This month I would like to discuss �conservative� treatment of lumbar spinal stenosis, a condition that we are seeing more of as the population ages. Incidence is difficult to evaluate but spine surgeons are now finding that spinal stenosis is the most frequent condition for which they operate.
How spinal stenosis presents:
Typically patients are elderly, although some may present in their 50�s or 60�s. Patients stand with lumbar spines and hips flexed and experience pain in the low back and/or leg(s) with lumbar extension. Walking more than a limited distance provokes pain. Sitting gives almost immediate relief.
The onset of the pain is usually gradual. Without treatment, the condition typically persists for many years. Because the mechanism of pain is encroachment on the cauda equina or a lumbar nerve root by narrowing of a canal, the definitive treatment has been considered (in some quarters) to be surgery.
For a more general discussion of spinal stenosis see: www.spinalstenosis.org.
What exactly is �conservative� treatment of spinal stenosis?
The list (by most medical authorities) is usually limited to anti-inflammatory medication, physiotherapy (whatever that means), corsets and caudal epidural steroids. In my experience, these are palliative treatments, although caudal epidurals (of procaine with or without steroids) may give months of relief in certain cases.
However things get interesting when we start looking at less conventional treatments. Among these I include manipulation, prolotherapy and neural therapy. None of these treatments directly addresss the narrowing of the canal. All target the conditions associated with the stenosis, e.g. poor mechanics, intervertebral instability, local inflammation and autonomic nervous system dysregulation.
Manipulation:
I had already begun writing this article when the current edition of the American Academy of Osteopathy Journal (December 2006) arrived with an article entitled �Non-operative management of spinal stenosis� by Phil Greenman. He reports on 15 patients with moderately severe symptoms who responded very well to a program of manipulation and intensive physiotherapy which included proprioceptive balance training, muscle stretching, muscle strengthening and aerobic conditioning. I personally have had some success treating spinal stenosis patients with manipulation and attention to muscle balance, but certainly not with results like this. Professor Greenman�s report is a challenge to the fatalistic mind-set that so often surrounds conservative treatment of spinal stenosis.
Prolotherapy:
Prolotherapy (or ligament-tightening injections) has been used in treating spinal stenosis for many years and the internet abounds with claims of its efficacy. However no scholarly reports have been published to my knowledge. My own results of treating spinal stenosis with prolotherapy (over 28 years) is mixed, with perhaps less than half of patients responding. Whether this reflects my skill level or my patient population is hard to say, but prolotherapy certainly should in my opinion be considered for spinal stenosis. A relatively safe treatment that provides relief is always worth trying in any condition that does not improve spontaneously, even when the failure rate is high.
Neural therapy: There appears to be even less written about the use of neural therapy for spinal stenosis, at least in the English literature. Dosch�s 1984 textbook does not mention it. However, if we consider manipulation to be a form of neural therapy in that it involves the autonomic nervous system, Greenman�s report suggests that interference fields could indeed contribute to the spinal stenosis sydrome.
A recent case in my practice confirms this. A vigorous, otherwise healthy 65 year old man presented with four years of bilateral low back pain extending into his buttocks when standing for more than 20 minutes or walking for more than a few minutes. Sitting provided immediate relief. Sleep was disturbed by pain and narcotics were needed. A MRI demonstrated �significant central canal and foraminal stenosis�. Previous osteopathic manipulation was ineffective, but an exercise program had helped. Apart from pain on lumbar extension and mild hamstring tightness, his musculoskeletal examination appeared non-contributory. Autonomic response testing indicated bilateral pre-vertebral sympathetic ganglion interference fields at the L3 level.
Both ganglia were treated for a little over a minute each using a Tenscam device. (For more information see tenscam.com). Immediate relief (less than 50% of the pre-existing pain) was obtained lasting about a week. At the next visit three weeks later, an interference field was detected on the left side only. Tenscam treatment resulted this time in more than two weeks relief, and a lower level of pain on relapse. Narcotic usage had declined significantly. On the third visit, an interference field was again found on the left side and was treated in the same way. On the fourth visit, this time after three weeks relief, an interference field was found in the right L3 sympathetic ganglion. It also was treated with the Tenscam.
A cure has not yet been obtained, although I am reasonably sure that it is on its way. However the point of this story is that the autonomic nervous system�s involvement in spinal stenosis pain can be important. A variety of mechanisms could explain neural therapy�s effect: e.g. alteration of local perfusion, improvement of intervertebral mechanics through optimization of muscle balance, regulation of local nociception, or perhaps some other mechanism.
All this is good news for patients with spinal stenosis. However it does require more effort and vigilance on the part of their physicians. Spinal stenosis is more treatable than we used to think.
Neural therapy mid-winter retreat � Sam Jakes Inn, Merrickville, Ontario - February 9th and 10th, 2007.
We are now only four weeks away from the neural therapy mid-winter retreat! Judging from the names of the people registered so far, this should be an interesting meeting. The best meetings seem to happen when imaginative people of diverse backgrounds come together - and that seems to be happening here!
For those of you just joining in, the plan is like this: This will be an opportunity for those with some neural therapy training to refresh and develop neural therapy skills � in a relaxed and informal environment. The emphasis will be on diagnosis, trouble shooting and practical application of neural therapy. There will be lots of time for discussion and sharing of experiences in integrating neural therapy into medical practice. Our keynote speaker is Professor Alasdair Ferguson, chairman of the Physiology Department at Queen�s University in Kingston Ontario. An engaging speaker, he has a special interest in autonomic nervous system physiology and is currently conducting research into the circumventricular organs (CVO�s). The ability of CVO neurons to respond to circulating factors which do not cross the blood-brain barrier provides the portal through which these substances exert feedback control on the brain. We expect that Professor Ferguson will provide us with fresh insights into how the autonomic nervous system and biochemistry interact. Interference fields and their successful treatment often depend on biochemical status, so this is practical information, applied neurophysiology at its best.
Also on the program is Pierre Larose DDS who will speak on �Dentistry that every physician should know�. Most physicians have only vague ideas about how dentists go about their business. Since neural therapy so often involves teeth, this is information that serious neural therapists need to know, if only to be able to communicate effectively with their dental colleagues.
Lynne August MD, creator of Health Equations� www.healthequations.com, will be speaking on nutrition, particularly as it pertains to cell membrane stability. Patients who are nutritionally deficient or neurotoxic respond poorly to neural therapy because their cell membranes are electrically unstable. This is a complex subject, but one in which Lynne has a great deal of practical experience.
I intend to do a review of basic neural therapy, discuss diagnosis and treatment of autonomic ganglia interference fields (including injection techniques), and provide practical approaches to diagnosing and treating neurotoxicities. Diagnosis and treatment strategies for chronic mercury toxicity will be discussed. Participants are invited to present free papers. Even a few minutes reporting an interesting case would be welcome. (Skill in neural therapy builds with experience and pooling of experience helps everyone). Interspersed between lectures and demonstrations will be opportunities for discussion and treatment of course participants and/or family members.
Course registration is only $350 Cdn (about $315 US). The price of accommodation is very reasonable as this is the hotel�s off-season. For details check the website at www.rfkidd.com/booksite/refreshcourseread.html or call my office at (613) 432-6596.
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Your feedback is always welcome
I invite your comments and questions-as well as brief case histories. Please e-mail me at [email protected]
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