The following information was put together to help in the decision-making process. The graphs show the answers of the members of EuroSpine, the Spine Society of Europe, considered to be the European experts in the field of treatment of spine pathology. This information should help you to learn and understand what most of the experts in the field would do in each specific situation. The information reflects a “common sense” approach to treatment of the members of EuroSpine, yet does not replace a careful evaluation of your individual situation. Therefore, if you find a significant difference between the answers below and you doctor’s opinion, ask your doctor what made him/her reach this decision.

Each specific situation has to be evaluated on an individual basis. EuroSpine and its members cannot be held responsible for any misunderstandings (or misdiagnosis) based on the information provided here, which in no way attempts to replace a targeted evaluation.

The graphs in the following text are the result of a questionnaire carried out among the members of EuroSpine, the Spine Society of Europe, which represents experts in different fields of spinal pathology.

Specialist's opinion:

The lumbar spine is the part of the spine located between the pelvis and the thoracic cage. It consists of five lumbar vertebrae. Each vertebra comprises a vertebral body and a vertebral arch that is connected to the corresponding vertebral body by two pedicles. The bony attachments are posterior: the spinous processes (the bone you can feel down the centre of your back), the paired transverse and the articular processes. The transverse processes serve as attachments for muscles, while the articular processes represent the posterior bilateral joints connecting each vertebra to its adjacent vertebrae. This enables motion of the corresponding intervertebral disc on the anterior part of the spine.

The intervertebral discs, joint capsules and ligaments hold the vertebrae together and control the range of segmental motion. The posterior wall of the vertebra, the bony arch and the yellow ligament extending from one arch to the next form a tube (spinal canal) containing the end of the spinal cord and the spinal nerves. Each segment has two lateral openings through which the corresponding nerve roots exit to the periphery.

Degenerative changes of the lumbar spine

General remarks

The main functions of the lumbar spine are to protect the spinal nerves and to facilitate most of the trunk's motion. The five lumbar vertebral bodies maintain distance and transmit loads from the thorax to the pelvis and serve as muscle attachments.

Motion and load create adaptive tissue changes during life. These changes include loss of tissue elasticity, growth of osteophytes and calcification of ligaments. As a result, the structures around the spinal canal increase in volume, thereby reducing the available space for the nerve roots in the canal or the outlets for the roots. This effect is sometimes emphasized by anterior vertebral slippage (degenerative spondylolisthesis) due to insufficiency by wear and tear of the vertebral facets.

The narrowing of the spinal canal is referred to as spinal stenosis.

Degenerative change is a physiological response of the body occurring during the life of an adult. Thus, depending on the age and activities of the individual, all of the imaging techniques (radiographs, computer tomography and magnetic resonance imaging) show these changes differently. Many of these changes may be asymptomatic and unknown to the person. The presence of corresponding symptoms (mostly local back pain) is dependent on the extent and localisation of the degeneration and the underlying individual anatomy.

This sometimes makes it difficult to detect the origin of pain, since the degenerative changes may be spread out (and visible) along the whole lumbar spine, but only one of them might be painful.

Symptoms of a narrow spinal canal

The predominant symptom of a narrow spinal canal is the so-called neurogenic claudication. This is a painful sensation occurring after a certain walking distance, or during a certain period of standing in an upright position. Typically, the pain disappears in a bending-forward position of the body, e.g. in the sitting position. Even if the most common symptom is leg pain (often in a specific area), other typical symptoms include weakness or unsteadiness in the legs after a certain walking distance. In severe cases, the patient may hardly be able to walk a few metres and is literally immobilized by this condition.

Diagnostics of LSS

The most important clue to diagnosis is the patient’s history, as the physical examination may not reveal conclusive findings. Imaging confirms the suspected narrowing and defines the extent of the stenosis. Magnetic resonance and sometimes computer tomography (also combined with myelography) are the most commonly used techniques.

