SPINE Volume 34, Number 10, pp 985–989 ©2009, Lippincott Williams & Wilkins Effectiveness of Physical Therapy and Epidural Steroid Injections in Lumbar Spinal Stenosis Zarife Koc, MD, Suheda Ozcakir, MD, Koncuy Sivrioglu, MD, Alp Gurbet, MD, and Selcuk Kucukoglu, MD Study Design. Randomized single-blind controlled trial. Objective. We aimed to compare the effects of epidural steroid injections and physical therapy program on pain and function in patients with lumbar spinal stenosis (LSS). Summary of Background Data. LSS is one of the most common degenerative spinal disorders among elderly population. Initial treatment of this disabling painful con- dition is usually conservative including analgesics, non- steroidal anti-inflammatory drugs, exercise, physical ther- apy, or epidural steroid injections. Owing to lack of sufficient data concerning the effectiveness of conserva- tive treatment in LSS, we aimed to compare the effective- ness of epidural steroid injections and physical therapy program in a randomized controlled manner. Methods. A total of 29 patients diagnosed as LSS were randomized into 3 groups. Group 1 (n  10) received an inpatient physical therapy program for 2 weeks, group 2 (n  10) received epidural steroid injections, and group 3 (n  9) served as the controls. All study patients addition- ally received diclofenac and a home-based exercise pro- gram. The patients were evaluated at baseline, 2 weeks, 1 month, 3 months, and 6 months after treatment by finger floor distance, treadmill walk test, sit-to-stand test, weight carrying test, Roland Morris Disability Index, and Notting- ham Health Profile. Results. Both epidural steroid and physical therapy groups have demonstrated significant improvement in pain and functional parameters and no significant differ- ence was noted between the 2 treatment groups. Signif- icant improvements were also noted in the control group. Pain and functional assessment scores (RMDI, NHP phys- ical activity subscore) were significantly more improved in group 2 compared with controls at the second week. Conclusion. Epidural steroid injections and physical therapy both seem to be effective in LSS patients up to 6 months of follow-up. Key words: epidural steroid injection, lumbar spinal stenosis, physical therapy. Spine 2009;34:985–989 Lumbar spinal stenosis (LSS) is one of the most common degenerative spinal disorders among the elderly popula- tion. Degenerative changes like facet joint and ligamen- tum flavum hypertrophy, disc degeneration, spondylolis- thesis, and scoliosis are common factors contributing to LSS. Symptom onset is usually after the fifth decade, major symptom being neurogenic claudication. Irrita- tion or ischemia of cauda equina or spinal nerves due to stenosis plays a role in the pathogenesis of this symptom. Other symptoms associated with stenosis are low back pain and lower limb complaints like pain, numbness, and weakness. 1 Symptoms vary with postural changes, as ex- tension causes a decrease in foraminal dimensions, whereas flexion has the opposite effects. 2 LSS is usually diagnosed with patient history and clin- ical findings, while imaging can provide additional infor- mation on the severity and level of stenosis. Magnetic resonance imaging (MRI) is useful for the assessment of the severity of stenosis via enabling spinal canal diameter measurements. Initial treatment of LSS should focus on patient edu- cation, pain control, exercise, and physical therapy to maintain or improve activities of daily living. Surgical treatment may also be considered in patients who do not improve with conservative care. 3 Since the introduction of epidural injections for the treat- ment of patients with sciatica and related spinal diseases in 1930s, 4 the use of epidural steroid injections for spinal ste- nosis has been advocated by some investigators. 5–7 The proposed underlying mechanism of action of epidurally administered steroid and local anesthetic injections is still not well understood. It is believed that the achieved neural blockade alters or interrupts nociceptive input, reflex mechanisms induced by afferent fibers, self- sustaining activity of the neurons, and central neuronal activities. On the other hand, corticosteroids reduce in- flammation via inhibiting pro-inflammatory mediators and causing a reversible local anesthetic effect. 8 Although there are several uncontrolled studies sug- gesting the efficacy of epidural steroid injections, pro- spective, randomized controlled studies are lacking for the treatment of LSS. Therefore, we aimed to compare, in a prospective, randomized controlled fashion, the effects of epidural steroid injections and a conservative inpa- tient physical therapy program on pain and function in patients with LSS. Materials and Methods A total of 33 patients who were diagnosed as LSS by medical history, physical and neurologic examination, as well as MRI findings and who gave informed consent were included in this study. Patients with the history of coronary artery disease, pe- ripheral artery disease, spinal surgery, recent vertebral fracture, progressive neurologic deficit, or cauda equina syndrome were From the Department of Physical Medicine and Rehabilitation, Uludag University School of Medicine, Bursa, Turkey. Acknowledgment date: September 2, 2008. First revision date: Novem- ber 10, 2008. Acceptance date: November 10, 2008. The device(s)/drug(s) is/are FDA-approved or approved by correspond- ing national agency for this indication. No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Suheda Ozcakir, MD, Department of Physical Medicine and Rehabilitation, Uludag Univer- sity School of Medicine, 16059 Gorukle, Bursa, Turkey; E-mail: suheda@uludag.edu.tr 985