As development of medical techniques provided the extension of human life, the number of elderly has been increasing. For this reason, prevalence rate of geriatric illness is also increase with growth of needs of geriatric patients. Among numerous geriatric diseases, low back pain occupied a large proportions and their will for treatment has been changing from conservative medical treatment to aggressive surgical treatment. Because many factors were involved in low back pain, it is hard to make a appropriate decision for treatment of low back pain in old patinets.

Among many factors causing low back pain, degenerative lumbar spinal stenosis is a major cause of pain in people over the age of 65 years16). Nonsurgical managements for treatment of spinal stenosis have been known as nonsteroidal anti-inflammatory drugs, physical therapy, and local nerve block, etc. Surgical treatment is indicated when nonsurgical management is unsuccessful and neurologic decline persists or progresses8). However, surgical treatment for elderly people is believed to be more difficult than younger people because of the systemic changes associated with aging. Although the evidence from current literatures suggests that surgical intervention is effective, the recent studies report that patients treated non-operatively also showed improved results13,15). Thus non-operative treatment such as nerve block, radiofrequency neurotomy often performed to elderly patient recently.

In present study, we analyzed and compared clinical outcome and efficacy of treatment to elderly patients who underwent nerve block, radiofrequency neurotomy and surgery for spinal stenosis in our hospital.

Spinal stenosis is a degenerative condition that affects the lumbar spine. This can be an incidental finding, but can cause back and leg symptoms, or neurogenic claudication11). The prevalence of symptomatic spinal stenosis is likely to increase with growing cohorts of the old and very old17). Stenosis in the lumbar spine is considered to have both structural and dynamic components, as walking causes further narrowing of the spinal canals and an increase in epidural pressure2). Patients are typically aged over 50 years with a long history of back pain, extensive degenerative changes on radiography and neurological deficits in some patients14).

Surgery for spinal stenosis has been on the increase. Some good outcomes from surgical interventions have been demonstrated, but outcomes vary widely, and complications and re-operations have been reported15,19). The natural history of spinal stenosis and response to non-surgical care can be favorable with numerous therapies being proposed2). So our study analyzed and compared clinical outcome and efficacy of treatment to elderly patients who underwent nerve block, radiofrequency neurotomy and surgery for spinal stenosis in our hospital.

The scientifically valid studies that have been performed in this area to date are few, and none of them had a clear age limit or age restriction. Direct comparisons of conservative and surgical treatment are further complicated by the fact that patients with mild stenosis generally undergo the former, while those with severe stenosis generally undergo the latter. Chou et al., in a review of this topic, concluded that moderately good evidence indicates the superiority of surgical over conservative treatment in the first two years. The available evidence is hard to assess, however, because the six randomized trials whose findings were presented involved different surgical methods and variable follow-up intervals6).

Atlas et al. prospectively followed patients for eight to ten years and found better results in the first four years in the patients who had undergone surgery. At the end of the follow-up period, however, the two groups no longer differed with respect to low back pain or overall satisfaction, while all patients had a marked reduction of the leg-pain component. It must be noted, however, that 37% of the patients who were initially treated conservatively went on to have surgery. Radicular symptoms were improved in 67% of the patients who had surgery and in 41% of those treated conservatively4). Chang et al., too, found that surgery yielded better results than conservative treatment after ten years of follow-up5). Analogously to the observations of Atlas et al., the two groups no longer differed with respect to low back pain or overall satisfaction, while the surgical patients had greater improvements in functional status and leg pain. In addition, Jang et al. reported that decompressive laminectomy alone is a relatively safe and effective treatment option for the elderly7). In our study, similarly, VAS score of surgery group was decreased 1 month after surgery and 74% of surgery group had excellent or good outcome.

Lumbar spinal stenosis is being treated surgically with more frequency. However, clinical experience indicates that many patients also do well on a regimen conservative treatment only. And it can be performed more frequently in elderly patients.

