Spine Center - Spinal Stenosis
The term spinal stenosis refers to narrowing of the spinal canal. The spinal cord and spinal nerves reside within the spinal canal. When narrowing of the spinal canal (spinal stenosis) develops, there is mechanical pressure on the spinal cord and/or nerves causing myelopathy (spinal cord dysfunction) or radiculopathy (nerve dysfunction).
Causes:
The most common cause of spinal stenosis is aging with degenerative (wear and tear) disease of the spine. Spinal stenosis is major cause of pain and dysfunction in our aging populations. Spinal stenosis most commonly affects elderly patients over the age of 65, but patients born with a narrow spinal canal (congenital spinal stenosis) can present at a younger age. Over a lifetime of bipedal upright activities, the spine suffers wear and tear changes. Arthritic changes develop in facet joints, and the facet joint as well as the ligamentum flavum can enlarge to encroach on the spinal canal. In addition, disc bulges and bone spur (osteophyte) formation from degenerative changes in the disc can also contribute to the narrowing of the spine.
Symptoms:
Spinal stenosis from degenerative spine disease develops slowly over years. Given the slow progression of disease, the spinal cord and nerves can adapt to mild or moderate compression from the spinal canal narrowing. However, when the narrowing becomes severe and is beyond the tipping point for adaptation, the blood supply to the spinal cord and nerve as well as nerve conduction become compression.
In the neck, the overwhelming presenting symptom is cervical myelopathy (spinal cord dysfunction). Typically, patients will complain about symptoms of weakness or sensory loss involving both sides of the body. Common complaints include dropping things with their hand, difficulty buttoning a shirt, changes in hand writing, trouble with balance and walking, and numbness to fingers and hands to both sides. In more severe case, patients will develop progressive loss of strength and can develop significant weakness or frank paralysis of their arms and legs in a short period of time.
The most common complaint in patients with lumbar spinal stenosis is pain. While many patients with spinal stenosis have low back pain and stiffness, the majority of the disabling pain is in the buttocks and legs on both sides. This pain is typically worsen with walking and standing, and many any patients will report that their symptoms are relieved with lying down, sitting, forward bending of their back, or pushing a shopping cart. The pattern of pain is also known as neurogenic claudication and it is the classic clinical presentation of spinal stenosis.
Diagnostic test:
A good clinical history and physical examination is paramount for the diagnosis of spinal stenosis. The diagnosis can often be made based on the clinical history alone. Nevertheless, an MRI of the spine is always obtained to assess the degree of spinal canal narrowing, the amount of pressure on the spinal cord or nerves, and the number of levels involved. An MRI is necessary prior to surgical procedure to determine the levels of decompression needed and the presence of spinal instability.
Treatment:
Similar to other degenerative disease of the spine, treatment of spinal stenosis often involves conservative treatment as the first line therapy. Anti-inflammatory medications, physical therapy, and epidural steroid injections are often used. These treatments are generally effective for mild or moderate stenosis, but less effect is seen in patients with severe stenosis. Surgical treatment is recommended for patients with severe pain, weakness, bladder or bowel dysfunctions, or have failed conservative therapy for greater than 6-9 months. The goal of surgery is improve symptoms and quality of life by enlarging the spinal canal and relieve pressure off the spinal cord and/or nerves (aka. decompression), and laminectomy (removal of the lamina and spinous process) is performed to accomplish that goal. In patients with significant low back pain or with spinal instability, spinal fusion is typically performed in conjunction with the decompression to improve low back pain and improve spinal stability.
Traditional multi-level laminectomy through open surgery requires a large incision and significant amount of muscle dissection. With new minimally invasive approaches, laminectomy can now be performed through several small 1 inch incisions to achieve spinal decompression (MIS laminectomy). Minimally invasive spinal fusions can also be performed in conjunction with MIS laminectomy with ease and without additional morbidities. The minimally invasive procedures have been shown to decrease blood loss, decrease hospitalization time, and decreased overall recovery time. In addition, devices with the capability of opening the spinal canal indirectly to relieve the pressures of nerve roots are now available. Placement of these devices can be performed with local anesthesia and patients can return home shortly following the procedure. With these newer minimally invasive approaches available, elderly patients can now benefit from surgical treatments without high surgical risks.
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