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Spinal Stenosis: Surgical versus Nonsurgical Treatment

Atlas, Steven, J*; Delitto, Anthony

Section Editor(s): Moskovich, Ronald MD, Guest Editor; Nordin, Margareta DrSci, Guest Editor

Clinical Orthopaedics and Related Research: February 2006 - Volume 443 - Issue - p 198-207
doi: 10.1097/01.blo.0000198722.70138.96
SECTION I: SYMPOSIUM II: Surgical versus Nonsurgical Management of Spinal Disorders
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Lumbar spinal stenosis is being diagnosed increasingly in older people as advanced imaging studies become more widely available and clinicians become more familiar with the presentation of this common condition. For symptomatic patients, the goal of treatment is pain relief and improved function, but there is little empiric evidence to support many of the common interventions used. The relative risks and benefits of various surgical and nonsurgical treatments are poorly understood, and the result has been wide variations in the evaluation and treatment of spinal stenosis across geographic regions. Current practice recommendations are based on expert opinion that incorporates available evidence into existing clinical and biologic paradigms. For most individuals, initial treatment should focus on patient education, medications to control pain, and exercise and physical treatments to regain or maintain activities of daily living. Surgical treatment most commonly is considered in patients not improving with nonsurgical care. Decompressive laminectomy is the standard surgical procedure for patients with spinal stenosis. The addition of fusion with or without instrumentation is considered when spinal stenosis is accompanied by degenerative spondylolisthesis or related to concerns about instability. We review the available evidence for nonsurgical and surgical interventions, and highlight comparative results wherever applicable.

Level of Evidence: Level V (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.

From the *General Medicine Division and the Clinical Epidemiology Unit, Medical Services, Massachusetts General Hospital, Harvard Medical School, Boston, MA and the †Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA.

One of the authors (SA) is supported by funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (P60 AR048094); another author (AD) supported by funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01-AR/NS45622). Correspondence to: Steven J. Atlas, MD, General Medicine Division, Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114; Phone: 617-724-4736; Fax: 617-724-3544; E-mail: satlas@partners.org.

One of the first descriptions of patients who walked bent forward with back or lower extremity pain indicative of spinal stenosis was at the start of the last century by Sachs and Frankel.69 Anatomically, spinal stenosis refers to narrowing of the central spinal canal or intervertebral foramen at single or multiple levels that can compress communicating nerves and other adjacent structures.7 The etiology of central canal or intervertebral foraminal narrowing can include one or more of the following: the intrinsic shape of the canal, degenerative changes that decrease the canal size, or movement of one anatomic segment in relation to another. Symptoms of spinal stenosis (in this review we use spinal stenosis to refer to lumbar spinal stenosis) include lower-back pain as well as unilateral or bilateral groin and leg pain, numbness, or weakness. Neurogenic claudication, defined as pain, paresthesias, and cramping of one or both lower extremities due to neurologic compromise brought on by standing or walking and relieved by sitting,60,84 is the most specific symptom of spinal stenosis, although not all patients report it.

Advances in imaging technology have led to a marked increase in the diagnosis of spinal stenosis.46,53 Among individuals eligible for Medicare, spinal stenosis is now the most common diagnosis among those having lumbar spine surgery.16 Despite the common nature of the condition and the widespread acceptance in clinical practice of various surgical and nonsurgical interventions for individuals with symptomatic spinal stenosis, there is limited evidence to support many of them, especially in terms of their relative benefit and risk compared with other options. After briefly reviewing the etiology and pathophysiology of spinal stenosis, this review will focus on current treatment options for patients with spinal stenosis-specifically the evidence supporting existing surgical and nonsurgical treatments and their relative benefits in reducing pain and functional impairment. Cochrane reviews of surgical treatments for spinal stenosis conclude that there is still insufficient evidence to support surgical compared with nonsurgical treatments.29,30 Fortunately, ongoing trials likely will help patients and physicians better compare various outcomes of established surgical and nonsurgical treatments.8,15,54

