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Lumbar spinal stenosis can be treated by non-surgical or surgical
means. The key to deciding which one to choose is the degree of
disability and pain resulting from the stenosis. If a patient can no
longer walk well enough to be independent, then surgery may be
recommended. Otherwise a non-surgical approach may be tried for a
period of time, or indefinitely if the results are satisfactory.
Conservative (non-surgical) treatments
There are two common non-surgical treatments for lumbar spinal
stenosis. These are:
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Activity modification. Since patients are more comfortable
when they are flexed forward, they can concentrate their
activity in that position. Modifications can include changing
exercise from walking to stationary biking, using a cane or
walker for walking while flexed forward, and sitting in a
recliner rather than a straight-back chair.
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Epidural injection. This is an injection of cortisone into
the space outside the dura (the epidural space). Approximately
50% of patients will experience good pain relief after an
epidural injection, although the results tend to be temporary.
If the injection is helpful it can be done up to three times
within a year. The action of the injection is not clearly known,
but is probably a combination of the anti-inflammatory effect of
the steroid and a flushing effect due to injecting a volume of
fluid. Although the injection can not be considered diagnostic,
typically if the pain from spinal stenosis is relieved by an
injection the patient can be expected to have a good result if
they later choose to undergo a surgical procedure.
Anti-inflammatory medication (such as ibuprofen,
aspirin or Cox-2 inhibitors) may also be helpful in treating spinal
stenosis. Exercise is important to maintain strength, but usually
does not relieve the symptoms.
Surgical treatment
If conservative treatments do not adequately increase the level of
activity a patient is able to tolerate, a surgical procedure might
be considered.
An open decompression or laminectomy is
the only way to change the anatomy of the spine and give the nerves
more room. Decompressing the nerves by removing a portion of the
enlarged facet joint prevents the nerve from being pinched when the
patient stands up. There are several methods, but there are key
components common to all such approaches:
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A correct and very detailed anatomical diagnosis is required. The
surgeon must consider the possibility of a double or triple
location of choking of a nerve, on one or both sides.
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The surgery should not create a new problem, such as a nerve
injury or a structural instability that might require additional
surgeries.
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The approach to correcting spinal stenosis should be minimally
destructive of normal structures. The surgeon should strive to
leave as much as possible of the normal or slightly abnormal
tissues alone. This again points to the importance of exactly
identifying the stenosis.
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The metabolic and physical status of the patient is important.
Even in experienced hands a decompressive procedure may require
a few hours of anesthesia, and this is not well tolerated by
some patients. Some surgeons will perform the spinal stenosis
surgery using an epidural anesthetic instead of a general.
Decompression surgery for spinal stenosis is
effective in approximately 80% of cases, but the results tend to
deteriorate over a 5-year period. Patients generally do well and are
able to increase their activity level and have a better walking
tolerance. The results are just as effective whether the surgery is
done right away, or delayed for years.
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