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Description
The lumbar spine (lower back)
provides a foundation to carry the
weight of the upper body. It also houses
the nerves that control the lower body.
With aging, the discs in the front of
the spine become dehydrated. The joints
in the back of the spine become
overgrown due to arthritis. These
degenerative changes are the result of
the normal "wear-and-tear" associated
with aging. Over time these changes can
also lead to narrowing, or stenosis, of
the spinal canal (see Figure 1).
Narrowing of the lumbar spinal canal
pinches the nerves that control muscle
power and sensation in the legs.
Sometimes the pinched nerves become
inflamed and cause pain in the buttocks
and/or legs. These changes also can
diminish the ability of the spine to
carry the load of the upper body. They
can lead to the forward slippage of one
vertebra on another. This slippage,
called "degenerative spondylolisthesis,"
can cause both back and leg pain.
Your orthopaedic surgeon can diagnose
lumbar spinal stenosis using a
combination of:
X-rays can show the presence of
arthritis and slippage of the vertebrae.
An MRI is used to determine whether
nerves are being pinched. For people who
cannot get an MRI (for example, people
with pacemakers), a special test called
a computed tomography (CT) myelogram may
be necessary. This test requires the
injection of a dye into the spine to
make the nerves visible.
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Risk Factors/Prevention
Lumbar spinal stenosis is usually
caused by the wear-and-tear changes of
aging. It usually affects middle-aged
and older adults. People who are born
with narrower spinal canals are more
likely to develop this problem.
The best way to avoid the symptoms of
lumbar spinal stenosis is to stay as
physically fit as possible. Regular
exercise can improve endurance and keep
the muscles that support the spine
strong. Avoiding weight gain can
decrease the load that the lumbar spine
has to carry. Patients should also avoid
cigarette smoking. Both the smoke and
the nicotine cause the spine to
degenerate faster than normal.
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Symptoms
Typically patients with lumbar spinal
stenosis have a long history of pain in
the back, buttocks or legs that
gradually becomes worse. The symptoms
are usually worsened by standing or
walking upright. This results in an achy
pain, tightness, heaviness and a sense
of weakness in the buttocks and/or legs.
These symptoms are generally relieved by
sitting down or leaning forward.
Although patients are unable to walk for
very long, they may be able to ride an
exercise bicycle for much longer. Some
patients also find that it is easier to
walk while leaning forward on a shopping
cart. This position tends to create more
space in the spinal canal. Leaning onto
the handlebars of a bicycle creates the
same effect. This relieves some of the
pressure on the nerves.
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Treatment Options
Non-surgical options to relieve the
symptoms of lumbar spinal stenosis
include:
A program of physical therapy with
activity modifications. A program of
gentle physical therapy may help. This
program usually includes:
Anti-inflammatory medications--such
as ibuprofen and naproxen--may be
prescribed. These medications decrease
pain and inflammation. Although they can
be helpful, these medicines can have
serious side effects. Prolonged use can
lead to gastrointestinal ulcers,
bleeding and kidney problems. Some of
them may also increase the risk of heart
attacks or strokes.
Epidural steroid injections.
These injections deliver
anti-inflammatory medication directly
into the spinal canal and to the area of
the inflammation. These injections are
more effective than the medications
taken by mouth. They may also have fewer
side effects.
These injections deliver steroid
medication straight to the nerve roots
that are being pinched. Such steroid
injections can give relief for weeks to
months. They allow the patient to
participate in more aggressive
rehabilitation. In some cases, they may
enable a patient to postpone or avoid
surgical treatment altogether.
Bracing is generally not recommended
for long-term use. If used for too long,
bracing can lead to deconditioning of
the muscles that support the back.
Acupuncture or chiropractic manipulation
can also be attempted.
All these nonsurgical treatments are
aimed at decreasing inflammation. They
also decrease the symptoms that patients
experience. However, these treatments do
not improve the narrowing of the spinal
canal.
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Treatment Options: Surgical
Most people with lumbar spinal
stenosis do not require surgery.
However, if patients are experiencing
severe pain that limits their activities
of daily living and their ability to
have a good quality of life, surgery may
be recommended. In general, surgery is
only considered as a last resort if all
attempts at non-surgical therapies are
unsuccessful and if the overall
potential benefits of surgery are
greater than the potential risks.
Surgery may be recommended on an urgent
basis if a patient has severe weakness
or loss of bowel and bladder control.
The surgical procedure for lumbar
spinal stenosis involves removing the
bone and soft tissue that are pinching
the nerves. This is called
"decompression" or "laminectomy." Some
patients require only a decompression.
However, patients with slippage of the
spine or a curvature of the spine may
require a stabilization procedure called
fusion. In this procedure, two or more
vertebrae are fused together using a
bone graft harvested from the hip.
Fusion eliminates motion and prevents
the slippage or curvature from worsening
after surgery, which would cause more
back and/or leg pain. Your surgeon may
use screws and rods to hold the spine in
place while the body heals the bone
together (see Figure 2). Using screws
and rods increases the rate of fusion
and enables the patient to get out of
the postoperative brace sooner. Overall
the results of surgery are good to
excellent in about 80 percent of
patients. Patients tend to see better
improvement of leg pain than back pain.
Most patients are able to resume a
normal lifestyle after a period of
recovery from surgery.
There are some risks to surgery,
including:
-
Bleeding
-
Infection
-
Blood clots
-
Reaction to anesthesia
-
Tear of the sac covering the nerves
(dural tear)
-
Failure to relieve symptoms
-
Return of symptoms after some time
-
Failure of the bone fusion to heal
-
Failure of screws or rods
-
Need for further surgery
-
Injury to the nerves
The risks of surgery depend on the
patient and the exact procedure being
performed. Elderly patients have higher
rates of complications from surgery. So
do overweight patients, diabetics,
smokers and patients with multiple
medical problems.
After surgery, patients may be
hospitalized for several days, depending
on the patient and the procedure
performed. Relatively healthy patients
who only have a decompression procedure
may be able to return home the same day.
They usually return to normal activities
after a few weeks.
Patients who have a fusion procedure
are hospitalized for several days. They
usually receive an outpatient physical
therapy program. A lumbar corset or
brace may also be prescribed after
surgery. They return to normal
activities after two to three months.
Older patients who need more physical
therapy may be transferred from the
hospital to a rehabilitation facility.
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Research on the Horizon/What's New?
There are two areas of research that
may change the way patients with spinal
stenosis are treated. First, surgeons
are developing ways to perform
decompression procedures through smaller
incisions. These techniques may cause
less pain after the operation. They may
allow quicker return to normal
activities. Researchers are studying
whether these new techniques are as
effective and safe as the traditional
procedures.
Surgeons are also beginning to use
manufactured bone-forming proteins to
fuse the spine. These proteins replace
harvesting bone from the patient's hip.
Harvesting a bone graft usually requires
another skin incision. It can cause pain
after the operation. However, the use of
bone-forming proteins in the back of the
spine for first-time surgeries is
currently considered experimental. It is
not approved by the U.S. Food and Drug
Administration.
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