Prevalence, Spinal Alignment, and Mobility of Lumbar Spinal Stenosis with or without Chronic Low Back Pain: A Community-Dwelling Study

Association between chiropractic spinal manipulation and gabapentin prescription in adults with radicular low back pain: retrospective cohort study using US data

OBJECTIVES

Radicular low back pain (rLBP) is often treated off-label with gabapentin or by chiropractors using chiropractic spinal manipulative therapy (CSMT). To date, no studies have examined the association between these interventions. We hypothesised that adults under 50 years of age receiving CSMT for newly diagnosed rLBP would have reduced odds of receiving a gabapentin prescription over 1 year-follow-up.

DESIGN

Retrospective cohort study.

SETTING

US network including linked medical records, medical claims and pharmacy claims of >122 million patients attending large healthcare organisations (TriNetX), queried 15 June 2023, yielding data from 2017 to 2023.

PARTICIPANTS

Adults aged 18-49 were included at their first occurrence of rLBP diagnosis. Exclusions were severe pathology, other spinal conditions, on-label gabapentin indications and gabapentin contraindications. Propensity score matching controlled for variables associated with gabapentin use and receipt of prescription medication over the preceding year.

INTERVENTIONS

Patients were divided into CSMT or usual medical care cohorts based on the care received on the index date of rLBP diagnosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

OR for gabapentin prescription.

RESULTS

After propensity matching, there were 1635 patients per cohort (mean age 36.3±8.6 years, 60% women). Gabapentin prescription over 1-year follow-up was significantly lower in the CSMT cohort compared with the usual medical care cohort, with an OR (95% CI) of 0.53 (0.40 to 0.71; p<0.0001). Sensitivity analyses revealed early divergence in cumulative incidence of prescription; and no significant between-cohort difference in a negative control outcome (gastrointestinal medication) suggesting adequate control for pharmacological care preference.

CONCLUSIONS

Our findings suggest that US adults receiving CSMT for newly diagnosed rLBP have significantly reduced odds of receiving a gabapentin prescription over 1-year follow-up compared with those receiving usual medical care. Results may not be generalisable and should be replicated in other healthcare settings and corroborated by a prospective study to reduce confounding.

Association between chiropractic spinal manipulation and lumbar discectomy in adults with lumbar disc herniation and radiculopathy: retrospective cohort study using United States' data

OBJECTIVES

Chiropractic spinal manipulative therapy (CSMT) and lumbar discectomy are both used for lumbar disc herniation (LDH) and lumbosacral radiculopathy (LSR); however, limited research has examined the relationship between these therapies. We hypothesised that adults receiving CSMT for newly diagnosed LDH or LSR would have reduced odds of lumbar discectomy over 1-year and 2-year follow-up compared with those receiving other care.

DESIGN

Retrospective cohort study.

SETTING

101 million patient US health records network (TriNetX), queried on 24 October 2022, yielding data from 2012 query.

PARTICIPANTS

Adults age 18-49 with newly diagnosed LDH/LSR (first date of diagnosis) were included. Exclusions were prior lumbar surgery, absolute indications for surgery, trauma, spondylolisthesis and scoliosis. Propensity score matching controlled for variables associated with the likelihood of discectomy (eg, demographics, medications).

INTERVENTIONS

Patients were divided into cohorts according to receipt of CSMT.

PRIMARY AND SECONDARY OUTCOME MEASURES

ORs for lumbar discectomy; calculated by dividing odds in the CSMT cohort by odds in the cohort receiving other care.

RESULTS

After matching, there were 5785 patients per cohort (mean age 36.9±8.2). The ORs (95% CI) for discectomy were significantly reduced in the CSMT cohort compared with the cohort receiving other care over 1-year (0.69 (0.52 to 0.90), p=0.006) and 2-year follow-up (0.77 (0.60 to 0.99), p=0.040). E-value sensitivity analysis estimated the strength in terms of risk ratio an unmeasured confounding variable would need to account for study results, yielding point estimates for each follow-up (1 year: 2.26; 2 years: 1.92), which no variables in the literature reached.

