Wednesday, September 22, 2010

Nonpharmacologic Interventions for Spinal Stenosis

From Medscape Nurses
Barbara Resnick, PhD, CRNP

Pathophysiology of Spinal Stenosis

Spinal stenosis is a narrowing of the spinal canal or neural foramina producing root ischemia and neurogenic claudication. There is compression of neural structures, which also compress the vascular supply of nerves so that symptoms are predominately those of neural ischemia. Both the neural canal and the neural foramen are narrowed when the spine is in extension, and they are opened when the spine is in flexion.
Therefore, the pain associated with the compression is most often temporary. Fortunately, the pain associated with the nerve compression induces patients to change position and relieve nerve pressure before permanent neurologic damage is done.

Daniel Lieberman, MD, from the Arizona Center for Neurosurgery, Phoenix, Arizona,[1] provided an extensive review of the pathophysiology of spinal stenosis and described this as a slow stroke of the spine.
Due to bone changes, there is bulging and herniation of the vertebral body and a narrowing of the spinal canal. Pain occurs because of narrowing of the spinal canal and a subsequent decrease in oxygenation of the nerve.
Increased physical activity further increases oxygen demand, causing an infarct to the nerve root and exacerbation of pain. A complete infarct or stroke occurs very slowly over time.

There may be either central or lateral recess stenosis. In cases in which there is lateral recess stenosis, the patient will experience compression of the nerve roots and may have severe radicular symptoms including numbness in the toes with exercise. With central stenosis, there is compression of the spinal cord or myelopathy, and the patient will be more likely to complain of falls and a sensation that his or her "legs go out" with physical activity or exercise.

Diagnosis of Spinal Stenosis

Diagnosis of spinal stenosis is best done in the office setting by obtaining a focused history, observing the patient with regard to functional activities, and attempting to replicate pain via positioning. The following are typical findings in patients with spinal stenosis:

1.Patients are usually 60 years old or older;
2.Symptoms of stenosis are usually unilateral or bilateral leg pain, with or without back pain;
3.Pain occurs when the patient is upright and particularly when walking;
4.Typical symptoms are leg pain, numbness, and weakness developing after patient walks a predictable distance;
5.Patient seeks relief by sitting, leaning forward to "relieve pressure," putting his foot on a raised rest, or lying down; and
6.Common denominator is changing the position of the spine from extension to flexion.
A Phalen's test is particularly useful in making the diagnosis of spinal stenosis. This test attempts to reproduce symptoms of leg pain, weakness, or numbness by causing neural ischemia. The patient is asked to stand in full extension for a minute. A positive test occurs if an increase in leg symptoms is noted, followed by a rapid relief of these symptoms by having the patient bend forward with hands on the examination table and one foot on a stool.

Magnetic resonance imaging (MRI) without contrast should be done to make the final diagnosis and facilitate treatment options. The MRI can also help to differentiate spinal stenosis from other possible causes of back pain such as evidence of a spinal tumor or compression fracture. It is likely with fracture, however, that the pain will be localized more to the back rather than presenting as radicular pain.

Treatment Options for Spinal Stenosis
Nonsurgical interventions should clearly be implemented prior to surgical intervention. These interventions generally require behavior change and lifestyle alterations, and, as such, may not be easily achieved. Numerous motivational interventions can be implemented to facilitate behavior change.[2] The Table provides an overview of techniques. As appropriate, patients should be encouraged to reduce weight to achieve a body mass index that is appropriate for their given age and gender. In addition to weight loss, exercise should be strongly encouraged. The ideal exercise for spinal stenosis is swimming, which exercises all back muscles, or water walking, which is nonweight bearing. Pain should be relieved so that exercise and physical activity can be enhanced. Patients should be informed repeatedly that remaining sedentary to control pain will only further exacerbate disease.

Table. Motivational Interventions for Behavior Change
Factors Specific Interventions to Improve Motivation to Perform Healthy Behaviors
Efficacy Beliefs Interventions to strengthen efficacy beliefs:

1.Verbal encouragement of capability to perform -- SPELL out clearly the activity to be performed
2.Expose older adult to role models (similar others who successfully perform the activity)
3.Decrease unpleasant sensations associated with the activity
4.Encourage actual performance/practice of the activity

Eliminate Unpleasant Sensations (pain, fear, hunger) 1.Facilitate appropriate use of pain medications to relieve discomfort
2.Use alternative measures such as heat/ice to relieve pain associated with the activity; or encourage low calorie snacks to relieve hunger
3.Cognitive therapy:
1.Explore thoughts and feelings related to sensations
2.Help patient develop a more realistic attitude to the pain (ie, pain will not cause further bone damage)
3.Use relaxation and distraction techniques
4.Use graded exposure to overcome fear of falling

Individualized Care 1.Demonstrate kindness and caring to the patient
2.Use humor
3.Provide positive reinforcement following a desired behavior
4.Recognize individual needs and differences
5.Make it fun, new, or different

Spirituality 1.Explore the influence of spirituality and traditional religion and, as appropriate, encourage the patient to participate in this
2.Physically being with the older adult, and listening
3.Use life review
4.Encourage spiritual experiences: pets, children, journal-keeping, reading, friends, prayer

Social Support 1.Evaluate the presence and adequacy of social network
2.Teach significant other(s) to verbally encourage/reinforce the desired behavior
3.Use social supports as a source of goal identification

Goal Identification 1.Develop appropriate realistic goals with the older adult
2.Set goals that can be met in a short time frame -- daily or weekly
3.Set goals that are challenging but attainable
4.Set goals that are clear and specific


Pain management should be instituted using pain guidelines developed for care of older adults.[3] Gabapentin, Dr. Lieberman indicated, may not be useful for pain control in spinal stenosis because the pain does not come from within the nerve root. Epidural steroid injections are an option for pain control if medications are not fully relieving symptoms.[4] Epidural injections should control pain for a week. Alternative treatment options such as acupuncture can likewise be tried, although there are no randomized controlled trials to demonstrate the effectiveness of this treatment.

Back braces for management of pain can be used, although it should be stressed to patients that braces should not be used indefinitely. Specifically, it was recommended that the back brace not be used for more than 8 weeks because it weakens muscles. Dr. Lieberman suggested that patients be told to wear the brace for a 4-week period and then begin tapering off the brace.

Surgical Interventions: When All Else Fails
Surgical intervention is sometimes appropriate, and surgery essentially opens the spinal column, relieves the pain, and improves nerve oxygenation. Surgical interventions, specifically laminectomy or the more conservative decompressive laminarthrectomy,[5] or techniques such as laminoplasty[6] have all been shown to be effective in relieving pain and improving symptoms. Certainly, however, the surgical risks should be weighed against potential benefits, and surgical interventions should not be implemented until all other interventions have been attempted.

Patients with back pain should be carefully evaluated to establish if there is evidence of spinal stenosis. Once a diagnosis of spinal stenosis is made, conservative interventions, including weight loss if indicated and adherence to regular exercise, should be initiated. Certainly pain management should also include use of appropriate analgesic agents, epidural injections, and alternative treatments such as acupuncture. Likewise, back braces and supports can be used for short periods of time if they help with pain relief. If symptoms persist following implementation of conservative treatments, surgical intervention should be considered as this can effectively relieve nerve compression and thereby decrease pain and allow the patient to return to optimal function and quality of life.

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