DEGENERATIVE DISEASES OF THE SPINE IN THE ELDERLY

Management of Degenerative Lumbar Spinal

Stenosis in the Elderly
Mohammed F. Shamji, MD,
PhD, FRCSC, FAANS*‡§
Thomas Mroz, MD, FACS¶
Wellington Hsu, MDk
Norman Chutkan, MD, FACS#
*Division of Neurosurgery, Toronto West-
ern Hospital, Toronto, Canada; ‡Depart-
ment of Surgery, and §Techna Research
Institute, University of Toronto, Toronto,
Canada; ¶Center for Spine Health, Cleve-
land Clinic, Cleveland, Ohio; kDepartment
of Orthopedic Surgery, Northwestern
University, Chicago, Illinois; #The Core
Institute, Phoenix, Arizona
Correspondence:
Mohammed F. Shamji, MD, PhD, FRCSC,
FAANS,
WW4-446,
399 Bathurst Street,
Toronto, Ontario,
Canada, M5T 2S8.
E-mail: mohammed.shamji@uhn.ca
Copyright © 2015 by the
Congress of Neurological Surgeons.
BACKGROUND: Lumbar spinal stenosis can cause symptomatic neurogenic clau-
dication alongside radicular pain and weakness. In appropriately selected patients,
surgical intervention has been demonstrated to provide for improvement in
pain, disability, and quality of life. This systematic review sought to define the
utility and safety of such decompression with or without arthrodesis in the man-
agement of symptomatic lumbar spinal stenosis for elderly patients older than 65
years of age.
METHODS: A systematic review was conducted using MEDLINE for literature published
through December 2014. The first question focused on the effectiveness of lumbar
spinal surgery for symptomatic lumbar spinal stenosis in elderly patients (over age 65 y).
The second question focused on safety of surgical intervention on this elderly pop-
ulation with emphasis on perioperative complication rates.
RESULTS: Review of 11 studies reveals that the majority of elderly patients exhibit
significant symptomatic improvement, with overall benefits observed for pain
(change visual analog scale 4.4 points) and disability (change Oswestry Disability
Index 23 points). Review of 11 studies reveals that perioperative complications
were infrequent and acceptable with pooled estimates of mortality (0.5%), inad-
vertent durotomy (5%), and wound infection (2%). Outcomes seem less favorable
with greater complication rates among patients with diabetes or obesity.
CONCLUSION: Based on largely low-quality, retrospective evidence, we recommend
that elderly patients should not be excluded from surgical intervention for symptomatic
lumbar spinal stenosis.
KEY WORDS: Complications, Elderly, Lumbar spinal stenosis, Outcomes, Surgery

Neurosurgery 77:S68–S74, 2015 DOI: 10.1227/NEU.0000000000000943 www.neurosurgery-online.com

L
ow back pain is one of the most common
reasons for which patients seek medical atten-
tion. Surgical intervention for lumbar degen-
erative disease can provide reduction in pain and
disability and improvements in health-related quality
of life in appropriately selected patients. Prospective
and randomized long-term data are available for the
surgical management of patients with disc-herniation
lumbarradiculopathy,1 degenerative spinal stenosis,2
and lumbar spondylolisthesis3 in whom conserva-
tive measures fail to manage symptoms. Surgery for
spinal deformity also has prospective data support-
ing its utility, although recent data suggest that it
carries significant incidence of adverse events that
must be considered during surgical decision-mak-
ing.4 Predictors of perioperative complications
include underlying diagnosis, surgical approach,
and patient factors such as smoking status, body
habitus, and diabetes.5-7
Lumbar spinal stenosis can have varied pathoa-
natomy, with combinations of disc herniation, facet
hypertrophy and cyst formation, and ligamentous
hypertrophy and buckling conspiring to narrow the
central canal8 (Figure 1). This is manifest by
patients with symptoms of neurogenic claudica-
tion occasionally with concomitant radicular pain
and lower extremity weakness, a syndrome that
carries a substantial disability burden.2
The elderly population represents a subgroup of
lumbar stenosis patients that are often perceived as
being physiologically frail and may be unduly
excluded from surgical therapy due to expected
higher morbidity and mortality. Despite its prev-
alence, there have been few and small reports of the

