strategy since whatever the non-surgical technique chosen, nearly 50% of patients have an improvement in their walking distance of at least 30%, a result close to that obtained in studies with surgery. . On the other hand, it is possible that there is a difference in terms of lower back pain between surgery and medical treatment. If we look at the comparison between the techniques, it appears that rehabilitation with stretching, mobilization and muscle strengthening is superior to the 2 other non-surgical techniques at 2 months, even if this difference fades at 6 months.
However, the study does not compare non-surgical techniques with surgical techniques and these are probably not the same patients. On the other hand, it did not compare treatment strategies combining different non-surgical techniques, which is currently done in France.
In practice
This study, the first of its kind, validates the interest of medical treatment in pain and disability in walking related to osteoarthritis of the spine and a narrowed lumbar canal in the elderly.
Surgery is therefore absolutely not mandatory, especially since the benefit on walking, the main handicap complained of by patients, is quite similar with the 2 types of treatment (even if the populations of operated patients and those who are not operated are probably not superimposable). Surgical indications must therefore be weighed carefully.
It also seems logical to combine different non-surgical techniques which are all effective in treating the symptoms of narrow lumbar canal, especially since they probably have a complementary effect, at least over time.
Thus, in the event of disabling pain and gait disorders related to a narrowed lumbar canal, it is not illegitimate to initially propose epidural infiltrations in order to quickly relieve the patients and to simplify the rapid realization of a rehabilitation based on stretching and muscle strengthening in lumbar delordosis. Insofar as it is a chronic condition, then taking over with group physical exercises is undoubtedly a good method of consolidating the functional result obtained.
In case of failure or insufficient result or rapid recurrence, the discussion of surgery will then be all the more legitimate.