What is the recommended treatment for lateral recess stenosis?

Treatment of Lateral Recess Stenosis

For patients with lateral recess stenosis, a stepwise approach is recommended, beginning with conservative management, followed by surgical decompression if symptoms persist, with fusion reserved only for cases with documented instability or spondylolisthesis. 1

Initial Conservative Management

• Multimodal non-pharmacological therapies should be the first-line treatment, including education, lifestyle modifications, home exercise programs, manual therapy, and rehabilitation 1
• Traditional acupuncture may be considered on a trial basis for symptom relief 1
• Serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants may be considered for pain management 1
• NSAIDs, paracetamol, opioids, muscle relaxants, pregabalin, gabapentin, and epidural steroid injections are NOT recommended for lateral recess stenosis based on current evidence 1

Surgical Intervention Criteria

• Surgical intervention should be considered when:
  • Patients have persistent symptoms despite 4-6 weeks of conservative management 2
  • Neurological deficits are present (e.g., weakness, reflex changes) 2
  • Imaging confirms lateral recess stenosis correlating with clinical symptoms 3
  • Functional impairment affects daily activities 2

Surgical Techniques

• Less invasive decompression techniques are preferred over extensive procedures to minimize tissue damage 4
• Full-endoscopic interlaminar approach has shown equivalent clinical outcomes to conventional microsurgical techniques with reduced complications and faster rehabilitation 4
• Percutaneous endoscopic decompression via transforaminal approach has demonstrated good outcomes even in geriatric patients, with excellent and good results in 87.5% of cases 5
• Bilateral lateral recess decompression via subarticular fenestrations is an effective technique that preserves bony structures and ligamentum flavum 6

Fusion Considerations

• Fusion is NOT recommended for isolated lateral recess stenosis without instability 7
• Fusion should ONLY be considered when:
  • There is evidence of preoperative spinal instability 7
  • Spondylolisthesis is present 8
  • Significant deformity exists (e.g., scoliosis, kyphosis) 7
  • Multiple-level extensive decompression might create iatrogenic instability 8

Diagnostic Evaluation

• Lateral recess stenosis is best evaluated using CT scan measurements:
  • Lateral recess angle (LRA) ≤ 30 degrees is highly indicative of stenosis 3
  • Lateral recess height (LRH) ≤ 3.6 mm also suggests stenosis 3
• MRI findings should correlate with clinical symptoms and neurological deficits 2

Outcomes and Follow-up

• Regular follow-up is essential to monitor clinical, functional status, and treatment adherence 8
• Successful decompression typically results in:
  • Significant reduction in leg pain (VAS scores typically improve from ~8.5 to <2.0 within one month) 5
  • Improved walking capacity and reduced claudication symptoms 6
  • Enhanced quality of life and reduced disability (ODI scores typically improve from ~60 to <30 within one month) 5

Potential Complications and Considerations

• Surgical complications are less common with minimally invasive techniques compared to open procedures 4
• Potential complications include:
  • Transient neurological symptoms (numbness, paresthesia) 5
  • Dural tears (more common with conventional techniques) 4
  • Infection (rare with endoscopic approaches) 5
• Patients with multiple comorbidities may still benefit from minimally invasive decompression techniques 5