Review Article

Degenerative Lumbar Spinal

Stenosis: Evaluation and
Management

Paul S. Issack, MD, PhD
Matthew E. Cunningham, MD,
PhD
Matthias Pumberger, MD
Alexander P. Hughes, MD
Frank P. Cammisa, Jr, MD
Abstract
Degenerative lumbar spinal stenosis is caused by mechanical
factors and/or biochemical alterations within the intervertebral disk
that lead to disk space collapse, facet joint hypertrophy, soft-tissue
infolding, and osteophyte formation, which narrows the space
available for the thecal sac and exiting nerve roots. The clinical
consequence of this compression is neurogenic claudication and
varying degrees of leg and back pain. Degenerative lumbar spinal
stenosis is a major cause of pain and impaired quality of life in the
elderly. The natural history of this condition varies; however, it has
not been shown to worsen progressively. Nonsurgical management
consists of nonsteroidal anti-inflammatory drugs, physical therapy,
and epidural steroid injections. If nonsurgical management is
unsuccessful and neurologic decline persists or progresses,
surgical treatment, most commonly laminectomy, is indicated.
Recent prospective randomized studies have demonstrated that
surgery is superior to nonsurgical management in terms of
controlling pain and improving function in patients with lumbar
spinal stenosis.

D egenerative lumbar spinal

From the Hospital for Special
Surgery, New York, NY.
J Am Acad Orthop Surg 2012;20:
527-535
http://dx.doi.org/10.5435/
JAAOS-20-08-527
Copyright 2012 by the American
Academy of Orthopaedic Surgeons.
stenosis is a major cause of
pain and dysfunction in the elderly.
Most patients report leg and/or back
pain and have progressive symptoms
after walking or standing for even
short periods of time.1 Diagnosis is
typically made based on clinical his-
tory and physical examination and is
confirmed on imaging studies. In
most cases, treatment should begin
with nonsurgical management. In the
rare case of a progressive neurologic
deficit or cauda equina syndrome,
urgent surgical decompression is in-
dicated. In most cases, the natural
history of degenerative lumbar steno-
sis is variable and does not follow a
progressively deteriorating course.
Recent prospective randomized tri-
als, particularly the Spine Patient
Outcomes Research Trial (SPORT)
study, have provided compelling evi-
dence that decompressive surgery is
an effective treatment that provides
pain relief and functional improve-
ment in patients with degenerative
lumbar spinal stenosis.2,3
Etiology
Lumbar spinal stenosis is a reduction
in the volume of the central spinal
canal, the lateral recesses, and/or
neuroforamina that decreases the
space available for the thecal sac
and/or exiting nerve roots.4,5 Ap-
proximately 20% of the time, this
condition is caused or exacerbated

