Lumbar Spinal Stenosis: Pathophysiology, Biomechanics, and Innovations in Diagnosis and Management

Abstract

Lumbar spinal stenosis (LSS) is a common condition caused by the narrowing of the spinal canal, resulting in compression of neural and vascular structures. This compression leads to symptoms such as claudication, paresthesia, and lower extremity weakness. LSS is the leading cause of low back pain and functional limitations, affecting over 103 million people worldwide. Degenerative changes, including ligamentum flavum hypertrophy, facet joint osteoarthritis, and intervertebral disc degeneration, are the primary contributors to LSS. Additional factors, such as genetic predisposition, congenital abnormalities, and autoimmune conditions, are also emerging as contributors. A major challenge in managing LSS lies in differentiating it from other causes of neurogenic symptoms and low back pain while devising an appropriate treatment plan from the wide array of conservative and surgical options available. Minimally invasive surgical techniques, such as lumbar spinous process-splitting laminoplasty and partial facetectomy, are often compared to the gold standard laminectomy with or without fusion. Surgical interventions offer significant improvements in pain relief, disability, and quality of life within 3-6 months; however, these benefits often diminish after 2-4 years. Contrasting evidence demonstrates that long-term outcomes of non-surgical treatments, such as physical therapy, pharmacological management, and lifestyle modifications, are often comparable to surgical modalities. Emerging therapies, including interspinous devices and stem cell therapy, show promise but require further research. Managing LSS requires a multidisciplinary approach tailored to patient-specific factors, including age, comorbidities, and functional goals. Future research should aim to improve diagnostic accuracy, refine surgical techniques, and explore innovative therapies to enhance outcomes for patients with LSS.

Keywords: Conservative Treatment; Degenerative Changes; Interspinous Devices; Laminectomy; Laminoplasty; Ligamentum Flavum Hypertrophy; Lumbar Spinal Stenosis; Lumbar spinous process-splitting laminoplasty; Minimally Invasive Surgery; Neurogenic Claudication; Spinal Biomechanics; Stem Cell Therapy.

Figure 1:

Angiopoietin-like Protein 2 (Angptl-2) induces IL-6-mediated fibroblast activation, leading to ligamentum flavum hypertrophy and spinal canal narrowing, contributing to neurogenic claudication and postural adaptation.

Figure 2:

Pelvic tilt comparison: Abnormal anterior tilt (>20°) in lumbar spinal stenosis causes pain and posture issues, unlike proper alignment in healthy individuals.

Figure 3:

Conservative Management Options for lumbar spinal stenosis (LSS). PRP, platelet rich plasma.

Figure 4:

Surgical Management Options for lumbar spinal stenosis (LSS).