The usual recommendation: medications, physical therapy, lifestyle modification, and possibly injections into the spine before resorting to surgery.
Only about 20% of patients with SS improve substantially without surgery.
Surgical treatment results have been limited and inconsistent.
Disc deterioration can contribute to nerve pinching: The disk casing may weaken and ruptured or herniate, permitting the gelatinous contents to extend into the spinal canal and impinge on the spinal cord or nerve roots.
Commonly a herniated disk presses on the root of the sciatic nerve causing ((sciatica)).
Sciatica causes pain and numbness that radiates down the buttock and thigh and sometimes to the knee and foot.
As one ages, disks shrink in size, reducing the spaces between the bones of the facet joints.
Stress on these facet surfaces can produce osteoarthritic changes, including bone spurs, which narrow the spaces through which nerve roots leave the spine.
In addition disk shrinkage can cause the ligament flavum to fold inward, crowding the spinal cord and nerve roots.
Spondylolisthesis, is much more common in women than in men:
a vertebra slips forward on the one below it, misaligning the spinal column.
Additional causes of spinal stenosis include tumors, trauma, infection, complications from an earlier spinal surgery, and Paget’s disease.
Spinal stenosis resulting in nerve compression and is often caused by age-related changes.
Osteoarthritis of the facet joints and the formation of bone spurs narrow the spaces through which nerve roots pass.
A disk displacement over another, spondylolisthesis, narrowing the spinal canal.
A weakened disk may herniate, rupture, and protrude into the spinal canal.
The ligament lining the spinal canal may fold in, crowding the spinal cord or cauda equina.
Diagnosing lumbar spinal stenosis:
symptoms, history,physical exam, Imaging studies- MRI or CT scans.
The clinical hallmark of spinal stenosis is neurogenic claudication.
Neurogenic claudication: low back, buttock, and leg pain that worsens with walking or standing and improves with sitting, crouching, or leaning forward.
Lumbar spinal stenosis may make walking upright uncomfortable, but riding a bike or walking while leaning on a shopping cart or other support is beneficial.
Lower back flexing reduces pressure on nerves in the lumbar spine.
Spinal stenosis symptoms are usually bilateral involving the lower body, though sciatica may affect only one leg.
Patients with spinal stenosis are unsteady on their feet and have a wide-based gait.
The foundation of nonsurgical treatment is physical therapy to strengthen abdominal and back muscles, preserve motion in the spine, and improve overall fitness.
Stretching, strengthening, and aerobic exercises are usually recommended.
Abdominal corsets or braces can ease pain, but weaken postural muscles.
Using abdominal corsets or braces you shouldn’t be used more than a few hours a day.
Analgesics including acetaminophen, aspirin, other nonsteroidal anti-inflammatory drugs, and opiates are useful.
Injections of corticosteroids into the space surrounding the nerve roots or into the facet joints can reduce inflammation and relieve pain for weeks to months.
Chiropractic manipulation helps relieve pain, but is been not more effective than traditional nonsurgical care.
The aim of surgery is to relieve pressure on the spinal cord and nerve roots.
It also helps restore the alignment of the spine.
Surgery removes the bony or other tissues causing the pressure or misalignment.
The most common surgical procedure is laminectomy.
Laminectomy removes the lamina of one or more of the vertebrae to create more space for the nerves.
Parts of facet joints may also be removed, along with any bone spurs or disk herniation.
With both stenosis and spondylolisthesis spinal fusion, a procedure that joins the vertebrae and permanently fixes their position, often with plates and screws may be done.
In patients with concomitant degenerative, spondylolisthesis, and or scoliosis, decompression for lumbar spinal stenosis, is often performed in combination with lumbar fusion, in which adjacent vertebrae refuse to prevent motion.
Rationale for a fusion is that pain may arise from spinal instability, which may worsen following decompression, unless there is fusion.
Fusion is generally accomplished, with autologous bone graft from the iliac crest, and often supplemented with instrumentation, in which screws, rods, interbody cages are inserted through anterior, anterior lateral, lateral, posterior lateral, or posterior approaches.
In a trial involving patients undergoing surgery for degenerative lumbar spondylolisthesis, most had symptoms for more than a year, decompression alone was non-inferior to decompression with instrumental fusion over a period of two years: reoperation occurred somewhat more often in the decompression alone group than in the fusion group (Austevoli IM).
For up to at least two years, laminectomy is more effective than nonsurgical treatment for people with severe pain from spinal stenosis not related to spondylolisthesis.
The Spine Patients Outcomes Research Trial (SPORT), a five-year multicenter investigation found surgical patients got greater pain relief and more improved function, and they were more satisfied with the results.
Other SPORT studies suggest that surgery is more effective over two years for spinal stenosis related to spondylolisthesis.
Surgery and nonsurgical care are equally helpful for sciatica and disk herniation.
Studies of conservative treatment are not associated with increased pain or lower physical functioning.
Longterm studies suggest that 60% to 90% of spinal stenosis patients improve in the first year after surgery, but the benefit diminishes over time.
10% to 25% of surgically treated lumbar spinal stenosis cases need another operation.
Lumbar decompression is the most frequently performed surgical treatment for spinal stenosis: other surgical options include percutaneous decompression through minimally, invasive lumbar decompression procedure, or indirect decompression through an inter-spinous spacer device inserted surgery between a vertebrae.
Interspinous devices are associated with improve symptoms for patients with mild to moderate stenosis, but have higher rates of preoperation, then open decompression.