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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.
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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:
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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.
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The surgery should not create a new problem, such as
a nerve injury or a structural instability that might
require additional surgeries.
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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.
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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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