Most patients improve with non-operative treatment. Surgery is for persistent disabling symptoms or neurological deficit.
Non-operative treatment (3 to 6 months).
- Education, activity modification, flexion based exercise, core stabilisation, walking, and weight loss.
- Paracetamol 1 g orally every 6 hours as needed (maximum 4 g daily; 3 g daily when weight is under 50 kg, with chronic alcohol use or hepatic impairment).
- Ibuprofen 400 mg orally every 8 hours with food (maximum 1200 mg daily) or naproxen 500 mg orally every 12 hours with food (maximum 1000 mg daily), for up to 2 weeks at a time.
- Add omeprazole 20 mg orally once daily in patients over 65 or with ulcer risk.
- Avoid NSAIDs with eGFR under 30 mL/min/1.73 m2, peptic ulcer, heart failure, uncontrolled hypertension or anticoagulant use.
- Neuropathic pain, gabapentin: 300 mg orally at night, increased by 300 mg every 1 to 3 days to 300 to 600 mg three times daily (maximum 3600 mg daily; reduce at creatinine clearance under 60 mL/min).
- Neuropathic pain, pregabalin: 75 mg orally at night or twice daily, increased after 3 to 7 days to 150 mg twice daily (maximum 300 mg twice daily; reduce with renal impairment). Monitor sedation, dizziness and falls.
- Neuropathic pain, duloxetine: 30 mg orally once daily for 1 week, then 60 mg once daily (maximum 120 mg daily). Avoid with monoamine oxidase inhibitors, uncontrolled hypertension, and creatinine clearance under 30 mL/min.
- Epidural steroid injection under image direction: transforaminal dexamethasone 8 to 10 mg (non-particulate) or interlaminar triamcinolone 40 mg. Give no more than 3 in 12 months and at least 2 to 4 weeks apart. It gives relief for weeks to months in 30 to 60%.
- Avoid epidural injection with infection, uncontrolled diabetes (blood glucose rises for 3 to 5 days) and unheld anticoagulants. Hold apixaban or rivaroxaban for 72 hours and warfarin for 5 days with INR under 1.5, by the proceduralist's requirement.
Surgery (persistent disabling claudication or radiculopathy after 3 to 6 months, progressive neurological deficit, or cauda equina syndrome).
- Decompression alone (laminectomy or laminotomy with preservation of the facets) for low grade, stable slips with mainly leg symptoms.
- Decompression with instrumented fusion (pedicle screws with posterolateral or interbody fusion) for unstable or progressive slips, grade 2 or higher, a dynamic slip, a collapsed disc height, or predominant back pain.
- Fusion gives better leg and back outcomes in some patients, at the cost of longer operations, more blood loss and adjacent segment disease.
- Overall, 70 to 85% report good outcomes at 2 years. Complications: dural tear 2 to 10%, infection 1 to 3%, neurological injury 1 to 2%, non-union 10 to 20%, adjacent segment disease 10 to 30% by 10 years, venous thromboembolism.
- Bone health: treat osteoporosis before and after fusion. Alendronate 70 mg orally once weekly, taken with 200 mL water on waking and upright for 30 minutes. Avoid with oesophageal disease, creatinine clearance under 35 mL/min and hypocalcaemia.
- Teriparatide 20 micrograms subcutaneously daily is used off label to improve fusion in osteoporotic patients (maximum duration 24 months). Avoid with Paget disease, prior skeletal radiotherapy, hypercalcaemia and bone malignancy.
Operative antibiotic prophylaxis. Cefazolin 2 g intravenously (3 g when weight is 120 kg or over) within 60 minutes before incision as a single dose (repeat after 4 hours or blood loss over 1500 mL). With severe penicillin allergy, give vancomycin 15 mg/kg intravenously starting 90 to 120 minutes before incision as a single dose, with levels and creatinine checked in prolonged cases. Intrawound vancomycin powder 1 g is used in some centres.
Tranexamic acid (fusion). Tranexamic acid 15 mg/kg (maximum 1 g) intravenously over 10 minutes before incision, repeated once after 3 hours if bleeding continues (maximum 2 g). Avoid with a history of thromboembolism, active intravascular clotting, seizures, or recent coronary stent. Reduce the dose at creatinine clearance under 50 mL/min.
Thromboprophylaxis. Mechanical prophylaxis and early mobilisation. Enoxaparin 40 mg subcutaneously once daily, started 24 to 48 hours after surgery once haemostasis is secure and continued for 7 to 14 days (20 mg once daily at creatinine clearance under 30 mL/min; check the platelet count on days 5 to 14).
Analgesia after surgery.
- Paracetamol 1 g orally every 6 hours.
- Oral morphine 5 to 10 mg every 4 hours as needed for up to 3 to 5 days (start 2.5 to 5 mg with age over 75 or eGFR under 30 mL/min/1.73 m2).
- Gabapentin 300 mg orally at night, increased to 300 to 600 mg three times daily (maximum 3600 mg daily; reduce at creatinine clearance under 60 mL/min), or pregabalin 75 mg orally twice daily (maximum 300 mg twice daily; reduce with renal impairment), for up to 2 weeks.
- Laxative.
Monitoring. Clinical review and neurological examination at 2 weeks, 6 weeks, 3 months, 6 months and 12 months, with standing flexion and extension radiographs to assess fusion and alignment, and yearly afterwards. Walking distance and disability score at each visit.
Referral and escalation. Refer patients with refractory symptoms, progressive weakness, or a slip of grade 3 or more to a spinal surgeon. Emergency referral for cauda equina syndrome (urinary retention, saddle anaesthesia, faecal incontinence or bilateral progressive weakness).
Special groups.
- Older and frail patients: minimally invasive decompression; optimise comorbidities, bone density and nutrition.
- Diabetes: strict glucose control (6 to 10 mmol/L perioperatively) before surgery and during steroid injections.
- Anticoagulated patients: plan the interruption of therapy with the prescribing team.
- Kidney impairment: avoid NSAIDs, reduce gabapentin, pregabalin and morphine doses, and adjust enoxaparin.
