by David Borenstein, MD
For a person with comorbidities, it is important to remember that you are, as the saying goes, only as young as your oldest part. For example, you may have leg pain from spinal stenosis, but it may not be your leg pain that limits your physical function. If you have heart or lung disease, you may be able to walk only a block or two before chest pain or shortness of breath causes you to stop. In this case, the non–spinal stenosis problems are your “oldest part” and should be the main focus of treatment. If you are otherwise healthy and spinal stenosis is your limiting factor, your spine is your oldest part and your spinal stenosis should be treated aggressively.
Conservative treatment. The basic goal of therapy is to maximize the space in the spinal canal for the blood vessels that supply the nerves. Consider the following recommendations as part of a conservative self-management program for lumbar spinal stenosis:
Drug treatment. Medicines can be effective in improving physical function and decreasing pain in people with spinal stenosis. Nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen (Advil, Motrin IB) and naproxen (Aleve), have the dual benefit reducing inflammation and relieving pain. NSAIDs can decrease soft tissue swelling in the spinal canal, allowing greater room for the spinal nerves. The downside of NSAIDs is their potential side effects, which include gastrointestinal ulcers and bleeding, high blood pressure, and edema (swelling caused by water retention) in the legs. People considering long-term NSAID use need to think carefully about the benefits and risks of these drugs and be sure that they take the smallest effective dose.
People who experience too many side effects with NSAIDs may consider opioids. Opioids such as hydrocodone (Vicodin) and oxycodone (Percocet) are effective pain relievers but have their own list of side effects, especially in older people. Opioids can cause severe constipation and may also bring about mental clouding, dizziness, and loss of balance.
Epidural injections are sometimes used for spinal stenosis if exercise and NSAIDs have not relieved symptoms well enough. Epidural injections are delivered into the spine. Most people know about their use in pregnant women during delivery, when anesthetics are injected into the spine to numb the lower half of the body. In people with spinal stenosis, the injected drug is a corticosteroid, a powerful anti-inflammatory that can shrink swollen tissues. The injection is given at the area of the spine that has the greatest degree of narrowing, as determined by MRI or CT. Also, people have to stop taking NSAIDs or other blood-thinners before getting the injection.
People receiving corticosteroid injections need to consider the possible side effects of the drugs, which include high blood glucose, high blood pressure, and low bone mass. Because of the possibility of side effects, only three injections of corticosteroids should be administered in a given six-month period. If leg pain returns, people can receive an injection every two months thereafter, but may also decide to delay subsequent injections until leg pain with walking recurs. Epidural corticosteroid injections can be given over many years if necessary and if side effects do not become too troublesome.
Surgery. People should consider lumbar spine surgery only if they are physically incapacitated by spinal stenosis and have not had success with drug therapy. Candidates for surgery have leg pain after standing 10–15 minutes or walking short distances. In some people, spinal stenosis affects nerves that aid in bladder or rectal function. Surgery may be required for people who experience incontinence as a result. Age is not a deciding factor in the decision to undergo surgery; general medical health is more important. People who are 80 or 90 years of age and are in good health may benefit from surgery.
Last Reviewed on July 27, 2011
David Borenstein is a rheumatologist and Clinical Professor of Medicine at The George Washington University Medical Center in Washington, DC. Over the course of his 32-year career, his major medical interest has been the evaluation and treatment of spinal disorders.
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