CONCLUSIONS

Our findings suggest receiving CSMT compared with other care for newly diagnosed LDH/LSR is associated with significantly reduced odds of discectomy over 2-year follow-up. Given socioeconomic variables were unavailable and an observational design precludes inferring causality, the efficacy of CSMT for LDH/LSR should be examined via randomised controlled trial to eliminate residual confounding.

Efficacy and Safety of Add-on Mirogabalin to NSAIDs in Lumbar Spinal Stenosis with Peripheral Neuropathic Pain: A Randomized, Open-Label Study

INTRODUCTION

In Japan, conservative therapy for patients with lumbar spinal stenosis (LSS) includes non-steroidal anti-inflammatory drugs (NSAIDs), prostaglandin E1, tramadol, physical/exercise therapy, and nerve blocks. Mirogabalin, a selective oral α2δ ligand, is approved for treating peripheral neuropathic pain, though data regarding visual analog scores (VAS) for pain in patients with LSS are limited. We investigated the efficacy and safety of mirogabalin as an add-on treatment in patients with LSS taking NSAIDs compared with patients taking NSAIDs only.

METHODS

This multicenter, randomized, open-label study (MiroTAS) was conducted at 32 centers in Japan between June 2020 and October 2021. Patients were randomly assigned to mirogabalin and NSAIDs or NSAIDs alone in a 1:1 ratio. NSAIDs were administered according to their Japanese package inserts; mirogabalin was administered based on renal function [creatinine clearance (CrCL) ≥ 60 mL/min, 5 mg twice daily (BID) in Weeks 1-2, 10 mg BID in Weeks 3-4, and 15 or 10 mg BID after Week 5; CrCL 30 to < 60 mL/min, 2.5 mg BID Weeks 1-2, 5 mg BID Weeks 3-4, and 7.5 or 5 mg BID after Week 5]. The primary endpoint was the change in VAS score for leg pain from baseline to Week 12. Secondary endpoints were quality of life, evaluated using the EuroQol five-dimensional descriptive system (EQ-5D-5L) (at baseline and Week 12) and Patient Global Impression of Change (PGIC) (at Week 12), and safety. Change in VAS score at Week 12 was calculated using a linear mixed model for repeated measures. The safety endpoints were treatment-emergent adverse events (TEAEs) and adverse drug reactions.

RESULTS

In total, 220 patients who met the eligibility criteria were enrolled. In the mirogabalin and NSAIDs and NSAIDs groups, mean ages (67.8 vs. 70.9 years), proportions of female patients (54.5% vs. 49.0%), mean body weights (63.9 vs. 62.0 kg), mean CrCL values (81.5 vs. 70.7 mL/min), proportions of patients with CrCL 30 to < 60 mL/min (27.3% vs. 33.7%), mean VAS scores (63.8 vs. 62.8 mm), and proportions of patients with VAS score ≥ 60 (53.6% vs. 52.9%) at enrollment were similar. The median durations of LSS were 9.0 and 11.0 months and the spine pain DETECT questionnaire (SPDQ) scores were 6.8 and 7.8, respectively. The least square (LS) mean change in VAS score from baseline to Week 12 was - 24.1 mm in the mirogabalin and NSAIDs group and - 14.2 mm in the NSAIDs group (both P < 0.0001 vs. baseline). The difference in LS mean was - 9.9 [95% confidence interval (CI), - 18.0, - 1.8] (P = 0.0174). The improvement in EQ-5D-5L score at Week 12 was significantly greater in the mirogabalin and NSAIDs group versus the NSAIDs group [mean difference, 0.0529 (95% CI, 0.0036, 0.1022), P = 0.0357]. At Week 12, the proportions of patients with PGIC scores ≤ 3 and ≤ 2 were higher in the mirogabalin and NSAIDs group vs. the NSAIDs group (76.2% vs. 50.0%, P = 0.0006, and 47.6% vs. 32.4%, P = 0.0523). In the mirogabalin and NSAIDs group, the incidences of TEAEs and adverse drug reactions were 60.9% and 57.3%, respectively, and the most common TEAEs were somnolence (30.0%) and dizziness (25.5%).

