The Complexity of Lumbar Spinal Stenosis

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Table 2: Two-by-two table analysis of spinal stenosis testing, assuming that sensitivity and specificity are 90% and that the prior probability is 1% (left) or 30% (right)

Strategies for Overcoming Treatment Challenges

Devising a treatment plan for spinal stenosis can be challenging. It is helpful to discuss these options with patients over the course of many visits. A potential solution to the problem of difficulty walking is for patients to do aerobic exercises that can be accomplished in flexion; stationary bicycling is a good example. The problem of medication intolerance is not easy to overcome. Patients with spinal stenosis often do well with acetaminophen as their principal medication along with low and intermittent doses of NSAIDs and low doses of opiates, particularly at night. Topical nonsteroidal medicine can be helpful as well. Some patients find acupuncture helpful, although there is no clear evidence to support the efficacy of acupuncture for pain relief in spinal stenosis. Patients with concomitant spondylolisthesis or scoliosis often have an instability component to their pain and benefit from periodic use of a lumbar corset. It is particularly important for specialists and the primary care physician to communicate clearly about medication use in older patients, as the risks of drug toxicity and interactions are high.

It is useful to work carefully with a surgeon who is thoughtful, conservative, and able to simplify the complicated details and concepts of spinal arthrodesis when explaining the options to patients. Minor neurologic deficits are not urgent indications for surgery, and there is no evidence that surgery needs to be performed promptly in patients with spinal stenosis. Thus, patients can—and should—take their time in making these decisions. The decision should be made electively, be based on symptoms, and involve thoughtful discussions between patients and their surgeon, rheumatologist or primary care doctor, and family.

Summary

LSS is a common and disabling problem, and its prevalence will increase over the coming years with the aging of the population. The diagnosis can be challenging to make because the history, physical examination, and imaging findings are either insensitive, nonspecific, or both. Further, the clinician must distinguish between LSS and coexisting diagnoses, such as bursitis or osteoarthritis, to identify the primary cause of symptoms. After arriving at a diagnosis, clinicians must navigate the additional challenges of both the operative and nonoperative treatments for this condition. There is no “correct” decision regarding use of conservative therapy, injections, and surgery. Clinicians and patients should engage in a shared decision-making process and arrive at a decision that is consonant with the patient’s values.