Mark McFarland, DO
Acute and chronic neck and back pain represents a major health concern in the United States. Nearly everyone has back pain that, at some point, interferes with work, routine daily activities, or recreation. Americans spend at least $50 billion each year treating back pain, which is the most common cause of job-related disability and a leading contributor to missed work. Fortunately, most occurrences of back pain go away within a few days. Others take much longer to resolve or lead to more serious conditions. There are many conditions that can cause lower back pain, including fibromyalgia, sciatica, bulging disc, spinal degeneration, and spinal stenosis. This article will explain spinal stenosis and available treatment options. Before I delve into spinal stenosis, a quick anatomy lesson might be helpful in understanding this condition.
Anatomy of the Back
The back is an intricate structure, consisting of bones, muscles, and other tissues. The core of the back is the spinal column, which houses and protects the spinal cord — the delicate nervous system “highway” that carries signals to and from the brain, which control the body’s movements and convey its sensations. Stacked on top of one another are more than 30 bones — the vertebrae — that form the spinal column, also known as the spine. Each of these bones contains a central opening that, when stacked with all the others, creates a channel that surrounds the spinal cord. The spinal cord descends from the base of the brain and is about 18 inches long in men and 17 inches long in women, which is much shorter than the length of the bony spinal column. Small nerves enter and emerge from the spinal cord through spaces between the vertebrae. The spaces between the vertebrae are maintained by round, spongy pads of cartilage called intervertebral discs. These discs allow for flexibility in the lower back and act much like shock absorbers throughout the spinal column to cushion the bones as the body moves. Bands of tissue, known as ligaments and tendons, hold the vertebrae in place and attach the muscles to the spinal column.
Starting at the top, the spine has four regions:
• the seven cervical or neck vertebrae (labeled C1 – C7)
• the 12 thoracic or upper back vertebrae (labeled T1 – T12)
• the five lumbar vertebrae (labeled L1 – L5), which we know as the lower back
• the sacrum and coccyx, a group of bones fused together at the base of the spine
The lumbar region of the back is where most back pain is felt. It has the important task of supporting the weight of the upper body, which can be put under a great deal of strain and stress by daily activities, job-related tasks, and recreation. Another factor working against us is time: as we age, bone strength and muscle elasticity and tone tend to decrease. The discs begin to lose fluid and flexibility, which decreases their ability to cushion the vertebrae, so the likelihood of experiencing low back pain from disc disease or spinal degeneration increases with age.
Spinal Stenosis Overview
Spinal stenosis is a condition of abnormal narrowing in the spinal canal. This narrowing limits the amount of space available for the spinal cord and nerves. If only a small amount of spinal narrowing occurs, no pain will result. As spinal stenosis becomes more severe, there is compression or squeezing of the spinal cord and its nerves. If narrowing continues, the nerves that travel through the spinal column to the legs become squeezed, leading to back and leg pain and leg weakness. Spinal stenosis can occur anywhere in the spinal canal, but it is most common in the cervical and lumbar spine.
Spinal Stenosis Causes
Spinal stenosis occurs when bulging discs, arthritic spurs, and thickened tissues combine to compress the nerves traveling through the spinal canal. The normal “wear and tear” of aging can cause arthritis in the spine that leads to spinal stenosis. This can be from bone spurs (osteophytes) forming, bulging and wear of the intervertebral discs, and thickening of the ligaments between the vertebrae.
Spinal stenosis is part of the aging process for many people. It is usually seen in patients over 50 years of age, and becomes progressively more severe with increased age. Not everyone develops spinal stenosis as they become older. Certain people are more likely to develop spinal stenosis than others and it is impossible to predict who will be affected. No clear correlation is noted between the symptoms of stenosis and race, occupation, sex, or body type. The degenerative process can be managed, but it cannot be prevented by diet, exercise, or lifestyle.
People who have a family history of spinal stenosis or other back problems are at an increased risk of developing spinal stenosis because of a genetic trait. Also, people who subject their backs to greater demands, such as heavy laborers or athletes, are also at an increased risk to develop spinal stenosis than someone with a more sedentary job.
The symptoms of spinal stenosis depend on where the stenosis occurs and how severe it is. The most common symptom of spinal stenosis is lower back pain when standing or walking. Leg pain and numbness may inhibit walking and the spine may lose the lumbar curve and appear flat.
When stenosis develops in the neck (cervical spine stenosis) there can be compression of the spinal cord and the nerves that travel into the arms and hands. This can cause symptoms of:
• Worsening balance
• Dropping objects
• Difficulty buttoning buttons or picking up small coins
• Loss of control of the bowel and/or bladder
When the stenosis develops in the lower back (lumbar spine stenosis) there is compression of the nerves that travel into the legs and feet. This can cause:
• Weakness or cramping in the legs and feet, particularly progressively with walking and finding relief in resting
Exams and Tests
If you find you are experiencing some of these symptoms, I recommend that you make an appointment with a Fellowship-trained orthopaedic spine specialist who can help determine a diagnosis, if any, and a treatment plan. When you see me or one of my colleagues, we will discuss your medical history and symptoms then perform a physical exam. I will check your muscle strength, reflexes, sensation, balance, and circulation to help determine if you have spinal stenosis. The specific location of your symptoms can help me determine which nerves are affected by the stenosis.
After the physical exam, I may order tests to help confirm the diagnosis of spinal stenosis, including Magnetic Resonance Imaging (MRI). MRI is a method used by physicians to look inside the human body to obtain diagnostic information. Incorporating an advanced technology, an MRI scan produces images of the anatomy to help physicians properly diagnose their patients’ conditions. At Orthopaedic & Spine Center, we have an open MRI, which is much more comfortable for our patients than the standard confining MRI design. MRI is the preferred method of diagnosing stenosis.
