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Lumbar Spinal Stenosis

Treatment of Degenerative Lumbar Spinal Stenosis

Degenerative lumbar spinal stenosis is defined as a focal narrowing of the spinal canal, although there is some variation among investigators about the precise amount of narrowing that must occur before the canal is considered stenotic.

The general term "spinal stenosis" can be applied to three root compression mechanisms alone or in combination:

    Disk protrusion or herniation.

    Osteotic overgrowth into the spinal canal or the foramina through which the roots pass laterally.

    Vertebral slippage or spondylolisthesis.

Although symptoms overlap for these three mechanisms, the second category, osteotic stenosis, is specifically termed spinal stenosis. This category is the focus of this evidence report, with spondylolisthesis also being addressed.

In extreme cases, lumbar stenosis can cause cauda equina syndrome, a syndrome characterized by neuromuscular dysfunction, and may result in permanent nerve damage. Because many studies excluded patients with cauda equina syndrome, we were not able to consider evidence related to it. Therefore, consideration of cauda equina syndrome is beyond the scope of this evidence report. This report focuses on less extreme manifestations of lumbar spinal stenosis and considers the evidence surrounding all aspects of this condition.

Findings

    Patients with back pain or claudication tend to have narrower spines than asymptomatic patients.

    Increased patient age and the presence of herniated disks may also contribute to the development of back pain and other symptoms of stenosis. The strength of these relationships and the exact ages at which patients are most likely to develop symptoms cannot be determined from the information available.

    Some evidence suggests that disk degeneration, narrowing of the spinal canal, and degenerative changes in the spinal ligaments contribute to stenosis and that instability increases with age. However, the strength of this relationship and the age at which stenosis is most likely to occur cannot be determined from the available information.

    Heavier patients may be more likely to develop the degenerative changes leading to stenosis. Similarly, patients with osteoarthritis of the hips, as well as patients who perform heavy labor, tend to have more disk degeneration than other patients.

    Very little evidence exists correlating degree of narrowing of the lumbar spine with the presence or severity of the signs, symptoms, or conditions associated with stenosis. Difficulties associated with finding such correlations include the presence of large numbers of patients with spinal narrowing and no symptoms, variations in canal size throughout the population, and lack of an accepted system for quantifying the degree of narrowing.

    Only two studies provide numerical evidence of a lack of association between severity of stenosis or spondylolisthesis and severity of back pain. There is some evidence of a relationship between degree of spinal instability and back pain. Among patients with symptomatic stenosis, those with more severe stenosis tend to have more disability.

    Clinical signs and symptoms do not appear to predict whether the results of imaging tests will show severe stenosis.

    Evaluation of conservative treatment trials is complicated by the lack of patient inclusion criteria restricted to lumbar spinal stenosis. Controlled trials specifically examining and reporting on patients with lumbar spinal stenosis who receive conservative treatments are rare.

    Few studies have examined the question of the relationship of initial signs and symptoms to the final status or amount of change following conservative treatment. Studies reporting patient outcomes for conservative treatment vary in their results.

    One well-designed randomized controlled trial (RCT) indicates that local anesthetic block provides temporary relief from neurogenic claudication for about 1 month. Conclusions about effectiveness beyond 3 months cannot be made.

    Evidence for the efficacy of other conservative treatments in lumbar spinal stenosis patients is lacking. However, the lack of evidence for effectiveness does not prove that these treatments are not effective.

    The few studies that did stratify outcomes by patient characteristics, especially those that examined degree of stenosis, did not find a connection between successful treatment and specific patient characteristics.

    The lack of comparable patient groups and pretreatment data is a common problem in evaluating studies that examined both surgical and nonsurgical treatment groups.

    One RCT provides evidence that patients with severe symptoms will benefit more from surgery than conservative therapy.

    In general, data are lacking on the effect of conservative treatment on patients with severe stenosis since these patients seem to receive surgery shortly after diagnosis.

    There is limited, contradictory evidence on whether patients with moderate pain benefit more from surgery or from conservative treatment.

    No published trials provided the data necessary to determine whether the results of an imaging examination will determine the extent of success of surgical treatment.

    We are unable to determine whether imaging results can identify patient groups that would be more or less likely to benefit from surgery.

    The results of two RCTs seem to suggest that instrumentation in addition to fusion does not improve surgical outcomes among patients with spondylolisthesis. However, both trials likely had too few patients (and, therefore, insufficient statistical power) to render any definitive conclusion.

    One study provides evidence that fusion is beneficial compared to decompressive surgery alone.

    Information on the cost of surgical treatment of lumbar spinal stenosis came from several sources. Because present data did not allow us to estimate the effectiveness of any treatment or diagnostic, we were unable to perform a cost-effectiveness analysis.




This information came from an
AHCPR online article.

*** Any law, statute, regulation or other precedent is subject to change at any time ***

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