Well it depends how bad are the symptoms of the patient and his/her medical conditions. One of the main problems with this disease is claudication, and it can occur with less than 100 meters of walking. The Sport Trial 8 year review sat that after 6 years the patients gradually decay on his/her condition of improvement after surgery. We are studying a new technique do decompress  the spine for this patients, but our results are not ready yet. So for now that's what we have. 

For a majority of patients it is not necessary. Read article in N Eng J Med, A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis, by P. Försth.

I also read this eye opening article in NEJM (see attachment).

Please be careful about interpreting data without understanding the patient population and the diagnostic criteria. The quoted paper refers to patients with neurogenic claudication and radiological stenosis with 3 mm listhesis and "no radiological instability". In this population perhaps there is no difference between the fused and unfused groups. However, if the patient has significant back pain and/or radiological instability of dynamic X rays I believe it is rational to fuse the motion segment. Also it may be remembered that post laminectomy instability does not always develop within the 2 year follow up done in the above paper.

NEJM has the track record of producing controversial papers

I believe it depends on the clinical and radiological findings and a randomized trial is controversial. The neurogenic claudication in many cases can be treated without fusion. Factors such as osteoporosis, the patient's health, sagittal balance, the existence of degenerative scoliosis, should be taken into consideration. It is also often possible to perform decompression with laminotomy (unilateral or bilateral), rather laminectomy, which reduces the possibility of post-operative instability. Generally the purpose of these operations is adequate neural decompression without creating instability and fusion should be considered only in cases where this is not achievable.

I agree with you

As already said above, the answer depends upon the indiviual pathology. However, in my opinion the elderly people do well only with decompression.

Can anyone define the term "instability"? A slip is not the same as instability and when it comes to spinal motion, it is not always easy to say what pathological motion is referring to x-rays.

Due to degenerative changes in elderly people, the Spine becomes stiff and hence most of the time decompressión alone is sufficent, even in the presence of minor radiological instability

Refer:  2 randomised trials in NEJM.  Swedish Study of 247 persons. US study of 66 persons.

Refer also article by Deyo et al in NEJM.

Thanks

I agree with my colleagues that we should  take good history from patients . if the patient has only claudication with or without mild back pain decompression is enough . but if the patient has claudication associated with standing intolerance and severe pain I prefer to fuse with decompression .

I agree with my colleagues that we should  take good history from patients . if the patient has only claudication with or without mild back pain decompression is enough . but if the patient has claudication associated with standing intolerance and severe pain I prefer to fuse with decompression .

In my opinion,  there are two important points in this topic. The first, the answer of "How can we define instability?  Are dynamic X rays enough to define instability? And the second, the patient is stable before the operation. There is no abnormal movement of vertebrates in dynamic X-rays before the boperation. But can we claim that after the operation?  The most innocent approach is unilateral decompression, a part of facet joint should be removed with ligamentum flavum and half of the lamina. Interspinous ligamant can be injured during the retraction of muscles. On the other hand  posterior tension band is completely  devastated in total laminectomy .

Briefly direct X-rays before the operation is not definitive statement for instability and second patients admitted with stable before surgery,  are not stable after surgery. Most of the patients need stabilisation but it is not always necessary to perform  fusion with rigid fixation..

My take on this issue is that the minor instability in elderly may be ignored after decompression and the major instability (radiologically proved) must be addressed by additional fixation.

What are the limits of minör instability?

Grade 1 or less