Progression of Spinal Stenosis and Surgical Options

Question: What Surgery Should I Undergo for Further Spinal Stenosis Treatment?

My CT and discogram show that once again, I have spinal stenosis. I am a 53 year old female. 10 years ago I had a laminectomy/discectomy that made things worse.

My new surgeon was appalled at the amount of material taken. He performed a pedicle screw fusion L-4, L-5, S-1 9 years ago (I had 3 other opinions that strongly recommended the same surgery). Now, 9 years later, the pain is back. He suggests first an epidural to see if it helps with the pain from spinal stenosis; second an L-3/L-4 fusion.

He felt that a laminectomy might not work and that I would then require another surgery for the fusion. Also, he said that in over 20 years of practice, he has had this result (the L3/L4) only 15 times and that a fusion had 50-50 success with leg pain and less with back pain.

My pain is 90% leg pain. I cannot drive more than 5 miles, have trouble walking, and my stomach is getting to be a problem, due to taking non-narcotic drugs. My weight is good and I am doing all non-invasive therapies.

Is this development of spinal stenosis at the L3/L4 typical in such cases? What is your sense of success with laminectomy vs. fusion at the higher level? Will the problem continue to return over the years (I am only 53)? Will it continue creep up the spine? Does stenosis pain just get worse and worse as the facet area increases?

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Doctor’s Response: Maximize Your Conservative Treatments Before Exploring Further Surgery

It is not typical to get a transfer lesion to the level above a fusion, but it definitely happens. The only two choices for treating your spinal stenosis are either further surgery, and a spine fusion is usually necessary, or continued conservative treatment.

The problem with further surgery is that it then creates an even longer lever arm to transfer stress to the next (L2-L3) level in the spine. My own experience is that the results are probably slightly better than 50-50, but the real problem is that you are taking another joint and further changing the biomechanics of the back.

I usually will advise my patients to maximize their conservative treatment for spinal stenosis (including epidural injections, therapy and even chiropractics), and if they cannot live with their activity limitations anymore, then consider surgery only as a salvage procedure.

It is possible to do only a decompression surgery if there is no associated instability (i.e. degenerative spondylolisthesis). Obviously, the risk with a decompression surgery alone is that a spine fusion surgery may be necessary in the future. Basically, there is risk either way.

A spine fusion surgery may lead to further breakdown at the next level, and decompression surgery alone may lead to instability at the affected level and require a fusion in the future. In general, if a patient has mostly leg pain, and there is no instability, I will counsel him or her to have the decompression alone.

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In Spine-health’s Doctor Advice section, physicians respond to frequently asked questions about back pain issues. These responses represent the opinion of one physician, and do not necessarily reflect the views of the broader medical community. The advice presented has not been peer reviewed by Spine-health’s medical advisory board.

Written by Medical Reviewer