Lumbar Spinal Stenosis
Lumbar Spinal Stenosis
What Is Lumbar Spinal Stenosis and Myelopathy?
The lumbar spine (lower back) consists of a series of bones connected to each other. The bones circumscribe the spinal canal through which the spinal cord passes. Other structures that form the borders of the spinal canal are intervertebral discs, facet joints, and connective tissues (ligamentum flavum).
With advancing age, the discs between the vertebra begin to lose their spongious structure and their water content decreases. This condition leads to a decrease in disc height and bulging of the hardened disc into the spinal canal. The spinal cord carries the nerves that give sensation and power to the legs. The thickening of the bones and ligaments of the facet joints due to arthritis (loss of cartilage tissue) may also cause pressure on the spinal canal. These changes result in the narrowing of the spinal canal, and this condition is named "spinal stenosis" or "narrow canal".
What Are Symptoms?
Narrow canal does not always cause symptoms. In many people, despite the presence of significant narrowing proven by MRI, there may be no complaints.
Possible symptoms include loss of sensation or power in the legs or leg cramps. In rare instances,problems with bladder and intestinal control may occur. The symptoms worsen with prolonged periods of sitting or standing. The symptoms may fluctuate and their intensities may vary. Bending forward or sitting will increase the diameter of the spinal canal, and enable a decrease or total disappearance of pain. The most typical symptom is pain and weakness in the leg after walking for a distance. Sensory changes may also occur during walking. Sitting and leaning forward relieves leg pain and patients continue walking. However, the same symptoms come back after walking for a while.
How Is It Diagnosed?
After asking questions about your illness, your doctor will examine you and order the necessary tests.
X-rays may reveal decreased disc spaces or thickened facet joints. Today, narrowing in the spinal canal and compression of the spinal cord can be shown in detail using MRI, which is the gold standard. CT or lumbar myelogram can be used for similar purposes. Each of these studies may provide information on the constriction of the spinal canal and the presence, location, and severity of nerve root compression. A stepwise treatment algorithm is applied for the treatment of lumbar stenosis.
Treatment of Lombar Spinal Stenosis
What Are Treatment Options?
When your doctor determines lumbar narrow canal (canal stenosis) as the source of your pain, he/she will first try non-surgical treatments. These treatments include antiinflammatory drugs (oral or injectable) or painkillers (analgesics). Physical therapy may be suggested to preserve and increase your flexibility, power, and conditioning. Also, spinal injections (such as epidural cortisone injections) may be recommended.
Non-surgical Treatment
Some analgesics named non-steroidal antiinflammatory drugs (NSAIDs) may be added for control of irritation and inflammation. These include ibuprophen, naproxen, and various drugs sold with prescription. If your doctor gives you painkillers or anti-inflammatory drugs, you have to be cautious about gastric irritation or bleeding, and inform your doctor of problems that may occur in long-term use of painkillers sold with/without prescription and NSAIDs.
If your pain that is severe and persistent, and not relieved with other analgesics or NSAIDs, then your doctor may prescribe narcotic analgesics (such as codein) for a short period. You should use only the recommended amount. A higher dose will not accelerate your healing. Side effects include: nausea, constipation, dizziness, and vertigo, also may cause addiction. All drugs must be taken the way they are prescribed. Inform your doctor on all drugs you are using, and if you previously tried the drugs prescribed to you, tell your doctor whether they were effective.
There are other drugs with anti-inflammatory effects. Due to their anti-inflammatory properties, corticosteroids (tablet or injection) are sometimes prescribed in cases of very intense lower back and leg pain. Corticosteroids may have side effects like NSAIDs. Discuss the benefits and risks of these drugs with your doctor. Selective spinal injections or "blocks" may used to relieve very intense pain. These are corticosteroid injections made into the epidural space (space around the spinal nerves) or facet joints, by a doctor trained on this technique. Depending on the response to treatment, the first injection may be later supplemented by one or two injections. These are most commonly performed as a part of a comprehensive rehabilitation and treatment program.