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 LUMBAR STENOSIS IN THE ELDERLY

FIGURE 1. Sagittal (A) and axial (B) lumbar spine magnetic resonance imaging for an 84-year-old patient with lumbar spinal
stenosis symptomatic with neurogenic claudication. Minimally invasive surgery bilateral lumbar spinal decompression through
a unilateral approach was performed with excellent outcome observed both after surgery and at 1-year follow-up.

risk experienced and benefit conferred by surgical intervention for
lumbar spinal stenosis in the elderly. This study reviewed the
literature surrounding surgical intervention for the management of
symptomatic lumbar spinal stenosis in the elderly. The primary
outcomes of interest include clinical outcomes of pain and disability
and perioperative complications.
Data Analysis
Due to variable mechanisms of neurological outcome reporting, clinical
outcomes were described in a narrative review format with pooled
estimates for dichotomous outcomes as feasible. Summary statistics

METHODS
TABLE 1. PICO Summary of Inclusion and Exclusion Criteriaa
Electronic Literature Search
Inclusion Exclusion
We conducted a systematic search in MEDLINE for literature
published through December 2014, limiting the search results to human Patient Age .65 Lumbar disc
studies published in the English language. Search terms included herniation
neurogenic claudication, radiculopathy, lumbar spinal stenosis, decom- Neurogenic claudication or Lumbar
pression, laminectomy, spinal fusion, surgery, aged, and elderly as well as lumbar radiculopathy spondylolisthesis
derivatives therefrom. Reference lists of key articles were also systemat- MRI demonstrated lumbar
ically checked to identify additional eligible articles. The first question spinal stenosis
focused on the effectiveness of lumbar spinal surgery for symptomatic Intervention Lumbar spinal surgery
lumbar spinal stenosis in elderly patients (over age 65 y). The second Comparison Preop vs Postop
Operative vs Nonoperative
question focused on safety of surgical intervention on this elderly
Outcome Clinical outcome
population with emphasis on perioperative complication rates. Studies
VAS
with an underlying diagnosis of lumbar disc herniation or lumbar
ODI
spondylolisthesis were excluded. Furthermore, case reports, case series Complications
that consisted of less than 10 patients, and animal, cadaveric, and Study Design Randomized controlled trials Case reports
biomechanical studies were also excluded. Table 1 summarizes this Cohort studies Studies with n , 10
selection process. Case series
Biomechanical
Data Extraction studies
Cadaver studies
We extracted the following data from the included articles: study a
MRI, magnetic resonance image; ODI, Oswestry Disability Index; PICO, population
design, patient demographics, diagnosis, and surgical procedure. From
intervention comparison outcomes; postop, postoperative; preop, preoperative;
these studies, we also compiled the reported clinical outcomes of pain and VAS, visual analog scale.
disability and cited perioperative complications.