August 2012, Vol 20, No 8 527

Degenerative Lumbar Spinal Stenosis: Evaluation and Management

by congenital causes, such as failure
of the posterior elements to develop,
resulting in short pedicles and
laminae.4-6 More commonly, lumbar
stenosis is the result of degenerative
changes. The degenerative process is
thought to be initiated by disk dehy-
dration, disk bulging, and collapse of
the disk space, which sets in motion
the sequence of events that result in
narrowing of the spinal canal. Disk
space narrowing and loss of the nor-
mal shock absorptive capacity of the
spinal segment results in an increased
transfer of stress to the facet joints,
which accelerates facet joint cartilage
degeneration and osteophyte forma-
tion.5,7 Facet joint hypertrophy, in-
folding of the ligamentum flavum,
and development of bulging disk os-
teophyte complexes all contribute to
circumferential narrowing of the cen-
tral spinal canal and lateral recesses,
that is, the area of the spine bordered
by the superior articular facet poste-
riorly, the disk and vertebral body
anteriorly, the thecal sac medially,
and the pedicle laterally. These
stenotic changes cause neural com-
pression that presents clinically as
variable degrees of leg and back
pain, as well as gait deterioration
and other neurologic deficits (eg,
numbness and weakness).
Natural History
Prevalence of degenerative lumbar
spondylosis in the general popula-
tion ranges from 20% to 25% and
increases with age >50 years.8 The
natural history of this disease re-
mains unclear given the lack of pro-
spective studies with observational
cohorts. Johnsson et al9 followed 32
untreated patients with spinal steno-
sis over 49 months. Symptoms of
neurogenic claudication remained
unchanged in 22 patients (70%),
symptoms improved in 5 patients
(15%), and symptoms worsened in 5
patients (15%). None of the patients
had severe deterioration.
Cauda equina syndrome is a rare
condition caused by compression of
the lumbosacral nerve roots within
the spinal canal that produces vary-
ing degrees of motor weakness; sad-
dle anesthesia; and bowel, bladder,
and gait dysfunction. Acute presenta-
tion frequently occurs in patients
with large central disk herniation,
whereas delayed presentation often
occurs in patients with chronic spinal
stenosis. Surgical decompression
should be performed as soon as pos-
sible to avoid progression of neuro-
logic deficits.10
Diagnosis
Clinical Presentation
Patients with lumbar spondylotic
stenosis most commonly present
with neurogenic claudication and re-
port discomfort while standing as
well as diminished walking capacity.
In a series of 68 patients with lumbar
spinal stenosis confirmed with mye-
lography and surgery, neurogenic
claudication was observed in 94% of
patients, with primary symptoms of
pain (93%), numbness (63%), or
weakness (43%) reported.1 These
symptoms may be localized to the
buttocks and can radiate to the
lower extremities in a proximal to
distal fashion. Patients with lumbar
spondylotic stenosis have diminished
standing and walking tolerance;
however their ability to walk dis-
tances can be increased by ambulat-
ing with the spine in a flexed-
forward posture such as that used
when pushing a shopping cart.4 Typi-
cally, spinal extension narrows the
spinal canal and worsens neurogenic
symptoms, whereas spinal flexion
and sitting increases the diameter of
the spinal canal, partially alleviating
symptoms.4,5,11
On physical examination, back
pain or lower extremity symptoms
can be elicited with lumbar exten-
sion. Objective sensory findings such
as diminished sensation along a spe-
cific dermatome or motor weakness
suggest long-standing neural com-
pression. Radicular symptoms are
most commonly seen in patients with
lateral recess or foraminal stenosis.
Patients with spondylotic stenosis
may also present with neurogenic or
vascular claudication. The orthopae-
dic surgeon must distinguish neuro-
genic claudication from vascular
claudication; patients with vascular
claudication may present with di-
minished walking capacity due to
cramping of lower extremity muscles
on exertion. Unlike patients with
neurogenic claudication, patients
with vascular claudication cannot
improve walking tolerance with pos-
tural changes. Patients with neuro-

Dr. Hughes or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of
NuVasive; serves as a paid consultant to BOSS Medical, Bovie Medical Corporation, Orthovita, and SpineView; and has received
research or institutional support from NuVasive. Dr. Cammisa or an immediate family member has received royalties from NuVasive;
serves as a paid consultant to Alphatec Spine, Centinel Spine, Disc Motion Technologies, HealthpointCapital Partners, IVY
Healthcare Partners, Mazor Surgical Technologies, NuVasive, Orthogem, Orthovita, Paradigm Spine, Spinal Kinetics, Spinal Partners
III, and Viscogliosi Brothers; and has stock or stock options held in Alphatec Spine, BI Members, Centinel Spine, Disc Motion
Technologies, HealthpointCapital Partners, IVY Healthcare Partners, Mazor Surgical Technologies, NuVasive, Orthovita, Orthopaedic
Investment Partners, Paradigm Spine, Small Bone Innovations, Spinal Kinetics, and Viscogliosi Brothers. None of the following
authors or any immediate family member has received anything of value from or owns stock in a commercial company or institution
related directly or indirectly to the subject of this article: Dr. Issack, Dr. Cunningham, and Dr. Pumberger.