The increasing number of systematic reviews of various treatments for lower-back pain disorders has helped to foster renewed interest in clinical outcome trials for patients with this common complaint. For individuals with symptomatic spinal stenosis, still there is little evidence to guide clinical practice. Most systematic reviews of spinal stenosis treatments have not included quantitative analyses because of few randomized trials, heterogeneous patient populations, and outcome measures that were not validated.29,81 There are reviews in which many of the nonsurgical treatments used for patients with lower-back pain have been studied,82 but most involve nonspecific lower-back pain, again with no specific focus on evaluating patients with spinal stenosis. Because of these limitations with the existing literature, in our review we will focus on incorporating findings from available studies into existing clinical and biologic paradigms in order to provide a rational basis for treatment recommendations. After reviewing specific treatment options, we will discuss the implications of widespread variations in the management of spinal stenosis across geographic regions-likely related to treatment patterns reflecting physician preferences rather than evidence-based science. Although results from randomized trials and systematic reviews have been emphasized, other recommendations need to come from nonrandomized studies and case series because of the lack of comparative trials. Therefore, our discussion should be taken as more interpretive than definitive in nature.

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Etiology And Pathophysiology

Spinal stenosis is classified as either primary (eg, congenital) or secondary. Primary stenosis is very uncommon and involves spinal canal narrowing caused by a congenital abnormality or a disorder in postnatal development.13 Secondary stenosis is the most frequent form and usually results from degenerative changes.13,28 As such, it is most common in adults starting in the fifth and sixth decades of life.13,51 Secondary stenosis also may occur after surgery (eg, when there is inadequate decompression, excessive scar tissue or proliferation of bone), as a result of infection, or after a trauma (eg, fracture).

Broadly, lumbosacral spondylosis includes several distinct degenerative processes involving the facet joints, intervertebral discs, and intraspinal soft tissues.47 Hypertrophy of the ligamentum flavum and facet joints leads to narrowing of the lateral recess or nerve root foramen. Aging is associated with loss of disc height, which also narrows the foramen vertically and if pronounced can allow buckling of the ligamentum flavum into the spinal canal.71 Facet joint hypertrophy and hypertrophic changes in the soft tissues, osteophytes, or disk bulging can all result in narrowing of the spinal canal, creating the trefoil-shaped narrowing of the canal referred to as spinal stenosis. Facet degeneration can be associated with anterior spondylolisthesis that usually affects L4 on L5 and contributes to narrowing of the foramina.49

Neurogenic claudication may result from mechanical irritation of the cauda equina or from exercise-induced ischemia of the cauda equina caused by narrowing of small intraneural arterial branches and venous congestion.67 In patients with spinal stenosis, spine extension results in marked decreases in the anteroposterior diameter of the dural sac.77 Penning and Wilmink58 found narrowing of the spinal canal in extension and widening of the canal with relief of nerve root involvement in flexion.

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Treatment

The impact of back, groin, or leg pain and numbness caused by spinal stenosis can vary widely among individuals and can be a key factor in deciding which treatment to have and when to have it. The goals of treatment are to relieve pain and to maintain and/or improve usual activities. These outcomes correlate better with patient satisfaction than more objective measures such as walking distance.89 For some people, nonsurgical interventions treat symptoms well. For others, pain may make it impossible to do their usual daily activities, socialize, or participate in family or work life. For such individuals, surgical treatment is reasonable to consider.

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Nonsurgical Treatment

In 1987, the Quebec Task Force on Spinal Disorders reviewed the available literature on the treatment of spinal conditions, including spinal stenosis.78 The Task Force recognized that no evidence exists from randomized clinical trials for any nonsurgical approach to the treatment of spinal stenosis. The Task Force could only recommend nonsurgical treatment of patients with spinal stenosis based on practice patterns and empirical evidence, noting that orthoses, activity modification, pelvic traction, and exercises were commonly used. After almost 20 years, little has changed and most nonsurgical treatment recommendations are based on expert opinion rather than empirical evidence. In the absence of such studies, determining the relative merits of various nonsurgical treatment options for spinal stenosis is difficult, and one must rely instead on the biologic plausibility of the various approaches, where a clinician must rely on what is known about underlying mechanisms of spinal stenosis from basic and experimental studies (eg, biomechanical, anatomic) in order to formulate a treatment that on the surface appears sensible.

