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Ask the Expert: Spinal Stenosis

Lumbar Spinal Stenosis: Another "Gift" of Aging 

What is spinal stenosis?Older Americans are enjoying more active lifestyles than ever before. While this is great news, there are physical effects of the aging process that are not cause for celebration. An aging spine can lead to a variety of conditions that may affect your ability to enjoy your golden years. Johns Hopkins neurosurgeon Dr. Jared Marks, who practices at Suburban Hospital, discusses one of these conditions: lumbar spinal stenosis.

Stenosis means a narrowing of a vessel or channel in the body. Spinal stenosis occurs when there is a narrowing of the spinal canal, which puts pressure on the spinal cord and nerves, causing pain.

Stenosis can occur at any level of the spine: cervical, thoracic or lumbar. Lumbar stenosis is the more common form of spinal stenosis. Lumbar spinal stenosis is a degenerative condition in the lumbar section of the spine. It is a form of arthritis in the spine that results in the compression of the spinal nerves that run down the legs.

Are some people more at risk for lumbar spinal stenosis?

The disorder affects males and females equally and is most common in those older than 55 years of age. As individuals live longer and stay physically active longer, more people are seeking treatment for lumbar spinal stenosis.

What are the symptoms of lumbar spinal stenosis?

Symptoms include pain that radiates through the buttocks and down one or both legs, numbness in the legs and feet, and a feeling of fatigue and heaviness with standing or walking that is relieved by sitting. The condition is often, although not always, associated with lower back pain as well. In severe cases, bladder and bowel functions may be affected.

What should I do if I am experiencing symptoms?

Your first call should be to your primary care physician. It’s important to rule out other conditions such as vascular insufficiency or peripheral neuropathy. Blockage of arteries to the legs can cause symptoms similar to stenosis, although back pain is rarely involved. Nerve problems such as diabetic neuropathy can cause leg and foot numbness and tingling.

The management of spinal stenosis for non-surgical patients can often be handled by your internist, by a pain specialist, or by a physician who specializes in physical medicine and rehabilitation. In many cases, spinal stenosis can be managed with medications and physical therapy as well as lifestyle changes that include modified exercises. It’s also important to plan your activities so that you are able to sit down when needed.

Specific medications include anti-inflammatory medicine (e.g., ibuprofen and naproxen) and muscle relaxants, as well as medications that alter the transmission of nerve impulses, such as gabapentin or Lyrica. Narcotic analgesics are not, often, helpful in the management of symptoms due to stenosis.

Ironically, some exercises that involve extension and strengthening may actually exacerbate symptoms of lumbar spinal stenosis, whereas flexing exercises relieve symptoms.

When should I see a specialist and what will the specialist do?

When symptoms become progressive and begin to interfere with your enjoyment of life, when you can’t sleep through the night, or you become incapacitated by your symptoms, it’s time to get a firm diagnosis and to see a spinal surgeon.

The best diagnostic tool is an MRI of the lower spine. A CT scan may be used but this is a secondary option to an MRI. X-rays of the patient standing and bending forward and backward are also helpful. It’s best to have these test results in hand when seeing a specialist. Treatment recommendations are based on your history, your neurological exam, and the degree to which the spinal stenosis is affecting your life.

Initially I might recommend a trial of epidural steroid injections to reduce inflammation of the nerves that is caused by the stenosis. I often recommend physical therapy along with epidural injections to help with flexibility and strengthening of the muscles that support the spine. Many of my patients have also found that acupuncture is helpful with symptom management and some patients feel they benefit from the services of a chiropractor or osteopathic manipulation.

When should surgery be considered?

For patients who are significantly symptomatic, surgery offers the best long-term improvement in symptoms. The goals of surgery are twofold: The first goal is to decompress the spinal nerves and open up the spinal channel. The second goal is to maintain the mechanical stability of the spine.

In terms of the overall success rates for surgery, between 80 and 85 percent of patients who undergo surgery feel they have benefited from the procedure.

What does surgery involve?

There are three surgical options for the treatment of lumbar spinal stenosis. The first option involves lumbar decompression alone. This entails an operation where we remove bone and ligament and shave down the joints to free up the spinal nerves.

The second surgical option involves lumbar decompression along with spinal fusion. This surgery is recommended for patients who exhibit significant abnormal motion in the spine or who require such a significant amount of decompression that it would leave them unstable.

The third surgical option is lumbar decompression and stabilization using non-fusion technology. We use a coflex® device, which is a titanium spring-like mechanism that gives stability to the spine while maintaining motion.

Where do you perform surgery and what do I need to know about recovery time and risks?

All the procedures are performed at Suburban Hospital in Bethesda, Maryland. Typical hospital stays range from overnight to three days if the surgery includes spinal fusion. For the more extensive procedures, treatment may also include time at a rehabilitation facility. Recovery time is typically three to four weeks.

The risks of surgery include the same risks that would pertain to any operation, including complications from the anesthesia and infection. Nerve damage is a rare complication.

Can the symptoms of lumbar spinal stenosis recur after surgery?

While the likelihood of recurrence is not high, a patient can develop the same problem at different areas in the spine. Recurrence is more common for patients who have undergone fusion due to increasing stress above and below the site of the fusion. These areas of the spine may break down faster.

Will I end up in a wheelchair?

Those individuals who neglect their symptoms may become more immobile. That’s why it’s important not to ignore any symptoms such as weakness in the legs or unsteadiness when walking. A significant number of symptomatic patients can live their lives without surgery but these individuals must treat the condition and modify their behaviors.

Can lumbar spinal stenosis be prevented?

Lumbar spinal stenosis is a progressive condition that cannot be prevented. The goal of treatment is to minimize symptoms. While spinal stenosis cannot be cured, it can be managed.