528 Journal of the American Academy of Orthopaedic Surgeons

 Paul S. Issack, MD, PhD, et al

Figure 1

A, Parasagittal T2-weighted magnetic resonance image of the lumbar spine demonstrating multilevel lumbar
spondylosis, with disk dehydration (arrowhead), disk protrusion (arrow), and central canal narrowing at L2-S1.
Hypertrophic changes in the ligamentum flavum and facet joint are most prominent at L4-S1. B, Axial T2-weighted
magnetic resonance image of the L4-5 interspace showing hypertrophy of the facet joint (arrowhead) and ligamentum
flavum (arrow), causing severe central canal and lateral recess stenosis. C, Parasagittal T1-weighted magnetic
resonance image of the lumbar spine demonstrating loss of epidural fat (arrow) about the lower lumbar exiting nerve
roots (L3, L4, and L5) and neuroforaminal stenosis.

genic claudication typically cannot
alleviate symptoms simply by ceasing
to walk; these patients must sit or
adopt a flexed-foward posture to al-
leviate symptoms. Patients with vas-
cular claudication have similar
symptoms whether ambulating or
riding a stationary bicycle, whereas
patients with neurogenic claudica-
tion have diminished symptoms of
claudication while in a seated posi-
tion. In addition, patients with vas-
cular claudication may have evidence
of vascular changes such as trophic
changes in the skin of the legs and
feet as well as diminished distal puls-
es; this is typically not observed in
patients with neurogenic claudica-
tion.12
Radiographic Evaluation
Clinical history and physical exami-
nation aid in diagnosis of degenera-
tive lumbar spinal stenosis. Typically,
imaging studies are used to confirm
the diagnosis and identify the levels
involved as well as any associated
pathology. Plain standing AP and lat-
eral radiographs may demonstrate
spondylolisthesis, disk space narrow-
ing, end plate sclerosis, osteophytes,
and facet hypertrophy.13 Lateral and
flexion and extension stress radio-
graphs may be helpful in determining
whether spondylolisthesis is mobile
and may demonstrate a slip that is
not visible on the plain standing lat-
eral view.
No consensus exists regarding the
definition of spinal stenosis in terms
of the diameter of the spinal canal or
area measurements. Often, the de-
gree of soft-tissue compression that
can be caused by ligament infold-
ing is underestimated when these
measurements are used to assess spi-
nal stenosis on CT. Furthermore,
measurements of midsagittal and
anterior-posterior canal diameter
may appear normal in patients with
trefoil-shaped spinal canals who
have clinically relevant lateral recess
stenosis with compression of travers-
ing nerve roots. The degree of spinal
stenosis is best evaluated on MRI be-
cause it can demonstrate disk degen-
eration or herniation, hypertrophy of
the ligamentum flavum and facet
capsule, and narrowing of the central
canal and lateral recess (Figure 1, A
and B). Parasagittal T1-weighted
magnetic resonance images may
demonstrate loss of epidural fat at
the exiting nerve root or frank nerve
root deformation, which suggests en-
trapment of the root in the foram-
ina13 (Figure 1, C). Radiographic
findings that indicate likely instabil-
ity include the presence of gapped
facets on axial CT scan and fluid-
filled facets visible on axial T2-
weighted magnetic resonance im-
ages.14 In patients without lumbar
spinal stenosis, supine magnetic reso-
nance images show sedimentation of
the lumbar nerve roots to the dorsal
part of the thecal sac as a result of
gravity. The absence of normal sedi-

