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Lumbar spinal stenosis can be treated by non-surgical or surgical means.
The key to deciding which one to choose is the degree of disability and
pain resulting from the stenosis. If a patient can no longer walk well
enough to be independent, then surgery may be recommended. Otherwise a
non-surgical approach may be tried for a period of time, or indefinitely if
the results are satisfactory.
Conservative (non-surgical) treatments
There are two common non-surgical treatments for lumbar spinal stenosis.
These are:
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Activity modification. Since patients
are more comfortable when they are flexed forward, they can concentrate
their activity in that position. Modifications can include changing
exercise from walking to stationary biking, using a cane or walker for walking
while flexed forward, and sitting in a recliner rather than a straight-back
chair.
·
Epidural injection. This is an
injection of cortisone into the space outside the dura (the epidural
space). Approximately 50% of patients will experience good pain relief
after an epidural injection, although the results tend to be temporary. If
the injection is helpful it can be done up to three times within a year.
The action of the injection is not clearly known, but is probably a
combination of the anti-inflammatory effect of the steroid and a flushing
effect due to injecting a volume of fluid. Although the injection can not
be considered diagnostic, typically if the pain from spinal stenosis is
relieved by an injection the patient can be expected to have a good result
if they later choose to undergo a surgical procedure.
Anti-inflammatory medication (such as ibuprofen, aspirin or Cox-2
inhibitors) may also be helpful in treating spinal stenosis. Exercise is
important to maintain strength, but usually does not relieve the symptoms.
Surgical treatment
If conservative treatments do not adequately increase the level of activity
a patient is able to tolerate, a surgical procedure might be considered.
An open decompression or laminectomy is the only way to
change the anatomy of the spine and give the nerves more room.
Decompressing the nerves by removing a portion of the enlarged facet joint
prevents the nerve from being pinched when the patient stands up. There are
several methods, but there are key components common to all such
approaches:
·
A correct and very detailed anatomical
diagnosis is required. The surgeon must consider the possibility of a
double or triple location of choking of a nerve, on one or both sides.
·
The surgery should not create a new problem,
such as a nerve injury or a structural instability that might require
additional surgeries.
·
The approach to correcting spinal stenosis
should be minimally destructive of normal structures. The surgeon should
strive to leave as much as possible of the normal or slightly abnormal
tissues alone. This again points to the importance of exactly identifying
the stenosis.
·
The metabolic and physical status of the
patient is important. Even in experienced hands a decompressive procedure
may require a few hours of anesthesia, and this is not well tolerated by
some patients. Some surgeons will perform the spinal stenosis surgery using
an epidural anesthetic instead of a general.
Decompression surgery for spinal stenosis is effective in approximately
80% of cases, but the results tend to deteriorate over a 5-year period.
Patients generally do well and are able to increase their activity level
and have a better walking tolerance. The results are just as effective
whether the surgery is done right away, or delayed for years.
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