By Joseph Williams, M.D.
Board Certified Orthopedic Surgeon
Lumbar spinal stenosis is a very common and debilitating condition of the low back. There are many different causes. However, by far the most frequent cause is a result of degenerative changes. As we age our spines begin a process of slow degeneration. The discs in the low back begin to show signs of wear. For some people, this process advances more rapidly than in others. Some individuals have certain risks factors that cause the process of degeneration to accelerate. While others have a genetic predisposition.
Spinal stenosis is a condition in which the spinal canal is narrowed. When the canal narrows the structures within it become compressed. These stuctures are the nerves to the lower extremities. When nerves get compressed or pinched it initiates an inflammatory reaction. This causes the nerve to swell and release inflammatory molecules. This process causes pain. The location of this pain will depend on the nerves that are getting compressed. If it is a nerve that courses down the back of the leg, then the individual will complain of pain in that particular location called “sciatica”.
Degenerative disc disease is the end result of a natural progression of wear that occurs in all of our spines. It is not really a “disease,” but more of a process. It only becomes a “disease” when this natural process causes pain and disability. Beginning at the age of thirty, most of us will show the very early signs of degeneration within the structures of the lower spine. The discs, facet joints and vertebral bodies are three of the main components of the lumbar spine, or low back. The molecules that make up these structures begin to oxidize and break apart. Within the discs, these molecules function by binding to one another and to water molecules. As they oxidize, they break apart and loose their ability to bind to other molecules including water. This loose binding of these molecules along with the ablility to hold the water molecules is the basis to the function of the discs. They are structures that provide stability and absorb energy applied to our spines– the “shock absorbers” of our spine. When the molecules of the disc break down, the discs begin to collapse. The height of the disc decreases. The lining of the disc, or annulus, will then become slack and “bulge”.
We all have friends or family members who have been diagnosed with “bulging” discs. These bulges occur because of the underlying degenerative process occurring within these “bulging discs”. It’s analogus to the tires on your car. When the tire is fully inflated the side wall is under tension and it maintains a nice vertical position between the rim and the road. However, if one were to deflate that same tire the sidewall would loose this tension and “bulge” outward away from the rim. Bulging discs become a problem when they protrude in the spinal canal and pinch the nerves within that canal. Those same nerves travel through the canal to the lower extremities. This is basis of spinal stenosis.
The symptoms of spinal stenosis are varied. Again, each individual will report varying severity and varying locations of pain. However the more common complaints include back pain, numbness and tingling in the lower extremities, pain radiating down the lower extremities. Another very common complaint is heaviness and pain in the legs that occurs with walking any significant distance. This is termed neurogenic claudication. The distance that is required before the pain and heaviness occurs will become less as time passes. Patients will report symptoms after walking approximately four blocks. These same patients will return to clinic a year later and report that the symptoms are now manifested after only three blocks, thus showing the progression of the disease process.
There are several ways to treat spinal stenosis. The approach will depend on the severity of the pain, the severity of the stenosis and cause. Assuming that this discussion relates only to stenosis resulting from advanced degenerative disc disease, we will focus on the severity of the pain and the severity of the stenosis.
There are studies that support use of physical therapy in the treatment of spinal stenosis. Physical therapy involves the use of exercises and modalities. Certain exercises are used to “decompress” the canal. Much of the emphasis of physical therapy use in the treatment of spinal stenosis focuses on stretching and strengthening the muscles of the back. It also focuses on improving posture. There are so-called modalities of physical therapy– deep heat, ultrasound therapy and massage. Each of these treatments focus on reducing the symptoms associated with the condition, the back pain and the leg pain. This approach to treatment is usually reserved for stenosis that is not severe but mild or moderate.
Nonsteroidal Anti-Inflammatory Medications
Nonsteroidal anti-inflammatory medications are used commonly to treat the inflammatory reaction to the compression of the nerves. As mentioned earlier, the pinching of the nerve will initiate an inflammatory reaction. The molecules released in this reaction then cause the pain perceived by the individual. NSAIDs function by preventing this inflammatory cascade. The swelling in the nerve then decreases, thus resulting in less pressure on the nerve and less pain. Oral NSAIDs are a great first response to a sudden (acute) worsening of symptoms. These medications can be obtained without a prescription. They include Motrin, ibuprofen, Aleve, and Naprosyn. However, their use should be done with a doctor’s supervision.
Epidural Steroid Injections
Epidural steroid injections are a useful option in the treatment of lumbar spinal stenosis. They involve directly bathing the affected nerve in a high-dose steroid. Steroids are very potent anti-inflammatory medications. These injections are performed by a trained physicians in a procedure room similar to an operating room. They are easy to get done and relatively very low risk. Dr. Paul Smucker and Dr. John Watson are members of the Orthopedic Center of Illinois and provide these injections. They are much more effective at battling the inflammation and pain, than simply taking nonsteroidal anti-inflammatory medications. An individual can usually receive up to three of these injections.
If the stenosis is severe and/or the pain is poorly controlled with lesser invasive options, then surgical treatment is an option. Current surgical techniques focus on minimally invasive approaches. The basis for surgical treatment lies in decompressing the affected nerves where the pressure and compression of the nerves is physically removed. This can be done with the use of minimally invasive techniques. Studies have supported the use of these techniques. They have been shown to result in less blood loss and are associated with a decreased rate of infection and less scarring. Patients are spending less time in the hospital. In fact a majority of these procedures do not require a hospital stay. Best of all, patients are able to return to an active, pain-free lifestyle much sooner.
Lumbar spinal stenosis can be a very debilitating and painful condition. However, it is treatable. It is a very common spinal condition managed at the Orthopedic Center of Illinois. Our Spine Center provides the latest technology in regards to imaging. This includes the newest technology in CT and MRI. We also have both nonsurgical physicians and surgeons who take pride in providing the most technologically advanced minimally invasive forms of both surgical treatment and nonoperative treatment.
This article was published in the October-December 2013 edition of “FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.