Yonsei Med J.  2013 Jul;54(4):999-1005. 10.3349/ymj.2013.54.4.999.

Conservative and Surgical Treatment Improves Pain and Ankle-Brachial Index in Patients with Lumbar Spinal Stenosis

• Ohtori S
• Yamashita
• Murata Y
• Eguchi Y
• Aoki Y
• Ataka H
• Hirayama J
• Ozawa T
• Morinaga T
• Arai H
• Mimura M
• Kamoda H
• Orita S
• Miyagi M
• Miyashita
• Okamoto Y
• Ishikawa T
• Sameda H
• Kinoshita
• Hanaoka E
• Suzuki M
• Suzuki M
• Aihara T
• Ito T
• Inoue G
• Yamagata M
• Toyone T
• Kubota G
• Sakuma Y
• Oikawa Y
• Inage K
• Sainoh T
• Yamauchi K
• Takahashi
• Chiba Low Back Pain Research Group

• KMID: 2158237
• DOI: http://doi.org/10.3349/ymj.2013.54.4.999

Abstract

PURPOSE
The pathological mechanism of lumbar spinal stenosis is reduced blood flow in nerve roots and degeneration of nerve roots. Exercise and prostaglandin E1 is used for patients with peripheral arterial disease to increase capillary flow around the main artery and improve symptoms; however, the ankle-brachial index (ABI), an estimation of blood flow in the main artery in the leg, does not change after treatment. Lumbar spinal nerve roots contain somatosensory, somatomotor, and unmyelinated autonomic nerves. Improved blood flow by medication with prostaglandin E1 and decompression surgery in these spinal nerve roots may improve the function of nerve fibers innervating muscle, capillary, and main vessels in the lower leg, resulting in an increased ABI. The purpose of the study was to examine whether these treatments can improve ABI.
MATERIALS AND METHODS
One hundred and seven patients who received conservative treatment such as exercise and medication (n=56) or surgical treatment (n=51) were included. Low back pain and leg pain scores, walking distance, and ABI were measured before treatment and after 3 months of conservative treatment alone or surgical treatment followed by conservative treatment.
RESULTS
Low back pain, leg pain, and walking distance significantly improved after both treatments (p<0.05). ABI significantly increased in each group (p<0.05).
CONCLUSION
This is the first investigation of changes in ABI after treatment in patients with lumbar spinal stenosis. Improvement of the spinal nerve roots by medication and decompression surgery may improve the supply of blood flow to the lower leg in patients with lumbar spinal stenosis.

Keyword

Ankle-brachial index; pain; lumbar; spinal stenosis

MeSH Terms

Adult
Aged
Aged, 80 and over
Alprostadil/therapeutic use
*Ankle Brachial Index
Decompression, Surgical/methods
Female
Humans
Low Back Pain/drug therapy/physiopathology/surgery/*therapy
Lumbar Vertebrae/physiopathology/*surgery
Male
Middle Aged
Pain/surgery
Spinal Nerve Roots/physiopathology
Spinal Stenosis/physiopathology/*surgery/*therapy
Treatment Outcome
Alprostadil

Reference

1. Konno S, Yabuki S, Sato K, Olmarker K, Kikuchi S. A model for acute, chronic, and delayed graded compression of the dog cauda equina. Presentation of the gross, microscopic, and vascular anatomy of the dog cauda equina and accuracy in pressure transmission of the compression model. Spine (Phila Pa 1976). 1995; 20:2758–2764.

2. Sekiguchi M, Kikuchi S, Myers RR. Experimental spinal stenosis: relationship between degree of cauda equina compression, neuropathology, and pain. Spine (Phila Pa 1976). 2004; 29:1105–1111.

3. Müller B, Schmidtke M, Witt W. Action of the stable prostacyclin analogue iloprost on microvascular tone and -permeability in the hamster cheek pouch. Prostaglandins Leukot Med. 1987; 29:187–198.

4. Takahashi K, Olmarker K, Holm S, Porter RW, Rydevik B. Double-level cauda equina compression: an experimental study with continuous monitoring of intraneural blood flow in the porcine cauda equina. J Orthop Res. 1993; 11:104–109.

