Degenerative lumbar spinal stenosis in older people: current treatment options

Abstract

Background: Degenerative lumbar spinal stenosis is increasingly being diagnosed in persons over age 65. In 2011, 55 793 older people with this condition were treated as inpatients in German hospitals. Among physicians, there is much uncertainty about the appropriate treatment strategy.

Method: Selective literature review.

Results: Lumbar spinal stenosis in older people is characterized by spinal claudication and neurological deficits. A precise clinical history and physical examination and ancillary radiological studies are the necessary prerequisites for treatment. Magnetic resonance imaging is the radiological study of choice. Conservative treatment consists of physiotherapy, drugs, and local injections; various surgical treatments can be considered, depending on the severity of the problem. The main purpose of surgery is to decompress the spinal canal. If the lumbar spine is demonstrably unstable, an instrumented fusion should be performed in addition. There is, however, only moderately good evidence supporting the superiority of surgery over conservative treatment. In a prospective study, the complication rate of purely decompressive surgery was found to be 18%. The utility of the current operative techniques cannot be definitively assessed, because they are applied to a wide variety of patients in different stages of the disease and at different degrees of severity, and the reported results are thus not comparable from one trial to another.

Conclusion: No evidence-based recommendation on the diagnosis and treatment of lumbar spinal stenosis in older people can be formulated at present because of the lack of pertinent randomized trials.

Figure 1

The number of spinal operations performed annually in Germany from 2005 to 2010. Overall increase, 105%; increase in persons over age 65, 162%.(Source: Federal Statistical Office, Bonn)

Figure 2

Methods of simple decompression: a) laminectomy b) hemilaminectomy c) bilateral and d) unilateral interlaminar fenestration with undercutting

Figure 3

Bilateral, severe spinal canal and lateral recess stenosis a) Preoperative axial T2-weighted MRI at the L3 and L4 levels b) An MRI six months after surgery reveals the extent of decompression, performed in this case as a unilateral interlaminar decompression from the left with undercutting on the right. The typical spinal claudication that was present before surgery resolved completely. Back pain on movement remained to some extent but did not cause any significant impairment. (With kind permission of the Neuroradiology Division at the Universitätsklinikum Jena)

Figure 4

This otherwise healthy 79-year-old woman presented in 2011 with severe pain and could not walk more than 200 m without pausing. She also had marked radicular symptoms. Imaging revealed lumbar scoliosis with rotational slippage and consequent spinal stenosis, along with typical age-associated degenerative changes at all of the spinal levels depicted

Figure 5

A lateral view of the same patient reveals loss of height of all of the lumbar discs, with vacuum phenomena at L2/3, L4/5, and L5/S1 and corresponding osteochondrosis. The double contours of the posterior edges of the L2 and L3 vertebral bodies indicate that these two vertebrae are rotated

Figure 6

1 1/2 years after unilateral, multisegmental, dorsoventral decompression and fusion, the spinal deformity in the frontal x-ray view has been fully corrected. Laminectomies were performed at the apex of the curvature. There are unaltered signs of degeneration at the levels adjacent to the fusion. More important than the postoperative images is the clinical result: the patient now complains only of mild back pain and takes no medication. For longer walks away from home, she uses a cane to feel secure. She has no radicular symptoms

Figure 7

A lateral view of the same patient reveals a correct implant configuration without any evidence of loosening or dislocation. There are unaltered signs of degeneration at the adjacent levels. No instability has arisen