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SHAMJI ET AL
FIGURE 2. Study selection flow chart for search for articles pertaining to surgical
management of lumbar spinal stenosis in elderly patients.
regarding overall reported complication rates were generated by pooled
estimates based on study size.
RESULTS
Study Selection
The search strategy yielded 56 relevant citations, of which 38
were excluded on the basis of title and/or abstract. Eighteen
were selected for full-text review, from which 5 were further
excluded on the basis of outcomes not being reported or
differentiated by treatment. The flow of this process is
summarized in Figure 2. When articles reported either
outcome or perioperative complications, they were incorpo-
rated only into specific types of analysis for which data was
available. Consequently, 11 articles were found suitable for
reporting outcomes6,9-18 and 11 articles were found suitable
for reporting complications.6,9,11-14,16-20
Clinical Outcomes
Table 2 summarizes the studies included for analysis of clinical
outcomes. Among studies that reported the fraction of patients who
improved from surgical intervention,10-12,14,15 a range of 67% to
97% of patients reported improvement from preoperative features
of neurogenic claudication with a pooled estimate mean of 83%.
Among studies that reported visual analog scale leg pain
scores,6,10,13,18 a range of 2.7 to 5.1 point improvement on the
visual analog scale score was reported with a pooled estimate mean
of 4.4. Among studies that reported Oswestry Disability Index
(ODI) scores,9,10,13,17,18 a range of 19 to 29 point improvement on
the ODI score was reported with a pooled estimate of 23. Taken
together, these data support that the majority of elderly patients
undergoing surgical intervention for neurogenic claudication
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associated with lumbar spinal stenosis will exhibit clinical
improvement, in excess of the minimum clinically important
difference on both the visual analog scale and ODI scales. Among
the patients in this review, 931 underwent decompression alone
and 45 underwent decompression and fusion. Only 1 study9
addressed outcome differences based on surgical approach,
reporting benefits in disability measured by ODI among both
elderly groups at 215 for the 28 patients undergoing
decompression alone and 227 for the 13 patients undergoing
decompression and fusion, a statistically significant difference
with the recognition that the indication to fuse was not clarified
for each patient in that group.
Complications
Table 3 summarizes the studies included for analysis of
perioperative morbidity and mortality. Among the 1013 patients
represented in these studies, the most common reported compli-
cation was inadvertent durotomy occurring in 5% of patients
(range, 0%-16%). A similar fraction of patients also exhibited
perioperative urinary retention (range, 0%-11%). Wound infections
occurred in 2% of patients (range, 0%-5%). Cardiovascular
morbidity was observed in 3% of patients (range, 0%-7%), most
frequently including perioperative arrhythmia or myocardial infarc-
tion. Mortality was reported in 0.5% of patients (range, 0%-2%),
most frequently the consequence of perioperative myocardial
infraction or pulmonary embolus.
Reoperation was highly variable among this group of patients,
occurring in 56 patients (5.5%) with indications of either
recurrent spinal stenosis requiring revision decompression or
postoperative instability requiring stabilization. This ranged from
0% to 10% in the various series, likely reflecting variability in
surgical decision-making and postoperative follow-up.
DISCUSSION
With an elderly population growing in the face of significant
disability conferred by osteoarthritic disease, decisions about
interventions that improve quality of life in both cost-effective
and clinically significant ways must be analyzed. The literature
summarized in this analysis suggests that significant improvement
from neurogenic claudication can be observed among elderly
patients, with low rates of revision surgery for restenosis or
instability, and acceptable mortality and morbidity.
The role of nonoperative therapy for lumbar spinal stenosis with
neurogenic claudication has been reviewed by Ammendolia et al.21
The literature is replete with low-quality evidence suggesting that
most implemented therapies have limited and transient effect,
without durable benefit to the patient. Specifically, prostaglan-
dins and neuromodulator medication may improve walking
distance, epidural steroid injections may provide for short-term
relief of pain, and exercise benefits leg pain and function
compared with no treatment. Conversely, they observe that
operative therapy offers advantage compared to nonoperative
therapy in appropriately selected and suitable candidates.
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 LUMBAR STENOSIS IN THE ELDERLY