August 2012, Vol 20, No 8 529

Degenerative Lumbar Spinal Stenosis: Evaluation and Management
mentation is a positive sign of lum-
bar spinal stenosis.15
When MRI cannot be obtained,
myelography followed by CT may be
used to assess the degree and loca-
tion of stenosis; these imaging mo-
dalities are helpful for preoperative
identification of locations that re-
quire decompression. Radiographic
changes are often seen in patients
who are asymptomatic; therefore,
correlation of imaging results with
clinical findings is essential for iden-
tification of relevant pathology. In a
study of 67 asymptomatic patients
who had no reports of low back
pain, sciatica, or neurogenic claudi-
cation, Boden et al16 reported that
MRI findings in patients aged ≥60
years were abnormal on approxi-
mately 57% of the scans, with 21%
of scans demonstrating spinal steno-
sis.
Management
Nonsurgical
The goals of therapy in patients with
degenerative lumbar stenosis are to
alleviate pain and improve func-
tion. Nonsteroidal anti-inflamma-
tory drugs (NSAIDS) may temporar-
ily and partially alleviate pain. In
general, narcotic analgesics should
be avoided or used on a short-term
basis preoperatively and as needed in
the immediate postoperative period.
Both NSAIDs and narcotic analgesics
can be especially problematic in the
elderly patient population. NSAIDs
have been associated with an in-
creased risk of bleeding, gastrointes-
tinal, liver, renal, cardiovascular, and
central nervous system complications
in the elderly.17 Narcotic analgesics
are associated with significant altera-
tions in normal mood and sleep-
wake cycle as well as gastrointestinal
complications and potential respira-
tory suppression; these symptoms are
magnified in the elderly population.
530
Physical therapy, with an emphasis
on abdominal flexion exercises and
core muscle strengthening, may help
to improve muscle strength, maintain
range of motion, and improve global
functioning.18 In a randomized clini-
cal trial that compared two physical
therapy programs for patients with
lumbar spinal stenosis, 18 of 29 pa-
tients (62%) treated with a 6-week
regimen of manual physical therapy,
body weight supported treadmill
walking, and exercise demonstrated
improvement in disability, satisfac-
tion, and treadmill walking tests at
1-year follow-up.19
Epidural steroid injections can also
be used to provide temporary relief
of radicular symptoms in select pa-
tients.20 In a prospective study of 34
patients with radicular pain caused
by degenerative lumbar spinal steno-
sis, Botwin et al21 treated patients
with fluoroscopy-guided lumbar
transforaminal epidural injections.
The authors reported that 75% of
patients noted at least a >50% re-
duction in pain scores, 64% had im-
proved walking tolerance, and 57%
had improved standing tolerance at
1-year follow-up. Other studies have
reported temporary improvement in
pain and function following epidural
injection. Tran et al22 performed a
meta-analysis of randomized con-
trolled trials to examine nonsurgical
management of lumbar spinal steno-
sis, including the use of lumbar epi-
dural injection used to manage lum-
bar spondylotic stenosis. They
determined that there may be no
added benefit in adding steroids to
the anesthetic injection. Additionally,
concerns exist regarding the effects
on bone quality and blood glucose
levels with repetitive use of ste-
roids.4,20 In patients with severe neu-
rologic deficit, including limited
walking capacity or cauda equina
syndrome, epidural steroid injections
can exacerbate symptoms; case re-
ports have described complications
Journal of the American Academy of Orthopaedic Surgeons
such as vascular injury, hematoma
formation, and paralysis.23,24 Further-
more, clear evidence-based guide-
lines are lacking regarding the num-
ber and frequency of injections
needed to manage spinal stenosis.
Surgical
Surgery is indicated in patients with
clinical and radiographic evidence of
spinal stenosis who have intractable
pain, altered quality of life, or sub-
stantially diminished functional ca-
pacity and have either failed nonsur-
gical treatment or are not candidates
for nonsurgical treatment.25 Surgery
can predictably address positional
back pain and neurogenic claudica-
tion, but may not adequately address
pain secondary to degenerative disk
disease (eg, low back pain, referred
pain).2,3,25-27
The method of surgical interven-
tion is based on the location and
character of stenosis. Spinal stenosis
usually occurs as the result of a
global degenerative process that in-
volves the central canal, lateral re-
cesses, neuroforamina, or a combina-
tion of these structures. Compression
may be isolated or may extend to
multiple levels and can involve the
central or lateral nerve roots, those
in the foramen, or a combination of
all three. Radicular symptoms or
motor weakness along specific nerve
root distributions require careful as-
sessment of the lateral recess and fo-
ramen.4,6 Relative stability of the dis-
eased segment should also be
assessed. Hypermobile segments (ie,
segments demonstrating spondylolis-
thesis, lateral listhesis, widened fac-
ets with fluid visible on MRI) adja-
cent to more normal segments may
require stabilization with in situ fu-
sion techniques or instrumented ar-
throdesis and fusion. Neurogenic
claudication with central canal
stenosis may require laminectomy,
laminotomy, or indirect reduction
 Paul S. Issack, MD, PhD, et al

