to the editor: I am board-certified in family medicine but have been working exclusively in pain management for 10 years. The article by Drs. Hardy and Alvarez on spinal stenosis1 seems to recommend surgery for virtually all cases. I believe this recommendation is inappropriate and misleading.
Spinal stenosis is a chronic condition that is less prone to spontaneous improvement than disc disease. However, a Swedish study documented the remarkable stability of the condition, with only 15 percent of cases progressing in severity, although not seriously, over 49 months.2
The majority of patients with spinal stenosis are elderly at the onset of symptoms, and most will not progress to a severe neurologic deficit within their lifetime. If neurologic deficits develop, the progression is gradual. Therefore, most patients must deal with pain as the primary symptom. In elderly patients, justification of extensive surgery to treat a pain problem demands that other treatments must first be tried. Rarely do patients receive many nonsurgical treatments.
Many patients with symptomatic spinal stenosis are obese with pendulous abdomens, causing hyperlordosis that accentuates the stenosis. Many of these patients improve with weight loss.
As pointed out in the article, the degree of stenosis is poorly correlated with the degree of pain. One reason is that physicians are basing the diagnosis on magnetic resonance imaging rather than taking an adequate history and giving a physical examination. Many elderly patients have weakness of the sacroiliac ligament that generates pain similar to that of spinal stenosis—that is, pain on ambulation and standing. This diagnosis is easily confirmed by injection of local anesthetic. Such patients will respond to ligament prolotherapy.
Epidural administration of corticosteroids is, of course, not curative; however, many patients who receive them experience a prolonged period of relief. If the interval of relief is good—for instance, six months or more—then this treatment is a practical alternative to surgery with its inherent risks.
Patients with a difference in the length of their legs and pain on the side with the longer leg may respond to a lift to correct the shorter leg.
Patients with clearly unilateral symptoms often respond to ligament prolotherapy on the painful side of the body.
Patients with listhesis and/or disc disease that contributes to the stenosis often respond to prolotherapy at that level in the spine.
Physical therapy and chiropractic treatments sometimes provide adequate relief.
Every physician's practice has an inherent selection bias. In a pain management practice, it would appear that surgery rarely helps. Of course, we often see the patients in whom surgery has failed. However, I do believe that the figures presented by Drs. Hardy and Alvarez in their article are overly optimistic. As they point out in the article, decompressive surgery can worsen instability of the spine. As a consequence, the sciatic pain often improves, but the lower back pain often worsens.
In summary, in the absence of any serious neurologic signs, many forms of treatment should be explored before surgery is recommended.
in reply: We appreciate Dr. Matthew's comments in regard to our article on the treatment of lumbar spine stenosis.
Controversy exists among subgroups of clinicians about whether symptomatic lumbar canal stenosis should be managed solely with nonsurgical “conservative methods,” or whether all patients should undergo a nonsurgical treatment regimen and be given the option of surgery if the initial therapy fails.
Dr. Matthews stated that so-called weakness of the sacroiliac ligament can mimic the symptoms of neurologic claudication. He suggested that treatments such as “ligament prolotherapy,” chiropractic manipulation and corticosteroid injections be offered to patients in lieu of surgical decompression. He did not, however, address the risks or benefits of these treatment modalities or their long-term efficacy (if any) in relieving the symptoms of claudication, nor did he substantiate his claims with data from the existing literature.
We agree that lumbar stenosis and its clinical syndrome may be underdiagnosed, misdiagnosed and, at times, overdiagnosed. Entities such as weakness of the sacroiliac ligament should not be confused with neurologic claudication, since the latter condition presents with classic, almost unmistakable signs and symptoms. It is unfortunate that patients who are misdiagnosed often undergo multiple noninvasive therapies that may provide short-term relief (as stated by Dr. Matthews), yet provide little or no long-term benefit to the patient.
Dr. Matthews commented that he sees many patients in whom surgery has failed; however, he did not specify which types of surgical procedures these patients underwent and for what indications. In a prospective study, Javid and colleagues1 found that 70.8 percent of patients who underwent decompressive laminectomies for stenosis improved postoperatively. The follow-up period was from one to 11 years. Silvers and colleagues2 noted a success rate of 93 percent after surgery for lumbar spine stenosis. Of course, the literature is replete with studies on decompressive surgery with wide-ranging improvement rates. However, most of the recent literature confirms that more than two thirds of symptomatic patients benefit from surgery.
Meticulous adherence to strict surgical criteria is imperative to ensure a good outcome. Back pain should not be the sole criterion used when deciding to operate on a patient with lumbar stenosis. Discogenic or degenerative back pain in patients with or without stenosis is a completely different entity, and the management algorithm, which may include surgical fusion, is different than that for neurogenic claudication.
Failure to differentiate among patients on the basis of their clinical presentation, pathology (e.g., lumbar canal stenosis, discogenic back pain, traumatic instability, spondylolisthesis) and radiologic findings, and thus to make treatment recommendations accordingly, may be why some groups have had such low success rates with surgery. Furthermore, the psychologic and medical profiles of a patient can also significantly influence the surgical outcome. This was demonstrated by Thomas and colleagues,3 who found a statistically significant relationship between the presence of comorbid medical and emotional problems and surgical outcome following decompressive lumbar laminotomies for stenosis. Therefore, the overall medical and biopsychosocial status of the patient should be taken into serious consideration in the presurgical evaluation and, in selected cases, this may influence which patients are optimal candidates for surgery and which patients are not.
As clearly stated in our article, patients with mild leg pain or symptoms of short duration may be offered physical therapy, analgesics or other nonsurgical therapies initially. Morbidly obese patients may indeed improve by following a weight loss program. We feel that while it is reasonable to recommend a non-surgical treatment regimen initially, patients who present to the primary care provider with unremitting, disabling leg and back pain caused by lumbar canal stenosis with appropriate radiologic correlation should be offered the option of surgical decompression. Surgical management is by far the most effective treatment for this disabling disease and delaying surgery with unproven “therapies” may result in the progression of symptoms and unnecessary prolonged suffering. This is clearly a disservice to our patients.