Surgery of Conservative Pain Management Treatment for Symptomatic Lumbar Spinal Stenosis?

spinal stenosis

In America, the most common reason for spine surgery in individuals over the age of 65 is lumbar spinal stenosis. What is it? Spinal stenosis represents a narrowing of the area available for the dural sac (spinal cord remnant) and the nerve roots emanating from it. Typically, there is plenty of room for both the dural sac along with the bilateral nerve roots coming out at every level of the spine. There is actually enough room for these to be bathed in cerebrospinal fluid and be comfortable.

As people age, arthritis sets in. Along with that arthritis in the spine, there can be an overgrowth of both the bone along with the soft tissues of the spine due to this. This overgrowth may start to impinge on the amount of space available for the dural sac and the nerve roots. If severe enough, pinching can occur, and patients may start to experience, back, buttock, and/or leg pain. This becomes a mechanical problem. Fortunately, most patients who have spinal stenosis do not have debilitating painful symptoms as a result.

Symptoms may result when the overgrowth causes reduced blood flow or nerve root excitement from inflammation. This can be in numerous anatomic areas. Symptoms are variable between patients depending on the area of pinching and the particular individual's reaction. Regardless of all this, it is the most common reason for surgery in people over the age of 65.

What if pain exists, should surgery be done? This question has been debated for decades since spinal stenosis really is a quality of life condition. It doesn't kill anyone, and the severity of symptoms should guide treatment. If the symptoms do not improve despite nonoperative pain management for 3 to 6 months, a decompressive surgery may be considered. Some evidence has shown limited effectiveness overall for this surgery.

A recent review in Spine looked at over 10 high quality studies to determine the effectiveness of decompressive surgery for stenosis. The results overall showed that in patients who had failed conservative treatment for 3 to 6 months, surgery improved function, pain, and quality of life more than conservative measures. It did not, however, statistically improve walking ability.

These benefits were noted to decrease over time but not go away completely, even up to 10 years. Over ten year results were not established. These results were in place regardless of advancing age, obesity, lung issues, several levels, or other medical problems. Concomitant medical problems do increase the risks of complications, so they should be weighed against the benefits in deciding whether to have the surgery or not.

The results were similar among all the studies evaluated whether or not the patients had spondylolisthesis, which is one vertebra having slipped on another. The overriding factor is that it is a quality of life decision, and considerable conservative treatment should be attempted first.

The risks of surgery cannot be ignored in the patient population over the age of 65. At that point of failed conservative treatment, however, multiple studies now support the decision for a simple decompression procedure (laminectomy).