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Medications

A variety of oral medications are available over-the-counter and by prescription to control pain in patients with spinal stenosis (Table 1). Although there are many randomized studies of various medications for lower-back disorders, few have focused on older individuals and patients with spinal stenosis.83 Nonsteroidal anti-inflammatory drugs (NSAIDS) have anti-inflammatory and pain relief properties that make them attractive for treatment of low back disorders including spinal stenosis, but are equally efficacious compared to acetaminophen which only provides pain relief.83 There is no evidence that one nonsteroidal agent is more effective for lower-back pain than another, but cyclo-oxygenase (COX)-2 selective agents had been recommended in older individuals because of fewer serious gastrointestinal side effects. However, recent evidence of increased cardiovascular risk especially with long-term use in higher-risk individuals makes these agents unattractive in patients with spinal stenosis.62 Because nonsteroidal agents may be less effective for patients with radicular pain and their efficacy in those with chronic pain is uncertain, it is reasonable to use nonselective nonsteroidal agents for acute pain for those with spinal stenosis, but longer-term use and their relative efficacy compared with other treatments is uncertain.

TABLE 1

TABLE 1

For pain inadequately controlled with acetaminophen or nonsteroidal agents, opioids and muscle relaxants are commonly prescribed for lower-back pain even though they have not been shown to be more effective than acetaminophen and nonsteroidal anti-inflammatory drugs in well-controlled studies.83 Given the underlying degenerative process thought to be associated with the development of symptomatic spinal stenosis, the use of muscle relaxants (such as diazepam or cyclobenzaprine) in spinal stenosis makes less inherent sense, although there is no evidence arguing that the relative risks and benefits favor other agents. For patients without severe pain, muscle relaxants and narcotics offer few advantages and have more side effects.17 Narcotics may be helpful when used for short periods on a regular basis in individuals with severe pain including radicular pain associated with spinal stenosis that is not controlled with nonsteroidal agents or acetaminophen. For patients with persistent symptoms, short-acting and long-acting opioids often are used despite very limited evidence of efficacy. Few authors have compared the risks and benefits of opioids with other medications when used on a continuous basis for a longer period of time, especially in older individuals who may be at greater risk for side effects.39,66 Therefore, despite their common use, the role of long-term opioid use in spinal stenosis remains unclear.

Other oral medications including corticosteroids and antidepressants are prescribed for patients with lower-back pain, especially those with radicular symptoms including spinal stenosis. Corticosteroids have anti-inflammatory properties and antidepressants act on central nervous system receptors that may be involved in chronic pain syndromes.20,55 However, evidence supporting their use is lacking. Because systemic steroids have unproven benefit but considerable side effects when used for prolonged periods, especially in older women, they should be used only with caution. Antidepressant therapy is appropriate for patients with depressive symptoms that accompany chronic pain, but its value for patients who are not depressed is unproven.17 When used, antidepressants with serotonergic-noradrenergic agents such as tricyclic antidepressants have more consistent antinocioceptive effects than serotonergic-only agents.20 Finally, a randomized study of nasal calcitonin was ineffective compared with a placebo for patients with spinal stenosis.59 This study represents what will hopefully be an increased number of high-quality controlled trials of treatments for this disorder.

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Activity, Exercise, and Physical Interventions

Although nonsurgical interventions almost are recommended universally for the initial treatment of people with spinal stenosis, the literature is vague when it comes to specifics. Non-descriptive terms such as “therapeutic,” postural," and “strengthening,” are used to refer to exercise treatments. Like other interventions for spinal stenosis, studies of nonsurgical physical interventions are fraught with flaws in methodology including lack of randomization or controls, small sample size, inadequate follow-up, and outcome assessments that have not been validated.

Aerobic conditioning is considered a well-validated treatment for chronic lower-back pain. However, there are few reports in the literature regarding the effectiveness of aerobic exercises in people with spinal stenosis. Iversen et al38 reported positive results of a bicycle-based aerobic conditioning program in a study of older individuals, but only 15% had definitive spinal stenosis and concomitant neurogenic claudication.

