Spinal stenosis

Treatment

Surgery

Predicting outcome

When deciding on surgical intervention consider potential risks and benefits. There is limited evidence on which to base treatment recommendations; randomized trials and systematic reviews do not find definitive evidence of a substantial benefit for surgical over nonsurgical treatments. Patient preferences should weigh heavily in decision-making. Benefits of surgery decline over time and repeat operations (for same or adjacent level disease) are performed in 15 to 25 percent. Several studies have identified predictors for outcome of surgical treatment of lumbar spinal stenosis. Predictors are variable from study to study. A systematic review identified the following predictors in one or more high-quality studies.[1]

Negative predictors:

Depression
Concomitant disorder influencing walking capacity
Cardiovascular comorbidity
Scoliosis

Positive predictors:

Male gender
Younger age
Better walking ability
Better self-rated health
Less comorbidity
More pronounced canal stenosis

Smoking

Smoking is associated with negative surgical outcomes, including nonunion, delayed healing, and increased pseudarthrosis. Smoking cessation appears to be beneficial in improving outcomes after surgery. In one review of 357 patients undergoing spinal fusion, the nonunion rate of those who stopped smoking for six months or longer after surgery was similar to nonsmokers and significantly less than those who continued to smoke (17 versus 14 versus 26 percent) [1].

Obesity

Obese patients have a higher risk of complications but experience benefit from surgical treatment that may be comparable to nonobese patients. [1]

Surgical timing

Delayed surgery appears to produce benefits that are similar to surgery when conservative therapy is selected as the initial treatment choice [1]

Surgical approach

Without spondylolisthesis

Laminectomy

Laminectomy involves removal of part or all of one or both lamina of the vertebra at the involved level. Interpretation of randomized clinical trials is limited but in the aggregate they suggest a modest benefit of surgery that diminishes over time. [1]

In a multicenter study in the United States, 289 patients with symptomatic LSS but no spondylolisthesis were randomized to decompressive surgery versus nonsurgical care and followed for two years. Two-thirds of those randomized to surgical treatment and 43 percent of those assigned to nonsurgical care underwent surgery during the study period. In this study, the intention-to-treat analysis did find a benefit for surgery for a measure of bodily pain, but not for disability or functional outcome. An as-treated analysis, which also included an observational cohort of an additional 365 patients, demonstrated a benefit for surgery on all outcome measures at three months and two years, which was maintained at four years. Surgical benefit persisted through four years, but by eight years, outcomes of pain and functional status were similar among patients treated surgically and nonsurgically; 19 percent of those treated surgically had had a second operation. [1]