Expert consensus on diagnosis and treatment for degenerative lumbar spinal stenosis

As the population ages, degenerative lumbar spinal stenosis (DLSS) has become one of the most common orthopaedic conditions, seriously affecting the quality of life and physical and mental health of middle-aged and elderly people.

The diagnosis and treatment of DLSS remains controversial. For this reason, the North American Spine Society (NASS) formulated guidelines for the diagnosis and treatment of DLSS in 2011, and the Chinese Expert Consensus on Surgical Treatment Specification for Lumbar Spinal Stenosis was published in 2014. In recent years, with the emergence and development of minimally invasive diagnostic and treatment techniques and the concept of accelerated recovery after surgery (ERAS), the diagnosis and treatment of DLSS have changed significantly, and there is a need to supplement and update the existing diagnostic and treatment guidelines or consensus. Initiated by the Osteoporosis Prevention and Rehabilitation Committee of the Chinese Society of Rehabilitation Medicine and the Orthopaedic Minimally Invasive Branch of the China Geriatrics and Healthcare Association, a questionnaire was formulated through the use of the modified Delphi survey research method and literature review, and the contents of the questionnaire that received the approval of more than 75% of the experts (including agreement and basic agreement) were included in the consensus category by the well-known domestic experts in spinal surgery after five rounds of meeting discussion and survey voting. The consensus was written on the basis of this consensus.

10 recommendations:

Recommendation 1: DLSS refers to the corresponding symptoms caused by stenosis of the spinal canal, lateral recesses and nerve root canal due to degenerative diseases, excluding stenosis caused by lumbar disc herniation, lumbar instability, lumbar spondylolisthesis or scoliosis.

Recommendation 2: The diagnosis of DLSS is based on ① lumbar, hip and lower limb pain or accompanied by lumbar stiffness and cauda equina symptoms with typical intermittent claudication symptoms; ② imaging studies showing spinal canal stenosis, radicular nerve canal stenosis, lateral saphenous fossa stenosis and other changes; ③ clinical symptoms, signs and symptoms of spinal canal segmental stenosis consistent.

Recommendation 3: Selective nerve root block is an auxiliary diagnostic percutaneous puncture technique, which can clarify the responsible stenosis site and has good clinical application value, and can be selectively applied in hospitals with conditions.

Recommendation 4: Patients with DLSS who opt for non-surgical treatment should be treated with anti-inflammatory, analgesic, vasodilator and nerve-nourishing drugs, and the efficacy should be evaluated after 3 months of regular medication.

Recommendation 5: Simple decompression of the spinal canal is the method of choice for the treatment of DLSS, with the extent of removal of the lamina and synovium determined by the degree of spinal stenosis and synovial hyperplasia.

Recommendation 6: Open spinal decompression is the main surgical procedure for the treatment of lumbar spinal stenosis. Depending on the location of the stenosis, a less invasive, shorter operation time and faster postoperative recovery should be chosen whenever possible.

Recommendation 7: Minimally invasive spinal decompression is an effective surgical method for the treatment of DLSS, with the advantages of low trauma, low postoperative pain, low influence on lumbar stability, etc. Under the premise of strictly understanding the indications, hospitals with these conditions should give priority to minimally invasive spinal decompression.Recommendation 8: For patients with preoperative lumbar instability or intraoperative decompression that may lead to segmental instability, lumbar fixation and fusion should be performed so that the fused segments can maintain long-term mechanical stability, and the fused segments should be determined according to the clinical symptoms and decompression range.Recommendation 9: Lumbar internal fixation provides immediate stabilisation after decompression of the spinal canal. Internal fixation segments are generally determined according to the extent of decompression and instability to increase the fusion effect of the procedure.

Recommendation 10: Perioperative RAS management for DLSS should be active and regular: preoperative appropriate assessment, precise surgical planning, prophylactic analgesia and patient education; intraoperative gentle manipulation, neural and soft tissue protection and reduction of bleeding; postoperative multimodal analgesia should be given and patients should be encouraged to perform early rehabilitation exercises to achieve accelerated recovery.