Dilemma in the Surgical Management of Lumbar Canal Stenosis

For a long time wide decompressive laminectomy, direct visualization and decompression of affected nerve roots, foraminotomy and when necessary discectomy had remained the gold standard to operate patients with lumbar canal stenosis. There was confusion in the literature concerning the role of fusion even in the presence of instability in degenerative lumbar canal stenosis due to absence of prospective randomized clinical trials. This has led to uncertainty about the correct choice of surgical strategy as no evidence based recommendations on the role of instrumented PLIF in older patients. Such thoughts have compelled some to try minimally invasive instrumentation with micro decompression, transforaminal interbody fusion and percutaneous pedicle screws. It has the advantage of short incision, less morbidity, shortened bed rest and early ambulation which is so essential in older patients with comorbid conditions. In this study we discuss the pathogenesis of development of spinal conditions and their treatment options through the history of spinal surgery. Also discussed is the dilemma that exists in spinal surgeons regarding the selection of appropriate treatment strategy for stenosis amongst the elderly.