Postural education using flexion-oriented exercise regimens is based mainly on spinal canal and neuroforaminal opening associated with spinal flexion.25,57,74 Although a flexion approach is widely accepted, it is not known if such an approach results in better outcomes than other postures. Simotas et al75 report on a case series of 49 patients treated nonoperatively for spinal stenosis. In addition to pharmacologic intervention that may have included oral analgesics and epidural steroids, the intervention consisted of therapeutic exercise (postural instruction, lumbopelvic mobilization exercises, and a flexion-based exercise program). After three years, nine of 49 patients (18%) had surgical intervention. Five patients (10%) reported their condition to be worse, and the remaining 35 patients (71%) either reported no deterioration in their condition or reported improvement (slight or sustained).

In addition to spinal extension postures, compressive loading also has been determined to decrease neuroforaminal cross-sectional area, providing a basis for physical approaches that unload the spine.58,88 In a case series by Fritz et al,23 a general exercise regimen combined with bodyweight support treadmill training was assessed. Although the results of this report are positive, the sample was small and the case-series nature did not offer any control, so the results must be interpreted cautiously. Authors of a more recent report comparing this program to a “watchful waiting” approach provide a more optimistic picture of the effectiveness of this program, at least in the short term.87 Traction and water-based therapies offer additional alternative strategies that use unloading as the biologic basis for treatment. Although sometimes considered, the results of either traction or water-based therapies for people with spinal stenosis have not been reported in the literature. The short-term effect, if any, of decompression through traction or body weight support must also be studied with regard to its long-term effectiveness.

Specific muscular and biomechanical impairments have been identified in people with spinal stenosis, including paraspinal muscle denervation52 and trunk extensor muscle function.44 Such findings suggest that nonsurgical physical interventions should include exercises specifically directed toward the spinal extensor muscle group. There have been no reports in the literature of exercise regimens that have targeted the spinal extensor muscle group in those with spinal stenosis.

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Other Considerations

In addition to addressing methodological shortfalls of the existing literature, future studies of nonsurgical treatments for spinal stenosis should address what is currently being done with little supporting evidence as well as translating well-established general principles associated with other lower-back conditions. With regard to the former, complimentary and alternative therapies commonly are used for lower-back pain including older individuals with spinal stenosis.80 However, there is no evidence in the literature supporting the effectiveness of interventions such as acupuncture and spinal manipulation.3,27

General principles identified in other lower-back conditions that may apply to spinal stenosis include the importance of psychosocial factors on outcomes of care.32 Psychosocial factors are key predictors of chronicity in patients with acute lower-back pain,45 and treatments focused on these psychologic factors have been associated with improved outcomes in patients with chronic low back pain.41 In addition, approaching a heterogeneous condition like spinal stenosis with a one-size-fits-all mentality contradicts consensus opinion that treatment effects may be specific to patient subgroups.9 There is some evidence that such patient subgroups exist in spinal stenosis based on physical findings.10,24,90 Future interventions may examine response in an overall population with predefined subgroups based on objective findings (eg, degree of spinal stenosis), physical impairments (eg, walking tolerance and documented neurogenic claudication), and psychosocial factors. This may lead to nonsurgical clinical trials that assess whether precisely defined interventions targeted based on patient classification result in improved outcomes.

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Invasive Nonsurgical Treatments

Although the primary emphasis of the initial treatment of spinal stenosis should be nonsurgical interventions including patient education, medications for acute pain, exercise, and physical treatments, more invasive nonsurgical treatments such as steroid and anesthetic injections often are considered by patients and providers. Patients can request more invasive treatments based on the severity of symptoms and information from family, friends, and the media. For patients with persisting symptoms not adequately controlled with other treatments, physicians may recommend a local spine injection. Regardless of the indication, patients need to understand the limitations of these treatments including the lack of evidence supporting benefit, the potential for complications, and the recurrence of symptoms after initial benefit.55