In 2011, Boxem et al. reported that among the patient who underwent radiofrequency neurotomy for spinal stenosis, 22.9% presented 50% pain relief after 6 months and after 12 months in 13.1% of the cases22). Similarly, in 2012, Klessinger reported that during a time period of 3 years, 1490 patients were treated with lumbar radiofrequency neurotomy. A significant pain reduction was achieved in 65% of the patients12). Roy et al. reported that a patient had a mean VAS score of 8.6 before the radiofrequency neurotomy and steroid block. Thereafter, VAS score was 0.91 immediately after the procedure and 0.3, 2.8, 3.7 and 3.6 at 1 month, 2 months, 6 months, and 1 year18). In our study, both nerve block and radiofrequency neurotomy had favorable outcome. Especially, radiofrequency neurotomy group had a mean VAS score of 7.4 before the treatment. And the mean score of immediately post-radiofrequency neurotomy was 3.4 and then the mean score of recent follow up was 1.3. And our study indicated that 71% of the radiofrequency neurotomy group presented excellent or good outcome by pain reduction after radiofrequency nuerotomy.

The complication rate after surgical treatment of spinal stenosis is considerable. In a prospective study published in 2010, 101 patients over the age of 70 who underwent surgery had an 18% complication rate. The most common complication was a dural injury without further clinical consequences (9%). Two patients had deep wound infections, and three died of concomitant, unrelated illnesses 26 days, 9 months, and 11 months after surgery9). In our study, among surgical group, 4 cases (6%) of complications occurred it was post-operative infections (2 cases) and adjacent segment disease (2 cases). On the other hand, no complications of radiofrequency neurotomy were reported, also in the other studies, there was no mention of neurological complications. Furthermore, inadequate decompression may leave a significant degree of recurrent stenosis. Jansson et al. documented a reoperation rate of 11% over ten years of follow up10). In our study, 2 patients received revision surgery. However, if we have a long term follow up for surgery group, we may observe other complication such as adjacent segment disease. Adjacent segment disease is complication following spinal fusion. This is a broad term that encompasses symptoms such as listhesis, instability, herniated nucleus pulposus, stenosis, hypertrophic facet arthritis, scoliosis, and vertebral compression fracture.

The pain relief from the radiofrequency neurotomy is sufficient to allow many of the patients to improve their activity tolerance and reduce other therapies for pain1,12,18). And there is no contraindication to repeating the denervation if the symptoms recur, nor is there an additional technical disadvantage presented by repeat denervation. Compared with surgical therapy, these considerations favor the minimally invasive route in elderly patient.

A limitations of our study; first, it was selection of patient groups. We studied to only mild to moderate stenosis patients, excluding severe stenosis patient who need to surgical treatment. Also, in our study, we performed nerve block or radiofrequency neurotomy to patients who do not need to surgery. Therefore, our results were barely suitable for comparison to surgical outcomes. Second, we did not long term follow up. Slatis et al. reported that, based on data concerning functional ability and perceived back and leg pain, surgical treatment of lumbar spinal stenosis provided better results than conservative methods of treatment at the 6-year follow up21). And Amundsen et al., too, concluded that the outcome was most favorable for surgical treatment in their 10-year prospective study3). Lumbar spinal stenosis worsen as time go on because it is degenerative disease. Therefore, we evaluate clinical outcome at 1 month after procedure to assess effectiveness of treatment in the short term.

According to the above mentioned, long term outcomes of surgical treatment were better than conservative manage such as nerve block and radiofrequency neurotomy. However, we suggest that radiofrequency neurotomy may consider the effective secondary treatment to elderly patient that unable or refuse to surgery for lumbar spinal stenosis.

Recently, many of therapies were development and performed for symptomatic spinal stenosis because the symptoms related to quality of life in elderly patients. In our study, as a result of effectiveness of treatment for spinal stenosis, we found that radiofrequency neurotomy and nerve block were effective treatment. Although the long term outcome of surgical treatment was most favorable, radiofrequency neurotomy and nerve block can be considered for the secondary management of elderly lumbar spinals stenosis patients.