TABLE 2. Study Demographics and Treatment for Lumbar Spinal Stenosis Surgery in the Elderlya
Reference N Design Intervention Outcomes Grade of Evidenceb
11
Fast et al, Arch Phys Med Rehabil, 1985 19 (50-80 y) Ret. D (18) Improvement (18) Very Low (Low (21))
D 1 F (1) No change (1)
Worse (0)
Hanakita et al,12 Neurol Med Chir (Tokyo), 1999 52 (651 y) Ret. D (49) Improvement (35) Low (Low)
D 1 F (3) No change (3)
Worse (9)
Unreported (5)
Kalbarczyk et al,14 Acta Neurochir (Wien), 1998 148 (70-88 y) Ret. D (139) Improvement (144) Low (Low)
D 1 F (9) No change (3)
Worse (0)
Unreported (1)
Gepstein et al,6 Clin Orthop Relat Res, 2004 298 (651 y) Ret. D (298) VAS 8.2 / 3.3 Low (Low)
D 1 F (0) Barthel 76 / 85
66% satisfied
Rosen et al,18 Neurosurgery, 2007 57 (751 y) Pro. D (57) VAS 5.7 / 2.3 Moderate (Low (11))
ODI 48 / 27
Bouras et al,10 J Neurosurg Spine, 2010 125 (651 y) Ret. D (125) Improvement (87) Low (Low)
DVAS—5.1
DODI—29.1
Kaptan et al,15 Ann N Y Acad Sci, 2007 32 (65-80 y) Ret. D (32) Improvement (20) Low (Low)
No change (12)
Worse (0)
Jakola et al,13 BMC Surg, 2010 100 (701 y) Pro. D (100) VAS 6.0 / 3.3 Moderate (Low (11))
ODI 44 / 26
Nanjo et al,16 Arch Orthop Trauma Surg, 2013 46 (801 y) Ret. D (46) Excellent/good (26) Moderate (Low (11))
Fair/poor (20)
Aleem et al,9 Clin Orthop Relat Res, 2014 41 (701 y) Ret. D (28) DODI (D)—15 Very Low (Low (21))
D 1 F (13) DODI (D 1 F)—27
Rihn et al,17 J Bone Joint Surg Am, 2015 58 (801 y) Ret. D (39) DODI—19 Very Low (Low (21))
D 1 F (19)
a
D, decompression only; D 1 F, decompression and fusion; Pro, Prospective; RCT, randomized controlled trial; Ret, Retrospective; VAS, Visual Analog Score (leg pain).
b
Grade: quality of evidence is stated and in parentheses is stated the initial quality assessment and any modifiers.

Among the highest-quality evidence available is the prospective
4-year dataset gathered for patients with spinal stenosis2 and
spondylolisthesis,3 more specifically evaluated by Rihn et al17 for
the octogenarian population. This work reveals that operative
treatment of lumbar spinal stenosis offers significant benefit
compared with nonoperative therapy, with benefit in all patient-
reported measures of pain, disability, and quality of life. The rate
of perioperative morbidity in this group is not prohibitive, similar
to their younger counterparts in the same trials. A nationwide
perspective on complications was also undertaken by Deyo
et al,22 examining the Medicare database and summarizing the
experience of more than 30 000 elderly patients (over age of 65
years) undergoing surgical intervention for lumbar spinal stenosis
with or without comorbid spondylolisthesis (18.4%) or scoliosis
(5.1%). While this was a heterogeneous population, the overall
complication rates were low and comparable to this literature
review. Mortality occurred in 0.3% of decompression only and
0.6% of decompression and fusion cases. Wound complications
occurred in 1.0% of first-time spine operations. Perioperative
complications among elderly patients in this study were not
substantially different, suggesting that such procedures can be
performed safely with acceptable risk. There is a notably higher
incidence of urinary retention and urinary tract infection that can
affect hospital length of stay, eventual disposition, and initiation
of rehabilitation.
While the best available evidence supports that surgical
intervention for symptomatic lumbar spinal stenosis can provide
for significant improvements in pain and disability among elderly
patients, there are subgroups of patients who are at greater risk of
a poor outcome. For example, Arinzon et al7 studied 62 elderly
patients with diabetes (over age of 65 years) compared with an age
and sex matched cohort of nondiabetic patients, all undergoing
decompression surgery for symptomatic lumbar spinal stenosis.
They observed improvement in pain among both cohorts, more
so in the nondiabetic group, alongside fewer revision operations.
Certainly, the duration of diabetes diagnosis and the presence of
concomitant diabetic neuropathy will impact on the patient’s
perioperative experience and postoperative improvement.

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S72 | VOLUME 77 | NUMBER 4 | OCTOBER 2015 SUPPLEMENT

