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Lumbar spinal stenosis: Treatment and prognosis

INTRODUCTION

Lumbar spinal stenosis (LSS) refers to an anatomic condition that includes narrowing of the intraspinal (central) canal, lateral recess, and/or neural foramena. Spondylosis, or degenerative arthritis affecting the spine, is the most common cause of LSS and typically affects individuals over the age of 60 years [1].

LSS is a cause of disability in the aging population [2,3]. Treatment approaches are often not straightforward and require careful consideration of potential risks and benefits.

This topic will discuss the prognosis and treatment of LSS, focusing on lumbar spondylosis. Other topics discuss more general issues related to the evaluation and treatment of low back pain, and also the pathophysiology, clinical features, and diagnosis of lumbar spinal stenosis. (See "Approach to the diagnosis and evaluation of low back pain in adults" and "Subacute and chronic low back pain: Nonsurgical interventional treatment" and "Subacute and chronic low back pain: Pharmacologic and noninterventional treatment" and "Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis".)

PROGNOSIS

The natural history of lumbar spinal stenosis (LSS) due to degenerative spondylosis is relatively benign. Among 32 patients with symptoms and neuroimaging consistent with LSS who were followed for a mean 49 months without surgical intervention, symptoms remained unchanged in 70 percent, improved in 15 percent, and worsened in 15 percent [4]. However, LSS causes discomfort, often limiting activities of daily living, and can lead to progressive disability.

Radiographic studies suggest that over time adjacent spinal segments also become affected in almost half of patients [5,6]. Some data indicate that this phenomenon may be a more frequent occurrence in those who undergo surgical fusion and contribute to re-operation rates.

             

