Current Treatment Options
2. Current Treatment Options
In one meta-analysis of 74 journal articles related to the surgical management of lumbar spinal stenosis, it was determined that the mean time of symptom duration for patients electing to undergo decompressive laminectomy was 46.51 months (3.87 years) and the minimum time from first onset to surgery was 11 months.7
While some patients experience a rapid decline in physical function and a rapid increase in symptom severity, for many more, the process of becoming disabled from lumbar spinal stenosis is a slow one. Once the diagnosis has been made positively, the process of treating the disease begins with a regimen of non-invasive conservative therapy.
2.1 Conservative Treatment
Conservative treatment typically consists of bedrest and controlled physical activity, physiotherapy, anti-inflammatory drugs and the use of a lumbar corset.8 While some patients are able to obtain some relief from symptoms with these measures, many others do not.
2.1.1 Bed Rest, Orthosis and Controlled Physical Activity
Because strict bed rest can lengthen the healing time as a result of muscular stiffness and deconditioning, bed rest for short periods interspersed with light activity and the use of a lumbar corset are often advised.9,10 The rationale for decreasing physical activity is to allow any inflammatory reaction to subside, sometimes resulting in temporary relief of symptoms.
2.1.2 Physical Therapy
Exercises that encourage lumbar flexion and flattening of the lumbar lordotic curve can be of a clinical benefit to patients suffering from lumbar spinal stenosis. An exercise program must be used 4 to 5 times a week to be beneficial, and any early signs of improvement are observed 4 to 6 weeks after the program has begun.11
Non-steroidal anti-inflammatory medications, such as, ibuprofen, aspirin, acetaminophen and naproxen sodium, are often recommended to patients suffering from lumbar spinal stenosis, but oral steroids and narcotics are generally contraindicated.12,13
Anti-inflammatory agents are prescribed based on the theory that inflammation within the affected tissues is a major cause of pain. The most comprehensive studies to examine NSAIDs have looked at the various medications in combination with bed rest. Based on these studies, no single drug appears to be superior to any other. 9,14,15
One double-blind, placebo-controlled trial of piroxicam (feldene) showed that a greater amount of pain relief in the treatment group was evident only during first few days of back pain; however, after 2 weeks, more of the untreated group had returned to work.16
2.1.4 Epidural Injections
Epidural steroid injections have been reported to be helpful in the short-term pain relief for some patients with lumbar spinal stenosis.11,12,17,18 However, few controlled trials have investigated the efficacy of epidural steroid injection in the treatment of lumbar spinal stenosis. Hoogmartens and Morelle17 and Rosen and coworkers18 retrospectively evaluated the effectiveness of epidural steroid injections and reported that approximately 50% of patients received short-term pain relief.
Much controversy exists with respect to the efficacy and patient satisfaction associated with steroid injections for lumbar spinal stenosis. Given the lack of research evidence for efficacy and the potential for complications, their use has been considered largely as an attempt to avoid surgery after the failure of other conservative management approaches.19,20,21
2.2 Decompressive Laminectomy
The most common surgical procedure for stenosis is a decompressive laminectomy sometimes accompanied by fusion. Often referred to as 'unroofing' the spine, this procedure involves the removal of the lamina as well as the attached ligaments that cause compression of the spinal sac and nerve roots, and the removal of hypertrophic facet capsules and osteophytes, uncinate spurs, and protruding disc material such that the nerves are free from compression.
In some cases, patients may be identified prior to surgery that have pathology requiring sufficient removal of the stabilizing structures to require concomitant arthrodesis. In other cases, this decision must be made at the time of the operation.
There is inconclusive evidence that arthrodesis, instrumented or not, has a significant impact on symptom severity, physical function or patient satisfaction. For patients undergoing laminectomy with arthrodesis, the associated morbidity, however, increases dramatically.
2.2.1 Success Rates
With success rates reported between 26% and 100% (the mean being 64%)7, surgery for degenerative lumbar spinal stenosis is generally performed electively to improve quality of life, except in rare cases of cauda equina syndrome or rapidly progressing neurologic deficits.22,23
The variations in reported surgery rates across geographic regions in the United States suggest that there still exits considerable uncertainty among physicians regarding the appropriate indications for decompressive laminectomy.24,25,26,27
Further, while patient satisfaction is an important outcome for elective surgeries, patient satisfaction after surgery for spinal stenosis has received little study. One retrospective study with an average of 4.6 years of follow-up showed that 31% of patients were dissatisfied with their operation.28,29
There has been limited prospective study of outcomes of surgery for spinal stenosis, and to date there is no published information on the clinical and sociodemographic factors associated with patient satisfaction after surgery for spinal stenosis, nor has there been a study comparing surgery of any type to conservative care.7
The indications for the surgical treatment of lumbar spinal stenosis have not been clearly defined.10,11 It is generally agreed that surgery is elective, performed to improve the quality of life for individuals who have disabling back and leg pain and significant limitations in walking tolerance.4,9,30,31,32
Larequi-Lauber and associates33 evaluated the appropriateness of surgical indications in 328 consecutive patients undergoing laminectomy for lumbar spinal stenosis or disc herniation. The authors used the consensus of a panel of experts to determine the appropriateness criteria and concluded that 38% of patients had inappropriate indications for surgery. The most common reason for a classification of inappropriate was insufficient preoperative duration of conservative treatment.
Surgery is clearly indicated in cases of acute cauda equina syndrome or with rapidly deteriorating neurologic status, but these cases are rare.34,35,36 Cauda equina syndrome is in fact the only absolute indication for decompressive laminectomy.37
Deyo et al used the ICD-9-CM codes to compile complications from lumbar spine procedures including decompressive laminectomy.38,39,40 These included death, operative hemorrhage, hematoma, gastrointestinal problems, urinary tract problems, respiratory complications, cardiac problems, postoperative infections, central nervous system problems, wound dehiscence, peripheral vascular problems, transfusion problems. Other authors in defining complications for decompressive laminectomy procedures have cited one or more of the following; death, pain, infection, dural tears, bleeding, neurological deficit, re-operations and functional disability.7,10,11,28,29,30,33,38,39,40
In an analysis of 1985 Medicare claims, Deyo reported a 6-week mortality rate of 1% in patients with spinal stenosis treated with arthrodesis, as compared with 0.8% in laminectomy without fusion.39