CONCLUSIONS

The addition of mirogabalin to NSAIDs improved VAS, EQ-5D-5L, and PGIC. The main TEAEs were somnolence and dizziness. The addition of mirogabalin to NSAIDs improved peripheral neuropathic pain associated with LSS and raised no new safety concerns.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCTs021200007).

The Lumbar Stenosis Prognostic Subgroups for Personalizing Care and Treatment (PROSPECTS) study: protocol for an inception cohort study

Background

Lumbar spinal stenosis (LSS) is a common degenerative condition that contributes to back and back-related leg pain in older adults. Most patients with symptomatic LSS initially receive non-operative care before surgical consultation. However, there is a scarcity of data regarding prognosis for patients seeking non-surgical care. The overall goal of this project is to develop and evaluate a clinically useful model to predict long-term physical function of patients initiating non-surgical care for symptomatic LSS.

Methods

This is a protocol for an inception cohort study of adults 50 years and older who are initiating non-surgical care for symptomatic LSS in a secondary care setting. We plan to recruit up to 625 patients at two study sites. We exclude patients with prior lumbar spine surgeries or those who are planning on lumbar spine surgery. We also exclude patients with serious medical conditions that have back pain as a symptom or limit walking. We are using weekly, automated data pulls from the electronic health records to identify potential participants. We then contact patients by email and telephone within 21 days of a new visit to determine eligibility, obtain consent, and enroll participants. We collect data using telephone interviews, web-based surveys, and queries of electronic health records. Participants are followed for 12 months, with surveys completed at baseline, 3, 6, and 12 months. The primary outcome measure is the 8-item PROMIS Physical Function (PF) Short Form. We will identify distinct phenotypes using PROMIS PF scores at baseline and 3, 6, and 12 months using group-based trajectory modeling. We will develop and evaluate the performance of a multivariable prognostic model to predict 12-month physical function using the least absolute shrinkage and selection operator and will compare performance to other machine learning methods. Internal validation will be conducted using k-folds cross-validation.

Discussion

This study will be one of the largest cohorts of individuals with symptomatic LSS initiating new episodes of non-surgical care. The successful completion of this project will produce a cross-validated prognostic model for LSS that can be used to tailor treatment approaches for patient care and clinical trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05598-x.

Association between chiropractic spinal manipulative therapy and benzodiazepine prescription in patients with radicular low back pain: a retrospective cohort study using real-world data from the USA

OBJECTIVES

Although chiropractic spinal manipulative therapy (CSMT) and prescription benzodiazepines are common treatments for radicular low back pain (rLBP), no research has examined the relationship between these interventions. We hypothesise that utilisation of CSMT for newly diagnosed rLBP is associated with reduced odds of benzodiazepine prescription through 12 months' follow-up.

DESIGN

Retrospective cohort study.

SETTING

National, multicentre 73-million-patient electronic health records-based network (TriNetX) in the USA, queried on 30 July 2021, yielding data from 2003 to the date of query.

PARTICIPANTS

Adults aged 18-49 with an index diagnosis of rLBP were included. Serious aetiologies of low back pain, structural deformities, alternative neurological lesions and absolute benzodiazepine contraindications were excluded. Patients were assigned to cohorts according to CSMT receipt or absence. Propensity score matching was used to control for covariates that could influence the likelihood of benzodiazepine utilisation.

OUTCOME MEASURES

The number, percentage and OR of patients receiving a benzodiazepine prescription over 3, 6 and 12 months' follow-up prematching and postmatching.

RESULTS

After matching, there were 9206 patients (mean (SD) age, 37.6 (8.3) years, 54% male) per cohort. Odds of receiving a benzodiazepine prescription were significantly lower in the CSMT cohort over all follow-up windows prematching and postmatching (p<0.0001). After matching, the OR (95% CI) of benzodiazepine prescription at 3 months was 0.56 (0.50 to 0.64), at 6 months 0.61 (0.55 to 0.68) and 12 months 0.67 (0.62 to 0.74). Sensitivity analysis suggested a patient preference to avoid prescription medications did not explain the study findings.