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Literature review current through: Jul 2014. | This topic last updated: Aug 11, 2014.
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References
Top
  1. Atlas SJ, Delitto A. Spinal stenosis: surgical versus nonsurgical treatment. Clin Orthop Relat Res 2006; 443:198.
  2. Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med 2008; 358:818.
  3. Ciol MA, Deyo RA, Howell E, Kreif S. An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations. J Am Geriatr Soc 1996; 44:285.
  4. Johnsson KE, Rosén I, Udén A. The natural course of lumbar spinal stenosis. Clin Orthop Relat Res 1992; :82.
  5. Lee MJ, Dettori JR, Standaert CJ, et al. The natural history of degeneration of the lumbar and cervical spines: a systematic review. Spine (Phila Pa 1976) 2012; 37:S18.
  6. Xia XP, Chen HL, Cheng HB. Prevalence of adjacent segment degeneration after spine surgery: a systematic review and meta-analysis. Spine (Phila Pa 1976) 2013; 38:597.
  7. Ammendolia C, Stuber K, de Bruin LK, et al. Nonoperative treatment of lumbar spinal stenosis with neurogenic claudication: a systematic review. Spine (Phila Pa 1976) 2012; 37:E609.
  8. Mazanec DJ, Podichetty VK, Hsia A. Lumbar canal stenosis: start with nonsurgical therapy. Cleve Clin J Med 2002; 69:909.
  9. Rittenberg JD, Ross AE. Functional rehabilitation for degenerative lumbar spinal stenosis. Phys Med Rehabil Clin N Am 2003; 14:111.
  10. Bodack MP, Monteiro M. Therapeutic exercise in the treatment of patients with lumbar spinal stenosis. Clin Orthop Relat Res 2001; :144.
  11. Willner S. Effect of a rigid brace on back pain. Acta Orthop Scand 1985; 56:40.
  12. Whitman JM, Flynn TW, Childs JD, et al. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine (Phila Pa 1976) 2006; 31:2541.
  13. Roelofs PD, Deyo RA, Koes BW, et al. Nonsteroidal anti-inflammatory drugs for low back pain: an updated Cochrane review. Spine (Phila Pa 1976) 2008; 33:1766.
  14. Cuckler JM, Bernini PA, Wiesel SW, et al. The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study. J Bone Joint Surg Am 1985; 67:63.
  15. Koes BW, Scholten RJ, Mens JM, Bouter LM. Efficacy of epidural steroid injections for low-back pain and sciatica: a systematic review of randomized clinical trials. Pain 1995; 63:279.
  16. Cannon DT, Aprill CN. Lumbosacral epidural steroid injections. Arch Phys Med Rehabil 2000; 81:S87.
  17. Ciocon JO, Galindo-Ciocon D, Amaranath L, Galindo D. Caudal epidural blocks for elderly patients with lumbar canal stenosis. J Am Geriatr Soc 1994; 42:593.
  18. Fukusaki M, Kobayashi I, Hara T, Sumikawa K. Symptoms of spinal stenosis do not improve after epidural steroid injection. Clin J Pain 1998; 14:148.
  19. Radcliff K, Kepler C, Hilibrand A, et al. Epidural steroid injections are associated with less improvement in patients with lumbar spinal stenosis: a subgroup analysis of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976) 2013; 38:279.
  20. Amundsen T, Weber H, Nordal HJ, et al. Lumbar spinal stenosis: conservative or surgical management?: A prospective 10-year study. Spine (Phila Pa 1976) 2000; 25:1424.
  21. Chang Y, Singer DE, Wu YA, et al. The effect of surgical and nonsurgical treatment on longitudinal outcomes of lumbar spinal stenosis over 10 years. J Am Geriatr Soc 2005; 53:785.
  22. Carragee EJ. The increasing morbidity of elective spinal stenosis surgery: is it necessary? JAMA 2010; 303:1309.
  23. Deyo RA, Mirza SK, Martin BI, et al. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 2010; 303:1259.
  24. Gibson JN, Waddell G. Surgery for degenerative lumbar spondylosis. Cochrane Database Syst Rev 2005; :CD001352.
  25. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 2008; 358:794.
  26. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976) 2010; 35:1329.
  27. Malmivaara A, Slätis P, Heliövaara M, et al. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976) 2007; 32:1.
  28. Atlas SJ, Keller RB, Robson D, et al. Surgical and nonsurgical management of lumbar spinal stenosis: four-year outcomes from the maine lumbar spine study. Spine (Phila Pa 1976) 2000; 25:556.
  29. Katz JN, Lipson SJ, Larson MG, et al. The outcome of decompressive laminectomy for degenerative lumbar stenosis. J Bone Joint Surg Am 1991; 73:809.
  30. Katz JN, Lipson SJ, Chang LC, et al. Seven- to 10-year outcome of decompressive surgery for degenerative lumbar spinal stenosis. Spine (Phila Pa 1976) 1996; 21:92.
  31. Zak PJ. Surgical management of spinal stenosis. Phys Med Rehabil Clin N Am 2003; 14:143.
  32. Desai A, Bekelis K, Ball PA, et al. Variation in outcomes across centers after surgery for lumbar stenosis and degenerative spondylolisthesis in the spine patient outcomes research trial. Spine (Phila Pa 1976) 2013; 38:678.
  33. Lauryssen C. Appropriate selection of patients with lumbar spinal stenosis for interspinous process decompression with the X STOP device. Neurosurg Focus 2007; 22:E5.
