Patients with lumbar spinal stenosis often receive different recommendations. One may be offered surgery to relieve pressure on the nerves without implants, while another may be advised to have a cage and screws inserted as well. Why can operations differ when the diagnosis appears similar?
The decision depends on more than the degree of narrowing of the spinal canal. It is important to understand what is causing the symptoms: compression of the nerves, instability of a spinal segment, or a combination of these problems.
My basic approach is as follows: for isolated lumbar spinal stenosis without instability, I perform decompression without stabilization. If stenosis is accompanied by spondylolisthesis, instability, or a marked loss of disc height together with predominantly lower back pain, I consider whether stabilization is needed. This is an individual decision, not an automatic recommendation based on a single term in an MRI report.
Decompression and stabilization address different problems
Decompression means relieving pressure on the nerves. During the operation, the structures that narrow the canal or the space around the nerve roots are removed.
Its main goal is to reduce symptoms caused by nerve compression: leg pain, difficulty walking, and neurogenic intermittent claudication.
Stabilization has a different goal: to provide stability to a spinal segment. In my practice, when stabilization is needed, I combine an interbody cage with minimally invasive pedicle screw fixation.
A cage is an implant placed between the vertebral bodies to restore the interbody space and support the segment. The screws hold the segment in place. Spinal fusion—the formation of a bony union between vertebrae—takes place gradually, not at the moment the implants are inserted. An explanation of spinal fusion and internal fixation—AAOS.
The question, therefore, is not which operation is “more modern.” We need to determine whether relieving pressure on the nerves is enough, or whether the segment also needs to be stabilized.
When is surgery needed at all?
Narrowing of the spinal canal on an MRI scan does not, by itself, mean that a patient needs surgery.
If there are no clinical symptoms, I do not regard the scan alone as a reason for surgical treatment. Similarly, if nonsurgical treatment provides the desired and lasting benefit, surgery may not be necessary.
The following changes prompt me to discuss surgical treatment:
- progression of neurogenic intermittent claudication;
- a reduction in the distance the patient can walk;
- increasing pain in the lower limbs.
It is important to assess not only the intensity of the pain, but also how the condition affects everyday life: whether the person can walk, manage their usual tasks, and maintain their normal level of activity.
Progressive weakness in the lower limbs and suspected cauda equina syndrome require particular attention. New problems with urination or bowel control, especially when accompanied by neurological symptoms, require urgent medical assessment. In these circumstances, patients should not wait for a routine appointment. WFNS recommendations on urgent assessment.
When I choose decompression without stabilization
For uncomplicated lumbar spinal stenosis without spondylolisthesis or instability, my choice is decompression without a stabilizing implant construct.
In this situation, the purpose of the operation is to relieve pressure on the nerves. A cage and screws do not need to be added simply because the canal is narrowed.
Multilevel stenosis is also not, in itself, a reason for me to add stabilization. The number of affected levels is considered when planning the operation, but does not by itself determine whether fixation is needed.
An approach based on decompression without mandatory fusion is consistent with WFNS recommendations for patients whose leg symptoms predominate and who have no signs of instability. Nevertheless, the anatomy and the extent of decompression required are considered during planning. This does not mean that removing any amount of supporting tissue cannot affect stability. WFNS recommendations.
Does spondylolisthesis always mean that fixation is necessary?
No. Spondylolisthesis—the displacement of one vertebra relative to another—is not always accompanied by instability.
For Grade I spondylolisthesis without signs of instability, when leg symptoms predominate, I may consider decompression without fixation.
If the main complaint is lower back pain, I am more inclined to consider stabilization. However, I make the final decision after assessing the nature of the pain together with the examination and imaging findings.
The five-year Nordsten-DS study found that, in patients with stenosis and degenerative spondylolisthesis who met the study's inclusion criteria, decompression without fixation was not inferior to decompression with spinal fusion for the main clinical outcome. This supports the view that fixation is not needed for every such patient, but does not mean that it can be ruled out in every case. Nordsten-DS, BMJ, 2024.
How I assess instability
For me, the combination of specific symptoms and findings on flexion–extension X-rays is important. These images are taken with the patient bending forwards and backwards.
When talking with a patient, I pay attention to lower back pain that becomes worse:
- when turning over in bed;
- when moving from sitting to standing;
- with repeated bending;
- during walking, if it is specifically the lower back pain that increases.
In my experience, some of these patients feel better in the morning.
These complaints help me understand the nature of the problem, but do not prove instability on their own. On the flexion–extension images, I look for a change in vertebral displacement between the two positions and assess this together with the symptoms.
In other words, the decision is not based on a single image or a single symptom.
When I consider stabilization
I consider stabilization when we need to address not only nerve compression, but also the stability of the spinal segment.
The combination of stenosis with instability, spondylolisthesis, and predominantly lower back pain requires particular attention.
I also take a marked degenerative loss of disc height into account when it is accompanied by predominantly lower back pain. “Disc collapse” on an image does not, by itself, automatically mean that implants are necessary.
The guiding points of my clinical approach can be summarized as follows:
On a phone, scroll the table horizontally to read all columns.
| Clinical situation | How I approach the choice of operation |
|---|---|
| Isolated stenosis without instability or spondylolisthesis | Decompression without stabilization |
| Stable Grade I spondylolisthesis, with predominantly leg symptoms | Decompression without fixation may be an option |
| Stenosis with symptomatic instability | I consider adding stabilization |
| A marked loss of disc height and predominantly lower back pain | I assess whether stabilization is appropriate together with the other findings |
| Stenosis at several levels | The number of levels alone is not a reason for fixation |
This table is not intended for choosing an operation yourself. It explains the reasoning behind a decision that requires an individual examination and assessment of the investigations.
