The Economics and Treatment of Lumbar Spinal StenosisSpinal stenosis is an unfortunate condition associated with aging. Various factors combined together result in a narrowing of the spinal canal and openings for the spinal nerves to exit. Pressure on these sensitive nerve tissues causes low back (and often leg) pain and impaired quality of life. The personal and economic cost of this condition and what can be done about it are the focus of this review article.
Fortunately, many studies have been done to help surgeons identify the best way to treat this problem in older adults. The Spine Patient Outcomes Research Trial (called SPORT) has provided much of the evidence needed to provide effective treatment. And by effective, we mean both in terms of reducing pain and improving function as well as providing a cost effective treatment.
Let's take a closer look at what is now known in terms of the management of this condition. The first step to managing this condition is usually conservative (nonoperative) care. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) are used to control pain and swelling.
NSAIDs combined with physical therapy may be all that some patients need. The physical therapist addresses posture, strength (especially core strength), and modification of activities. The therapist can teach patients positions and exercises to ease the symptoms. The therapist may use lumbar traction to gently stretch and lengthen the low back, taking pressure off the spinal nerves.
Some patients are given an epidural steroid injection (ESI). The spinal cord is covered by a material called dura. The space between the dura and the spinal column is called the epidural space. It is thought that injecting steroid medication into this space fights inflammation around the nerves, the discs, and the facet joints. This can reduce swelling and give the nerves more room inside the spinal canal.
When conservative care doesn't work, then surgery may be advised. In fact, the results of the SPORT studies supports the use of surgery in such cases. When there is pain that doesn't go away with nonoperative care, decreased quality of life, or loss of function, surgery may be the only answer. There are several different ways to approach the problem surgically. The most common technique is called decompression.
The surgeon performs either a laminotomy (shaving some of the bone away from the nerve tissue or removing a small amount of bone on one side of the lamina) or laminectomy (removing the bone from around the nerve tissue). The lamina is the covering layer of the bony ring of the spinal column. It forms a roof-like structure over the back of the spinal canal. Decompressive surgery takes the pressure off the spinal nerves.
Although surgery of this type is expensive (estimated in the SPORT study to be $77,600 per quality of life year), the gains made in pain control and improved health were worth it to the patients. Two years later, patients who had the surgery were still reporting positive results from the procedure. When the cost is spread out over the long-term, the economic benefit becomes clear.
There is one other minimally invasive surgical procedure for lumbar spinal stenosis still under investigation. A device called the X-STOPÂ®. The X-STOPÂ® is a metal implant made of titanium. The implant is inserted through a small incision in the skin of your back. It is designed to fit between the spinous processes of the vertebrae in the lower spine. It stays in place permanently without attaching to the spinal bone or ligaments.
There are several advantages of the X-STOPÂ®. It can be inserted using local anesthesia on an outpatient basis. A small incision is made so the procedure is minimally invasive and no bone or soft tissue is removed. The implant is not close to nerves or the spinal cord. With the implant in place, the patient doesn't have to bend forward to relieve painful symptoms. The X-STOPÂ® keeps the space between the spinous processes open. With the implant in place, it is possible to stand upright without pinching the spinal nerves.
Research shows that these implants don't work well for patients with severe stenosis. No improvement and a high revision rate have been reported for patients with severe stenosis. A 73 per cent satisfaction rate has been reported in patients with mild stenosis. And comparing use of the X-STOPÂ® with no treatment has also been shown effective for the patients with the implant.
The problem of a degenerative spine resulting in stenosis is not one that is going to go away anytime soon. With the aging of our Baby Boom generation, surgeons can expect to see more (not less) of this condition.
Studies like the SPORT study will help guide treatment by showing the effectiveness of surgical management. Whereas the high cost of surgery may put some people off, the positive long-term results are very convincing. Nonsurgical care is the first line of treatment but patients should be told that it is not the end-of-the line, so-to-speak. Minimally invasive, surgical approaches are effective for many people at a cost that becomes "affordable" when pain is relieved, function is improved, and quality of life is restored.
Paul S. Issack, MD, PhD, et al. Degenerative Lumbar Spinal Stenosis: Evaluation and Management. In Journal of the American Academy of Orthopaedic Surgeons. August 2012. Vol. 20. No. 8. Pp. 527-535.
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