A variety of substances (anesthetics, corticosteroids, opioids) can be injected into various spinal structures,55 and are used in patients with spinal stenosis with unproven results.68 Randomized trials of epidural steroid injections for patients with radicular symptoms most commonly caused by a disc herniation have shown conflicting but generally negative results.7,48,56 In spinal stenosis, there also are conflicting results.56,63,64,68 Ng et al56 showed that corticosteroids did not improve outcomes compared with anesthetics alone for patients with radicular symptoms including patients with spinal stenosis. Authors of one small study that included patients with radicular pain caused by spinal stenosis or a herniated disc showed improved symptoms among those receiving corticosteroid injections compared with those receiving an anesthetic without steroids.63 Rivest et al64 showed patients with spinal stenosis faired worse than those with a disc herniation. Steroid injections are also used as a means to avoid surgery, but only one set of authors have been able to show this short-term benefit.63

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Surgical Treatment

The complex relationship among symptoms, examination findings, and imaging results make determining the optimal surgical intervention difficult. Different types of spinal stenosis do not correspond to unique clinical features.40 Radiographic findings are often more extensive than expected from reported symptoms, and the degree of narrowing also does not correspond with clinical severity.1 As such, there are no clear guidelines to identify the significant stenotic level(s). Details about surgical indications and technique can be found elsewhere72,91 and are not the goal of this review-rather evidence supporting surgical options is discussed. Surgical interventions for patients with degenerative spondylolisthesis and spinal stenosis are also not discussed here, but have been recently reviewed.73 The goal of surgery is to relieve pain and improve function. For patients with back and leg pain symptoms, decompressive surgery is more effective at relieving neurogenic claudication symptoms than lower-back pain itself.6

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Laminectomy

Broadly, surgical treatment is designed to alleviate compression on the neural tissues in the central canal and/or lateral recesses. Decompression or laminectomy of the lumbar spine at one or more levels has been the standard treatment for spinal stenosis involving the central canal despite little evidence from comparative trials of nonsurgical treatment or alternative surgical interventions.29 The operative challenge is to provide adequate decompression of the neural elements while maintaining spinal stability. Iatrogenic instability can be decreased by preserving the facet joint and the pars interarticularis. A variety of different surgical techniques, including laminotomy, laminar-threctomy, laminoplasty, and microscopic decompression have been reported with a general goal of providing adequate clinical outcomes with less invasive decompression.61,72 However, the relative effectiveness and complications of various decompressive procedures remain uncertain.30

There are no large randomized studies to show the relative benefit of surgical decompression compared to nonsurgical treatment. Short-term results from a randomized trial presented to date only as an abstract report improved outcomes associated with surgical treatment.54 Among published studies, a single randomized study compared 13 surgically treated and 18 nonsurgically treated patients with spinal stenosis.2 Although Amundsen et al2 reported better outcomes with surgery, 56% of nonsurgically treated individuals crossed over to surgery after a median of only 3.5 months, outcomes were judged by physicians not patients, and no statistical comparisons were done.

The Maine Lumbar Spine Study, a prospective, observational cohort study of community-based care followed up on 148 patients with spinal stenosis initially treated surgically (n = 81) or nonsurgically (n = 67) during a 10-year period.4-6 Long-term outcomes from this study6 were considerably different from a study done by Amundsen et al2 especially in terms of change with time. In the Maine study, improvement according to initial surgical or nonsurgical treatment was reported by 77% and 44% of patients at 1 year, 70% and 52% of patients at 4 years, and 54% and 42% of patients at 8 to 10 years, respectively (Fig 1). Lower-back and leg pain and whichever symptom was the initially most bothersome (predominant) all are improved similarly among patients treated surgically and nonsurgically after 1 year, but not by 8 to 10 years. The initial improvement seen in patients treated surgically diminishes but to a greater extent for lower-back pain than for leg pain. In the Amundsen et al randomized study,2 the overall outcome was judged “good” according to initial surgical or nonsurgical treatment in 69% and 33% of patients at 1 year, 92% and 47% of patients at 4 years, and 91% and 71% of patients at 10 years, respectively. For observational patients followed up on by Amundsen et al,2 the overall outcome was judged “good” according to initial surgical or nonsurgical treatment in 89% and 64% of patients at 1 year, 84% and 57% of patients at 4 years, and 71% and 73% of patients at 10 years.

