Vol 11 | Issue 2 | July-December 2025 | page: 3-6 | Rahul Jaiswal, Shailesh Hadgaonkar, Ajay Kothari, Siddharth Aiyer, Pramod Bhilare, Darshan Sonawane, Ashok Shyam, Parag Sancheti

https://doi.org/10.13107/jmt.2025.v11.i02.258

Author: Rahul Jaiswal [1], Shailesh Hadgaonkar [1], Ajay Kothari [1], Siddharth Aiyer [1], Pramod Bhilare [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]

[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Shivaji- nagar, Pune, Maharashtra, India.

Address of Correspondence
Dr. Rahul Jaiswal,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Shivajinagar, Pune, Maharashtra, India.
E-mail: rj199116@gmail.com

Abstract

Background: Lumbar canal stenosis commonly causes leg pain, numbness and reduced walking distance in middle-aged and older adults. Degenerative loss of disc height, enlargement of facet joints and thickening of the ligamentum flavum narrow the spinal canal, compressing nerve roots and producing neurogenic claudication and disability. Conservative care—physiotherapy, medications and epidural injections—helps many patients, yet persistent symptomatic stenosis often requires surgical decompression to relieve nerve compression and restore walking tolerance and independence.
Hypothesis: The study proposes that decompression alone, applied to patients with degenerative lumbar canal stenosis and Grade I spondylolisthesis without clear instability, will yield meaningful and sustained reductions in leg and back pain and substantial improvement in daily function and overall health. It further proposes that measurable restoration of lumbar lordosis and pelvic alignment will be modest for most patients, and that symptomatic recovery will depend chiefly on relief of neural compression and reversal of pain-driven antalgic posture rather than on large radiographic corrections.
Clinical importance: If these expectations are met, a decompression-first strategy supports a less invasive pathway for most patients who lack objective instability, avoiding the additional morbidity of fusion while delivering reliable symptom relief. Emphasis on validated patient-reported outcomes—pain scores, the Oswestry Disability Index and general health measures—keeps decision-making focused on what matters to patients: reduced pain, improved mobility and better quality of life. Counseling should set realistic expectations about likely functional gains and the limited degree of radiographic change to be expected after decompression alone.
Future research: Randomized, multicentre trials comparing decompression alone with decompression plus fusion in patients who have borderline sagittal parameters are needed to define radiographic thresholds that justify fusion. Longer follow-up and objective measures—quantitative assessment of paraspinal muscle quality and gait analysis—will help predict who benefits most from fusion versus decompression alone. This study reports prospective medium-term outcomes using validated measures and standardized standing radiographs to examine the link between symptom relief and sagittal alignment. Findings aim to guide practical surgical decisions for everyday spine care. Durable outcomes.
Keywords: Lumbar canal stenosis, Decompression, Lumbar lordosis, Spinopelvic parameters, Oswestry Disability Index, Neurogenic claudication

Background
Lumbar canal stenosis is a common degenerative condition of the lower spine that produces leg pain, numbness and progressive difficulty with walking. Over time, loss of disc height, enlargement of the facet joints, osteophyte formation and thickening of the ligamentum flavum narrow the spinal canal and compress nerve roots. Patients typically report leg symptoms that worsen with standing and walking and ease with sitting or forward flexion; back pain often coexists but the dominant complaint is usually reduced walking tolerance and functional decline. [1–4]
Initial care is conservative: physiotherapy, analgesics, activity modification and epidural injections can relieve symptoms for many patients. When symptoms persist or progressive neurological deficit develops despite nonoperative care, surgery is considered. The surgical aim is straightforward — remove the compressive elements to free the nerves, reduce pain, and restore walking ability and day-to-day function. Traditional open laminectomy achieves reliable decompression but may injure paraspinal muscles or destabilize the posterior elements in some patients. Over the years, muscle-sparing laminotomies and other less invasive decompressive techniques have been developed to lower soft-tissue trauma while preserving the neural benefit. [5–9]
Beyond nerve decompression, modern practice considers spinal balance. Spinopelvic parameters — pelvic incidence, pelvic tilt, sacral slope and lumbar lordosis — describe how the spine and pelvis align in the sagittal plane and influence load distribution and long-term mechanical pain. In degenerative disease, patients commonly adopt a flexed, antalgic posture; relief of pain may permit a more erect stance and a measurable increase in lumbar lordosis. However, true structural correction depends on reversing degenerative disc collapse, facet arthropathy and muscle degeneration — changes that often cannot be corrected solely by decompression. Reported effects of decompression on sagittal metrics therefore vary: some series show modest improvement in lordosis, whereas others find little change. [10–13]
This uncertainty has important clinical consequences. For patients with clear instability or marked deformity, fusion with realignment may be necessary. For the majority with symptomatic stenosis and at most low-grade spondylolisthesis, the question is whether decompression alone will deliver the functional recovery they need without the added morbidity of fusion. Large cohort studies and randomized trials have demonstrated that decompression reliably reduces leg pain and improves disability and quality of life for many such patients, though a subset will later require fusion for mechanical symptoms or progression. [14, 15, 21]
Measuring both patient-reported outcomes (pain scores, Oswestry Disability Index, general health measures such as SF-36) and standing spinopelvic radiographs before and after surgery provides practical information. It shows whether symptom relief aligns with measurable changes in sagittal balance, and it helps surgeons decide when radiographic findings should push them toward fusion rather than decompression alone. The present work reports a prospective series that tracked validated clinical scores and standardized standing radiographs in patients undergoing lumbar decompression, with the aim of clarifying the relationship between symptomatic recovery and radiographic alignment. [16–20]