CONCLUSIONS

These findings suggest that receiving CSMT for newly diagnosed rLBP is associated with reduced odds of receiving a benzodiazepine prescription during follow-up. These results provide real-world evidence of practice guideline-concordance among patients entering this care pathway. Benzodiazepine prescription for rLBP should be further examined in a randomised trial including patients receiving chiropractic or usual medical care, to reduce residual confounding.

Factors associated with low back pain in patients with lumbar spinal stenosis: a cross-sectional study

BACKGROUND

Low back pain (LBP) is a major symptom of symptomatic lumbar spinal stenosis (SLSS). It is important to assess LBP in patients with SLSS to develop better treatment. This study aimed to analyse the factors associated with LBP in patients with SLSS.

METHODS

This cross-sectional study included consecutive patients with SLSS aged between 51 and 79 years who had symptoms in one or both the legs, with and without LBP. The participants were classified into two groups: the high group (LBP visual analogue scale [VAS] score ≥ 30 mm) and the low group (LBP VAS score < 30 mm). We performed multiple logistic regression analysis with the high and low groups as dependent variables, and a receiver operating characteristic (ROC) analysis.

RESULTS

A total of 80 patients with LSS were included (35 men and 45 women; mean age 64.5 years), with 47 and 30 patients in the high and low groups, respectively. Multivariate logistic regression analysis revealed that the sagittal vertical axis (SVA; + 10 mm; odds ratio, 1.331; 95% confidence interval, 1.051 - 1.660) and pelvic incidence-lumbar lordosis (PI-LL; + 1°; odds ratio, 1.065; 95% confidence interval, 1.019-1.168) were significantly associated with LBP. A receiver operating characteristic analysis revealed cut-off values of 47.0 mm of SVA and 30.5° of PI-LL, respectively.

CONCLUSION

Our results indicated that SVA and PI-LL were significant predictors for LBP in SLSS. It is suggested that these parameters should be taken into consideration when assessing LBP in patients with SLSS.

The Change of Lumbar Spinal Stenosis Symptoms over a Six-Year Period in Community-Dwelling People

Background and Objectives: The high prevalence of lumbar spinal stenosis (LSS) and its negative impact on quality of life in the elderly is well known. However, the longitudinal time course of LSS symptoms remains unclear. The purpose of this study was to clarify the longitudinal time course and associated factors of LSS symptoms over a period of six years in a community. Materials and Methods: This study was conducted with data prospectively collected in 2004 and 2010 under a retrospective design. In 2004, 1578 subjects (age range: 40 to 79 years) were interviewed on LSS symptoms using a specially designed and validated questionnaire. In 2010, a follow-up study was performed by mail, to which 789 subjects of the 2004 study population responded. Considering that the presence of osteoarthritis (OA) of the knee or hip may influence the participants’ answers in the questionnaire, analysis was performed in all 789 subjects with and 513 subjects without either knee or hip OA. Changes in LSS symptoms between the initial and the 6-year survey were investigated. Multiple logistic regression analysis was used for detecting the risk factors for LSS symptom presence at the six-year follow-up. Results: 1. At the six-year follow-up, more than half of the subjects who showed LSS symptoms at the initial analysis became LSS-negative, and 12–15% of those who were LSS-negative became LSS-positive. 2. From the multiple logistic regression analysis, a lower Roland-Morris Disability Questionnaire (RDQ) score and a positive LSS symptom at the initial analysis were detected as predictive factors of the presence of LSS symptoms at the six-year follow-up in the total number of subjects, as well as just in those who did not have either knee or hip OA. Conclusions: More than half of the subjects who were LSS-positive at their initial assessment still experienced improvement in their symptoms even after 6 years. This means that both LSS symptoms and their time course vary from person to person. Predictive factors for the presence of LSS symptoms during the six-year follow-up period were RDQ score and positive LSS symptoms.

