Lumbar Canal Stenosis: Surgical Treatment - When Conservative Therapy Fails

Surgical Treatment: When Conservative Therapy Fails

Lumbar canal stenosis is the most frequent indication for spinal surgery in patients older than 65 years. Surgery is usually recommended when symptoms, particularly pseudoclaudication, fail to respond adequately to nonsurgical care. Surgery is almost always elective, as cauda equina syndrome is extremely rare in degenerative spinal stenosis.

A variety of surgical techniques are used, including decompressive laminectomy, with or without instrumented or noninstrumented fusion, and laminotomy (48,49). Microsurgical techniques are employed in an effort to reduce surgical morbidity in a frequently high-risk patient group.

Reported success rates of surgery vary considerably in uncontrolled trials.11,50-56 Reoperation rates as high as 21% have been reported (11,57). Across the country, rates of lumbar spine procedures for spinal stenosis vary by as much as 50% (49).

Randomized prospective controlled trials of surgical vs nonsurgical treatment are not available. Most nonrandomized comparisons suggest an advantage in surgically treated patients, at least in the short term. However, up to one third of patients treated nonsurgically also do well. Data comparing the outcomes of patients who underwent surgery earlier vs later in the disease suggest no difference in outcome (58).

The recent Maine Lumbar Spine Study, (58) a nonrandomized study comparing surgical and nonsurgical management of spinal stenosis, found that stenotic symptoms improved significantly more often in surgically treated patients than in conservatively treated patients, and that most surgically treated patients would again choose surgery.

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Address: Daniel J. Mazanec, MD, Spine Center, C21, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195; e-mail mazaned@ccf.org.