eMedicine Specialties > Neurosurgery > Spine

Spinal Stenosis: Treatment

Author: John Nk Hsiang, MD, PhD, Director of Spine Surgery, Seattle Neuroscience Institute
Contributor Information and Disclosures

Updated: Jul 30, 2009

Treatment

Medical Therapy

If symptoms are mild, nonsurgical treatment can be effective. Nonsurgical treatments include physical therapy, anti-inflammatory drugs, and epidural steroid injections. These treatments may be used to manage symptoms on a long-term basis for patients who are not surgical candidates. Urgent surgical intervention is indicated for patients who present with signs and symptoms of spinal cord compression.

Surgical Therapy

Surgical treatment for lumbar stenosis includes laminectomy and posterior foraminotomy at the involved levels. For cervical stenosis, either an anterior or a posterior approach can be used. Because most patients are elderly, they usually have comorbidities from cardiac or pulmonary problems. Multilevel decompression requires general anesthesia, and significant blood loss is possible. A cardiologist or pulmonologist must evaluate these patients before surgery. Many of these patients are taking antiplatelet medications. If possible, they should discontinue these drugs 1 week before the operation.

Lumbar laminectomy is straightforward. To obtain effective decompression of the lateral recess, the surgeon should remove the medial part of the hypertrophic facet joint. However, wide decompression and removal of much of the facet joints occasionally results in spondylolisthesis, particularly in patients who already demonstrate preoperative spinal instability. Sometimes, it is necessary to perform spinal fusion surgery after the decompressive laminectomy.

For cervical stenosis, surgical decompression can be performed through either the anterior or posterior approach. The posterior approach is indicated for multilevel compression or posterior compression from a hypertrophied ligamentum flavum. Again, violating the facet joints can result in development of swan-neck deformity. For this reason, some surgeons prefer a cervical laminoplasty to cervical laminectomy. Cervical laminoplasty allows decompression of the spinal cord and unilateral nerve roots with the preservation of the contralateral facet joints. It also allows for a construction of the elevated lamina to provide stability.

Frequently, cervical stenosis is caused by anterior compression due to osteophyte formation. An anterior approach is technically more demanding, carries a higher risk, and often requires fusion. In experienced hands, anterior decompression and fusion for 3 or fewer disk levels (2-level vertebral corpectomy) is relatively safe, and the success rate is high.

With more than 3 disk levels, the nonfusion rate and morbidity rate are significantly higher. For 1-level anterior cervical fusion, allograft is almost as effective as autograft in terms of fusion rate. Anterior cervical plating may not be necessary for single-level operations, even though US surgeons commonly perform it. For 2 or more levels of decompression and fusion, autograft is preferred over allograft.

Instrumentation using an anterior cervical plate is highly recommended in that setting. In general, surgery involving more than 2 levels of fusion is not indicated for patients in poor medical condition and with poor bone density.

After decompressive surgery, some patients, especially those with myelopathy, require physical therapy or rehabilitation.

Complications

Surgery for spinal decompressive laminectomy is a relatively safe procedure. The more common complications include wound infection, cerebrospinal fluid leak, and iatrogenic injury to neural structures. Long-term complications can include spinal instability.

As expected, the anterior approach to the cervical spine carries a greater risk of complications. Other than the usual risks of wound infection and nerve damage, additional risks include vascular injury (carotid and vertebral arteries), injury to the recurrent laryngeal nerve (with vocal cord paralysis), injury to the esophagus (and subsequent dysphagia), instrumentation failure, and failure of fusion.

The rate of nonunion is significantly higher in long-term smokers and with multilevels of fusion. The risk of complications increases with greater levels of decompression and in patients with other medical conditions, such as diabetes, and long-term steroid use.

More on Spinal Stenosis

Overview: Spinal Stenosis
Workup: Spinal Stenosis
Treatment: Spinal Stenosis
Follow-up: Spinal Stenosis
Multimedia: Spinal Stenosis
References
Further Reading
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References

  1. Jonsson B, Stromqvist B. Symptoms and signs in degeneration of the lumbar spine. A prospective, consecutive study of 300 operated patients. J Bone Joint Surg Br. May 1993;75(3):381-5. [Medline].

  2. Fehlings MG, Skaf G. A review of the pathophysiology of cervical spondylotic myelopathy with insights for potential novel mechanisms drawn from traumatic spinal cord injury. Spine. Dec 15 1998;23(24):2730-7. [Medline].

