Spinal injection into the epidural space Treatment options for aim to cure the underlying cause of the condition, such as lumbar spinal stenosis (LSS) or other degenerative spinal diseases. Decreased walking and lower body motor ability due to is the primary disabling feature of LSS. Constant discomfort and pain in the lower extremities and an inability to sleep lying down are also disabling features of that affect a patient's quality of life. Therefore, the target of most treatments is to solve these complications. Currently, several treatment options are available to patients, and they can be grouped broadly into nonsurgical and surgical options. Nonsurgical treatments include medications, physical therapy, and spinal injections. Medication options for<unk>  have included non-steroidal anti-inflammatory drugs (NSAIDs), prostaglandin-based drugs, gabapentin, and methylcobalamin. However, the quality of evidence supporting their use is not high enough for specific recommendations. Physical therapy is commonly prescribed to patients, but the quality of evidence supporting its use for<unk>  is also low. One quarter of all epidural injections are administered to treat symptoms of . Preparations may contain lidocaine and/or steroids. They may be considered for short-term pain relief or to delay surgery, but their benefit is considered small. Physical Therapy Patients that experience light to mild symptoms are commonly treated through physical therapy, which involves stretching and strengthening the lower back, abdominal (core) and leg muscles. Common stretches used include the knee to chest stretch, posterior pelvic tilt, neural stretching of the legs, hip-flexor stretch and lower trunk rotation. In conjunction with these stretches, various strengthening exercises are often implemented, targeting the core, lower back and hip muscles. Common exercises include bridges, bird to dog, tabletop leg press, clamshell and knees to chest. Depending on the age, mobility and physical health of patients, a combination of easier and more difficult exercises should be prescribed to suit the patient's needs. More difficult exercises may include the incorporation of resistance training (weights), gym equipment and more explosive movements. Other exercises such as cycling (stationary), swimming and water-based activities have also been found to strengthen and improve overall stability and strength in the core, lower back and hips. Ultimately, the aim of physical therapy is to loosen and relax the tight muscles and ligaments that contribute to the symptoms, and to strengthen those muscles to prevent further reocurrences of the condition. However, studies have found conflicting conclusions in regards to the effectiveness of physical therapy as a treatment option for patients. Thus, the low quality of evidence supporting its use has prompted further research into physical therapy as a treatment option for to be necessary. Stretching Exercises Common stretching exercises used to relieve pain and treat include: * Knee to chest stretch - Laying down on the back, bring one leg up and pull it towards the chest and hold for 30–45 seconds. * Posterior pelvic tilt (bridges) - Laying on the back, bend both legs and place your feet on the floor. Raise stomach from the ground, lifting the back and pelvis, until the back is straight. Hold for 5–10 seconds and relax. * Neural Stretching of the legs - Laying on the back, bring one leg up with a stretching band until a stretch is felt in the legs. Ensure your legs are straight. Once the stretch is felt, hold for 30–45 seconds and relax. * Hip-flexor stretch - To stretch the right hip-flexor, bring the left leg forward, and kneel on the right knee. Push the pelvis forward (lean forward), whilst keeping the upper body straight. Hold the position for 30–45 seconds and relax. To stretch the left hip-flexor, bring swap the positions of the legs. * Lower trunk rotation - Laying down on the back, bring both knees towards your chest whilst keeping the back flat on the floor. Rotate the bent legs from the left to right side and vice versa whilst keeping back flat on the ground. Strengthening Exercises Common strengthening exercises used to treat and prevent future reocurrences of include: * Posterior pelvic tilt (bridges) - Laying on the back, bend both legs and place your feet on the floor. Raise stomach from the ground, lifting the back and pelvis, until the back is straight. Hold for 5–10 seconds and relax. * Quadruped opposite arm/leg (bird to dog) - On all fours (knees on ground and arms against floor supporting upper body) straighten one knee whilst straightening the opposite side arm and hold for 3 seconds and repeat for the other arm/leg pair. * Tabletop leg press press - Laying on the back, bring both knees towards the chest and then straighten both legs (such that