How endoscopy and stabilization are combined
My specialization is endoscopic spine surgery.
It is important to distinguish two questions: how the operation is performed, and whether stabilization is needed. An endoscopic approach does not mean that fixation is always necessary or always unnecessary.
For uncomplicated stenosis, I perform endoscopic decompression without stabilization.
If stabilization is indicated, I always use a combination: I insert the cage endoscopically and supplement the operation with minimally invasive pedicle screw fixation—MIS.
The purpose of this construct is to restore the interbody space and provide stability to the segment. Endoscopic cage insertion and minimally invasive screw placement are different components of the same operation.
Why bone quality matters before stabilization
All my patients undergoing an operation with stabilization have a CT scan beforehand.
In each vertebra that I plan to include in the fixation, I assess bone quality, including its density in Hounsfield units—HU. This is part of assessing the bone and planning the operation, not a universally sufficient standalone test for osteoporosis.
Reduced bone quality matters when selecting the construct and assessing possible problems with fixation. CNS recommendations also emphasize preoperative assessment of patients with suspected osteoporosis. Preoperative osteoporosis assessment—CNS.
Which implants I use
In my practice, I use 3D-printed porous titanium cages. This choice is informed by our clinic's experience and scientific evidence.
However, achieving spinal fusion and cage subsidence are different outcomes and should not be combined into a single promise.
For example, a retrospective study published in 2023 found a higher fusion rate with porous titanium cages than with PEEK cages, but did not find a statistically significant difference in subsidence. Yang and colleagues, 2023.
In a randomized study published in 2026 with two-year follow-up, the overall fusion rates were comparable, while subsidence was less frequent with 3D-printed titanium cages, including in the subgroup with osteoporosis. Shin and colleagues, 2026.
Both studies concerned posterior lumbar interbody fusion—PLIF. Their findings are not direct measures of the outcomes of our endoscopic operations and do not guarantee the result for an individual patient.
In patients with osteoporosis, I use fenestrated screws augmented with bone cement. I use cement augmentation specifically in osteoporosis, not in every stabilization operation.
Who manages osteoporosis treatment?
I do not prescribe medication for osteoporosis myself. In my practice, I recommend that the patient see the appropriate specialist at an osteoporosis center one month after the operation.
This describes my postoperative follow-up process; it is not a recommendation for everyone to postpone treatment for a month. The timing of assessment and treatment is determined individually. International recommendations also include preoperative assessment and, when indicated, treatment of osteoporosis. CNS recommendations.
Special implants and cement augmentation of screws do not replace treatment of osteoporosis itself.
What results to expect—and what may persist
After decompression, I primarily expect a reduction in pain and an improvement in walking distance.
However, not all symptoms necessarily disappear at the same time. Numbness may persist even after a correctly performed operation. It is therefore important to discuss beforehand which symptoms we expect to improve and which outcomes are less predictable.
Similarly, inserting a cage and screws should not be viewed as a guarantee that all lower back pain will disappear. That is why we need to identify the problem stabilization is intended to address before operating.
Does minimally invasive surgery mean there are no risks?
No. My own clinical observations do not establish that decompression and an operation with stabilization carry the same risks.
Surgical treatment can involve infectious, neurological, and other complications. When implants are used, the possibility of incomplete fusion, cage subsidence, loosening, or failure of fixation must also be considered. Possible complications—AAOS, risks related to bone quality—CNS.
This does not mean that stabilization should be avoided when it is indicated. Its expected benefits and risks need to be assessed for the individual patient.
Recovery in our practice
After endoscopic decompression without stabilization, the patient usually goes home the following day.
After an operation with a cage and MIS fixation, the hospital stay is usually 4–5 days.
These are typical discharge times in our practice, not times to full recovery or a guarantee that every patient's course will be the same.
On a phone, scroll the table horizontally to read all columns.
| Question | Decompression without stabilization | An operation with a cage and MIS fixation |
|---|---|---|
| Typical discharge in our practice | The following day | After 4–5 days |
| Lumbar brace | We usually recommend one for several weeks | We do not prescribe one |
| Activity | Walking and a gradual return to usual activity | The same basic recommendations |
| Restrictions in the first weeks | No heavy lifting or strenuous physical activity | The same basic restrictions |
After an operation with stabilization, we use an epidural catheter for pain relief for 4 days. This is how we manage pain in our practice; the specific regimen requires a decision by the anesthesiologist and medical supervision.
After both types of operation, I recommend walking and a gradual return to usual activity. During the first weeks, patients should avoid heavy lifting and strenuous physical activity. Any further increase in activity is agreed with the doctor according to the course of recovery.
What to ask your surgeon before the operation
It is important for the patient to understand not just the name of the operation, but also why it has been chosen.
At the consultation, it is worth discussing:
- Which of my symptoms are specifically related to stenosis?
- Are there signs of instability, and how have they been confirmed?
- Why is decompression enough in my case, or why is stabilization needed?
- What specific problem are the cage and screws intended to address?
- Which symptoms may remain after the operation?
- How does my bone quality affect the treatment plan?
- Which recovery recommendations apply specifically to me?
Key takeaway
Not every patient with lumbar spinal stenosis needs a cage and screws. If the main problem is nerve compression and there is no instability, decompression without stabilization may be enough.
If stenosis is accompanied by clinically significant instability or other changes that correspond to the patient's symptoms, we consider additional stabilization.
My principle is to choose an operation that addresses the patient's specific problem. To do this, I assess the symptoms, examination findings, and investigations together, rather than making the decision solely on the wording of an MRI report.
For an individual discussion of surgical treatment for lumbar spinal stenosis, you can arrange a consultation through stenosis.surgery.
This article explains the author's clinical approach and does not replace an individual consultation. The final treatment plan is determined after an examination and assessment of the investigations.