Does Pain Location in Stenosis Matter to Treatment?Patients with pressure on the spinal nerves from two conditions (listhesis and stenosis) are the focus of this study. Both sets of patients have leg and/or back pain. Previous studies have shown that patients with either of these spine problems have better results if their symptoms are mostly leg pain (as opposed to back pain or both leg and back pain). But those studies combined patients with both conditions. So we don't know if patients with listhesis get better (or worse) results than those with stenosis.
Let's make sure we know what is being referred to as listhesis and stenosis. You may have heard of a condition called spondylolisthesis where one vertebra (spine bone) slips in front of another. With listhesis, one vertebral bone starts to slide off to the side of the next vertebra. Spondylolisthesis is more of a front-to-back shift of the bones. Listhesis (also known as lateral listhesis is a shift from side-to-side.
Spinal stenosis is a narrowing of the spinal canal. The spinal canal is the opening where the spinal cord and nerve roots travel from the brain down to the limbs. Many degenerative changes common with aging can cause this space to get smaller. Bone spurs, thickening of the ligaments, and flattening of the discs reduce the space in the spinal canal putting pressure on the nerve tissue. The result is often leg and/or back pain.
In this study, results of surgical and nonoperative treatment were compared for each diagnosis (listhesis versus stenosis) separately. Within each diagnostic group, the patients were further divided into leg pain (predominant), back pain (predominant), and both leg and back pain equally. The groups were fairly evenly distributed with about one-third with just leg pain, slightly less than one-third with back pain, and slightly more than one-third with equal leg and back pain.
Outcomes were then measured following treatment for each group separately and compared. Treatment was either surgery or conservative (nonoperative) care. Surgery consisted of decompression (removing bone pressing on nerves) with or without fusion to stabilize the spine. Conservative care included physical therapy, education, and medications. Everyone was followed for two years.
Comparing painful symptoms between degenerative listhesis and spinal stenosis, the authors report patients had the worst pain if it was present in both the back and the leg. That was true for both diagnoses. And the results of treatment were less successful for this pain group for both diagnoses, too.
Just as other studies showed, patients had the best results when leg pain was their main symptom. Surgery yielded better results than nonoperative (conservative) care for patients with predominant back pain. The group with the poorest overall treatment results was the equal pain group. The equal pain group did have an intermediate response to treatment but it wasn't nearly as good as the results for patients with leg pain only or back pain only.
The authors conclude that this is the first study comparing treatment results for degenerative listhesis and spinal stenosis based on pain location. The benefit of surgery for patients with low back pain only was reinforced by the results. Results were even better with surgery for the patients with predominant leg pain. For both diagnostic groups and in all pain types, outcomes were better for surgery compared with conservative care.
Those conclusions may lead surgeons to think surgery is the answer to the problem of pain associated with degenerative listhesis or spinal stenosis. But the authors suggest these results point out the need to find better ways to treat these two problems with conservative approaches.
It's possible that some nonoperative treatment (or combinations of nonoperative care) might work better than others based on the location of the pain. Finding the treatment path that gives the best outcomes by diagnosis and by pain location is the next goal.
Adam Pearson, MD, MS, et al. Predominant Leg Pain is Associated with Better Surgical Outcomes in Degenerative Spondylolisthesis and Spinal Stenosis. In Spine. February 1, 2011. Vol. 36. No. 3. Pp. 219-229.
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