The difficulties in evaluating the indication, diagnostics, and treatment and assessing the therapeutic success after treating lumbar spinal stenosis in older patients were emphasized once more at the end of our article (1). The correspondence from Schiltenwolf and Wörz also describes the complexity of the problem and fits in seamlessly with our explanations. In our CME article, we mostly gave space to the aspects relating to the symptoms. The psychological comorbidities of older patients and their influence on the results of any medical treatment constitute important aspects that concern not only the treatment of spinal stenosis but also other therapeutic approaches. A more detailed explanation would have exceeded the word limit of our article and was therefore not undertaken.
With regard to Wörz’s correspondence, we wish to point out that the medical history and clinical examination—as formulated in our article—are clearly the first steps and lead to the diagnosis of neurogenic claudication. The diagnosis of spinal stenosis does, however, require confirmation by imaging methods. Early on in our article, we explained the lack of correlation between imaging results and clinical diagnoses as a function of the wide range of radiological findings with generally low interobserver reliability.
Especially the absence of validated and guideline supported treatment pathways in the therapy of lumbar spinal stenosis requires the initiation of steps in this direction. A differentiated reflection, especially of the treatment result, is useful and important. Appropriate scoring systems (for example, SF 36/Oswestry Disability Index) exist and allow—within limitations—a reproducible and objectifiable assessment of the disease course. The registry of the German Spine Society (Deutsche Wirbelsäulengesellschaft, DWG), introduced two years ago, is a nationwide platform and provides an obvious option for the collection of disease course data and for describing the importance of different approaches. On a voluntary basis, data on the validity of therapeutic approaches are collected, also under the aspect of future quality management. A further continuing, scientifically funded workup of the problem will result in increased safety and an even higher degree of individualized therapy and therefore the avoidance of unnecessary interventions.
On behalf of the authors:
PD Dr. med. Christian Ewald
Klinik und Poliklinik für Neurochirurgie
Conflict of interest statement
The authors of all contributions declare that no conflict of interest exists.
|1.||Kalff R, Ewald C, Waschke A, Gobisch L, Hopf C: Degenerative lumbar spinal stenosis in older people—Current treatment options. Dtsch Arztebl Int 2013; 110(37): 613–24. VOLLTEXT|