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Anti-inflammatory medications should be used with caution in the elderly due to the risks of GI bleeding, fluid retention, renal failure, and cardiovascular risks.
Side effects of opioids, include constipation, confusion, urinary retention, drowsiness, nausea, vomiting, and the potential for dependence.
>10% of elderly lack Achilles reflexes.
‚
ISSUES FOR REFERRAL
Refer to a spine surgeon when patients are in unremitting pain or have a neurologic deficit. ‚
ADDITIONAL THERAPIES
- Patients with spinal stenosis are typically able to ride a bicycle because leaning forward tends to relieve symptoms.
- Aquatic therapy (helpful for muscle training and general conditioning)
- Strengthening of abdominal and back extensor muscles
- Gait training
- A brace or corset may help in the short term but is not recommended for prolonged periods due to development of paraspinal muscle weakness.
- Encourage physical activity to prevent deconditioning.
SURGERY/OTHER PROCEDURES
- Surgery is indicated when symptoms persist despite conservative measures (7)[A].
- Age alone should not be an exclusion factor for surgical intervention. Cognitive impairment, multiple comorbidities, and osteoporosis may increase the risk of perioperative complications in the elderly.
- Lumbar decompressive laminectomy is the mainstay of treatment. The traditional approach is laminectomy and partial facetectomy.
- Controversy exists about whether the decompression should be supplemented by a fusion procedure:
- There is evidence that fusion (simple or complex), as opposed to decompression procedure alone, may be associated with higher risk of major complications, increased mortality, and increased resource use in the elderly.
- A less-invasive alternative, known as interspinous distraction (X STOP implant), is an option (11)[B].
- The evidence for use of the Aperius interspinous implant device is inconclusive (12,13)[C].
- A unilateral partial hemilaminectomy combined with transmedial decompression may adequately treat stenosis with less morbidity in the elderly (14)[C].
- Transforaminal balloon treatment may be a viable option for resistant spinal stenosis pain and functional impairment (15)[B].
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Acute or progressive neurologic deficit ‚
Discharge Criteria
Improved pain or after neurologic deficit has been addressed. ‚
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Follow up based on progression of symptoms.
- No limitations to activity; patients may be as active as tolerated. Exercise should be encouraged.
Patient Monitoring
Patients are monitored for improvement of symptoms and development of any complications. ‚
DIET
Optimize nutrition for weight management and surgery. ‚
PATIENT EDUCATION
- Activity as tolerated, if no other pathology is present (e.g., fractures).
- Patients should present for care if they develop progressive motor weakness and/or bladder/bowel dysfunction.
- Patients should know the natural history of the condition and how best to relieve symptoms.
PROGNOSIS
- Spinal stenosis is generally benign, but the pain can lead to limitation in ADLs and progressive disability.
- Surgery usually improves pain and symptoms in patients who fail nonoperative treatment.
- Surgical outcomes are similar in terms of pain relief and functional improvement for patients of all ages.
COMPLICATIONS
- Severe spinal stenosis can lead to bowel and/or bladder dysfunction.
- Surgical complications include infection, neurologic injury, chronic pain, and disability.
