Recurrent Lumbar Stenosis

A 69-year-old male presents with chronic low back pain that seems to improve with sitting. The patient had had a prior laminectomy for severe stenosis and in situ fusion five years prior which means that we used bone graft to perform the fusion but no instrumentation. He had done well. Over the last year or so he developed low back pain but no leg pain. The patient had tried all means of conservative management including physical therapy, chiropractic care, acupuncture and epidural injections. Neurologically he was intact. MRI revealed significant stenosis at L2-3 above his prior laminectomy and fusion (Fig 1). We discussed options including surgery. One of the problems we face is a patient with severe stenosis that has severe low back pain with no leg pain. This is particularly challenging when the back pain goes away in flexion or sitting. The quandary is that anecdotally patients with these specific symptoms do tend to improve their back pain after laminectomy, although there are no good studies to support this. Patients with classic neurogenic claudication with pain down their legs when they walk and improved when they sit have a better chance of success. Subjecting a patient to laminectomy for just back pain in the face of having prior surgery puts the patient at risk for not only a potential dural leak because of scarring, but also there may be less of a chance of relieving the back pain than if the patient has leg symptoms. After a discussion, since the patient for the most part is able to manage with conservative treatment modalities is just wait and see over the next three months.