SHAMJI ET AL
TABLE 3. Study Reported Complications for Lumbar Spinal Stenosis Surgery in the Elderly
Acute Spine
Periop Dural Neurological Recurrent Periop DVT/ Urinary Urinary Tract Wound
Study N Death Tear Deterioration Stenosis Instability Periop Cardio CVA PE Retention Infection Infection
Fast et al,11 Arch Phys Med 18 0 0 0 0 0 0 0 0 0 0 0
Rehabil, 1985
Hanakita et al,12 Neurol Med 52 1 2 0 3 0 0 0 0 0 0 0
Chir (Tokyo), 1999
Kalbarczyk et al,14 Acta 148 1 0 0 13 1 MI 3 1 4 0 1 1
Neurochir (Wien), 1998
Gepstein et al,6 Clin Orthop 298 1 0 0 31 reoperations MI 1 2 0 33 22 11
Relat Res, 2004
Angina 4
AFIB 15
Cassinelli et al,19 Spine (Phila Pa 166 0 26 2 0 0 MI 1 0 1 13 9 0
1976), 2007
Arrhythmia 4
Rosen et al,18 Neurosurgery, 57 0 3 0 1 1 AFIB 1 0 0 6 2 0
2007
Jakola et al,13 BMC Surg, 2010 100 1 9 0 2 0 MI 1 0 0 0 1 5
Deschuyffeleer et al,20 Acta 29 0 3 1 0 0 0 0 0 0 0 0
Orthop Belg, 2012
Nanjo et al,16 Arch Orthop 46 0 3 1 0 0 0 0 0 0 1 1
Trauma Surg, 2013
Aleem et al,9 Clin Orthop Relat 41 0 0 0 0 0 0 0 0 1 2 1
Res, 2014
Rihn et al,17 J Bone Joint Surg 58 1 8 0 4 reoperations 0 0 0 0 0 2
Am, 2015

AFIB, atrial fibrillation; CVA, cerebrovascular accident; DVT/PE, deep venous thrombosis/pulmonary embolism; MI, myocardial infarction; Periop, perioperative.
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Furthermore, the overall complication rate was also 67% among
diabetic patients and 38% among the control group. Similarly,
Gepstein et al6 studied 298 elderly patients (over age of 65 years)
undergoing decompression surgery for symptomatic lumbar
spinal stenosis, stratified by body habitus to explore the impact
of obesity on perioperative morbidity and postoperative outcome.
While surgical intervention provided for significant clinical
improvement in all groups, the obese elderly exhibited a lesser
degree of improvement, higher complication rate, and greater
degree of dissatisfaction than their normal body habitus
counterparts.
When considering not only decompression, but also instru-
mented stabilization, the role of osteoporosis must be considered
to define preoperative therapy, surgical decision-making, and
postoperative rehabilitation. Lee et al23 studied a cohort of
postmenopausal female patients with symptomatic lumbar spinal
canal stenosis for the presence of osteoporosis using bone mineral
density analysis. When regarding data for lumbar spine results,
among the cohort of 60 to 69 years of age, 12% had osteoporosis
and 56% had osteopenia. Among the cohort of patients older
than 70 years of age, 27% had osteoporosis and 53% had
osteopenia. While certainly these data will vary regionally based
on preventative medicine strategies, the realization that such
disease has high prevalence should mandate seeking it out among
patients in whom arthrodesis is being considered.
Limitations
This is a systematic review of largely retrospective clinical
studies, in which the patient management was nonrandomized,
subject to surgeon assessment of patient candidacy for surgical
intervention, and with unpredictable complication recording.
Furthermore, variability was observed among studies for both
outcome and complication. The systematic review process for
predominantly retrospective studies suffers from the procedure for
data capture, patient selection for surgery, and patient-specific
factors that can affect outcome or predispose to complication. It is,
nevertheless, reassuring that many of the complication rates for
these studies are in line with magnitudes observed in reported
national databases.
CONCLUSION
Neurogenic claudication from lumbar spinal stenosis has the
potential to cause substantial pain and disability for which limited
nonoperative therapeutic options exist. Surgical intervention does
provide for relief of such symptoms, with elderly patients more
frequently undergoing both decompression and fusion proce-
dures. This review has summarized the literature surrounding the
efficacy and perioperative morbidity for such interventions among
elderly patients, finding that surgery is both effective and safe.
With concomitant diabetes or obesity, outcomes are less favorable
and complications rates are higher, although neither is prohibitive
insofar as selecting against such subgroups, but rather serves to
better inform both surgeon and patient. Based on largely
NEUROSURGERY
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LUMBAR STENOSIS IN THE ELDERLY
low-quality, retrospective evidence, we make a weak recommen-
dation that elderly patients are appropriate candidates for surgical
management of symptomatic lumbar spinal stenosis.
Disclosure
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
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