Spinal Stenosis is a common condition seen associated with arthritis and degenerative changes of the spine. It results in narrowing of the spinal canal through which the spinal cord and the nerve roots pass. With the degenerative changes that take place, many structures inside the spinal canal enlarge leaving less space for the nerve roots. Patients are usually in their 6o’s or 70′s and have noticed difficulty in walking with pain(neurogenic claudications). The disease process is slow and progressive so the changes can be noticed over one or two years. However some patients may report rapid progress of pain and walking difficulty over a few short months.
The spinal column consists of square bony elements called the vertebra. Between each vertebrae an intervertebral disc exists that acts as a cushion between each segment. Between each segment, few joints exist that allow some motion, and are called the facet joints. Ligaments help hold the structure of the spine together and the most prominent one is called the yellow ligament (Ligamentus Flavum).
As our bodies grow older, the structure of our spines will undergo wear and tear or degenerative changes. This includes the breakdown of disc and arthritis of the facet joints. In an attempt to stabilize the spine, our body will enlarge the facet joints, as well as the yellow ligament. This attempt to stabilize comes with the price of smaller space available for the nerve roots and is the basis for spinal stenosis. The degenerative disc changes seen may also cause bulging of the discs and further decreasing the size of the spinal canal.
Classically, patients will present complaining of difficulty walking, pain and stiffness in the legs. To get relief of the pain they must stop and rest. They may only be able to walk one or two blocks before the onset of pain. The described pain is a feeling of pressure, dull pain, and discomfort in the legs. Back pain is not the major complaint in most cases. The yellow ligament is tighter and thinner when stretched, and this occurs as the patients’ bends forward. For this reason patients will find some relief from a bending posture. Walks in the supermarket while pushing a cart in a bending position will give marked pain relief and ability to walk for longer periods. Bicycling and sitting will also provide relief since a bending posture is necessary for these activities.
Usually the diagnosis is made based on history and physical examination. However, diagnostic studies will be performed for confirmation. These may initially include an x-ray or an MRI. The most common level of involvement is the lower lumbar areas of L-4, L-5, and S-1. Some patient will require other studies for improved accuracy in diagnosis. For these patients we resort to Myelograms and CT scans. Since this is mostly a bony problem, the CT scan is utilized for better visualization of the bony anatomy. Patients with certain types of implant will not be able to undergo an MRI and the Myelogram/CT scan will be provided as the first test. The picture to the right represents an MRI of a normal person. The white structure in the middle represents the nerves passing within the spinal canal being surrounded by spinal fluid. In contrast, the picture below, represents an MRI of a person with Spinal Stenosis. No white area could be seen in the area which means there is no flow to the spinal fluid around the nerves in that area. That section is so stenotic (or tight) which does not allow free flow to the fluid bathing the nerves. In consequence there is also pressure on the neural structures causing the dysfunction normally seen in patients afflicted with Spinal Stenosis.
The initial treatment will consist of anti-inflammatory medications and activity modifications. These medications will decrease inflammation and swelling resulting in more space for the nerve roots. These medications usually reduce symptoms and increase walking endurance. However, realistic goals should be set with this treatment regime since not all symptoms are likely to resolve. Many patients may find enough relief to have acceptable lifestyle. Physical therapy will improve physical conditioning and increase endurance. If these initial options are not helpful, we will offer epidural steroid injections. These involve the injection of steroidal medication around the dural sac and the neural element. Since steroids have powerful anti-inflammatory properties, the symptoms may markedly improve. We recommend a set of three injections separated each by few weeks for increased benefit. In most cases patient will not recieve more than 3 injections within an eight month period.
If a patient is still suffering from sever pain and changed lifestyle, after conservative treatments have been exhusted, operative intervention will be offered. Small subset of patients will present with sever enough symptoms that operative treatment may be the first line of treatment. In these cases, operative treatment may actually be the conservative treatment. For this reason the term non-operative, rather than conservative, is a more appropriate term to use. Almost all patients will decide to have the operative procedure on an elective basis. The procedure involves the removal of the bony “roof” of the spinal canal and the excess bone produced by the body under the facet joints. In addition, the hypertrophied yellow ligament that is present in the canal will be removed. The procedure is called decompression laminectomy and is described separately in the highlighted section. Other conditions may be complicated by spinal stenosis. One example is Spondylolisthesis. This condition may require further operative procedures in addition to a decompression. Research studies have shown that fusion procedures in addition to a decompression yield better results in those cases.. However, the discussion on the best operative procedure is best suited with your spine surgeon who will guide you with knowledge, experience, and judgment specifically in your case.
Most patients with this condition will remain in the hospital for a few days. From there they could continue their stay in an acute rehab center or be discharged home. If there is good support network for the patient the continued recovery period could take place at home, however not all patients are fortunate to have good family support. In these cases we will provide the necessary resources for complete recovery and return to a productive, painless, and functional lifestyle.
For more information regarding this condition, or other concerns and questions please contact our office for an evaluation. This information does not substitute the advice and knowledge of your spine surgeon. It is not intended to evaluate, diagnose or treat any conditions using the information in this web site. This information is only to provide some guidance for the patient with the ultimate information presented by your spine surgeon.