Lumbar Extensor Muscle Size and Isometric Muscle Strength in Women with Symptomatic Lumbar Degenerative Diseases

Study Design

A cross-sectional design.

Purpose

To determine the characteristics of lumbar extensor muscle (LEM) size and isometric muscle strength and examine their correlations in women with lumbar degenerative diseases (LDDs).

Overview of Literature

Many studies have evaluated the relationship between muscle size and strength, but the results have been controversial.

Methods

Seventy-four female patients (mean age, 66 years) who consecutively underwent posterior lumbar interbody fusion (L1–S1) were recruited. The cross-sectional area (CSA) of the back extensor muscles was measured between L1–2 to L5–S1, and the total sum of the CSAs at each disc level was calculated. Back extensor muscle strength was evaluated using a MedX lumbar extension machine. The Oswestry Disability Index (ODI, 0–100) and Visual Analog Scale (VAS, 0–10) of lower back pain were determined.

Results

The mean CSAs of the LEM at each level (L1/2–L5/S1) and the total sum were 34.3, 36.3, 35.1, 31.4, 21.9, and 156.2 cm2, respectively. The mean isometric strength at each angle (range, 0°–72°) was 32.5, 50.1, 72.0, 88.7, 100.7, 112.2, and 126.2 ft-lb, respectively. The mean ODI and VAS scores were 54.6 and 6.6, and the mean body weight and body mass index (BMI) were 59.9 kg and 24.9 kg/m₂, respectively. The CSAs of the upper lumbar level (L1–4) and the total sum of the CSAs were associated with isometric strength, which was negatively correlated with patients’ age and ODI and positively associated with body weight and BMI, mainly at higher lumbar flexion angles (48°–72°).

Conclusions

In women with LDD, LEM sizes of the upper lumbar levels (L1–4) were larger than those of the lower levels (L4–S1) and were positively associated with muscle strength. The upper lumbar levels in patients with LDDs appear to play a compensatory role when degenerative lesions are present in the lower lumbar levels.

Magnitude of dural tube compression does not show a predictive value for symptomatic lumbar spinal stenosis for 1-year follow-up: a prospective cohort study in the community

Background

The North American Spine Society states that lumbar spinal stenosis (LSS) is a clinical syndrome, and there is insufficient evidence to make a recommendation for or against a correlation between clinical symptoms or function and the presence of anatomic narrowing of the spinal canal on MRI. The main purpose of this study was to assess the influence of the magnitude of dural tube compression on MRI on LSS symptoms at the cross-sectional and 1-year follow-up.

Methods

This was a prospective cohort study of 459 participants who were assessed for LSS using a questionnaire and conventional MRI of the lumbar spine. After 1 year, 335 subjects (follow-up rate 73.0%) were assessed for LSS using the same questionnaire. The time course of the clinical subjective symptoms of LSS and the relationship between the said symptoms of LSS and magnitude of dural tube compression on MRI were analyzed in a cross-sectional and longitudinal fashion.

Results

1) The dural sac cross-sectional area (DCSA) decreased with age. 2) Severe dural tube compression had a strong influence on the presence of symptomatic LSS; however, 40%–70% of participants with severe dural tube compression did not show clinical symptoms of LSS. 3) At the 1-year follow-up, >50% of the LSS-positive participants in the initial year were reclassified as LSS negative, and 10% of the LSS-negative participants were reclassified as LSS positive. 4) The magnitude of the DCSA on MRI did not directly affect the presence of LSS at the 1-year follow-up.

Conclusion

LSS symptoms were changeable. Anatomical dural tube compression on MRI did not predict the presence of clinical LSS symptoms at the 1-year follow-up.

Prospective one-year follow-up of lumbar spinal stenosis in a regional community

Purpose

Lumbar spinal stenosis (LSS) is a common condition in the aging population. However, limited information exists on discrepancies between LSS symptoms and imaging findings and/or prognostic factors of LSS, as well as the relationship between changes in LSS symptoms and quality of life (QoL) during the natural course of LSS. The purpose of the current study was to clarify any changes in clinically diagnosed LSS at a one-year follow-up, and identify its prognostic factors, using a community-dwelling cohort.