Treatment

Treatment of symptomatic LSS can be non-operative or surgical.
Non-operative: Although the narrowness in the spinal canal has its mechanical factor, some tissue swelling and oedema are often involved in (part of) the origin of symptoms. Medical treatment may positively influence these non-mechanical factors and lead to a reduction of pain.

Specialist's opinion:

LSS is primarily a mechanical problem. If not solved otherwise, surgery has to be performed. The goal of intervention is to decompress the spinal canal and to relieve pressure on neural structures, thus diminishing (or eliminating) the severity of symptoms.

Specialist's opinion:

Decompression of the nerve roots in the spinal canal can be performed by different techniques. Indirect decompression is applied if part of the stenosis is caused by infolding ligaments. By posterior distraction, the ligaments can be stretched and the volume of the spinal and nerve root canal increased. This technique avoids manipulation in the direct vicinity of neural structures and represents a minor procedure.

Laminectomy is the most invasive procedure. All posterior elements covering the nerve roots are removed and the neural structures are thus efficiently decompressed. This method might involve some problems with the stability of the spine and necessitate an additional fusion in certain cases.

Selective (undercutting) laminotomy decompresses the neural structures by removing the thickened ligaments, thinning the laminae and reducing the volume of the facets. This technique does not usually interfere with the stability of the spine. The technique is less invasive, but the operative area might be less accessible.

Newer, less invasive methods decompress the spinal canal by percutaneous methods. By inserting instruments into the spinal canal, decompression is performed using different techniques such as with razors or lasers.

Specialist's opinion:

Simultaneous fusion combined with decompression is occasionally discussed as a possible treatment. Fusion (immobilization) of the spine (or part of it) might be helpful in reducing back pain and eliminating instability or deformity, but it calls for longer surgical procedures. (See also “Fusion of the lumbar spine”)

Specialist's opinion:

Low back pain (LBP) is an unspecific description of pain located in the lumbar spine or pelvic region. The pain does not typically radiate down the legs or at least follow the typical pattern of the anatomic distribution of the nerves. (See “Lumbar nerve root pain”).

The list of treatment modalities is endless and includes surgery, which reflects the fact that none of these procedures are the ideal solution for the problem of low back pain.

With regard to surgery, the literature is controversial. Some papers deny the existence of an objective anatomical origin of LBP and reject surgery – regardless of the procedure chosen – as a possible treatment. Others support surgery if the diagnostic procedure leads to an identifiable anatomic source (facet/disc) of pain. Newer surgical techniques promise to improve the results by preserving segmental motion of the lumbar spine.

Specialist's opinion:

One of the problems with surgery for LBP is accurately identifying the source (disc, facets, ligaments, etc.) of pain. Several diagnostic procedures are regarded as suitable for this purpose. Not all of these diagnostic tests are adequately validated and their significance remains somewhat controversial.

Specialist's opinion:

Specialist's opinion:

If the painful anatomical structure is identified, it seems logical to approach this structure to eliminate pain. Different surgical options are available.

Specialist's opinion:

The traditional method to approach various pathologies of the spine is fusion of one or more segments depending on the individual situation. This technique of immobilizing motion segments was adopted from other areas of orthopaedic surgery, such as that of the hip and knee, where the painful joint was immobilized if the problem could not otherwise be solved. Increased understanding and improved technology allowed the joint to be replaced in spite of fusing it. This type of surgery has developed into a standard procedure for most joints in the body.

Fusion is still the most frequently used technique in the spine. The complexity of the anatomy and proximity to neural structures makes it more difficult to replace parts of the spine and preserve motion. These techniques do exist today, but widespread conclusive clinical data and results are not yet available. (See also chapter “Motion preserving procedures”)

Fusion of the spine can be performed in various ways. However, the principle always remains the same: to achieve solid bony union between the fused vertebrae. The fusion mass to enhance bony union is generally the autologous bone of the patient, specially prepared allogenic bone or bone substitutes. To enhance solid union, metallic implants are generally used anteriorly, posteriorly or combined.

Specialist's opinion: