Spinal Stenosis

What is Spinal Stenosis?

Spinal stenosis is a narrowing of the spinal canal, the side pockets (lateral recesses) or the openings where nerve roots exit, which can squeeze the nerves.^[1] It is most common in the lower back (lumbar stenosis), and the neck can be affected too.^[2] Lumbar spinal stenosis affects an estimated 11% of older adults in the US and is a prevalent and disabling cause of back and leg pain in older people.^[3]

Common symptoms

The typical symptom is back and leg pain that is brought on by standing or walking and relieved by bending forward or sitting. This pattern is called neurogenic claudication.^{[2, 3]}

• Pain, cramping or heaviness in the buttocks and legs when walking or standing
• Numbness or tingling in the legs or feet
• Weakness in the legs
• Relief when sitting, leaning on a cart or bending forward

Central narrowing can cause symptoms in both legs, while narrowing at the side of the canal or the exit openings usually affects the nerve root on one side.^[1]

Causes and risk factors

Most spinal stenosis is degenerative and part of the aging process. Thickening of the ligamentum flavum, bulging discs and bony overgrowth from facet joint arthritis all take up room in the canal.^{[1, 2]} Symptoms do not match the scan findings closely: there is no clear-cut link between stenosis on imaging and the presence of symptoms.^[2]

How it is diagnosed and treated conventionally

The diagnosis is usually made from a history of back and leg pain provoked by extension of the spine and relieved by bending forward, and then confirmed with CT or MRI.^[3] Doctors also need to rule out other causes of leg pain and walking problems.

First-line treatment is activity modification, pain medicines such as anti-inflammatory drugs, and physical therapy.^[3] A systematic review found moderate-quality evidence that manual therapy plus exercise improved symptoms and function in the short term, and that epidural steroid injections were not effective for neurogenic claudication.^[4] Followed for up to 3 years without surgery, about a third of patients improved, about half stayed the same and 10% to 20% got worse.^[3]

Decompression surgery may help carefully selected patients who do not improve with non-surgical care.^{[3, 5]} A Cochrane review of five trials had very little confidence about whether surgery or non-surgical care is better, and noted surgical complication rates of 10% to 24% in some studies.^[6]

Why Spinal Stenosis calls for a whole-person approach

Spinal stenosis is more than a narrow canal on a scan. Symptoms depend on the nerves, the muscles and joints, general fitness and mood, and they do not track closely with imaging.^{[2, 7]}

Care that also addresses movement, muscle tension, pain sensitivity and emotional well-being is therefore a reasonable addition to treatment aimed at the spine.

Aging and joint wear

Stenosis is part of the aging process, and the degenerative process can be slowed down, though not prevented, by exercise, diet and lifestyle.^[2]

Movement and fitness

Exercise is a central part of non-operative care. A review of 13 trials of exercise for neurogenic claudication found that successful programs more often included stretching, strengthening, fitness exercise such as cycling, and psychologically informed approaches.^[8]

Mood and psychological distress

Lumbar spinal stenosis is associated with higher levels of psychological distress, including depression. A systematic review of 23 articles found that depression before surgery was linked with worse disability and symptoms afterward, with moderate-quality evidence.^[7]

Nerve pain and pain sensitivity

Nerve compression can cause neuropathic leg pain that does not always match what scans show.^[2] Laboratory research suggests that acupuncture may affect how the spinal cord and brain process pain signals.^[9]

Acupuncture for Spinal Stenosis

What the research shows

Research suggests acupuncture may modestly reduce pain-related disability in degenerative lumbar spinal stenosis, though effects are small. In a trial at five hospitals in China, 196 people with mainly neurogenic claudication had 18 sessions of real or sham acupuncture over 6 weeks. Disability improved more with real acupuncture, but the difference from sham did not reach the threshold for a clinically important change, and benefits seemed to last up to 24 weeks.^[10]

A trial of 80 people over age 50 compared 24 sessions of acupuncture with a non-insertive sham over 8 weeks. Acupuncture reduced disability and leg and buttock pain more, but the authors said the evidence was insufficient to conclude that it gives clinical benefits over sham.^[11] A smaller pilot trial of 50 people found that adding 12 to 16 sessions of acupuncture to usual care did not significantly improve function at 3 months.^[12]

Reviews agree that the evidence is promising but weak. A 2023 meta-analysis of 37 studies of Chinese non-drug therapies found moderate-quality evidence, from two trials of 128 people, that 6 to 8 weeks of acupuncture beat sham for back pain and lumbar function at 6 months, and low-quality evidence for short-term benefit, with no effect on leg pain.^[13] An earlier review of six trials from China found no conclusive evidence, because of risk of bias.^[14] A 2022 review of non-operative treatments said that most options other than manual therapy with exercise had insufficient quality of evidence to draw conclusions.^[4]

How acupuncture may work

Researchers propose that acupuncture acts through the nervous system. Laboratory studies suggest it can quiet pain-amplifying glial cells in the spinal cord, lower inflammatory molecules and activate the descending pain-control pathways of the brain, which involve endogenous opioids.^[9] These are proposed explanations, mostly from animal research, and have not been shown to relieve nerve compression itself.

