Spinal Stenosis: What’s the Right Answer?

Spinal Stenosis is one of the leading causes of pain and disability in people over 65.

Currently, it is estimated that 1 in 1000 people over 65 and 5 in 1000 people over 50 suffer from spinal stenosis. If you’ve ever known someone with spinal stenosis, especially an older person, you know that it is a debilitating and vexing medical problem. The trouble is, there are no clear and effective treatments, including surgery. Most spinal stenosis is in either the lower back (lumbar, or LSS) or in the neck (cervical, CSS). As our population ages, more and more people will suffer from this condition. Unfortunately, spinal stenosis is still poorly understood. There are many different reasons the spinal canal can become narrowed, including degenerative changes to the bones, thickening of the ligaments and bulges of the discs in between the vertebrae. Furthermore, the natural course of spinal stenosis is variable, some people live with the same symptoms for many years, a few see improvements without surgery, while others decline. An article in Medscape reports:

Many patients with lumbar spinal stenosis (LSS) show symptomatic and functional improvement or remain unchanged over time. In one study 90% of 169 untreated patients with suspected lateral recess stenosis improved symptomatically after 2 years. A 4-year study of 32 patients treated conservatively (without surgery) for moderate stenosis reported unchanged symptoms in 70% of patients, improvement in 15%, and worsening in 15%. Walking capacity improved in 37% of patients, remained unchanged in 33%, and worsened in 30%.

Eventually, over time, everyone with spinal stenosis will worsen. However, when performed on the right person, surgery can be effective at alleviating some pain and disability. Nevertheless, spine surgery can result in devastating complications,such as a tear in the dura, which is the lining of the spinal canal (think Steve Kerr). The kind of surgery performed is also variable, with decompression (removal of the blockage and widening of the space) being the least that is performed and fusion and/or insertion of a device being the more aggressive approach. The rationale for fusion or device insertion is to mitigate the instability, sometimes called spondylolisthesis, that results after taking a disc out. However, even the most enthusiastic spine surgeons will admit that surgery is rarely a cure.

An article in the New England Journal of Medicine (NEJM) this month added more fuel to the fire about surgery for spinal stenosis. Studying 2 groups of patients with spinal stenosis (some of whom in each group had instability in their spine), no benefit from fusing the vertebrae after decompressing the stenosis was found at 2 and 5 years. In other words, the lesser surgery was as effective as the more extensive surgery. Notably, both groups (the lesser surgery and the more aggressive one) had the same number of complications from surgery and neither group fared better in any measure after surgery. The main difference was in length of hospital stay (average of 4 days for decompression alone surgery and 7 days for decompression plus fusion surgery).

The first decision anyone with spinal stenosis must make is whether to have surgery at all.

Given that a significant number of people improve without surgery, the potentially devastating complications of surgery (again, think Steve Kerr) and the unclear long term benefits of surgery, it should be reserved for those with intractable pain or worsening/dangerous neurologic symptoms.

Recent studies have indicated that surgery and medical management including physical therapy, non-steroidal antiinflammatories and epidural steroid injection are equally effective at reducing the symptoms of spinal stenosis. Given that and the results of the above study in the NEJM, patients considering spinal surgery should consider opting for the least invasive option possible.

5 Questions for your doctor if you have been diagnosed with spinal stenosis:

  1. What is the location of my stenosis? (cervical, thoracic or lumbar?)
  2. Do I also have instability of the spine? (spondylosis or spondyloilsthesis)?
  3. How likely is it that my symptoms will get worse?
  4. What symptoms should I worry about?
  5. Should I consider having spine surgery?

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