Fig 1

Fig 1

In the Maine study, surgical outcomes declined with time whereas nonsurgical outcomes remained fairly stable.11 In contrast, except for the surgical patients in the observational cohort, Amundsen et al's2 patients' outcomes improved with time regardless of treatment. A number of other observational studies show stable or declining long-term outcomes.35,42,65,70 Regardless of temporal trends in outcome, there is considerable variation in the percentage of individuals reporting long-term benefit from surgical decompression treatment.2,14,33,36,37,65,70

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Fusion

The addition of fusion with or without instrumentation to surgical decompression is generally done when laminectomy might lead to spinal instability. However, there are no guidelines to help define situations when the risk is large enough to justify the increased complexity, cost, and complications in patients with spinal stenosis without degenerative spondylolisthesis.16 In a single trial, Herkowitz and Kurz34 compared 50 patients with spinal stenosis and degenerative spondylolisthesis showed improved outcomes when arthrodesis was added to decompressive laminectomy. Authors of studies comparing different fusion procedures including instrumented and noninstrumented procedures and different instrumented techniques have shown similar clinical outcomes.30,50 No authors have shown that the addition of fusion results in superior patient-reported outcomes compared to decompression alone in patients with spinal stenosis without degenerative spondylolisthesis. Future controlled studies should explore alternative surgical interventions, especially for patients without degenerative spondylolisthesis but who are clinically thought to have spinal instability.

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Other Surgical Procedures

A randomized trial of an interspinous process implant between symptomatic levels associated with spine extension has been reported to have significantly better short-term outcomes compared with nonsurgical treatment.92 Other newer surgical interventions, such as disc replacement, have focused on the degenerated disc rather than bony changes. However, comparison of these newer interventions with existing surgical treatments, longer followup periods, and larger studies are needed to determine their appropriate role. Unfortunately, past experience with fusion would indicate that widespread dissemination is common even in the absence of clear clinical superiority.26

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Variation in Practice Patterns

As a result of increased awareness of this condition and the availability of advanced imaging tests, rates of surgery for spinal stenosis have increased dramatically in the United States.12,79 However, the increase in surgical procedures has occurred at very different rates across the United States. Among geographic regions, rates of lumbar spine procedures, including laminectomy with or without fusion, vary considerably.8,53,79 The rate of surgery for spinal stenosis has been shown to vary 12-fold, with higher rates in parts of the northwest, mountain, midwestern, and southern states.8 Although not as well documented, it also is reasonable to expect similar variation in rates of common nonsurgical treatments used in patients with spinal stenosis.

Although differences in geographic rates of procedures for spine disorders long have been known, the reasons behind these differences have only slowly been identified. It has been debated about whether differences resulted from patient and/or physician preferences, and most importantly whether differing rates were associated with variations in outcome. Small area analytic techniques have been used to highlight that differences in geographic rates could not be explained by population differences in age or gender, and the substantial differences were hard ascribe to patients having such dramatically different preferences based on geography.85,86 Some authors suggest that ethnic and socioeconomic factors may contribute to differences in musculoskeletal surgery.76 Skinner et al76 showed that for knee arthroplasty, lower rates of surgery for the Hispanic population and for black women at a national level were caused in part to geographic differences. However, lower surgical rates were seen for black men across most geographic regions.

Lurie et al53 have shown that a substantial proportion of the variation in rates of spine surgery can be explained by differences in the rates of advanced spinal imaging. Little consensus exists around indications for advance spinal imaging and surgery, and considerable uncertainty continues to exist in terms of the nature and timing of symptoms and their treatment, the type of surgical or nonsurgical interventions to do, and the factors associated with improved treatment outcomes.6,19,53 Finally, more recent evidence suggests that higher rates of health care use are not uniformly associated with improved health outcomes.21,22,43 Rather, geographic regions with very high relative use of health care resources may even have inferior outcomes.21

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Comparing Surgical and Nonsurgical Options

Differences in practice patterns across regions of the United States highlight the importance of a better understanding of the relative benefits of various treatment options for patients with spinal stenosis and how they are communicated to patients. In studies comparing surgical and nonsurgical treatments, the nonsurgical treatment has been described with limited detail, especially relative to the surgical interventions. Currently there are no full-length reports of randomized trials or well-controlled cohort studies in the literature comparing a well-conceived, specific nonsurgical program with surgery for patients with spinal stenosis.