Participants and methods

In this study, the presence of LSS, its associated comorbidities, and the status of QoL pertaining to general health and low-back pain were assessed in 1,080 community-dwelling volunteers. The same assessment was carried out a year after the initial survey. Clinically diagnosis as LSS (LSS-positive) was determined by a validated diagnostic support tool in the form of a self-administered, self-reported history questionnaire. QoL was assessed using the 36-Item Short Form Health Survey and the Roland-Morris Disability Questionnaire.

Results

Among subjects who were LSS-positive in the initial assessment, 54% were clinically diagnosed as negative for LSS (LSS-negative) after the one-year period, whereas 10% of those who were initially diagnosed as LSS-negative changed to LSS-positive during the same period. With the improvement or deterioration of LSS-positive/negative status, low-back pain-related QoL and some components of the 36-Item Short Form Health Survey similarly improved or deteriorated. Decisive prognostic factors of LSS-positive status were not determined at the one-year follow-up.

Conclusion

Approximately half of the subjects who had initially been diagnosed as LSS-positive converted to LSS-negative after one year. Prognostic factors of LSS-positive diagnosis after one-year follow-up were not detected.

Relationship between sagittal spinal curves geometry and isokinetic trunk muscle strength in adults

PURPOSE

Sagittal spinal deviation has been reported to be a significant musculoskeletal problem affecting both genders and could develop at any age. Factors triggering this issue are still not well defined. The purpose of this study was to investigate the relationship between sagittal spine angles and isokinetic peak, average torque, and power of trunk muscles in asymptomatic adults.

METHODS

A convenient sample of 79 subjects with asymptomatic spine participated in this study. Thoracic and lumbar curves angles were measured using the Formetric 4D device. Thoracolumbar (T/L) ratio was calculated as an indicator of spine balance. Isokinetic peak and average torque and average power for trunk flexors and extensors were measured at 60°/s in seated and semi-standing test positions.

RESULTS

Lumbar curve angle was moderately inversely correlated (p < 0.001) with peak extension torque (ρ = - 0.532 and - 0.495 in seated and semi-standing positions, respectively) and peak flexion torque (ρ = - 0.604 and - 0.542 in seated and semi-standing positions, respectively). The T/L ratio was found to be significantly associated (p < 0.001) with trunk extension torque (ρ = 0.422 and 0.378 in seated and semi-standing positions, respectively) and trunk flexion torque (ρ = 0.396 and 0.321 in seated and semi-standing positions, respectively). Similarly, average torque and power measurements were significantly correlated with lumbar curve angle and T/L ratio.

CONCLUSIONS

Sagittal spine balance is associated with trunk muscles strength in adults, particularly, the lumbar spine muscles. Therefore, assessment of sagittal spinal balance and trunk muscles strength should be taken into consideration when designing rehabilitation programs for correction of sagittal spine curvature.

Pelvic retroversion: a compensatory mechanism for lumbar stenosis

OBJECTIVE

The flexed posture of the proximal (L1–3) or distal (L4–S1) lumbar spine increases the diameter of the spinal canal and neuroforamina and can relieve symptoms of neurogenic claudication. Distal lumbar flexion can result in pelvic retroversion; therefore, in cases of flexible sagittal imbalance, pelvic retroversion may be compensatory for lumbar stenosis and not solely compensatory for the sagittal imbalance as previously thought. The authors investigate underlying causes for pelvic retroversion in patients with flexible sagittal imbalance.

METHODS

One hundred thirty-eight patients with sagittal imbalance who underwent a total of 148 fusion procedures of the thoracolumbar spine were identified from a prospective clinical database. Radiographic parameters were obtained from images preoperatively, intraoperatively, and at 6-month and 2-year follow-up. A cohort of 24 patients with flexible sagittal imbalance was identified and individually matched with a control cohort of 23 patients with fixed deformities. Flexible deformities were defined as a 10° change in lumbar lordosis between weight-bearing and non–weight-bearing images. Pelvic retroversion was quantified as the ratio of pelvic tilt (PT) to pelvic incidence (PI).

