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I always thought there were too many choices at the grocery store. But now that seems simple compared with treatment choices for my back pain. The surgeon says I have stenosis. I can go with medication, physical therapy, steroid injections, or surgery. And for surgery, there are just as many different options. How do I decide which way to go?

You may want to read our Patient Guide to Lumbar Spinal Stenosis available at http://www.eorthopod.com/content/lumbar-spinal-stenosis. This guide will give you some background information about the condition, the various types of treatment, and what to expect. Having this type of patient information may help guide you. Another source of potentially helpful data comes from the Spine Patient Outcomes Research Trial (called SPORT). SPORT has provided much of the evidence needed to provide effective treatment for lumbar spinal stenosis. And by effective, we mean both in terms of reducing pain and improving function as well as providing a cost effective treatment. 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.

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