  3. Trouillier H, Birkenmaier C, Kluzik J, et al. Operative treatment for degenerative lumbar spinal canal stenosis. Acta Orthop Belg. Aug 2004;70(4):337-43. [Medline].

  4. [Guideline] Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 9: fusion in patients with stenosis and spondylolisthesis. J Neurosurg Spine. Jun 2005;2(6):679-85. [Medline].

  5. [Guideline] Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, et al. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 10: fusion following decompression in patients with stenosis without spondylolisthesis. J Neurosurg Spine. Jun 2005;2(6):686-91. [Medline].

  6. [Guideline] Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. Jan 2007;10(1):7-111. [Medline].

  7. Albert TJ, Vacarro A. Postlaminectomy kyphosis. Spine. Dec 15 1998;23(24):2738-45. [Medline].

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  9. Kaptain GJ, Simmons NE, Replogle RE, Pobereskin L. Incidence and outcome of kyphotic deformity following laminectomy for cervical spondylotic myelopathy. J Neurosurg. Oct 2000;93(2 Suppl):199-204. [Medline].

  10. Lee KK, Teo EC. Effects of laminectomy and facetectomy on the stability of the lumbar motion segment. Med Eng Phys. Apr 2004;26(3):183-92. [Medline].

  11. Postacchini F, Cinotti G, Perugia D. The surgical treatment of central lumbar stenosis. Multiple laminotomy compared with total laminectomy. J Bone Joint Surg Br. May 1993;75(3):386-92. [Medline].

  12. Saunders RL. Anterior reconstructive procedures in cervical spondylotic myelopathy. Clin Neurosurg. 1991;37:682-721. [Medline].

  13. Spratt KF, Keller TS, Szpalski M, et al. A predictive model for outcome after conservative decompression surgery for lumbar spinal stenosis. Eur Spine J. Feb 2004;13(1):14-21. [Medline].

  14. Stoops WL, King RB. Neural complications of cervical spondylosis: their response to laminectomy and foramenotomy. J Neurosurg. Nov 1962;19:986-99. [Medline].

  15. Turner JA, Ersek M, Herron L, Deyo R. Surgery for lumbar spinal stenosis. Attempted meta-analysis of the literature. Spine. Jan 1992;17(1):1-8. [Medline].

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Further Reading

Clinical guidelines
North American Spine Society (NASS). Diagnosis and treatment of degenerative lumbar spinal stenosis. Burr Ridge (IL): North American Spine Society (NASS); 2007 Jan. 262 p.

Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC 3rd, Wang J, Walters BC, Hadley MN, American Association of Neurological Surgeons/Congress of Neurological Surgeons. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 9: fusion in patients with stenosis and spondylolisthesis. J Neurosurg Spine 2005 Jun;2(6):679-85. 4

Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC 3rd, Wang J, Walters BC, Hadley MN, American Association of Neurological Surgeons/Congress of Neurological Surgeons. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 10: fusion following decompression in patients with stenosis without spondylolisthesis. J Neurosurg Spine 2005 Jun;2(6):686-91. 5

Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician 2007 Jan;10(1):7-111. 6

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Keywords

spinal stenosis, lumbar stenosis, narrowing of the spinal canal, narrowing of the nerve root canals, narrowing of the intervertebral foramina, spondylosis, degenerative disk disease, cervical spine, lumbar spine, thoracic spine, primary stenosis, congenital stenosis, acquired stenosis, osteophytes, bone spurs, facet hypertrophy, bulging disks, hypertrophy of the ligamentum flavum, canal narrowing, foraminal narrowing, degenerative spondylolisthesis, cauda equina syndrome

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Contributor Information and Disclosures

Author

John Nk Hsiang, MD, PhD, Director of Spine Surgery, Seattle Neuroscience Institute
John Nk Hsiang, MD, PhD is a member of the following medical societies: American Association of Neurological Surgeons, North American Spine Society, Sigma Xi, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Medical Editor

Paul L Penar, MD, Professor, Department of Surgery, Division of Neurosurgery, University of Vermont School of Medicine
Paul L Penar, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, and Congress of Neurological Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Allen R Wyler, MD, Former Medical Director, Northstar Neuroscience, Inc
Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

Allen R Wyler, MD, Former Medical Director, Northstar Neuroscience, Inc
Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons
Disclosure: Nothing to disclose.

 
 
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