What is the treatment for spinal stenosis?

Treatment of Spinal Stenosis

For symptomatic spinal stenosis, begin with at least 6 weeks of comprehensive conservative management including physical therapy, NSAIDs, and epidural steroid injections; if symptoms persist or worsen, proceed directly to surgical decompression with fusion (when instability or spondylolisthesis is present) or decompression alone (for isolated stenosis without instability). 1

Initial Conservative Management (Minimum 6 Weeks)

All patients should receive a trial of aggressive conservative treatment before surgical consideration, with the following components 1, 2:

• Physical therapy with flexion exercises, ultrasound, and short-wave therapy 3, 2
• NSAIDs and analgesics for pain control 2
• Epidural steroid injections for radiculopathy (highest evidence level for conservative treatment) 4, 2
• Activity modification with advice to remain active rather than bed rest 4
• Patient education about the generally favorable natural history and expected course 4

Important Caveat on Conservative Treatment

Conservative management fails in the vast majority (92%) of elderly patients with severe stenosis (<10mm canal diameter), and these patients should be counseled early about surgical options 3. However, exercise-based rehabilitation produces equivalent improvements regardless of stenosis severity (mild, moderate, or severe) in the short term 5.

Indications for Immediate Surgical Referral (Bypass Conservative Treatment)

Proceed directly to surgery without conservative trial in these scenarios 4, 1:

• Severe or progressive neurologic deficits (weakness, sensory loss) 4, 1
• Cauda equina syndrome (bladder/bowel dysfunction) 4
• Suspected vertebral infection or cancer with impending cord compression 4

Surgical Decision-Making Algorithm

Step 1: Obtain MRI or CT Imaging

MRI is preferred over CT for evaluating surgical candidates because it provides superior visualization of soft tissue, vertebral marrow, and the spinal canal without ionizing radiation 4. Add flexion-extension radiographs to identify segmental instability 1.

Step 2: Determine Surgical Approach Based on Pathology

For Stenosis WITHOUT Spondylolisthesis or Instability:

Decompression alone (laminectomy/laminotomy) is the treatment of choice 1, 6:

• Achieves 80% good or excellent outcomes 6
• Preserve facet joints and pars interarticularis to avoid iatrogenic instability 6
• Too little decompression is a more frequent mistake than too much 6

For Stenosis WITH Degenerative Spondylolisthesis:

Decompression with fusion is strongly recommended 1, 7:

• Produces 93-96% excellent/good outcomes versus only 44% with decompression alone 7
• Statistically significant reductions in both back pain (p=0.01) and leg pain (p=0.002) compared to decompression alone 7
• Posterolateral fusion with pedicle screw fixation is the standard approach 1
• Fusion rates reach 95% with instrumentation 1

For Stenosis WITH Instability, Deformity, or Recurrent Stenosis:

Fusion is mandatory 6:

• Includes cases with kyphosis, degenerative scoliosis, or postoperative instability 1, 6
• Fuse only the unstable segments rather than extensive multilevel constructs 6

Step 3: Special Populations

In achondroplasia patients with stenosis, fusion offers superior long-term outcomes compared to decompression alone, with 97% experiencing symptom recovery but 18% requiring reoperation 1.

Expected Outcomes and Monitoring

Approximately 97% of patients experience some symptom recovery after appropriate surgical intervention 1. However:

• Deterioration of initial improvement may occur over long-term follow-up 6
• Regular radiographic assessment is necessary to monitor fusion status and adjacent segment disease 1
• Surgical complications include nerve root injury, dural tear, infection, fusion failure, and hardware complications 1

Critical Pitfalls to Avoid

1. Do not perform routine imaging in patients without red flags or radiculopathy - it does not improve outcomes and increases costs 4
2. Do not recommend bed rest - remaining active is more effective 4
3. Do not perform fusion for isolated disc herniation without instability - there is no convincing evidence supporting routine fusion at primary disc excision 7
4. Do not delay surgery in elderly patients - age alone should not contraindicate surgical decompression, as elderly patients tolerate the procedure well 8
5. Do not perform decompression alone when spondylolisthesis is present - fusion significantly improves outcomes 7