Spinal Stenosis Treatment
A Cause of Pain in the Leg
The term stenosis means narrowing of an opening. Spinal stenosis refers to narrowing of the spinal canal or the neural foramen through which the nerves leave the spine. Spinal stenosis is a condition in which the nerves in the lumbar spine are compressed (“pinched”), usually due to a combination of overgrowth of bone and thickening of ligaments. This is often part of the aging process.
The nerves can be pressed upon as they pass down through the center of the lumbar spine or cervical spine, a condition known as the central stenosis. They may be pressed upon on the side gutters of the spine in cases of lateral recess stenosis. Foraminal stenosis is a condition in which the nerves are pinched as they leave the spinal canal.
Symptoms of Spinal Stenosis
Spinal stenosis in the lumbar spine typically causes numbness, tingling, burning and weakness in the lower extremities. It is usually worsened by standing or walking and is improved with sitting. The reason for this is that often central stenosis is caused by thickening of a ligament running behind the nerves known as the ligamentum flavum. When the patient stands, causing straightening of the spine, the ligamentum flavum buckles and pushes in on the spinal nerves, resulting in pain to the lower extremities. When the patient bends forward, this pulls on the ligamentum flavum, stretching it out and keeping it away from the nerve with reduction of pressure on the nerves and therefore relief of lower extremity pain.
Spinal stenosis in the cervical spine may result in pressure on the nerves causing pain to the upper extremities, or it may result in pressure on the spinal cord resulting in possible spinal damage. Symptoms of this spinal damage may be pain in the neck as well as difficulty in controlling the arms and legs, numbness through the body, bowel and bladder difficulties, and increased reflexes (jumpy legs) in the lower extremities.
Spinal stenosis is generally caused by thickening of ligaments in the spine and overgrowth of bone spurs in the spine. It is also associated with the generation and thickening of the facet joints of the spine. All of these are generally associated with the aging process. It may be also caused by conditions in which one bone has slipped upon the other, known as spondylolisthesis. Any condition which causes narrowing of the spinal canal may cause spinal stenosis. Also, when a herniated disc in the neck or back is extremely large, spinal stenosis may result.
The first step in diagnosing spinal stenosis is obtaining a complete history from the patient, followed by a detailed physical examination. If the physician is suspicious that spinal stenosis may be present, the next step is to confirm this with diagnostic studies. An MRI scan is a very sensitive study which will show spinal stenosis. If this does not give sufficient detail or if questions remain, a myelogram followed by a CT scan of the spine may provide more information. These imaging studies are excellent at showing the anatomy of the spine, but they do not give information about the function of the nerves. If there is a question as to how the nerves and functioning, an EMG/nerve conduction study may help.
Many of the factors which cause spinal stenosis are related to the aging process. Thickening of the ligaments in the spine, degeneration of the joints and growth of osteophytes are all related to the aging process. Although there is no way to prevent or reverse the aging process, it is known that this process is accelerated by a certain factors such as improper lifting, smoking and excessive body weight. Ways to slow down this process include staying in good shape, exercising, keeping weight down and using proper lifting techniques, which will decrease repetitive stress and trauma to the joints.
Nonsurgical management has a role in the treatment of spinal stenosis. In patients in whom the stenosis is not severe and the symptoms are mild, conservative/nonsurgical approaches may allow the patient to achieve sufficient pain relief.
Traditional nonsurgical measures are as follows:
- Nonsteroidal anti-inflammatory medications
- Spinal epidural injections
- Oral pain medications
- Short course of oral steroids
Surgery may be considered when symptoms of pain are not improved by conservative measures or when there is evidence of significant nerve damage with resulting weakness in the arms or legs. When there is evidence of impending paralysis, such as may be caused by significant compression of the spinal cord in the neck, then urgent surgery may be necessary to try to prevent permanent spinal cord injury.
Surgical options are as follows:
- Laminotomy or foraminotomy involves removing a focal portion of the bone either centrally (covering the central portion of the nerves as in laminotomy) or at the area of the neural foramen (in the area where the nerve root leaves the spine as in a foraminotomy).
- Decompressive laminectomy of the lumbar or cervical spine involves removing the roof of the spinal canal. This surgery is very effective at decompressing the nerves in the lumbar spine or the neck. It has a good success rate at relieving pain in the lower or upper extremities.
- Decompressive laminectomy with fusion is used because sometimes there is so much overgrowth of bone in the spine that, in order to sufficiently decompress the nerves, much of the facet joints need to be removed. This may result in instability of the spine. Therefore, the surgeon and patient may opt to consider a fusion of the spine in an attempt to prevent future slippage and instability of the spine. In cases of stenosis due to a spondylolisthesis, a fusion may often be recommended.
The prognosis for pain relief in the extremities is very good. The process of removing bone spur or ligament from around the nerve, resulting in freeing the nerve, has a very good chance of relieving pain to the extremities. The mechanical pain in the joints of this fine may still have arthritic changes, and although some of the back pain may improve, a component of it may remain as well. When surgery is done to decompress the spinal cord in the neck and when spinal cord damage has already been present before surgery, the likelihood of recovery may be variable.
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