Spinal stenosis: surgical versus nonsurgical treatment.

UNLABELLED: Lumbar spinal stenosis is being diagnosed increasingly in older people as advanced imaging studies become more widely available and clinicians become more familiar with the presentation of this common condition. For symptomatic patients, the goal of treatment is pain relief and improved function, but there is little empiric evidence to support many of the common interventions used. The relative risks and benefits of various surgical and nonsurgical treatments are poorly understood, and the result has been wide variations in the evaluation and treatment of spinal stenosis across geographic regions. Current practice recommendations are based on expert opinion that incorporates available evidence into existing clinical and biologic paradigms. For most individuals, initial treatment should focus on patient education, medications to control pain, and exercise and physical treatments to regain or maintain activities of daily living. Surgical treatment most commonly is considered in patients not improving with nonsurgical care. Decompressive laminectomy is the standard surgical procedure for patients with spinal stenosis. The addition of fusion with or without instrumentation is considered when spinal stenosis is accompanied by degenerative spondylolisthesis or related to concerns about instability. We review the available evidence for nonsurgical and surgical interventions, and highlight comparative results wherever applicable. LEVEL OF EVIDENCE: Level V (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.