Lumbar Spinal Stenosis A Patient's Guide to Lumbar Spinal Stenosis

See a Washington Post story about a woman whose worsening pain stumped specialist after specialist for five years until she saw UM spine surgeon Steven Ludwig, who diagnosed the cause as spinal stenosis and performed successful surgery.

Introduction

Spinal stenosis is term commonly used to describe a narrowing of the spinal canal. This problem is much more common in people over the age of 60. However, it can occur in younger people who have abnormally small spinal canals as a type of birth defect. The problem usually causes back pain and leg pain that comes and goes with activities such as walking.

The purpose of this information is to help you understand:

• The anatomy of the spine relating to spinal stenosis • The signs and symptoms of lumbar spinal stenosis • How the condition is diagnosed • The treatments available for the condition

Anatomy

In order to understand your symptoms and treatment choices, you should start with some understanding of the general anatomy of your lumbar spine (lower back). This includes becoming familiar with the various parts that make up the spine and how these parts work together.

Please review the document entitled:

• Anatomy and Function of the Spine

Causes

Although there is some space between the spinal cord and the edges of the spinal canal, this space can be reduced by many conditions. Bone and tough ligaments surround the spinal canal. This tube cannot expand if the spinal cord or nerves require more space. If anything begins to narrow the spinal canal, the risk of irritation and injury of the spinal cord or nerves increases. Some of the conditions that can lead to narrowing of the spinal canal include: infection, tumors, trauma, herniated discs, arthritis, thickening of ligaments, growth of bone spurs, and disc degeneration.

Spinal stenosis usually occurs in older people after years of wear and tear, or degeneration of the spine. This wear and tear results in changes in the structures around the spinal canal such as: thickening of the large ligaments that connect the vertebra together, bone spurs around the facet joints and disc space, and bulging of the discs themselves. All of these changes push into the spinal canal, making the tube of the spinal canal smaller. Eventually, there is not enough space in the spinal canal for the nerve to comfortably fit without causing too much pressure. Stenosis can also develop from injuries, infections, or tumors. Some people even have a narrow spinal canal from birth, an abnormality that leads to symptoms of stenosis.

The narrowing of the spinal canal can lead to irritation of the nerves of the spine. This can cause pain and problems with the nerves not working properly. The lack of space can also cause the supply of blood and oxygen to the spinal cord to be reduced. When the spine needs more blood flow during increased activity, the blood vessels may not be able to swell to get more blood to the spine. This can lead to numbness and pain in the nerves that are affected. In addition, the nerves lose some of their mobility when the space available to them is reduced. This leads to irritation and inflammation of the nerves. Stenosis can occur in all areas of the spine, but it is most common in the lumbar spine.

Symptoms

The main symptoms of spinal stenosis include a sensation of heaviness, weakness, and pain with walking or prolonged standing. With rest, these symptoms often disappear. These symptoms occur because the nerve roots are being tampered with, upsetting the normal signals that travel from the brain to the body. Irritation of the nerves in the spinal canal is worse when standing or walking due to the mechanical compression and stretching of the nerves. Diagnosis

Before a health care professional can diagnose your condition and design a treatment plan, a complete history and physical examination are necessary. There are many possible internal causes of pain. It is important to determine what is and is not the root of the problem. After the physician has a better idea of what is causing your discomfort, diagnostic tests of some sort may be recommended.

History

First, you will be asked for a complete physical history of your condition. This may begin by filling out a written form that asks you a number of questions relating to your pain. The more information you share with your provider the easier your problem will be to diagnose. Your physical history is important because it helps your doctor understand: when the pain began, anything that could have caused an injury, your lifestyle, physical factors that might be causing the pain, and any family history of similar problems. After reading through your written history, your physician will ask more questions relating to the information you have given. Typical questions include:

• When did the pain begin? • Was there an injury that could be related to the pain? • Where do you feel the pain? What is the intensity? • Does the pain radiate to other parts of the body? • What factors make the pain feel better or worse? • Have you had problems with your bladder or bowels? • Is there a history of osteoporosis in your family?

Physical Examination

After taking your history, the physician will give you a physical examination. This allows the doctor to rule out possible causes of pain and try to determine the source of your problem. The areas of your body that will be examined depend upon where you are experiencing pain - neck, lower back, arms, legs, etc. The following are some of the things that are checked in a typical exam:

• Motion of Spine and Neck - Is there pain when you twist, bend, or move? If so, where? Have you lost some flexibility?

• Weakness - Your muscles will be tested for strength. You might be asked to try to push or lift your arm, hand, or leg when light resistance is put against them.

• Pain - The doctor may try to determine if you have tenderness of certain areas.

• Sensory Changes - Can you feel certain sensations in specific areas of the feet or hands?

• Reflex Changes - Your tendon reflexes might be tested, such as under the kneecap and under the Achilles tendon on your ankle. • Motor Skills - You might be asked to do a toe or heel walk.

• Special Signs - The physician will also check for any "red flags" that could indicate something other than spinal/vertebrae problems. Some signs of other problems include: tenderness in certain areas, a fever, an abnormal pulse, chronic steroid use (leads to loss of bone mass), or rapid weight loss.