Figure 2 expose the neuroforamina and exit-

ing nerve roots, which may be de-
compressed using Kerrison rongeurs
(Figure 2, D). A ball-tipped probe,
Woodson elevator, or angled dural
separator should be used to assess
the anteroposterior and proximal-
distal volume of the neuroforamina.6
Several studies have evaluated out-
comes of decompressive laminec-
tomy for spinal stenosis. Some of
these studies reported on outcomes
of decompressive laminectomy and
nonsurgical treatment in a cohort of
148 patients with symptomatic lum-
bar stenosis who were followed for
10 years.26-28 Eighty-one patients un-
derwent laminectomy, and 67 re-
ceived nonsurgical treatment, with
both groups assessed at 1, 4, and 8
to 10 years following treatment.26
Leg or back pain was substantially
improved in 55% of patients in the
surgical group and 28% in the non-
surgical group at 1-year follow-up.26
However, these differences became
less substantial over time; at 8- to
10-year follow-up, leg or back pain
was significantly improved in 54%
of surgically treated patients com-
pared with 42% of nonsurgically
treated patients.28 These studies were
A, Illustration demonstrating resection of the spinous processes and
limited by their nonrandomized de-
detachment of ligamentum flavum from the ventral aspect of the lamina with sign in which potential confounders
a curet. B, Laminectomy and central decompression with a Kerrison rongeur. cannot be excluded, the high rate of
C, Partial medial facetectomy and foraminotomy are performed with a 45° loss to follow-up, and various de-
Kerrison rongeur. D, The superior tip of the superior facet is resected with a
45° Kerrison rongeur for decompression of the neuroforamen. grees of decompression; these issues
make it difficult to assess the value
of decompression surgery.26-28
techniques for decompression of the rior elements is performed from the More recently, prospective ran-
central canal. These techniques can midline to the lateral pars interartic- domized studies have rigorously
be performed via traditional open ularis and facets with great care evaluated surgical management of
approaches or minimally invasive taken to avoid damage to the facet spinal stenosis.3,29,30 Amundsen et al29
techniques. joint or pars interarticularis. After reported on the results of 100 pa-
resection of the spinous processes tients with symptomatic lumbar spi-
Laminectomy and superficial dorsal lamina, central nal stenosis who were assigned to
Laminectomy is performed with the decompression is performed with re- either surgical or nonsurgical treat-
patient positioned prone on a sup- moval of the midline laminae and ment. A partial randomization was
portive frame that allows the abdo- underlying ligamentum flavum (Fig- done, with 31 patients assigned to ei-
men to hang free to decrease epi- ure 2, A-C). Partial medial facetecto- ther nonsurgical or surgical treat-
dural venous pressure and surgical mies can then be performed to de- ment groups. At 4-year follow-up,
site bleeding. Exposure of the poste- compress the lateral recess and excellent or fair results were ob-