  34. Kuchta J, Sobottke R, Eysel P, Simons P. Two-year results of interspinous spacer (X-Stop) implantation in 175 patients with neurologic intermittent claudication due to lumbar spinal stenosis. Eur Spine J 2009; 18:823.
  35. Zucherman JF, Hsu KY, Hartjen CA, et al. A prospective randomized multi-center study for the treatment of lumbar spinal stenosis with the X STOP interspinous implant: 1-year results. Eur Spine J 2004; 13:22.
  36. Zucherman JF, Hsu KY, Hartjen CA, et al. A multicenter, prospective, randomized trial evaluating the X STOP interspinous process decompression system for the treatment of neurogenic intermittent claudication: two-year follow-up results. Spine (Phila Pa 1976) 2005; 30:1351.
  37. Kondrashov DG, Hannibal M, Hsu KY, Zucherman JF. Interspinous process decompression with the X-STOP device for lumbar spinal stenosis: a 4-year follow-up study. J Spinal Disord Tech 2006; 19:323.
  38. Hsu KY, Zucherman JF, Hartjen CA, et al. Quality of life of lumbar stenosis-treated patients in whom the X STOP interspinous device was implanted. J Neurosurg Spine 2006; 5:500.
  39. Siddiqui M, Smith FW, Wardlaw D. One-year results of X Stop interspinous implant for the treatment of lumbar spinal stenosis. Spine (Phila Pa 1976) 2007; 32:1345.
  40. Brussee P, Hauth J, Donk RD, et al. Self-rated evaluation of outcome of the implantation of interspinous process distraction (X-Stop) for neurogenic claudication. Eur Spine J 2008; 17:200.
  41. Siddiqui M, Nicol M, Karadimas E, et al. The positional magnetic resonance imaging changes in the lumbar spine following insertion of a novel interspinous process distraction device. Spine (Phila Pa 1976) 2005; 30:2677.
  42. Siddiqui M, Karadimas E, Nicol M, et al. Influence of X Stop on neural foramina and spinal canal area in spinal stenosis. Spine (Phila Pa 1976) 2006; 31:2958.
  43. Sobottke R, Schlüter-Brust K, Kaulhausen T, et al. Interspinous implants (X Stop, Wallis, Diam) for the treatment of LSS: is there a correlation between radiological parameters and clinical outcome? Eur Spine J 2009; 18:1494.
  44. Epstein NE. How often is minimally invasive minimally effective: what are the complication rates for minimally invasive surgery? Surg Neurol 2008; 70:386.
  45. Epstein NE. X-Stop: foot drop. Spine J 2009; 9:e6.
  46. Barbagallo GM, Olindo G, Corbino L, Albanese V. Analysis of complications in patients treated with the X-Stop Interspinous Process Decompression System: proposal for a novel anatomic scoring system for patient selection and review of the literature. Neurosurgery 2009; 65:111.
  47. Deyo RA, Martin BI, Ching A, et al. Interspinous spacers compared with decompression or fusion for lumbar stenosis: complications and repeat operations in the Medicare population. Spine (Phila Pa 1976) 2013; 38:865.
  48. Verhoof OJ, Bron JL, Wapstra FH, van Royen BJ. High failure rate of the interspinous distraction device (X-Stop) for the treatment of lumbar spinal stenosis caused by degenerative spondylolisthesis. Eur Spine J 2008; 17:188.
  49. Mekhail N, Vallejo R, Coleman MH, Benyamin RM. Long-term results of percutaneous lumbar decompression mild(®) for spinal stenosis. Pain Pract 2012; 12:184.
  50. Chopko BW. Long-term results of percutaneous lumbar decompression for LSS: two-year outcomes. Clin J Pain 2013; 29:939.
  51. Levy RM, Deer TR. Systematic safety review and meta-analysis of procedural experience using percutaneous access to treat symptomatic lumbar spinal stenosis. Pain Med 2012; 13:1554.
  52. Chen H, Kelling J. Mild procedure for lumbar decompression: a review. Pain Pract 2013; 13:146.
  53. Mekhail N, Costandi S, Abraham B, Samuel SW. Functional and patient-reported outcomes in symptomatic lumbar spinal stenosis following percutaneous decompression. Pain Pract 2012; 12:417.
  54. Sengupta DK, Herkowitz HN. Degenerative spondylolisthesis: review of current trends and controversies. Spine (Phila Pa 1976) 2005; 30:S71.
  55. Fischgrund JS, Mackay M, Herkowitz HN, et al. 1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine (Phila Pa 1976) 1997; 22:2807.
  56. Babu MA, Coumans JV, Carter BS, et al. A review of lumbar spinal instrumentation: evidence and controversy. J Neurol Neurosurg Psychiatry 2011; 82:948.
  57. Deyo RA, Ching A, Matsen L, et al. Use of bone morphogenetic proteins in spinal fusion surgery for older adults with lumbar stenosis: trends, complications, repeat surgery, and charges. Spine (Phila Pa 1976) 2012; 37:222.
  58. BMP use up sharply, but outcomes not improved. OR Manager 2012; 28:5.
  59. Carragee EJ, Hurwitz EL, Weiner BK. A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: emerging safety concerns and lessons learned. Spine J 2011; 11:471.
  60. Papakostidis C, Kontakis G, Bhandari M, Giannoudis PV. Efficacy of autologous iliac crest bone graft and bone morphogenetic proteins for posterolateral fusion of lumbar spine: a meta-analysis of the results. Spine (Phila Pa 1976) 2008; 33:E680.