What treatment involves

Treatment uses fine, sterile, single-use needles placed in the low back, buttocks, legs and sometimes distant points, usually left in place for about 20 to 40 minutes. The trials gave 12 to 24 sessions over 6 to 8 weeks.^{[10, 11, 12]} We reassess after a short course of visits.

In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[15] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Spinal Stenosis

The Ayurvedic view

Ayurveda has no exact classical equivalent for spinal stenosis. Age-related stiffness, back pain and leg pain on walking are traditionally described in terms of Vata, the principle said to govern movement and said to increase in later life, with the back conditions often grouped under Kati Graha or Gridhrasi. These are traditional categories for choosing care, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine intended to calm Vata, such as warm, regular meals and steady sleep hours
• Warm oil massage and local heat over the low back and legs
• Gentle movement and stretching suited to your condition
• Herbs traditionally used for joint and nerve complaints, prescribed individually by a qualified practitioner
• Basti, a medicated enema therapy from Panchakarma, only where traditionally appropriate

Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty, or before red-flag symptoms have been medically assessed. Because spinal stenosis is mainly a condition of older adults, many people are not suitable candidates for the more intensive Panchakarma therapies.

What the research shows

We found no clinical trials of Ayurvedic treatment for spinal stenosis, so the evidence is none. Any benefit is unproven. What the literature supports is general: exercise, diet and lifestyle may slow degenerative change in the spine, which is consistent with the lifestyle part of Ayurvedic care but is not evidence for Ayurvedic treatments.^[2]

Ayurvedic products also vary in quality: about one fifth of those bought online in one study contained detectable lead, mercury or arsenic.^[16]

Herbal medicine for Spinal Stenosis

Herbs and formulas that have been studied

Herbal research specific to spinal stenosis is sparse. Chinese herbal medicine appears as one of the treatments compared in a network meta-analysis of conservative care for lumbar spinal stenosis.^[17] Research on herbal products for non-specific low back pain includes capsicum (cayenne) cream or plaster, devil's claw and white willow bark.^[18]

What the research shows

The evidence for spinal stenosis is limited. A network meta-analysis of 12 randomized trials (1,194 patients) of conservative treatments found that traditional Chinese medicine and physiotherapy had a better effect on pain scores, and that traditional Chinese medicine and limaprost (a prescription drug) were associated with better improvement on the Japanese Orthopaedic Association score than other treatments. The authors concluded that limaprost may have the best efficacy overall. The abstract does not name specific formulas or herbs or say how well the trials were conducted.^[17]

A Cochrane review of 14 trials in non-specific low back pain, not spinal stenosis, found moderate-quality evidence that capsicum cream or plaster reduces chronic pain more than placebo, and low to moderate-quality evidence for short-term pain relief with devil's claw and white willow bark.^[18] Whether this carries over to stenosis is not known.

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. Case reports describe serious bleeding or clotting problems when warfarin was combined with herbs including dang gui (Angelica sinensis), dan shen (Salvia miltiorrhiza), ginger, ginseng and Boswellia.^[19] Older adults often take blood thinners, blood pressure and diabetes medicines, so a practitioner's review of every medicine and supplement is needed before any herb is used.

Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, have liver or kidney disease, or have surgery planned.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine describes pain on walking and numbness in the legs in older adults as blocked flow of qi and blood together with weakness of the kidney and the lower back. Researchers studying acupuncture measure things that loosely parallel this picture: local tissue response, muscle tension, inflammatory signaling and the way the nervous system amplifies pain.^[9]

Ayurveda's aggravated Vata describes dry, stiff, painful joints with limited movement. No study has shown that a dosha corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for spinal stenosis is complementary. Keep your physician, physical therapist or spine specialist, and do not stop or change prescribed medicines, injections or exercise programs without your prescriber. We do not diagnose spinal stenosis, so new or worsening leg symptoms should be medically evaluated, and decisions about surgery belong with you and your surgeon.

Please bring your diagnosis, any MRI or CT reports, a full list of medicines and supplements, and details of any injections or surgery, planned or past. We ask that you are under a physician's care for this condition and that your treating team knows you are receiving complementary care.

When to seek urgent medical care

Some symptoms point to severe nerve compression, such as cauda equina syndrome, or another serious cause, and need prompt evaluation.^[2]

• New trouble passing urine or loss of bladder or bowel control
• Numbness in the groin, genitals or inner thighs (the "saddle" area)
• Leg weakness that is new or getting worse, such as a foot that drags
• Severe pain, numbness or weakness in both legs
• Back pain with fever, unexplained weight loss or a history of cancer
• Symptoms that begin after a fall or accident

If any of these occur, call 911 or go to the nearest emergency department.