RESULTS

The average difference between lumbar lordosis on supine MR images and standing radiographs was 15° in the flexible cohort. Sixty-eight percent of the patients in the flexible cohort were diagnosed preoperatively with lumbar stenosis compared with only 22% in the fixed sagittal imbalance cohort (p = 0.0032). There was no difference between the flexible and fixed cohorts with regard to C-2 sagittal vertical axis (SVA) (p = 0.95) or C-7 SVA (p = 0.43). When assessing for postural compensation by pelvic retroversion in the stenotic patients and nonstenotic patients, the PT/PI ratio was found to be significantly greater in the patients with stenosis (p = 0.019).

CONCLUSIONS

For flexible sagittal imbalance, preoperative attention should be given to the root cause of the sagittal misalignment, which could be compensation for lumbar stenosis. Pelvic retroversion can be compensatory for both the lumbar stenosis as well as for sagittal imbalance.

Management of degenerative lumbar spinal stenosis: an evidence-based review

Lumbar spinal stenosis has become one of the most disabling pathologies in the elderly population.Some additional conditions such as foraminal stenosis or degenerative spondylosis with a history of back pain and leg pain must be considered before treatment.A completely appropriate protocol and unified management of spinal stenosis have not yet been well defined.The objective of this literature review is to provide evidence-based recommendations reflected in the highest-quality clinical literature available to address key clinical questions surrounding the management of degenerative lumbar spinal stenosis. Cite this article: Covaro A, Vilà-Canet G, García de Frutos A, Ubierna MT, Ciccolo F, Caceres E. Management of degenerative lumbar spinal stenosis: an evidence-based review article. EFORT Open Rev 2016;1:267-274. DOI: 10.1302/2058-5241.1.000030.

The Association between the Cross-Sectional Area of the Dural Sac and Low Back Pain in a Large Population: The Wakayama Spine Study

OBJECTIVE

The purpose of this study was to evaluate the relations between the degree of encroachment, measured as the cross-sectional area of the dural sac, and low back pain in a large population.

METHODS

In this cross-sectional study, data from 802 participants (247 men, 555 women; mean age, 63.5 years) were analyzed. The measurement of the cross-sectional area of the dural sac from the level of L1/2 to L4/5 was taken using axial T2-weighted images. The minimum cross-sectional area was defined as the cross-sectional area of the dural sac at the most constricted level in the examined spine. Participants were divided into three groups according to minimum cross-sectional area measurement quartiles (less than the first quartile, between the first and third quartiles, and greater than the third quartile). A multivariate logistic regression analysis was used to estimate the association between the minimum cross-sectional area and the prevalence of low back pain.

RESULTS

The mean minimum cross-sectional area was 117.3 mm2 (men: 114.4 mm2; women: 118.6 mm2). A logistic regression analysis adjusted for age, sex, body mass index, and other confounding factors, including disc degeneration, showed that a narrow minimum cross-sectional area (smaller than the first quartile) was significantly associated with low back pain (odds ratio, 1.78; 95% confidence interval, 1.13-2.80 compared to the wide minimum cross-sectional area group: minimum cross-sectional area greater than the third quartile measured).

CONCLUSION

This study showed that a narrow dural sac cross-sectional area was significantly associated with the presence of low back pain after adjustment for age, sex, and body mass index. Further investigations that include additional radiographic findings and psychological factors will continue to elucidate the causes of low back pain.