In addition to the MRI, I may also order testing of the patient\’s nerves to see if there is any damage to the nerves caused by the spinal stenosis. These tests are called nerve-conduction studies (NCS), which measure the response of nerves to electrical stimulation. NCS measures the speed and intensity of the electrical signals traveling along the nerves and the time it takes a muscle to respond to the signals.
In a nerve-conduction study, several flat electrodes are taped to your skin. A shock-emitting electrode is placed directly over the nerve we are studying. Mild electric pulses are delivered at one point on a nerve and then the reaction your nerve has to the stimulus is measured. A recording electrode tracks the time it takes for the muscle to contract in response to the electrical pulse. You will feel a brief, burning pain, a tingling sensation and a twitching of the muscle when the electrical pulse is applied.
If we determine that you do indeed have spinal stenosis, we will discuss your options. There are various treatment options available, depending on how severe your symptoms are. The majority of cases can be treated without surgery.
If your symptoms are fairly mild, you may not need medical treatment. I will encourage you to determine what activities worsen the condition, and try to avoid those activities if possible. You can apply heat or ice to the affected areas or take over-the-counter anti-inflammatory medications such as ibuprofen or naproxen to help reduce the swelling around the nerves being compressed.
In addition to these options, I may want to try:
• Prescription medications:
o Antidepressants – Nightly doses of tricyclic antidepressants, such as amitriptyline and nortriptyline, may help ease pain caused by spinal stenosis.
o Anti-seizure drugs – Some anti-seizure drugs, such as gabapentin and pregabalin, are used to reduce pain caused by damaged nerves.
o Opioids – Drugs such as oxycodone and hydrocodone contain substances related to codeine, which can be habit-forming.
• Epidural steroid (cortisone) injections – These can provide a larger dose of medication to reduce inflammation directly to the site of nerve compression.
• Exercise and physical therapy can help strengthen the muscles surrounding the spinal column and take some of the pressure off the spine. You will want to focus on strengthening the back and abdominal muscles, as well as stretching. This will help you control your pain and improve your balance and endurance.
If these treatment options do not ease the pain and your ability to engage in everyday activities is inhibited, you may want to consider spine surgery.
Surgery may be considered if; 1) other conservative treatments did not work; 2) you are in good overall health, and; 3) you are disabled by your symptoms. The goal of spinal stenosis surgery is to relieve the pressure on your spinal cord or nerve roots.
Below, I have outlined types of spine surgery that I utilize in my practice at OSC for the treatment of spinal stenosis:
• Laminectomy – The most common type of surgery for spinal stenosis, laminectomy involves the removal of the lamina, a portion of the vertebrae, to make room for the nerves. Some ligaments and bone spurs may also be removed. The surgery requires making an incision into the back and may include spinal fusion to help stabilize the spine.
• Cervical Disc Arthroplasty (CDA) – Cervical disc arthroplasty (or disc replacement surgery) may be an appropriate surgical treatment option for patients with a pinched nerve in the neck and/or a shocking, burning sensation in the patient’s arm related to spinal stenosis. CDA is an excellent alternative to spinal fusion for patients with no spinal arthritis.
• Spinal fusion – This procedure is recommended in severe cases and involves joining the bones together with screws or bone grafts to provide spinal stability. It may be combined with laminectomy surgery. The surgery lasts several hours and can be done using one of two methods:
o Bone is removed from elsewhere in the body or obtained from a bone bank. This bone is used to create a bridge between vertebrae and stimulates the growth of new bone.
o Metal implants, such as rods, hooks, wires, or screws, are secured to the vertebrae to hold them together until new bone grows between them.
In a recent case, a gentleman with near-complete loss of function in his left upper extremity was found to have significant spinal stenosis secondary to a large herniated disc compressing his cervical spinal cord. Surgical intervention, including a spinal decompression and instrumented fusion, allowed him to regain full use and strength in his left arm and resume his career as a personal trainer and avid recreational athlete.
Following surgery, a patient will likely be outpatient and sent home to recover. In some cases, they may be kept in the hospital overnight. The patient will be sent home with pre-planned therapy and home health care. Depending on progress, a patient typically participates in physical therapy in the home for 3-4 weeks. After that, the patient will go to outpatient physical therapy for an average of 2-3 months. Full recovery after surgery for spinal stenosis typically takes six months to one year, depending on the patient\’s progress in rehabilitation and the severity of the surgery. Spinal fusion often results in a longer recovery period than other procedures because it is more invasive than other surgeries.
Most patients obtain good relief of the symptoms in their arms and legs soon after the surgery relieves the compression of the nerves. The exception is in more severe cases where there was prolonged compression of the nerves that caused permanent nerve damage.
Many people obtain relief of their symptoms with non-surgical treatment options outlined above. In some cases, as the stenosis becomes more severe, those options are not as effective. For those patients, surgery is an alternative that may provide more significant relief. If you are experiencing symptoms that might be spinal stenosis, I encourage you to make an appointment with us at OSC. We will work with you to determine the cause of your symptoms and a course of action to help you feel better. Please call 757-596-1900 to make an appointment.
Mark W. McFarland, DO is a Board-Certified, Fellowship-Trained spine specialist and orthopaedic surgeon. His practice is focused primarily on the care and treatment of injuries and disorders of the spine. Dr. McFarland practices at Orthopaedic & Spine Center in Newport News, VA.