Your daily activities will be easier if your flexibility, strength, and conditioning are preserved or increased. Your physiotherapist or your doctor can tell you how you can add a continous exercise program to your therapy by using simple tools at home or at a gym.
In some patients with narrow canal, modifications performed in the house or improvement of house safety are significantly important. Household devices such as the washing machine may need to be transferred to more practical spots. A console next to the bed may be useful. Safety tools in the bathroom may be recommended. The organization of cooking, timing of activities, and decreasing workload are otherpossibilities. It is important for canes or walkers to fit properly to the patient. Unless it causes significant or progressive weakness in the legs, or problems in urine or stool control, the presence of a narrow canal is not dangerous in adults. Therefore the goal of treatment is to decrease pain and increase the functionality of the patient.
Non-surgical therapies do not correct the stenosis in the spinal canal, however they provide long-term pain control and increased functionality without the need to undergo surgery. A comprehensive rehabilitation program requires a three-month or longer treatment under supervision.
What If Surgery Is Necessary?
Surgery is recommended only to a limited number of patients whose pain cannot be treated with nonsurgical therapies. Surgery is also recommended for people with progressive leg weakness or problems in bladder and intestinal control. Surgery may be good option for patients whose walking distance is severely limited or whose life quality is low.
The objective of surgery in narrow canal is to widen the bony canal and provide adequate space for the nerves. This procedure is named lumbar decompression surgery or laminectomy.
Surgery will improve leg pain, and to a lesser extent, lumbar pain. Most patients are allowed to return to their normal activities within weeks. Postoperative rehabilitation may be recommended to assist in return to normal activities.
In narrow canal cases, the vertebrae may have slipped one over the other (spondylolisthesis). In that condition, there may be an abnormal movement (instability) between the vertebrae. In these cases, spinal fusion surgery should be added to decompression surgery.
Fusion is performed by placing bone fragments, bone substitutes between the vertebras that will be attached. Additionally metallic devices (instrumentation) may be used to stabilize the spinal column until fusion is achieved.
Fusion can be performed from the front, the back, or both. The approach in fusion surgery (from the front versus back) is determined according to numerous factors, such as: the need to remove bone spicules, the location of the bone spicules, and anatomic variations between patients, and the degree of instability. The success rate of fusion surgery is more than 65 percent.
After surgery, you will remain in the hospital at least for a few days. Most patients return to all previous activities within 6 or 9 months. A rehabilitation program is often initiated to ease return to daily activities and a normal life.
After Lumbar Spinal Stenosis Surgery: A STORY OF LUMBAR SPINAL STENOSIS SURGERY
It all started 5 years ago with a severe pelvic pain. An MRI revealed lumbar spinal stenosis. Surgery was the solution. Of course, I refused to have surgery in the beginning. However, my complaints gradually increased, limiting my walking distance and standing time. I barely walked and it hurt to stand for as short as 20 minutes. Then, I was looking for a place where I could sit down to decrease my pain. It made me really happy when I could walk for 30 minutes, which happened very seldom. Additionally, I was suffering from numbness on my left leg.
Another MRI revealed an increase in amount of stenosis. Walking increases the amount of compression on the nerves in the spinal canal, creating back and leg pain preventing my walking ability.
As a 62-year-old man, I did not want to spend my life like that. Also, since I had two stents in my heart, walking is an extremely important activity for my health. Finally, I decided to have this surgery!
The surgery was March, 31 2014. I was discharged on Saturday of the same weekend. The recovery period was one month, during which I wore a brace. Then I was back to my normal life and started walking, which I had missed so much! There were no traces of pain while I walked.
Afterward, I saved my walking paths via a smartphone app. Starting from May 16, 2014, until today I walked a total of 400 km.
These include;
10 km walking in the Euresia Marathon on 16.11.2014 (Time: 1,5 hours)
12 km walking (mostly climbing with 10 kg of weight on my backpack) in Likya- 1st path Ovacık-Faralya road on August 2015 (Time: 3.5 hours)
10 km walking in the Euresia Marathon on 15.11.2015 (Time: 1,5 hours)
Keep on walking…
Fikret KURTAY/İstanbul, 18.11.2015