Hypothesis
Two linked hypotheses guided the study.
First, in patients with degenerative lumbar canal stenosis — including those with Grade I spondylolisthesis but without clear mechanical instability — decompression alone will produce substantial and sustained reductions in leg and back pain, plus meaningful improvement in disability and overall health. Relief of direct neural compression reduces ongoing nociception and venous congestion of the nerve roots, allowing functional recovery and improved walking tolerance. Previous prospective studies support the expectation that decompression yields clinically important gains on VAS, ODI and general health measures. [7, 14, 15]
Second, measurable restoration of sagittal alignment after decompression will be modest for most patients and will not be essential for clinical recovery. Pain-driven forward-flexed posture and posterior pelvic tilt commonly accompany stenosis; when pain subsides, a degree of postural correction may occur, producing small increases in lumbar lordosis. Yet long-standing structural degeneration — disc height loss, facet arthropathy and fatty change of the paraspinal musculature — limits large or durable radiographic correction without reconstructive measures. Several reports document inconsistent changes in pelvic parameters after decompression, suggesting that functional recovery often occurs even in the absence of major alignment change. [10–13, 16–18]
To test these hypotheses, the study enrolled consecutive, eligible patients who met predefined inclusion criteria (symptomatic degenerative lumbar canal stenosis, age threshold, instability up to Grade I) and excluded those with higher-grade slips, prior fusion, infection or tumour. Each patient underwent decompression appropriate to the pathology (laminotomy, laminectomy or muscle-preserving techniques). Outcome assessment combined validated PROMs — VAS for back and leg pain, ODI for disability, and SF-36 for health-related quality of life — with standardized standing lateral radiographs that included the femoral heads to permit accurate measurement of pelvic incidence, pelvic tilt, sacral slope and lumbar lordosis. [20–22]
Follow-up extended to the medium term and compared baseline and postoperative PROMs and radiographic metrics. The core analytic questions were: how large are the clinical gains after decompression, do spinopelvic parameters change meaningfully, and are radiographic changes correlated with improvements in pain and function? The practical intent was to determine whether decompression-first remains the sound initial strategy for most patients without objective instability, reserving fusion for those with evidence of structural deformity or persistent mechanical symptoms. [21–25]

Discussion
The study observed consistent and clinically meaningful improvement in symptoms and function after lumbar decompression. Patients reported substantial drops in leg and back pain and marked reduction in disability scores; general health measures improved in parallel, reflecting greater mobility and daily independence. These clinical gains mirror those found in prior prospective cohorts and randomized studies that established decompression as the primary surgical treatment for symptomatic stenosis when instability is absent. [7, 14, 23]
On radiographs, changes in lumbar lordosis and pelvic parameters were generally modest. Some patients regained a measure of lordosis as pain relieved and antalgic posture resolved, but the cohort did not show large, uniform corrections of sagittal alignment. Importantly, the magnitude of radiographic change did not consistently predict the degree of functional recovery: many patients with little or no radiographic change experienced large symptomatic benefit, and conversely, radiographic improvement did not guarantee superior clinical outcomes. This dissociation underscores that relief of neural compression — not radiographic perfection — chiefly drives early to medium-term recovery after decompression. [10–12, 16–18]
Several considerations explain why radiographs and symptoms diverge. Decompression directly treats the proximate cause of neurogenic claudication, allowing nerve roots to recover function; this process improves pain and walking even when underlying degenerative deformity remains. Structural features such as disc collapse, facet joint arthropathy and paraspinal muscle atrophy restrict the scope for radiographic correction unless reconstructive procedures are performed. Measurement variability, heterogeneity in the number of levels decompressed, and patient factors (obesity, sarcopenia, and hip or knee compensation) further blur any simple relationship between angle changes and patient function. [11, 21, 22]
Clinically, the findings support a pragmatic approach. For patients whose principal problem is neurologic — leg pain and neurogenic claudication — and who lack clear dynamic instability or marked sagittal deformity, decompression alone is an appropriate initial strategy. It reduces operative morbidity compared with fusion while delivering predictable symptomatic relief. For patients whose predominant complaint is mechanical back pain linked to fixed sagittal imbalance, or those with high pelvic incidence–lumbar lordosis mismatch, fusion and alignment-restoring surgery should be considered to address the structural driver of pain and to prevent late progression. Thus, selection should integrate symptoms, objective instability assessment, radiographic measures and the patient’s functional goals. [23–25]
Limitations include single-centre design, potential selection bias, variability of surgical technique and medium-term rather than long-term follow-up. Radiographic measurement error and absence of quantitative paraspinal muscle assessment are additional constraints. Nonetheless, the results add to the body of evidence demonstrating that decompression alone provides meaningful symptom relief for the majority of appropriately selected patients and that substantial radiographic correction is not a necessary precondition for clinical benefit.

Clinical importance
Decompression without fusion reliably reduces leg pain, improves walking capacity and enhances quality of life in patients with degenerative lumbar canal stenosis and Grade I or absent spondylolisthesis when objective instability is not present. Prioritizing symptom-driven indications and validated patient-reported outcomes keeps decision-making focused on what matters to patients: less pain and better function. Fusion remains important for those with fixed deformity, progressive slip or predominant mechanical back pain, but for many patients a decompression-first pathway minimizes surgical risk while achieving the desired clinical goals. [21–24]

Future direction
Randomized, multicentre trials comparing decompression alone with decompression plus fusion in patients with borderline sagittal parameters are needed to define thresholds that justify adding fusion. Longer follow-up with objective measures — quantitative MRI of paraspinal muscles, gait analysis and standardized PROMs — will improve the ability to predict who will regain upright posture after decompression and who will progress to mechanical failure, enabling more precise, individualized surgical planning. [23–25]

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Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2022

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