Correspondence (letter to the editor): Methods Need to Be Adapted to Problems

I have several comments regarding the informative review article. When eliciting information about the symptoms associated with intermittent claudication and the obvious question of vascular or spinal pathogenesis, patients with arterial occlusive disease usually report that their symptoms disappear within minutes when they rest. Those with spinal claudication, by contrast, report a slow disappearance of their pain and the associated, diffusely described weakness in the legs.

The physical examination after the complete description of symptoms will lead to a clinical diagnosis of lumbar spinal stenosis, or the exclusion thereof. When using radiological criteria, however (1): “The term, standing alone, is a morphological description of imaging findings (anteroposterior [AP] diameter by computed tomography [CT] of less than 10 mm); it has no pathological significance in itself”), the cart is put before the horse.

Among the pathogenically relevant, empirically common factors, Kalff and coauthors did not include obesity, especially where it causes hyperlordosis of the lumbar spine. According to many studies in recent decades, however, obesity is not only a risk factor for internal medical complications but also for pain in the lower half of the body—starting with the lumbar spine, hips, knees, ankles, and feet (2– 4).

Once multimorbidity and increased individuality—common in older age—are included especially in older patients then the authors' conclusion, that “no evidence-based recommendation on the diagnosis and treatment of lumbar spinal stenosis in older people can be formulated at present because of the lack of pertinent randomized trials,” is not surprising—especially since such studies are not conducted in patients who might disrupt the smooth running of a randomized trial. Perhaps we should return to a recommendation from the times of Hippocrates of Kos (460–370 BC) and Aristotle (384–322 BC), that the methods have to be appropriate in view of the problems—and do not have to follow mechanistic algorithms.