Effects of Nasal Calcitonin vs. Oral Gabapentin on Pain and Symptoms of Lumbar Spinal Stenosis: A Clinical Trial Study

Lumbar spinal stenosis (LSS) is a chronic and prevalent disease that occurs in 10.8% of the general population, mostly in old age. We designed the first clinical trial study to compare the effects of administering the nasal salmon calcitonin spray and gabapentin in patients with LSS. In this clinical trial, 90 patients with symptoms of neurogenic claudication and magnetic resonance imaging-proven LSS were randomly assigned to nasal salmon calcitonin, gabapentin, or placebo treatments for eight weeks (30 participants in each group). This was followed by a washout period of four weeks. After three months of study and after four weeks off the prescription, mean values of Oswestry Disability Index in the calcitonin, gabapentin, and control groups were 23 ± 12.05, 32 ± 16.08, and 38 ± 22.09, respectively (P ≤ 0.05, calcitonin group vs. gabapentin group, and P ≤ 0. 001, calcitonin group vs. control group with respect to pretreatment scores). Thus, three months after the treatment, although most of the patients in the control group had a satisfactory period of improvement, the improvement in the calcitonin group was more than the other two groups with a significant difference (P ≤ 0.05 when compared to gabapentin group and P ≤ 0.01 when compared to placebo group). We revealed that the 200 International Unit (IU) and nasal calcitonin spray daily are more effective compared to 300 mg gabapentin three times per day and the placebo effect for eight weeks of treatment of symptoms of patients with LSS.

Lumbar spinal stenosis has a negative impact on quality of life compared with other comorbidities: an epidemiological cross-sectional study of 1862 community-dwelling individuals

Lumbar spinal stenosis (LSS) is common in the elderly. However, there have been few reports on its impact on quality of life (QoL) in community-dwelling individuals. The purpose of this study was to clarify how symptomatic LSS affects QoL at the community level. A total of 1862 people (697 males and 1165 females, most subjects were between 40 and 85 y.o.) agreed to participate and were interviewed. The presence of symptomatic LSS was assessed by a specially designed questionnaire. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) was also administered. In addition, the presence of comorbid conditions that affect QoL, such as osteoarthritis of the knee and hip, cardiovascular disease, cerebrovascular disease, or respiratory disease, was also analyzed. The prevalence of symptomatic LSS gradually increased with age. Furthermore, the presence of symptomatic LSS had a strong negative effect on all 8 physical and mental domains and the physical component summary (PCS) (OR: 1.547–2.544) but not the mental component summary (MCS). In comparison with comorbid conditions, LSS had a much stronger negative impact on health-related QoL (HR-QoL). The current study confirmed that the presence of symptomatic LSS might have a strong negative influence on HR-QoL in the community setting.

Prevalence of lumbar spinal stenosis, using the diagnostic support tool, and correlated factors in Japan: a population-based study

BACKGROUND

Few studies have examined the prevalence of lumbar spinal stenosis (LSS) in the general population. The purposes of this study were to estimate the prevalence of LSS and to investigate correlated factors for LSS in Japan.

METHODS

A questionnaire survey was performed on 4,400 subjects selected from residents aged 40-79 years in Japan by stratified two-stage random sampling in 2010. The question items consisted of lower-limb symptoms suggestive of LSS, the diagnostic support tool for LSS (LSS-DST), demographic and lifestyle characteristics, comorbidities, the Japanese Perceived Stress Scale (JPSS), and the Mental Health Index 5 (MHI-5). Using the LSS-DST, the presence of LSS was predicted to estimate the prevalence of LSS. Logistic regression analysis was performed to examine the relationship between LSS and correlated factors.

RESULTS

Questionnaires were obtained from 2,666 subjects (60.6 %), consisting of 1,264 males (47.4 %). The mean (standard deviation) age was 60.0 (10.9) years. According to the LSS-DST, 153 subjects were regarded as having LSS. The prevalence was estimated to be 5.7 %. When standardizing this value with the age distribution of the Japanese population, it was estimated that 3,650,000 Japanese subjects aged 40-79 years might have LSS using the LSS-DST. Prevalence increased with age and was particularly high in subjects aged 70-79 years, irrespective of gender. As correlated factors, an advanced age (60 years or older), diabetes mellitus, urological disorders, and osteoarthritis/fracture as comorbidities, and depressive symptoms, were associated with LSS.

CONCLUSIONS

This study elucidated the prevalence of LSS and factors associated with LSS in Japan. This is the first report describing the estimated prevalence of LSS and associated factors using a strictly sampled representative population.