241- Relieving Spinal Stenosis Without Surgery

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Langmaid. And on today's episode we are deep into the research. We are talking all about lumbar Spinal stenosis and specifically a paper that came out just last year in 2019 titled Clinical Outcomes in Neurogenic Claudication using a Multimodal Program for Lumbar Spinal Stenosis. This is clinically applicable, it's interesting, it's a topic we see each and every day in practice and something that can make a huge impact by having this knowledge on the quality of life of patients that are struggling with with neurogenic claudication and or spinal stenosis. We'll get into it and more in just a few moments. If you have not left a rating or review, I'm gonna ask you to please do so. If you're listening on an iPhone, you can scroll down, tap how many stars you think we earn or deserve and let help us enable our other docs more docs to know about what we're doing on this podcast. If you've been getting value out of it, if you're a listener, thank you, thank you for tuning in, thank you for listening, thank you for paying attention. And I'm just gonna have one ask of you and that is to please give us a rating or a review. It helps more and more docs find out about this podcast. So let's dive into the research on today's episode. As I said at the top, this study came out in 2019 in JMPT and it is titled Clinical Outcomes in Neurogenic Claudication Using a Multimodal Program for Lumbar Spinal Stenosis. I'm gonna drop a link to this paper in the show notes so you can access it on PubMed if you'd like. But let's break it down. Let's talk about the results and let's talk about how this can impact quality life of patients in your practice. This was released actually just this month, July 2020 as our research brief for all members of the evidence based chiropractor. So they are getting this out to those MDs, those DOs, those other healthcare providers in their community to help further bridge the gap and build those relationships to. It's just one of those studies that is a home run. It can help bridge the Gap and build relationships, get more referrals into your practice. Other docs need to know what goes on in your practice to be able to identify what patients to refer. And this is one of those great studies. So we know neurogenic claudication affects millions of people each and every year. It is a big deal. Neurogenic claudication, ultimately are the symptoms associated with lumbar spinal stenosis. Lumbar. Lumbar spinal stenosis. Narrowing of the spinal canal by disc, bone or ligament, predominantly causing a pinch, a crunch, or a slowing down of the pipes, as we might say. And that results in neurogenic claudication. Neurogenic claudication. We're talking leg pain, numbness, tingling and weakness. That's exacerbated by walking and also relieved by sitting. So these are those individuals, I used to see this all, all the time in the orthopedic group. Individually, I say, can you walk farther if you have a shopping cart in front of you? Oh, man, I can go around the whole store if I have a shopping cart. I bet you if I take that shopping cart away, you'd be looking for a chair very quickly. Yeah, that's for sure. That is Lumbar spinal stenosis and neurogenic claudication. When the patient sits down, pretty much almost like, bang, instant relief. But when they stand up, when there's compression, when there's loads of, pretty much instantly they are looking for the next opportunity to sit down. So it's exacerbated by walking, relieved by sitting. And here's the really interesting part. I had no idea. They actually estimate this creates more significant functional limitations than congestive heart failure or even copd, which is pretty wild to think about. The inability to walk leads to a substantial decline in health and an increase in mortality over time. This is just a bad news situation. As somebody slows down, they're more sedentary, they gain weight, other challenges come into play. It is a big deal. Somebody slowed down dramatically. Dramatically due to the effects of neurogenic claudication and lumbar stenosis, really, it can have a supreme impact in their quality of life. So even though this is an interesting part, even though degenerative lumbar spinal stenosis is the most common reason for people above 65 years old to undergo surgery, it's estimated that only 25% of those people who seek surgery end up receiving it. So an overwhelming majority, 75% of people, end up going to the non surgical conservative route. So this is where we're going with this paper. Right. It's where things can get very, very interesting. But this is also. Let's peel that back one more step. This is the number one reason why people above 65 years old have surgery. So is there a market there? Absolutely. Is there an opportunity to help people? Absolutely. Is there an opportunity to help people avoid surgery? And absolutely, all of these things ring true. So I think you're starting to probably understand the importance of being able to communicate this information as cleanly and clearly as possible. So this study found that a multimodal program consisting of self management, education, exercise and manual therapy administered by a chiropractor can provide significant short and long term improvement for people struggling with neurogenic claudication. So let's break down some quotes, let's get into the nitty gritty and talk about how we can apply this in your practice. These researchers found, quote, degenerative lumbar spinal stenosis refers to the anatomical narrowing of the central spinal canal, lateral recess, or intervertebral foramen from age related changes in the lumbar spine. We touched on that at the top. Now, how does that occur? Yes, occasionally there could be a fluid collection. Yes, occasionally there could be a cyst. Yes, occasionally there could be a piece of hardware from a previous surgery. But by and large, we look at three compressive tissues, disc, branch, bone and ligament. Obviously, there's bone spurs, right? Bone spurs can get in the way and cause compression, disc challenges, herniation, extrusion, protrusion, bulge, you name it, and ligament hypertrophy specifically related to ligamentum flavum can create that hard V within the spinal canal, cause compression and all those symptoms associated with neurogenic claudication. Researchers also found, quote, we observed statistically significant and clinically important improvements in all outcomes, overall symptoms, physical function, disability, leg pain while walking that were maintained in the long term with the median duration of 3.6 years. That is incredibly impactful. So we have statistically significant improvements, we have clinically important improvements. This is like holy grail stuff here. And it's across all outcome measures. That's insane. And not only is it long term, or, excuse me, not only is it short term, but also found that these things maintain up to practically close to four years later. Absolutely astounding when we think about hundreds of thousands of people undergoing surgical intervention because of this. And there might be an opportunity for at least a portion, maybe, I think probably a majority to avoid those sort of elective surgeries. Yes, in unbelievably extreme cases