Review Question - QID 219108

Lumbar Spinal Stenosis Treatment Operative QID: 219108 (OBQ10.249.1)

QID 219108 (Type "219108" in App Search)

A 54-year-old man presents with 6 months of bilateral buttock and leg pain. He is an avid cyclist and has minimal pain while on a bike; however, he has severe pain when walking. Initial treatment including physical therapy, NSAIDS, and an epidural steroid injection provided only temporary relief. On physical exam he has normal motor strength in his lower extremities, negative straight-leg raise tests bilaterally, and palpable bilateral dorsalis pedis pulses. Figure A shows his lumbar flexion and extension views. A video of the axial and sagittal views of his lumbar MRI is attached. What is the most appropriate next step in management?

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A decompressive laminectomy with bilateral medial facetectomies and foraminotomies

61%

401/656

A decompressive laminectomy, bilateral medial facetectomies and foraminotomies, and an instrumented fusion

27%

179/656

Anterior lumbar interbody fusion, decompressive laminectomy and posterior instrumented fusion

31/656

Continue physical therapy

20/656

Referral to vascular surgery for evaluation for peripheral vascular disease

15/656

Select Answer to see Preferred Response

The clinical presentation and imaging studies are consistent with neurogenic claudication due to spinal stenosis, without degenerative spondylolisthesis on flexion and extension radiographs. The patient has already failed an initial attempt at nonoperative management, and therefore a decompressive laminectomy is the most appropriate next step in management.

Lumbar spinal stenosis is a degenerative condition that is caused by the narrowing of the lumbar spinal canal. There are multiple anatomic causes for this narrowing including facet osteophytes, herniated discs, and ligament flavum hypertrophy or buckling. Classic symptoms of lumbar spinal stenosis include heaviness and pain in the buttocks and legs that is worse with standing, walking, or extension of the back, while relieved with sitting and flexing the back. Symptoms are not relieved by going from walking to standing still upright, as they are in vascular claudication. Spondylolisthesis can also cause narrowing of the spinal canal and should be identified in the diagnostic process. Segmental instability is typically treated with wide pedicle-to-pedicle decompression and instrumented fusion.

Weinstein et al. published the results of patients with spinal stenosis from the SPORT trial. This multi-center trial evaluated a total of 654 patients with at least 12 weeks of symptoms and spinal stenosis without spondylolisthesis. The authors concluded that patients who underwent decompressive surgery showed significantly more improvement in all primary outcomes when compared to patients who were treated non-surgically.

Atlas et al. published a prospective cohort study of patients with lumbar spinal stenosis, in conjunction with the Maine Lumbar Spine Study Group, of 119 patients treated surgically and 52 treated non-surgically. At 4-year follow-up, surgical treatment was associated with greater improvement in patient-reported outcomes than non-surgical treatment. The authors conclude that mid-term outcome data supports decompressive surgery in patients with spinal stenosis.

Figure A shows flexion and extension lumbar radiographs without spondylolisthesis. Figure B shows an embedded video that presents an MRI with T2 sequences in the axial and sagittal planes of a lumbar spine with spinal stenosis.

Incorrect Answers:
Answer 2 and 3: This patient does not have degenerative spondylolisthesis or segmental instability, and thus does not require lumbar fusion.
Answer 4: The patient has already failed a trial of nonoperative management over 6 weeks, thus is indicated for operative management.
Answer 5: Vascular claudication due to peripheral vascular disease is characterized by pain with activity, such as walking or cycling, that improves with rest, including standing upright. This patient's symptoms are not consistent with vascular claudication, and therefore referral to vascular surgery is not indicated.