This 2008 NEJM Clinical Practice review by Katz and Harris addresses the evaluation and treatment of lumbar spinal stenosis (LSS). It synthesizes diagnostic criteria, classification systems, imaging limitations, and trial data on nonoperative and operative management. The target patient is the elderly adult with neurogenic claudication — the most common indication for spinal surgery in patients over 65.
The 72-year-old who walks two blocks and leans on a shopping cart is a classic LSS presentation — and it is a clinical diagnosis first, an imaging diagnosis second.
Order MRI only when injection or surgery is being considered, not to confirm the diagnosis. More than 1 in 5 asymptomatic seniors over 60 will have stenosis on imaging. Acting on that finding without clinical correlation leads to unnecessary surgery.
When you counsel a surgical candidate, give them the honest numbers: surgery gets them better faster, but roughly one third will have back pain a decade out and 1 in 5 will need reoperation. Surgery is not a cure. It is an acceleration of recovery with a durable but imperfect result.
If spondylolisthesis is present on preoperative imaging, add fusion to the decompression. If there is no listhesis, decompression alone is the standard. Fusion adds complications and cost without evidence of added benefit.
This 2008 NEJM Clinical Practice review by Katz and Harris addresses the evaluation and treatment of lumbar spinal stenosis (LSS). It synthesizes diagnostic criteria, classification systems, imaging limitations, and trial data on nonoperative and operative management. The target patient is the elderly adult with neurogenic claudication — the most common indication for spinal surgery in patients over 65.
The 72-year-old who walks two blocks and leans on a shopping cart is a classic LSS presentation — and it is a clinical diagnosis first, an imaging diagnosis second.
Order MRI only when injection or surgery is being considered, not to confirm the diagnosis. More than 1 in 5 asymptomatic seniors over 60 will have stenosis on imaging. Acting on that finding without clinical correlation leads to unnecessary surgery.
When you counsel a surgical candidate, give them the honest numbers: surgery gets them better faster, but roughly one third will have back pain a decade out and 1 in 5 will need reoperation. Surgery is not a cure. It is an acceleration of recovery with a durable but imperfect result.
If spondylolisthesis is present on preoperative imaging, add fusion to the decompression. If there is no listhesis, decompression alone is the standard. Fusion adds complications and cost without evidence of added benefit.