where red flag surgery is warranted. But we know that's less than like 5% of the time. That means 95% of the time these people can probably avoid or at least delay surgery. At the bare minimum, I'm gonna go on the hedge and say probably avoid surgery due to natural history. When you combine the natural history of things with conservative care, you start to put yourself in a great situation to avoid surgical intervention. But we'll talk about that more in a moment. Finally, the researchers found in patients with neurogenic claudication due to lumbar stenosis particip in a six week multimodal program, clinically important improvements in pain and disability appear to be maintained over the long term. Right there. Again, a six week program and these things maintain the benefits, maintained for almost four years after a six week program. That is absolutely insane. It's completely powerful. And that's a story that needs to be told. I think way too many people, an overwhelming majority of individuals, have no clue that that's the case. Now, from clinical perspective, I can say I saw this all the time personally in my practice. Flexion distraction was a fantastic technique choice that provided people with pretty much immediate relief. My father is one of those individuals. He has some stenosis, really throughout his spine. You get him on a flexion distraction table and just practically getting him loaded in the position provides him a significant amount of relief sensation in his feet. You know, this can be extremely powerful. Now, the other interesting thing that I want to bring up is to not be fooled by the images. Now, red flags are red flags and clearly if somebody needs a second look, if they need a referral, by all means do so. However, I will say, as somebody who sat with 15 to 20 patients per day over the course of a few year period in a very large surgical and orthopedic group, we saw a lot of lumbar stenosis. And the crazy thing is, is just like with discs on mri, lumbar spinal stenosis can play tricks with you. Meaning I saw people come in with canals narrowed from the ideal is 10 millimeters or above, narrowed to 9 millimeters, that had severe functional limitations. And that's a real thing. And that becomes a challenge. And those people tend to do very, very well conservatively because, hey, they still have a lot of space there, still have 90% of that. So typically, getting segmental motion improved, improving some of the core, strengthening the balance of strength and flexibility, biomechanics made a huge difference, getting rid of the inflammation, et cetera. Now, on the other end of the spectrum, I can say we see people come In. And I've seen, and I've done some MRI reviews that we put up on YouTube where people come in and they have canal room of less than a millimeter and a half. It's practically impossible to see where the nerve roots and the cauda equina are going through or where it's literally completely obliterated. And the patient's, like, walking in with a slightly altered gait, and you're like, what the heck is. How is this even feasible? How are you up and walking? How do you not have cauda equina? How do you not have all these red flags going on? And how do you not have happened four years ago? Because there's absolutely no room. But you have to remember our bodies are dynamic, and they're incredible. And our ability to maintain homeostasis, so to speak, to maintain the functional ability, is absolutely incredible. So when you look at some of these images, it's very, very important, again, to maintain and take and document a very strong case history, really get a great understanding of what's going on with the patient. Secondarily, you're gonna go into your examination, do a thorough exam, get a really great understanding as far as what's going on with this individual. What are the challenges, what signs that they're exhibiting? And keep a close eye, certainly, on those yellow and red flags. And then when you examine the imaging, make sure, number one, that you're comfortable looking at the axial slices. I know every chiropractor on planet Earth, I feel like, puts up the laterals, and they're like, aha. I see exactly what's going on because it looks like an X ray. And then you put on the axial cuts, and it's like, oh, my gosh. I have no idea where to go with this or what I'm even looking at. If that's a challenge for you, head over to the evansbacechiropractor.com, click the shop, and we'll get the MRI Essentials course out to you. That'll give you an hour or two of time, and you will be able to read MRIs 100% or more better than you can today. That's specifically what that short course is designed for, is helping you feel comfortable reading our MRIs in front of your patients. And it stemmed from exactly kind of the story I'm telling right now, which is when I would sit down and look. It was very, very important to understand what's going on in the lateral recess. What's going on with ligamentum flavum, what's going on in terms of any disc or bone spur because it enabled me to approach my care and treatment in the most specific manner possible for that patient. If they had a ligamentum flavum that was 400% hypergrowth on the right side compared to the left side. There's different positioning I can do on a table, different ways I can go about my technique that stack the deck in my favor that give me a great opportunity to help that patient get maximum relief. And right here, when we see six weeks of a multimodal program yielding years of positive, clinically significant and additionally clinically significant and statistically significant, excuse me, findings and improvements, that's powerful. That's something we should all hang our hat on. That's where we can talk with other doctors and bridge the gap that way. That's where we could talk to the public, get on your social media channels, tell the story of how you can help these individuals and why surgery may not be their only option. Because I can tell you, out of those hundreds of thousands of individuals that are having surgery, elective surgeries, mind you, each and every year for lumbar spinal stenosis, an overwhelming majority of those individuals have not sought chiropractic care. And there is a big difference between a multimodal program that includes what they've talked about in this study and just going through a few visits of physical therapy. Not to take anything away from physical therapy whatsoever. But there is a difference. People need to explore both before they go through any surgical intervention, but people also need to be guided. They have no clue. If you're not out there telling the story, if you're not out there bridging the gap and building those relationships with the healthcare providers that will refer into your practice, then you have a lot of people in your community that are going to go through advanced interventions that may not need to. So get out there, tell the story. Be confident of what you do. Be proud of what you do. Know that the research stands behind it. If you want to check out the study, click the episode in the show notes. You'll be able to get right over there. Leave us a rating or review if you haven't yet. Make it a great week in practice and I will talk to you soon.

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