August 2012, Vol 20, No 8 531

Degenerative Lumbar Spinal Stenosis: Evaluation and Management
served in 9 of 18 patients in the non-
surgical group and 10 of 13 patients
in the surgical group. Malmivaara
et al30 evaluated 94 patients with
lumbar spinal stenosis treated either
surgically (50 patients) or nonsurgi-
cally (44 patients) in randomized
multicenter trial. The surgical group
included 10 patients treated with in-
strumented posterolateral fusion. At
2-year follow-up, disability, leg pain,
and back pain were improved to a
greater degree in the surgical group
than in the nonsurgical group. Walk-
ing ability did not differ between the
two treatment groups. A drawback
of the study is that inclusion of pa-
tients treated with fusion makes it
difficult to attribute good outcomes
to decompression alone. Crossover
of the patient population is another
limitation of this study; 9% of the
nonsurgical group underwent surgi-
cal intervention due to exacerbation
of symptoms, and 8% of the decom-
pressive surgery group did not un-
dergo surgery due to relief of symp-
toms, thereby further confounding
the researchers’ ability to detect dif-
ferences between the groups.
Effectiveness of surgical manage-
ment of lumbar spinal stenosis was
evaluated in the SPORT study. This
prospective randomized multicenter
trial had three study arms based on
diagnosis: lumbar disk herniation,
degenerative spondylolisthesis or spi-
nal stenosis.2,3 Patients with spinal
stenosis without spondylolisthesis
who had symptoms for at least 12
weeks and failed nonsurgical treat-
ment were enrolled in the spinal
stenosis arm of the study. These pa-
tients were assigned to either a ran-
domized or an observational cohort
and underwent decompressive sur-
gery or nonsurgical care, respec-
tively. Nonsurgical care consisted of
physical therapy, education and/or
counseling with home exercise in-
struction, and NSAIDs. Initially, 365
patients were assigned to the obser-
532
vational cohort; however, many pa-
tients in the nonsurgical group opted
to have surgery. At 2-year follow-up,
193 of 289 patients (67%) in the
randomized cohort had undergone
surgery, whereas 157 patients (43%)
in the observational cohort received
nonsurgical care and underwent sur-
gery. As-treated analysis, which com-
bined both cohorts, showed that sur-
gery had a marked advantage over
nonsurgical treatment, with substan-
tial decreases in pain and improve-
ment in physical function as mea-
sured by the Medical Outcomes
Study 36-item Short-Form General
Health Survey and the modified Os-
westry Disability Index (ODI). These
differences remained significant at 2
and 4 years.2,3
Complications associated with
laminectomy include infection, dural
tear, epidural hematoma, and insta-
bility. One study reported that, fol-
lowing laminectomy, 2 of 103 pa-
tients (2%) with lumbar stenosis
developed deep infection, requiring
irrigation and débridement.31 Re-
cently, a 10.5% incidence of durot-
omy was reported in 389 patients
who underwent laminectomy for
lumbar degenerative spondylolisthe-
sis. No significant differences in pain
or physical function based on Medi-
cal Outcomes Study 36-item Short
Form scores or ODI were observed
at 1, 2, 3, and 4 years in patients
with or without durotomy, which
suggests that incidental durotomy
does not significantly affect out-
come.32 Epidural hematoma follow-
ing laminectomy is rare and requires
urgent surgical decompression to
avoid neurologic deficit.33 In a study
of 27 patients treated with posterior
spinal decompression procedures,
the incidence of postlaminectomy in-
stability was 3.7%; this complication
can be avoided by preserving the
pars interarticularis and at least 50%
of the facet joints.34
Journal of the American Academy of Orthopaedic Surgeons
Minimally Invasive Surgical
Approaches
Compared with traditional open
techniques, minimally invasive sur-
gery (MIS) for management of spinal
stenosis results in better preservation
of posterior musculature, diminished
intraoperative bleeding, and requires
less recovery time.35,36 MIS ap-
proaches for stenosis include lamin-
otomy, microendoscopic laminotomy
with tubular retractors, and lamino-
plasty. Although MIS approaches
have some advantages over open
procedures, the economic value and
cost-effectiveness of MIS requires
further investigation.37
Laminotomy
Laminotomy involves removal of a
small portion of one side of the lam-
ina. Resection of the distal half of
the superior hemilamina is often nec-
essary to identify and remove the in-
sertion site of the ligamentum fla-
vum. Contralateral decompression
can be performed with preservation
of the spinous processes and supra-
spinous and interspinous ligaments
by tilting the operating table away
from the surgeon. Using an operating
microscope, the contralateral liga-
mentum can be visualized and re-
sected and then the lamina can be
undercut38,39 (Figure 3). Toyoda
et al38 reported on 57 patients who
underwent bilateral decompression
via unilateral laminotomies. Of these
patients, 27 had lumbar spinal steno-
sis without instability, 20 had degen-
erative lumbar spondylolisthesis, and
10 had degenerative lumbar scolio-
sis. At a mean 6-year follow-up, the
average Japanese Orthopaedic Asso-
ciation (JOA) score improved from
13.8 ± 3.6 points preoperatively to
22.6 ± 4.7 points at final follow-up.
At final follow-up, no significant dif-
ferences in JOA score or percentage
of slippage were noted among pa-
tients with these three diagnoses.
This technique is limited because of