  61. Kalanithi PS, Patil CG, Boakye M. National complication rates and disposition after posterior lumbar fusion for acquired spondylolisthesis. Spine (Phila Pa 1976) 2009; 34:1963.
  62. Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 1991; 73:802.
  63. Försth P, Michaëlsson K, Sandén B. Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis?: A two-year follow-up study involving 5390 patients. Bone Joint J 2013; 95-B:960.
  64. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med 2007; 356:2257.
  65. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am 2009; 91:1295.
  66. Tosteson AN, Lurie JD, Tosteson TD, et al. Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years. Ann Intern Med 2008; 149:845.
  67. Martin BI, Mirza SK, Comstock BA, et al. Are lumbar spine reoperation rates falling with greater use of fusion surgery and new surgical technology? Spine (Phila Pa 1976) 2007; 32:2119.
  68. Modhia U, Takemoto S, Braid-Forbes MJ, et al. Readmission rates after decompression surgery in patients with lumbar spinal stenosis among Medicare beneficiaries. Spine (Phila Pa 1976) 2013; 38:591.
  69. Radcliff K, Curry P, Hilibrand A, et al. Risk for adjacent segment and same segment reoperation after surgery for lumbar stenosis: a subgroup analysis of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 2013; 38:531.
  70. Turner JA, Ersek M, Herron L, Deyo R. Surgery for lumbar spinal stenosis. Attempted meta-analysis of the literature. Spine (Phila Pa 1976) 1992; 17:1.
  71. Li G, Patil CG, Lad SP, et al. Effects of age and comorbidities on complication rates and adverse outcomes after lumbar laminectomy in elderly patients. Spine (Phila Pa 1976) 2008; 33:1250.
  72. Farjoodi P, Skolasky RL, Riley LH. The effects of hospital and surgeon volume on postoperative complications after LumbarSpine surgery. Spine (Phila Pa 1976) 2011; 36:2069.
  73. Deyo RA, Ciol MA, Cherkin DC, et al. Lumbar spinal fusion. A cohort study of complications, reoperations, and resource use in the Medicare population. Spine (Phila Pa 1976) 1993; 18:1463.
  74. Cassinelli EH, Eubanks J, Vogt M, et al. Risk factors for the development of perioperative complications in elderly patients undergoing lumbar decompression and arthrodesis for spinal stenosis: an analysis of 166 patients. Spine (Phila Pa 1976) 2007; 32:230.
  75. Cloyd JM, Acosta FL Jr, Ames CP. Complications and outcomes of lumbar spine surgery in elderly people: a review of the literature. J Am Geriatr Soc 2008; 56:1318.
  76. Park DK, An HS, Lurie JD, et al. Does multilevel lumbar stenosis lead to poorer outcomes?: a subanalysis of the Spine Patient Outcomes Research Trial (SPORT) lumbar stenosis study. Spine (Phila Pa 1976) 2010; 35:439.
  77. Jönsson B, Annertz M, Sjöberg C, Strömqvist B. A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part II: Five-year follow-up by an independent observer. Spine (Phila Pa 1976) 1997; 22:2938.
  78. Aalto TJ, Malmivaara A, Kovacs F, et al. Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review. Spine (Phila Pa 1976) 2006; 31:E648.
  79. Gunzburg R, Keller TS, Szpalski M, et al. Clinical and psychofunctional measures of conservative decompression surgery for lumbar spinal stenosis: a prospective cohort study. Eur Spine J 2003; 12:197.
  80. Carreon LY, Glassman SD, Djurasovic M, et al. Are preoperative health-related quality of life scores predictive of clinical outcomes after lumbar fusion? Spine (Phila Pa 1976) 2009; 34:725.
  81. Freedman MK, Hilibrand AS, Blood EA, et al. The impact of diabetes on the outcomes of surgical and nonsurgical treatment of patients in the spine patient outcomes research trial. Spine (Phila Pa 1976) 2011; 36:290.
  82. Memtsoudis SG, Vougioukas VI, Ma Y, et al. Perioperative morbidity and mortality after anterior, posterior, and anterior/posterior spine fusion surgery. Spine (Phila Pa 1976) 2011; 36:1867.
  83. Radcliff KE, Rihn J, Hilibrand A, et al. Does the duration of symptoms in patients with spinal stenosis and degenerative spondylolisthesis affect outcomes?: analysis of the Spine Outcomes Research Trial. Spine (Phila Pa 1976) 2011; 36:2197.
  84. Møller AM, Pedersen T, Villebro N, Munksgaard A. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg Br 2003; 85:178.
  85. Andersen T, Christensen FB, Laursen M, et al. Smoking as a predictor of negative outcome in lumbar spinal fusion. Spine (Phila Pa 1976) 2001; 26:2623.
  86. Mooney V, McDermott KL, Song J. Effects of smoking and maturation on long-term maintenance of lumbar spinal fusion success. J Spinal Disord 1999; 12:380.
  87. Lee TC, Ueng SW, Chen HH, et al. The effect of acute smoking on spinal fusion: an experimental study among rabbits. J Trauma 2005; 59:402.
  88. Wing KJ, Fisher CG, O'Connell JX, Wing PC. Stopping nicotine exposure before surgery. The effect on spinal fusion in a rabbit model. Spine (Phila Pa 1976) 2000; 25:30.
  89. Glassman SD, Anagnost SC, Parker A, et al. The effect of cigarette smoking and smoking cessation on spinal fusion. Spine (Phila Pa 1976) 2000; 25:2608.