Nonsurgical and surgical management of lumbar spinal stenosis.

The symptoms associated with lumbar spinal stenosis can decrease quality of life and may cause patients to seek treatment. Except in rare cases of rapid neurologic progression or cauda equina syndrome, nonsurgical modalities should be the initial treatment choice. Activity modification, a variety of medications, epidural steroid injections, and other methods are recommended for pain reduction. A formal physical therapy program, which focuses on flexion-based exercises, may lead to improved patientfunction. Surgery is indicated in patients who remain symptomatic despite a course of nonsurgical therapy and who have advanced imaging studies that correspond to existing .symptoms. Adequate decompression of the neural elements and maintenance of bony stability are necessary for a good surgical outcome for patients with spinal stenosis. Laminectomy has long been the method of choice for thorough lumbar decompression. Preserving at least the lateral half of the facet joints bilaterally and bone in the area of the pars interarticularis minimizes the potential for iatrogenic instability. Numerous other decompression techniques have been described, including multilevel laminotomies, fenestration, distraction laminoplasty, and microscopic decompression. Arthrodesis, either with or without instrumentation, is also indicated in some patients. Several studies report that surgical treatment produces better outcomes than nonsurgical treatment in the short term; however, the results tend to deteriorate with time. Lumbar decompressive surgery can be complicated by epidural hematoma, deep venous thrombosis, dural tear, infection, nerve root injury, and recurrence of symptoms.