legs are hanging in the air), whilst keeping the back flat on the ground. * Clamshell - Whilst laying on the side with knees bent inwards, bring the top knee up (whilst keeping leg bent) and hold for 3 seconds. To exercise the opposite leg, lay on the opposite side and repeat. * Abdominal draw-in (knee to chest ) - Laying flat on the back, bend both legs and bring knees towards the chest without lifting the back from the ground and then straighten legs again. For a more difficult version of the exercise, keep one leg bent and feet on the ground and bring the other leg towards the chest. Medications Medications such as NSAIDs, prostaglandin-based drugs, gabapentin, methylcobalamin and epidural steroid injections are often used in conjunction with physical therapy to treat patients with mild or moderate symptoms of . The main goal of these medications is to reduce pain and provide temporary relief for patients. NSAIDs and prostaglandin-based medications control inflammation at sites of nerve damage or pressure by inhibiting cyclooxygenase activity, and reducing the production of prostaglandins, a key contributor of inflammation. By reducing inflammation, less pressure is put on the nerve roots, decreasing pain, and providing relief for patients. Gabapentin aims to reduce pain and provide relief by altering the normal functioning of neurotransmitters that induce a sensation of pain and discomfort. However, the exact mechanism of Gabapentin’s functioning in the body is not completely understood and current knowledge is based on experimental studies that target the nervous system. Methylcobalamin is another medication that targets the nervous system to reduce pain and provide patients with temporary pain-relief. The drug produces myelin to cover and protect nerves from damage, preventing pain induced from damaged nerve roots, as described in some cases of . Epidural steroid injections are the main epidural injections prescribed to treat . They inhibit the inflammatory cascade signalling to reduce inflammation at sites of spinal nerve damage or pressure. Consequently, they reduce pain and provide relief to individuals with . Whilst the use of medications is common among patients that experience frequent or constant pain, their effectiveness has yielded mixed results in studies. Further research into their viability as a medication for is necessary to allow doctors to provide better care and treatment options for patients. Surgical Interventions Depending on the cause and severity of the condition, surgical options for vary. Symptoms of , including , are the most common reason patients 65 and older undergo spinal surgery. Surgery is generally reserved for patients whose symptoms do not improve with nonsurgical treatments, and the main objective of surgery is to relieve pressure on the spinal nerve roots and recover normal mobility and quality of life. Lower Spinal Decompression is considered the mainstay of surgical treatment. In this procedure, the ligamentum flavum is first removed, followed by the removal of the superior facet osteophyte in the spinal canal, and then the decompression of the spinal nerve root. Another surgical method of decompression is the Fenestration method, which involves creating a small window in the spinal canal and then decompressing the nerves. Alternative surgical options include the use of interspinous process spacers, minimally invasive lumbar decompression (MILD) procedure, laminectomy, microdiscectomy and placement of a spinal cord stimulator. The MILD procedure aims to relieve spinal cord compression by percutaneous removal of portions of the ligamentum flavum and lamina. Laminectomy also involves partial or complete removal and sacrifice of the lamina, but in addition, facets in one or more segments of the spinal cord are usually sacrificed as well. Microdiscectomy is another surgical alternative which uses small incisions, and a miniature camera for viewing, to enter the spinal cord and release pressure on the nerve roots. Laminoplasty and spinal fusion surgeries are other alternative surgical procedures that can be performed. However, they are relatively new methods which still require more research and advancements in order for it to be safely performed with minimal risks. The use of interspinous spacers is associated with increased costs and rates of reoperation, while evidence comparing effectiveness of the MILD procedure to spinal decompression is insufficient. The effectiveness of laminectomy, microdiscectomy, laminoplasty and spinal fusion surgeries as an alternative to spinal decompression has also been heavily debated, with studies showing conflicting results. While studies show that surgery improves walking ability, minimizes constant pain and improves quality of life, comparisons between
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