The Essence of Clinical Practice Guidelines for Lumbar Spinal Stenosis, 2021: 4. Surgical Treatment.

・Surgical procedures should be selected with patient consent based on comprehensive evaluations, including short-term and long-term clinical outcomes, risk of complications, and cost-effectiveness. Surgical treatment is indicated when conservative treatments are less effective or severe neurological symptoms in the cauda equina, such as bladder and bowel dysfunction, are noted. ・Several reports have indicated that decompression for lumbar spinal stenosis (LSS) produces better clinical outcomes than conservative treatment. It is suggested to perform decompression for patients with LSS without spinal segmental instability diagnosed by physical findings and imaging, in whom conservative treatment is ineffective. ・While decompression with fusion is useful for patients with spinal instability and the improvement of Quality of Life (QOL)/Activities of Daily Living (ADL) is expected, the cost is higher than that of decompression alone, and the return-to-work rate is slightly poorer. The rates of complications and reoperation are also higher than those of decompression alone. So, fully considering pathological conditions and surgical procedures to examine indications is necessary, such as instability and the need for long-segment fusion. ・The bone union state may affect clinical outcomes, but a clear recommendation cannot currently be presented. ・It is suggested to use local bone and to combine the use of artificial bone, demineralized bone matrix, and allogenic bone as the bone graft material for spinal fusion. ・A clear recommendation cannot be made as to whether surgical treatment using Interspinous Process Devices (IPDs) or dynamic stabilization using pedicle screws is more useful than conservative treatment, decompression, or fusion surgery for LSS. ・For patients with LSS, minimally invasive spine surgery may be more useful for preventing the occurrence of iatrogenic instability, alleviating low back pain, and reducing the bleeding volume than conventional surgery, and it is suggested to perform it. ・Even in the very elderly aged 80 years (octagenarian and over), surgical treatment for LSS improves their clinical symptoms.