REFERENCES
11 Baker ‚ ADL. Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. In: Banaszkiewicz ‚ P, Kader ‚ DF , eds. Classic Papers in Orthopedics. London, England: Springer London; 2014:245 " “247.22 Ammendolia ‚ C, Stuber ‚ K, de Bruin ‚ LK, et al. Nonoperative treatment of lumbar spinal stenosis with neurogenic claudication: a systematic review. Spine Spine (Phila Pa 1976). 2012;37(10):E609 " “E616.33 Katz ‚ JN, Harris ‚ MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med. 2008;358(8):818 " “825.44 Suri ‚ P, Rainville ‚ J, Kalichman ‚ L, et al. Does this older adult with lower extremity pain have the clinical syndrome of lumbar spinal stenosis? JAMA. 2010;304(23):2628 " “2636.55 Ohtori ‚ S, Yamashita ‚ M, Murata ‚ Y, et al. Incidence of nocturnal leg cramps in patients with lumbar spinal stenosis before and after conservative and surgical treatment. Yonsei Med J. 2014:55(3):779 " “784.66 Li ‚ AL, Yen ‚ D. Effect of increased MRI and CT scan utilization on clinical decision-making in patients referred a surgical clinic for back pain. Can J Surg. 2011;54(2):128 " “132.77 Weinstein ‚ JN, Tosteson ‚ TD, Lurie ‚ JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med. 2008;358(8):794 " “810.88 Delitto ‚ A, Piva ‚ SR, Moore ‚ CG, et al. Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial. Ann Intern Med. 2015:162(7):465 " “473.99 Deyo ‚ RA, Ching ‚ A, Matsen ‚ L, et al. Use of bone morphogenetic proteins in spinal fusion surgery for older adults with lumbar stenosis: trends, complications, repeat surgery, and charges. Spine (Phila Pa 1976). 2012;37(3):222 " “230.1010 Deyo ‚ RA, Mirza ‚ SK, Martin ‚ BI, et al. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303(13):1259 " “1265.1111 Miller ‚ LE, Block ‚ JE. Interspinous spacer implant in patients with lumbar spinal stenosis: preliminary results of a multicenter, randomized, controlled trial. Pain Res Treat. 2012;2012:823509.1212 Postacchini ‚ R, Ferrari ‚ E, Cinotti ‚ G, et al. Aperius interspinous implant versus open surgical decompression in lumbar spinal stenosis. Spine J. 2011;11(10):933 " “939.1313 Surace ‚ MF, Fagetti ‚ A, Fozzato ‚ S, et al. Lumbar spinal stenosis treatment with Aperius perclid interspinous system. Eur Spine J. 2012;21(Suppl 1):S69 " “S74.1414 Morgalla ‚ MH, Noak ‚ N, Merkle ‚ M, et al. Lumbar spinal stenosis in elderly patients: is a unilateral microsurgical approach sufficient for decompression? J Neurosurg Spine. 2011;14(3):305 " “312.1515 Kim ‚ SH, Choi ‚ WJ, Suh ‚ JH, et al. Effects of transforaminal balloon treatment in patients with lumbar foraminal stenosis: a randomized, controlled, double-blind trial. Pain Physician. 2013;16(3):213 " “224.
SEE ALSO
Algorithm: Low Back Pain, Acute ‚
CODES
ICD10
- M48.00 Spinal stenosis, site unspecified
- M48.06 Spinal stenosis, lumbar region
- M48.04 Spinal stenosis, thoracic region
- M48.05 Spinal stenosis, thoracolumbar region
- M48.08 Spinal stenosis, sacral and sacrococcygeal region
- M48.07 Spinal stenosis, lumbosacral region
- M48.02 Spinal stenosis, cervical region
- M48.01 Spinal stenosis, occipito-atlanto-axial region
- M47.9 Spondylosis, unspecified
- M48.03 Spinal stenosis, cervicothoracic region
ICD9
- 724.00 Spinal stenosis, unspecified region
- 724.02 Spinal stenosis, lumbar region, without neurogenic claudication
- 724.01 Spinal stenosis, thoracic region
- 724.09 Spinal stenosis, other region
- 723.0 Spinal stenosis in cervical region
- 721.90 Spondylosis of unspecified site, without mention of myelopathy
- 724.03 Spinal stenosis, lumbar region, with neurogenic claudication
SNOMED
- 76107001 Spinal stenosis (disorder)
- 18347007 Spinal stenosis of lumbar region
- 41341006 Spinal stenosis of thoracic region
- 370471003 Lumbosacral stenosis (disorder)
- 8847002 Spondylosis (disorder)
- 83561009 Spinal stenosis in cervical region
- 202783003 Degenerative thoracic spinal stenosis (disorder)
- 202761002 Degenerative cervical spinal stenosis (disorder)
- 202788007 Degenerative lumbar spinal stenosis (disorder)
CLINICAL PEARLS
- Spinal stenosis often presents as neurogenic claudication (pain, tightness, numbness, and subjective weakness of lower extremities). This can mimic vascular claudication.
- Neurogenic claudication (as opposed to vascular claudication) is improved by uphill ambulation and lumbar flexion.
- Flexion of the spine generally relieves symptoms associated with spinal stenosis.
- Spinal extension (prolonged standing, walking downhill, and walking downstairs) can worsen symptoms of spinal stenosis.
- Urgent surgery should be considered for patients with cauda equina/conus medullaris syndrome or progressive bladder dysfunction. Most other patients with lumbar spinal stenosis can begin with conservative management.