Review Question - QID 217398

This patient has lumbar spinal stenosis that has failed nonoperative treatment. Posterior decompression has superior clinical outcomes compared to nonoperative care.

Lumbar spinal stenosis is a degenerative condition caused by the narrowing of the lumbar spinal canal that is characterized by low back pain with or without leg pain and improves with lumbar flexion. First-line treatment includes non-operative care with physical therapy, NSAIDs, weight loss, and epidural steroid injections. Surgical treatment is indicated when patients fail nonoperative management and consists of posterior decompression. The addition of instrumentation is reserved for associated segmental instability (spondylolisthesis) or surgical instability (resection of more than 50% of facet).

Asghar et al provided an overview of the Spine Patient Outcomes Research Trial (SPORT) which was a multicenter, prospective study comparing operative and nonoperative treatment for three conditions: intervertebral disk herniation, degenerative spondylolisthesis, and lumbar spinal stenosis. Overall, both surgical and nonsurgical treatment resulted in improvement in outcomes at 4 years, however, the as-treated analysis suggested that surgical treatment resulted in greater improvement. Across SPORT, patients with chronic diseases such as lumbar spinal stenosis and degenerative spondylolisthesis saw greater improvement with surgery than patients with intervertebral disk herniation. Lastly, there were no significant neurologic deficits as a result of surgical management or catastrophic progression of neurological deficits with watchful waiting in any of the three arms of the study.

Oster et al performed a systematic review and meta-analysis of all SPORT studies with up to 10 years of clinical outcomes. Surgery showed greater improvement in pain and physical function compared with nonoperative treatment through 4 years. Then from 4 to 8 years, the difference between operative and nonoperative diminished.

Figure A shows a lateral lumbar x-ray with multilevel disc space narrowing and osteophyte formation without listhesis. Figure B shows an axial view of a lumbar MRI with central and lateral recess stenosis.

Incorrect Answers:
Answer 1: According to the SPORT study, dural tears are the most common surgical complication.
Answer 2: About 13% of patients will undergo reoperation after 4 years, and about 50% of these are due to restenosis at the same level.
Answer 3: Posterior decompression with fusion has not been shown to have superior outcomes compared to decompression alone for patients with lumbar spinal stenosis without spondylolisthesis.
Answer 4: According to the SPORT study, it is unlikely watchful waiting will result in catastrophic neurological progression.