5. Murakami M, Takahashi K, Sekikawa T, Yasuhara K, Yamagata M, Moriya H. Effects of intravenous lipoprostaglandin E1 on neurogenic intermittent claudication. J Spinal Disord. 1997; 10:499–504.

6. Ooi Y, Mita F, Satoh Y. Myeloscopic study on lumbar spinal canal stenosis with special reference to intermittent claudication. Spine (Phila Pa 1976). 1990; 15:544–549.

7. Inoue M, Kitakoji H, Yano T, Ishizaki N, Itoi M, Katsumi Y. Acupuncture Treatment for Low Back Pain and Lower Limb Symptoms-The Relation between Acupuncture or Electroacupuncture Stimulation and Sciatic Nerve Blood Flow. Evid Based Complement Alternat Med. 2008; 5:133–143.

8. Dezawa A, Unno K, Yamane T, Miki H. Changes in the microhemodynamics of nerve root retraction in patients with lumbar spinal canal stenosis. Spine (Phila Pa 1976). 2002; 27:2844–2849.

9. Ferreira AC, Macedo FY. A review of simple, non-invasive means of assessing peripheral arterial disease and implications for medical management. Ann Med. 2010; 42:139–150.

10. Ichihara A, Kaneshiro Y, Takemitsu T, Sakoda M, Itoh H. Benefits of candesartan on arterial and renal damage of non-diabetic hypertensive patients treated with calcium channel blockers. Am J Nephrol. 2006; 26:462–468.

11. Sasamura H, Kitamura Y, Nakamura M, Ryuzaki M, Saruta T. Effects of the angiotensin receptor blocker candesartan on arterial stiffness and markers of extracellular matrix metabolism in patients with essential hypertension. Clin Exp Hypertens. 2006; 28:511–520.

12. Karlsson M, Hildebrand C, Warnborg K. Fibre composition of the ventral roots L7 and S1 in the owl monkey (Aotus trivirgatus). Anat Embryol (Berl). 1991; 184:125–132.

13. Ko HY, Shin YB, Sohn HJ, Chang JH, Ahn YH, Ha YH. Unmyelinated fibers in human spinal ventral roots: C4 to S2. Spinal Cord. 2009; 47:286–289.

14. Konnai Y, Honda T, Sekiguchi Y, Kikuchi S, Sugiura Y. Sensory innervation of the lumbar dura mater passing through the sympathetic trunk in rats. Spine (Phila Pa 1976). 2000; 25:776–782.

15. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007; 45:Suppl S. S5–S67.

16. Swainston Harrison T, Plosker GL. Limaprost. Drugs. 2007; 67:109–118.

17. Matsudaira K, Seichi A, Kunogi J, Yamazaki T, Kobayashi A, Anamizu Y, et al. The efficacy of prostaglandin E1 derivative in patients with lumbar spinal stenosis. Spine (Phila Pa 1976). 2009; 34:115–120.

18. Kovacs FM, Urrútia G, Alarcón JD. Surgery versus conservative treatment for symptomatic lumbar spinal stenosis: a systematic review of randomized controlled trials. Spine (Phila Pa 1976). 2011; 36:E1335–E1351.

19. Beebe HG, Dawson DL, Cutler BS, Herd JA, Strandness DE Jr, Bortey EB, et al. A new pharmacological treatment for intermittent claudication: results of a randomized, multicenter trial. Arch Intern Med. 1999; 159:2041–2050.

20. Strandness DE Jr, Dalman RL, Panian S, Rendell MS, Comp PC, Zhang P, et al. Effect of cilostazol in patients with intermittent claudication: a randomized, double-blind, placebo-controlled study. Vasc Endovascular Surg. 2002; 36:83–91.

21. Mohler ER 3rd, Beebe HG, Salles-Cuhna S, Zimet R, Zhang P, Heckman J, et al. Effects of cilostazol on resting ankle pressures and exercise-induced ischemia in patients with intermittent claudication. Vasc Med. 2001; 6:151–156.

22. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg. 2007; 33:Suppl 1. S1–S75.