Lumbar Spinal Stenosis ± Degenerative Spondylolisthesis

Lumbar stenosis is a leading cause of pain and functional limitation in older adults. Decisions hinge on symptom pattern (neurogenic claudication vs radicular), radiographic stenosis, and presence of dynamic instability or spondylolisthesis.

Core Concepts

Symptoms: neurogenic claudication improved by flexion; radicular pain from lateral recess/foraminal stenosis.
Imaging: MRI for canal, lateral recess, and foramina; flexion–extension radiographs for instability.
Treatment: decompression alone vs decompression with instrumented fusion guided by instability, back pain, and slip grade.
MIS vs open: choose based on anatomy, comorbidity, bone quality, and surgeon experience.

Imaging Examples

Axial T2 lumbar MRI with severe stenosis from ligamentum flavum hypertrophy and facet arthropathy — Axial T2 MRI showing severe canal stenosis from ligamentum flavum hypertrophy and arthropathy. Source: Wikimedia Commons (CC BY-SA 3.0; © Hellerhoff).

Sagittal lumbar MRI with L4-L5 left paramedian disc herniation — Sagittal MRI demonstrating L4-L5 paramedian disc protrusion. Source: Wikimedia Commons (CC0; © Miguel Tremblay).

Animated sagittal T2 MRI of the lumbar spine — Animated T2 sagittal series illustrating multilevel degenerative changes. Source: Wikimedia Commons (Various licenses; © contributors).

CT and radiographs of degenerative spondylolisthesis pre and post op — Degenerative spondylolisthesis pre-op and post-op after decompression and fusion. Source: Wikimedia Commons (CC BY 4.0; © Chester J Donnally III).

Lower limb dermatomes, anterior view — Dermatomes (anterior) for L5/S1 correlation in claudication with radicular features. Source: Wikimedia Commons (Public Domain).

Lower limb dermatomes, posterior view — Dermatomes (posterior) highlighting posterior L5/S1 distributions. Source: Wikimedia Commons (Public Domain).

Posterior view of lower limb nerves — Lower limb nerve map for peripheral vs root-level localization. Source: Wikimedia Commons (Public Domain).

Decision Framework

Decompression alone: single-level stenosis without instability, predominant leg symptoms, minimal axial back pain.
Decompression + fusion: motion segment instability, high-grade facet resection required, recurrent stenosis with slip, or significant back pain from segmental degeneration.
MIS options: tubular or endoscopic unilateral laminotomy for bilateral decompression; caution with facet preservation.

Outcomes

Strong improvement in leg pain and walking tolerance with appropriate decompression.
Fusion improves mechanical back pain and reduces reoperation in selected unstable cases; risk-balance with comorbidity and bone quality.

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