Figure 3
A, Illustration demonstrating microdecompression. The shaded area shows
the ipsilateral decompression. The dashed lines represent the contralateral
area to be decompressed under the midline structures. B, Axial view of the
contralateral decompression. The contralateral exiting nerve root is protected
during the procedure.
the difficulty in accessing stenosis in
the lateral canal and foramen.
Microendoscopic Laminotomy
In a prospective study of 53 patients
with spinal stenosis, Pao et al40 per-
formed microendoscopic laminot-
omy using a tubular retractor and a
fiberoptic endoscopic system. Of
these patients, 45 (85%) were satis-
fied with treatment at an average 16-
month follow-up. Significant im-
provement in ODI and JOA scores
was noted, and 40 patients (80%)
had good to excellent results. Com-
plication rates were high and in-
cluded dural tears in five patients
and transient neuralgia in four
patients. Khoo and Fessler41 com-
pared microendoscopic decompres-
sive laminotomy with open decom-
pression in patients with lumbar
spinal stenosis and noted that the mi-
croendoscopic procedure was associ-
ated with reduced blood loss, shorter
postoperative hospital stay, and di-
minished use of narcotics. A draw-
back of this technique is that the ip-
silateral lateral recess is difficult to
August 2012, Vol 20, No 8
access without extensive facetec-
tomy.42
Interspinous Process Devices
Recently, interspinous process de-
vices have been used to manage lum-
bar spinal stenosis. These implants
block spinal extension at the level of
the facet joint and limit canal nar-
rowing associated with spinal exten-
sion. In a prospective randomized
controlled multicenter trial, Zu-
cherman et al43 analyzed outcomes of
191 patients with symptomatic spi-
nal stenosis. Ninety-one patients
were treated nonsurgically and 100
were treated with the X-STOP inter-
spinous implant (Medtronic, Mem-
phis, TN). At 2-year follow-up,
symptom scores improved by 45%
over baseline in patients treated with
the X-STOP implant compared with
7% improvement in the control
group. The X-STOP group had a
44% mean improvement in function
compared with no improvement in
the control group. In addition, 73%
of patients treated with the X-STOP
device were satisfied with surgery
Paul S. Issack, MD, PhD, et al
compared with 36% of control pa-
tients. Tuschel et al44 recently re-
ported on 46 patients with spinal
stenosis who underwent implanta-
tion of the X-STOP device. At a
mean 40-month follow-up, no im-
provement was noted, and the revi-
sion rate was approximately 30%.
Most revisions occurred within the
first year. In addition, there is evi-
dence that implantation of these de-
vices may not improve outcomes and
in fact may worsen neural compres-
sion in severely stenotic patients.45,46
Indications for the use of these im-
plants are not well defined, and long-
term studies are lacking at this time.
Economics
A cost analysis performed using a
subset of patients with spinal steno-
sis from the SPORT study showed
that surgical management of spinal
stenosis improved health to a greater
extent than nonsurgical care (quality
adjusted life year [QALY] gained,
0.17) at a cost of $77,600 per QALY
gained at 2-year follow-up.47 At 4-year
follow-up, QALY gains were main-
tained (0.22) and costs per QALY
gained decreased to $59,400.48 The
authors concluded that the economic
value of surgery for spinal stenosis
compares favorably with many
health interventions.47,48
Summary
Degenerative lumbar spinal stenosis
is a major cause of impaired quality
of life and diminished functional ca-
pacity in the elderly. Patients com-
monly present with neurogenic clau-
dication and diminished standing
and walking tolerance; however,
their ability to walk distances can be
increased by ambulating with the
spine in a flexed-forward posture.
On physical examination, back pain
or lower extremity symptoms can of-
ten be elicited with lumbar exten-
533
Degenerative Lumbar Spinal Stenosis: Evaluation and Management
sion. Radicular symptoms may be
seen in patients with lateral recess or
foraminal stenosis.
Plain AP and lateral radiographs
may demonstrate spondylolisthesis,
disk space narrowing, end plate scle-
rosis, osteophytes, and facet hyper-
trophy. MRI can best demonstrate
the degree of narrowing in the cen-
tral canal and lateral recess. Because
the natural history of spinal stenosis
is generally benign but progressive,
initial treatment with NSAIDs; phys-
ical therapy, with an emphasis on
core strengthening; and epidural ste-
roid injections may be beneficial.
Surgical management is indicated
following failure of nonsurgical mea-
sures. Recent prospective random-
ized controlled studies have demon-
strated a definite advantage of
surgery over nonsurgical treatment
in decreasing pain and improving
function in patients with degenera-
tive spinal stenosis. Decompressive
laminectomy is the most commonly
performed procedure used to address
global stenosis. MIS approaches in-
clude laminotomy, microendoscopic
laminotomy, and laminoplasty. Fu-
sion is not indicated except in the
setting of concomitant spondylolis-
thesis, scoliosis, or iatrogenic insta-
bility. In well-selected patients, surgi-
cal decompression can provide
marked pain relief and restore physi-
cal function and quality of life.
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