Minimally invasive decompression versus open laminectomy for central stenosis of the lumbar spine: pragmatic comparative effectiveness study

Dear Editor,

We would like to thank the authors for a comprehensive review of 721 patients (of the 885 patients who were enrolled for this study) who had undergone surgical management of lumbar spinal stenosis, either by laminectomy or by microdecompression [1]. We feel that lumbar canal stenosis could be quite a frequent problem than we assume, although many a times it may not be reported or it may go unnoticed or undetected. We feel that lumbar canal stenosis may be affecting the general public in varying proportions starting from mid-life onwards, with a surge coming from around 60 years of age.

For many, just like graying of hair, fading eye sight (presbyopia), decreasing hearing acuity (prebycusis), and most other things coming up on with ageing, lumbar canal stenosis may just be another baggage that might be seen coming on with age. There is a wide range of symptoms associated with lumbar canal stenosis, and it may mimic other common issues involving lumbar region. The classic symptom of pain worsening on standing or walking, and relieved on sitting down or leaning forward may not appear until too late or when over 60 years. Therefore, we would like to suggest keeping lumbar canal stenosis in the differential diagnosis for patients having back ache right from the third decade onwards. Additionally, we would also like to suggest that the besides the other obvious and hitherto already known factors involved or implicated in the aetio-pathogenesis of stenotic pain, perhaps it may be prudent to take a closer look at any relationship of the blood circulation of the stenosed segment of the spinal cord with the symptoms and manifestations. Certainly the degree of involvement (stenosis) may vary, but to us it seems to be more frequent than is the common belief. We are of the view that this problem could have a beginning as early as in the second or third decades of life, and that there will be many more intermediate points, and everyone may not be reaching a perfect 10 (if we think on a zero to ten scale of associated morbidity coming on with lumbar canal stenosis, if zero is taken as no stenosis and 10 taken as the point of maximum stenosis and morbidity).

Some time ago, we had written to you of our non-invasive and painless “AGRA TECHNIQUE”, that can be effective in some patients [2]. Further research is definitely required for this “AGRA TECHNIQUE”, as we feel that this technique could become a successful modality for releasing some pressure from within the confined space of the lumbar canal without involving surgery of any kind. Moreover, we feel that not every patient may be so willing to undergo surgery for relief from stenosis, which involves laminectomy or microdecompression.

Requirement of surgery will perhaps always remain for managing lumbar canal stenosis, but we feel that the world does require some alternatives, whereby at least some help can be rendered safely, and without the obvious need of surgery. “AGRA TECHNIQUE” can be developed by further research by the global scientific and medical fraternity into a viable alternative. With our constraints, and within our own resources, we are unable to do anything further than what we already have [2-3]. We also presume that, with further research, a day might not be so far off when this technique might be used to help patients with just a marginal stenosis as well, and where the quality of life can be improved non-invasively, painlessly, and within a short time [4]. Finally, we would like to suggest that it might be prudent not to wait until the lumbar canal stenosis becomes too severe to warrant surgery. Early detection may help with better outcomes, and even non-invasive technique as ours could be helpful to an extent. Yes, as already stated, we would like to place the onus now on the global fraternity to improve upon this technique, making it absolutely safe, acceptable as a viable alternative, more precise, and with better outcomes which continue for a lifetime.

Best regards.

• Dr (Lt Col) Rajesh Chauhan
Hon’ National Professor, IMA CGP, India

• Dr. D.R. Rai
National Vice President, IMA, India

• Dr. Ajay Kumar Singh Parihar

• Dr. Shruti Chauhan

REFERENCES :

1. Nerland Ulf S, Jakola Asgeir S, Solheim Ole, Weber Clemens, Rao Vidar, Lønne Greger et al. Minimally invasive decompression versus open laminectomy for central stenosis of the lumbar spine: pragmatic comparative effectiveness study. BMJ 2015; 350 :h1603

2. Chauhan R, Parihar AKS, Chauhan S. Re: Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. BMJ 04 Nov 2013. Available at : http://www.bmj.com/content/343/bmj.d5278/rr/670106. (Accessed on 03 April 2015)

3. Chauhan R, Chauhan S, Parihar AKS. ‘Agra Technique’ for managing lumbar canal stenosis without surgery or needles. In : Innovative medical techniques showcased at international medical conferences. Lap Lambert Academic Publishing; 2014. Pp 32-36.

4. Chauhan R, Parihar AKS, Chauhan S. Medicine : Perhaps its time to look beyond the tunnels and to remove constraining straight-jackets. BMJ 26 Nov 2014. Available at : http://www.bmj.com/content/349/bmj.g6123/rr/788689 (Accessed on : 03 April 2015)