Diagnostic Tests

You may be asked to take a variety of diagnostic tests. The tests are chosen based upon what your physician suspects is the cause of your pain. The most common diagnostic tests to determine whether you have spinal stenosis are X-rays of your lower back and an MRI scan. In some cases, a CAT scan may be ordered either in addition to a MRI or instead of it.

X-rays

An X-ray is a painless process that uses radioactive materials to take pictures of bone. If your doctor suspects vertebral degeneration, X-rays can be used to verify: a decrease in the height of space between discs, bone spurs, nerve bundle sclerosis (hardening), facet hypertrophy (enlargement), and instability during flexion or extension of limbs. X-rays show bones, but not much soft tissue, so they will definitely be used if fractures, infections, or tumors are suspected.

During X-rays, you will be asked to lie very still on a table and hold certain positions while photographs are taken of your spine.

MRI Scan (Magnetic Resonance Imaging)

The MRI scan is a test that does not use radiation. By using magnetic and radio waves, the MRI creates computer-generated images. The MRI is able to cut through multiple layers of the spine and show any abnormality of soft tissues, such as nerves and ligaments. The test also can be used to verify: loss of water in a disc, facet joint hypertrophy (enlargement), stenosis (narrowing of spinal canal), or a herniated disc (protrusion or rupture of the intervertebral disc).

During an MRI test, you lie on a table that slides into a machine with a large, round tunnel. The machine's scanner then takes many pictures that are watched and monitored by a technician. Some newer MRI machines, called Open MRIs, are likely to be more comfortable for patients who experience claustrophobia. The procedure takes 30-60 minutes.

CAT Scans (Computer Assisted Tomography)

The CAT scan is an X-ray test that is similar to both the MRI and a regular X-ray, because it can show both bones and soft tissues. CAT scans are also able to produce X-ray "slices" taken of the spine, allowing each section to be examined separately. The scan forms a set of cross-sectional images that can show disc problems and degeneration of bones, such as bone spur formation or facet hypertrophy (enlargement). CAT scan images are not as clear as either X-rays or an MRI. To make the soft tissues easier to see, the CAT scan is often combined with a myelogram. Like an MRI, with a CAT scan you will lie on a table that slides into a scanner. The scanner is essentially an X-ray tube that rotates in a circle taking many pictures. The procedure takes 30-60 minutes.

Other tests are sometimes used to make sure there are not additional problems causing your back pain. To learn more about these tests, you may wish to review the document entitled:

• Diagnostic Tests for Spine Problems

Treatment

On your first visit to a back specialist, the initial decision that must be made is exactly how serious the problem is. Some problems need immediate attention - possibly even surgery. Fortunately, the vast majority of back problems do not require surgery. Spinal stenosis is a slowly progressive back problem that may respond to conservative, or non-surgical care.

A variety of treatment options exist for spinal stenosis, and in most cases simple therapies such as mild pain medications and rest are effective in relieving the immediate pain. The overall goal of treatment is to make you comfortable as soon as possible and get you back to normal activity in a timely manner.

Medications

Mild pain medications can reduce pain when taken properly. However, remember that medications will not help the fracture to heal. The medication is simply to help with pain control.

To review the types of pain medications used for back pain please review the document, entitled:

• Medications for Back Pain

Epidural Steroid Injections (ESI)

An ESI can be used to relieve the pain of stenosis and irritated nerve roots, as well as to decrease inflammation. Injections can also help reduce swelling from a bulging or herniated disc. The steroid injections are a combination of cortisone (a powerful anti-inflammatory steroid) and a local anesthetic that are given through the back into the epidural space. Epidural steroid injections are not always successful in relieving symptoms of inflammation. They are used only when conservative treatments have failed.

If you would like to read more about different types of injections that can be used to treat back problems please review the document, entitled:

• Spinal Injections

Surgery

Spinal stenosis may continue to get worse over time. Eventually, surgery may be considered as a treatment option. Surgery may be suggested to treat spinal stenosis if:

• You experience an increase in the weakness in your legs • You can no longer walk without leg pain • You begin to have trouble controlling your bowels or bladder • The pain becomes unbearable

Because spinal stenosis is more common in the elderly, one of the considerations for suggesting surgery is your overall physical condition. Back surgery is major surgery. If you have serious medical problems, your doctor may not feel it is worth the risk to undergo spinal surgery. The decision to have surgery should be a joint decision between you, your spine surgeon, and your regular medical doctor.

The main goal of any surgical procedure used to treat spinal stenosis is to remove the pressure on the nerve roots in the lumbar spinal canal. This means that the tube of the spinal canal must be made bigger and the bone spurs that are pushing into the nerve roots must be removed. This type of surgical procedure is usually called a decompression of the lumbar spine or a decompressive laminectomy of the lumbar spine.

This procedure may damage the stability of the spine. In order to free up or "decompress" the nerves requires the surgeon to remove a great deal of the bone from the back of the spine. The surgeon may have to remove a portion of the facet joints on the back of the spine, leading to instability of the spine. If you have both spinal stenosis and instability of the lumbar spine, any surgical procedure suggested may include a spinal fusion along with a decompression of the nerves.

To learn more about the surgical procedures used to treat spinal stenosis, please review the document,s entitled:

• Lumbar Laminectomy • Instrumented Lumbar Spine Fusion

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