What are the treatments for spinal stenosis?

Treatment of Spinal Stenosis

For symptomatic spinal stenosis, begin with conservative management including activity modification, NSAIDs, and physical therapy for at least 6 weeks; if symptoms persist with significant functional impairment, proceed to surgical decompression, adding fusion only when spondylolisthesis or instability is documented. 1, 2

Initial Conservative Management (First 6 Weeks Minimum)

All patients should start with non-operative treatment unless severe or progressive neurologic deficits are present. 1, 3

• Activity modification: Reduce standing and walking periods, as lumbar flexion relieves symptoms while extension provokes them 4
• NSAIDs for pain control 1, 4
• Physical therapy with core strengthening and exercises that incorporate individual tailoring, supervision, stretching, and strengthening 5, 6
• Patient education about the generally favorable prognosis, with approximately one-third improving, 50% remaining stable, and only 10-20% worsening over 3 years without surgery 7, 4
• Remain active rather than bed rest, which is more effective for symptom management 5

Epidural Steroid Injections

• Consider epidural steroid injections for radiculopathy as they have the highest evidence level among conservative treatments 1
• Important caveat: Long-term benefits have not been demonstrated, with relief typically lasting less than 2 weeks 7, 4
• Injections produce equivalent improvements regardless of stenosis severity 1

Indications for Immediate Surgical Referral (Skip Conservative Trial)

Proceed directly to surgery without conservative management in these scenarios: 1

• Severe or progressive neurologic deficits 1, 2
• Cauda equina syndrome 1, 2
• Suspected vertebral infection or cancer with impending cord compression 1

Surgical Decision-Making After Failed Conservative Management

Diagnostic Imaging for Surgical Candidates

• MRI is preferred over CT because it provides superior visualization of soft tissue, vertebral marrow, and spinal canal without ionizing radiation 5, 1
• Obtain upright radiographs with flexion-extension views to identify segmental motion and instability 1
• Use CT myelography when MRI is contraindicated or to better assess bony anatomy 1

Surgical Approach Algorithm

The choice between decompression alone versus decompression with fusion depends entirely on the presence of instability or spondylolisthesis: 1, 2

For Stenosis WITHOUT Spondylolisthesis or Instability:

• Decompression alone (laminectomy or laminotomy) is the recommended treatment 1, 2, 3
• Fusion has not been shown to improve outcomes in isolated stenosis without instability 7
• Decompression alone achieves good or excellent outcomes in 80% of patients 3
• Critical pitfall: Too little decompression is a more frequent mistake than too much; preserve facet joints and pars interarticularis to avoid iatrogenic instability 3

For Stenosis WITH Degenerative Spondylolisthesis:

• Decompression with fusion is strongly recommended 1, 2, 7
• Fusion produces superior outcomes: 93-96% excellent/good results versus 44% with decompression alone 7
• Patients have statistically significantly less back pain (p=0.01) and leg pain (p=0.002) with fusion 7
• Benefits are maintained for at least 4 years 1, 7

Fusion Technique Selection:

• Posterolateral fusion with pedicle screw fixation is the standard approach 1
• Add pedicle screw instrumentation in cases with kyphosis or evidence of instability on dynamic imaging 1
• Instrumentation improves fusion rates from 45% to 83% but does not necessarily influence clinical outcomes 3
• Fusion rates of 89-95% are achievable with appropriate technique 1, 7

Expected Outcomes

Surgical Outcomes:

• Decompressive laminectomy improves symptoms more than nonoperative therapy by 7.8 points on the Oswestry Disability Index (scale 0-100) 4
• 93% of patients treated with decompression/fusion report satisfaction with outcomes 7
• Approximately 97% of patients have some recovery of symptoms after surgery 1

Natural History Without Surgery:

• Approximately one-third improve spontaneously 4
• Approximately 50% remain stable 4
• Approximately 10-20% worsen over 3 years 4

Surgical Complications to Monitor

• Nerve root injury 1
• Dural tear 1
• Infection 1
• Failure of fusion 1
• Hardware complications 1
• Reoperation rate of approximately 18% in complex cases 1
• Fusion carries higher complication rates (31-40%) compared to decompression alone (6-22%), including greater blood loss, longer hospital stays, and higher costs 7, 4

Critical Pitfalls to Avoid

• Do not perform routine imaging in patients without red flags or radiculopathy, as it does not improve outcomes and increases costs 1
• Do not recommend bed rest; remaining active is more effective 5, 1
• Do not add fusion routinely to decompression in the absence of spondylolisthesis or instability, as it increases complications without improving outcomes 2, 7
• Avoid inadequate decompression; too little decompression is more common than excessive decompression 3
• Preserve facet joints and pars interarticularis during decompression to prevent iatrogenic instability 3