Helping patients decide on the treatment(s) most appropriate for them can be a challenge. Authors have investigated the potential impact of using interactive video programs to better inform and involve patients in major clinical decisions, such as whether to have surgery or not for spinal stenosis.18,30,31 A randomized trial at two sites in Washington found that a video program seemed to facilitate decision-making.18 For 110 eligible patients with spinal stenosis, surgical rates were higher for patients in the video group (39%) than for patients given an informational booklet in addition to usual clinical care (29%, p = 0.4).

Although patients were similarly satisfied with their care and outcomes, patients in the video group thought they were better informed. Whether such informational devices can lead to improved patient selection and better overall outcomes of care requires further study.

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DISCUSSION

Despite being an increasingly common diagnosis in aging individuals, there is little empiric evidence to support many of the common surgical and nonsurgical interventions for symptomatic individuals with spinal stenosis. This is especially true in terms of the relative benefits and risks comparing various options. The result has been wide variations in practice patterns for the evaluation and treatment of spinal stenosis across geographic regions that cannot be explained fully by differences in the demographic characteristics or treatment preferences of individual patients. Because of limitations with the existing literature that have been highlighted, current practice recommendations require incorporating findings from available studies into existing clinical and biologic paradigms in order to provide a rational basis for treatment recommendations. In addition, the absence of consensus guidelines from national or international organizations, the treatment of spinal stenosis remains highly dependent on patient and physician expectations and preferences.

For these reasons, a patient-centered approach can help guide recommendations for initial and subsequent treatments. All patients with symptoms suggestive of spinal stenosis require a careful history and physical examination to assess symptom severity and impact on usual activities and to identify other clinical disorders that can cause patients to present with similar complaints. For most individuals with appropriate symptoms and nothing to suggest a more serious process, initial treatment should focus on nonsurgical interventions to treat pain and maintain function. Spinal stenosis rarely is associated with the cauda equina syndrome, and those with radiculopathy causing marked or progressive leg weakness should be evaluated urgently for other potential causes.

Most nonsurgical treatment recommendations are based on expert opinion that uses available studies and the biologic plausibility of various approaches rather than empirical evidence from controlled trials. Evidence from nonsurgical treatment of nonspecific lower-back pain suggests efficacy for a variety of interventions compared to placebo or sham treatments,82 but comparable outcomes among therapies. Therefore, for patients with spinal stenosis, nonsurgical treatments should focus on patient education (Table 2), medications to control pain, and exercise and physical treatments to regain or maintain activities of daily living. For many patients, several nonsurgical treatments may be used sequentially or in combination depending on the severity of symptoms and their change with time.

TABLE 2

TABLE 2

For patients with inadequate response to nonsurgical interventions and time, surgery is appropriate to consider. Indications for surgical interventions include intolerable pain uncontrolled by medications, and persistent neurogenic leg symptoms unresponsive to 8 to 12 weeks of nonsurgical treatment. Surgery should be approached cautiously in patients with other major comorbid medical problems, predominantly lower-back pain as opposed to radicular pain, and advanced imaging findings that are inconsistent with symptoms or the examination findings. Authors of available studies suggest that surgical treatment provides better short-term outcomes than additional nonsurgical treatment.2,4,54 However, patients who are reluctant to have surgery may elect nonsurgical care, knowing that their symptoms likely will remain stable and that long-term outcomes are similar.5,6 The relative benefit of various surgical interventions is uncertain and given the increased complications associated with fusion procedures, decompressive laminectomy should be the surgical procedure of choice for most patients who have not had previous spine surgery or who do not have other concomitant conditions such as degenerative spondylolisthesis.30 Until results from larger, controlled studies are available, providers should offer their patients treatment options based on their symptoms, functional impairment, other limiting medical conditions, and personal preferences.31

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Acknowledgment

The authors thank Sharan Aranha for assistance in the preparation of this manuscript.

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