Spinal Stenosis

This is a relatively common condition of your spine that literally means narrowing (stenosis) of the spine.  This can occur at any level of your spine but most commonly occurs in the low back (lumbar) area.  This is typically a gradual condition that through the normal aging process eventually narrows the area in your spine to produce symptoms.  Lumbar spinal stenosis affects over 1.2 million people in the U.S.  You may experience back pain that may radiate down one or both legs with associated numbness, weakness, tingling.  Some people may not experience any pain but feel their legs are “heavy” usually worse with standing and walking and improved by sitting, resting, leaning forward and bending.

Spinal stenosis is not something that happens overnight.  The condition typically involves 3 factors in your spine that combine to cause the narrowing.  They include a disc problem usually a bulge that begins to push on the nerves from the front of your spine, joints in your back that become enlarged secondary to arthritis (lumbar spondylosis) that pushes the nerves from the back of your spine, and a ligament that becomes enlarged that also pushes from the back of your spine.  At times, there also may be a slight misalignment of your spine that can contribute to the narrowing as well (spondylolisthesis).  These 3 factors continue to crowd the nerves in your low back but you usually do not experience any of the above symptoms until the narrowing reaches a critical level.  Think of your spinal nerves as very bad neighbors.  As they get too close to each other, they become aggravated and inflamed thereby producing symptoms.

Most people with spinal stenosis can only walk for very short distances before the pain and/or weakness/heaviness causes them to rest.  Some will find relief leaning forward often referred to as the shopping cart sign as leaning forward on a shopping cart will improve your symptoms.  This opens the area of the narrowing of your spine to a small degree but can alleviate your symptoms.

As spinal stenosis occurs through normal aging of the spine when nerves become crowded or compressed in the center of your spine, it normally overlaps with other conditions in your spine that can cause similar symptoms.  Nerves can also be pinched as they leave the spine as well.  This will produce symptoms down one leg (lumbar radiculopathy) vs spinal stenosis typically involves both legs as this occurs before the nerves leave the spine.  It is extremely important to differentiate which one or both diseases are causing your symptoms.  Though both conditions may be seen on diagnostic studies such as x-rays and/or MRIs this does not necessarily mean they are causing your symptoms.  In addition, other conditions that may not be even related to your spine, such as narrowing of the blood vessels to your legs, may produce similar symptoms.  Being evaluated by a spine specialist is crucial in identifying a specific diagnosis.

Treatment for this condition depends on multiple factors.  Questions you may ask yourself are:  What are your goals/expectations for the treatment?  How effective is the treatment?  How long will the treatment provide relief from pain/discomfort?  What are the risks/benefits of the treatment?  Typically, initial treatment involves medications and physical therapy.  This can certainly give some relief and allow you to continue to function but as the underlying condition is a chronic problem, this does not cure the underlying disease.  In addition, like all medications, you must be careful in the side effects they may produce themselves and/or from the interactions they have with your current medication regimen.

If medication management fails to give you the relief you need, you may be a candidate for epidural steroid injections (interlaminar).  This can help decrease the inflammation around the nerves that are causing your symptoms.  Typically several of these are required to give you the relief you need.  Some people can have months to years of relief from this while others will have no relief.  It is important that the injection is done at the level of the stenosis if this can be done safely.

If the above conservative measures fail, surgery may be an option.  One type of surgery involves an open decompression surgery performed by a spine surgeon.  On average, a 4 inch incision is made and you will likely stay in the hospital for a day or two.  The surgery can cause major complications in 1 out of every 5 patients which includes tearing the sac that surrounds the spinal nerves that can lead to a debilitating headache possibly requiring repeat surgery as well as blood loss requiring a blood transfusion.  Furthermore, there is the risk of being put under general anesthesia which can be a significant stress on your heart and lungs.  70% of people had positive outcomes after the surgery in relieving their symptoms.

Surgery has been introduced to help patients with lumbar spinal stenosis.  This is called the MILD procedure standing for Minimally Invasive Lumbar Decompression.  This is an outpatient surgery, ie no hospital stay.  There are 2 incisions made, both the size of a baby Aspirin, so no stitches are needed.  This procedure addresses one of the 3 components causing your stenosis.  Through the tiny incisions, the thickened enlarged ligament is removed creating more space for the nerves in your spine.   Clinical studies showed an extremely low major complication risk and no general anesthesia is required.  The surgery is performed under local anesthesia with light IV sedation.  In the recent study for this procedure, approximately 3 out of every 4 people had positive outcomes (79%).  Currently this procedure is performed by only a handful of interventional spine physicians in the state of Virginia with one being at Virginia Interventional Pain & Spine Center.

If none of the above treatment options are right for you, other more advanced minimally invasive surgeries may help decrease your pain by >50% without the use of oral “pain” medications.  (see spinal cord stimulation and intrathecal drug delivery systems).  This does not fix the underlying problem but will allow you to live a better quality of life.

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