What are the treatment options for spinal stenosis and disk bulges?

Treatment of Spinal Stenosis and Disk Bulges

For spinal stenosis and disk bulges, a stepwise approach beginning with conservative management (NSAIDs, physical therapy, and exercise) for at least 6 weeks is strongly recommended, with surgery reserved for patients with persistent symptoms, neurological deficits, or significant functional limitations despite conservative treatment. 1

Initial Assessment and Diagnosis

• Imaging recommendations:
  • Standing lumbosacral X-rays as initial diagnostic study 1
  • MRI without contrast for persistent radicular symptoms after 6 weeks of failed conservative management 1
  • MRI with contrast if infection or malignancy is suspected 1
  • PET/CT with [18F]FDG when MRI is contraindicated or inconclusive 1

Conservative Management (First-Line Treatment)

Pharmacological Options

• First-line medications:
  • NSAIDs (recommended by American College of Internal Medicine) 1
  • Acetaminophen (second-line option) 1
  • Muscle relaxants for acute pain 1
  • Duloxetine as second-line therapy for chronic pain 1

Non-Pharmacological Options

• Physical interventions:
  • Exercise therapy focusing on core strengthening 1
  • Physical therapy 1
  • Multidisciplinary rehabilitation 1
  • Acupuncture or spinal manipulation 1
  • Self-care education using evidence-based materials 2

Interventional Procedures

• Image-guided epidural steroid injections for disc extrusion causing radicular symptoms, particularly with minimal nerve root compression 1

Surgical Management

Indications for Surgery

Surgery should be considered when:

• Conservative treatment fails after at least 6 weeks 1
• Progressive neurological deficit is present 1
• Spinal instability is documented 1
• Moderate to severe stenosis is confirmed by imaging 1

Surgical Approaches

1. For central spinal stenosis without instability or deformity:

   • Decompression alone (laminectomy) 1, 3

2. For stenosis with instability or deformity:

   • Decompression with fusion for:
     • Severe spinal canal stenosis at multiple levels
     • Presence of retrolisthesis
     • Bilateral leg weakness
     • Radicular symptoms with instability 1

3. For disc herniation with radicular symptoms:

   • Microdiscectomy 1

4. For severe canal narrowing and disc extrusion:

   • Posterior lumbar interbody fusion (PLIF) 1

5. Alternative surgical approaches:

   • Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF)
   • Anterior approach for lumbar spinal fusion
   • Lateral discectomy and interbody fusion 1

Perioperative Considerations

• Hold dual antiplatelet/anticoagulant therapy for 5 days prior to surgery 1
• Inpatient admission may be appropriate for:
  • Patients with suspected neoplasm
  • Intradural procedures
  • Significant bleeding risk 1
• Outpatient management is acceptable for stable patients without significant bleeding risk 1

Expected Outcomes and Follow-up

• Approximately 80% of patients with lumbar discopathy experience symptom resolution with appropriate conservative treatment 1
• Surgical decompression is usually associated with good or excellent outcomes in 80% of patients 3
• Regular clinical and functional assessments should be made following surgery 1
• Radiographic assessment at 12 months post-surgery, or earlier if bone deformity worsens 1
• Continue physical therapy post-surgery to maintain range of motion and strength 1

Important Considerations and Pitfalls

• Avoid iatrogenic instability during decompression by preserving the facet joint and pars interarticularis 3
• Inadequate decompression is a more frequent mistake than excessive decompression 3
• Long-term deterioration of initial post-operative improvement may occur 3, 4
• Fusion decisions should be selective, focusing on unstable segments only 3
• The British Medical Journal recommends against routine use of bone stimulators after spine surgery due to lack of meaningful clinical benefit 1

Treatment Algorithm

1. Initial 6 weeks: Conservative management with NSAIDs, physical therapy, and activity modification
2. If symptoms persist: Obtain MRI and consider epidural steroid injections
3. If symptoms continue or worsen: Evaluate for surgical candidacy based on:
   • Severity of symptoms
   • Functional limitations
   • Imaging findings
   • Presence of neurological deficits
4. Select surgical approach based on pathology:
   • Isolated stenosis → Decompression alone
   • Stenosis with instability → Decompression with fusion
   • Disc herniation → Microdiscectomy
5. Postoperative care: Continue physical therapy and regular follow-up