As we age, the normal wear and tear of our bodies can affect our level of functioning and enjoyment of life. This is more of a reality when we become middle aged or older and our spines are no exception. Within the spine, we expect some degree of degeneration that may include disc dehydration and loss of height, disc bulging or herniation, thickening and hardening of ligaments, enlarged joints, bone spurs and joint instability. These effects of aging can lead to narrowing and pressure around the spinal cord or nerve roots known as spinal stenosis. Men and women have an equal risk of developing this problem. Less often, spinal stenosis can be caused by an injury, congenital defect, genetic disorder or tumor. Age-related degeneration is the most common cause of central stenosis and is the focus of this article.
Spinal stenosis can be present at any level but is common in the cervical spine (neck) and is most often seen in the lumbar spine (low back). Cervical stenosis creates pressure on the spinal cord that may cause pain or weakness in the neck, shoulders, arms or legs. However, there may not be any back, body, or neck pain at all. Some patients notice clumsiness or lack of coordination and difficulty walking. Lumbar spinal stenosis may cause pain in the low back, buttocks, and/or legs particularly with activity. Symptoms often develop gradually and worsen when standing upright or walking. Often, relief is found with sitting or bending forward because these positions open the spinal canal allowing more space around nerves.
 Diagnosis of spinal stenosis is usually based on history, physical exam, and imaging. The description of symptoms and functional status are valuable in ruling out other conditions. The provider will also examine the patient for weakness, loss of sensation, decreased range of motion, and gait disturbances. If the history and physical exam indicate a potential spine problem, an MRI is ordered to confirm the diagnosis. An MRI is the preferred test to visualize the spinal cord and nerves and the condition of the spinal discs. The MRI will show the degree of spinal stenosis and how many levels are involved.
The symptoms of spinal stenosis are usually managed non-surgically. Conservative treatment includes medications, physical therapy, activity modification, and injections. Over-the-counter pain relievers such as aspirin, naproxen, and ibuprofen are commonly used because of their anti-inflammatory effect. Anti-depressants, anti-seizure medications, and opioids may also be prescribed for pain relief.
Physical therapy is usually one of the first steps in treating spinal stenosis. Therapists are trained to use a variety of methods and techniques to create individualized programs for patients based on specific needs. Exercises that focus on strengthening the muscles of the back and abdomen help to improve spinal support and endurance. Therapists can also teach the patient how to stretch properly to restore flexibility. The long term goal of physical therapy is to educate the patient about how to manage current symptoms and prevent further debilitation. Patients are encouraged to continue exercises at home and to try to stay as active as possible. In addition to physical therapy, exercises including stationary biking, limited walking, and swimming can help to control pain. Yoga, pilates, and tai chi can improve flexibility.
Oral and injectable steroid medications can also control pain from spinal stenosis. A short course of prednisone or Medrol can be a relatively inexpensive and convenient option. Cortisone is a strong anti-inflammatory that temporarily reduces swelling and relieves pain. Epidural spinal injections of cortisone provide a more direct delivery of the medication around the affected nerves. Injections can be repeated but are usually limited to a maximum of 3 per year.
Alternative medicine is another potential treatment but evidence is a lacking regarding its effectiveness for spinal stenosis. Insurance coverage may also be limited. The most common therapies include chiropractic, acupuncture, and massage.
When symptoms of spinal stenosis are not relieved by conservative measures, decompressive surgery may be an option. Most patients pursue surgery if their pain or weakness is disabling and is affecting their level of functioning and quality of life. A consultation with a spine surgeon will determine if surgery is an option and what type of procedure would be most effective. In most cases, surgery is successful in relieving the pain and discomfort of central stenosis. All surgery carries a risk so the decision should be considered carefully. The most common risks include bleeding, blood clots, infection, nerve injury, spinal fluid leak, and complications from anesthesia. There is also the possibility the pain may not improve or may worsen afterward.
Some patients with lumbar spinal stenosis may be candidates for a metal spine spacer called X-STOP in place of a laminectomy. It is an FDA approved device that is inserted between the bones of the spine at up to 2 affected levels. The implant limits extension, or bending too far backward, which in turn reduces narrowing. It is a same-day procedure and is reversible. Another implantable device option is the spinal cord stimulator (SCS). This may be an alternative for patients with chronic pain from spinal stenosis in which surgery is contraindicated or if previous spine surgery has been unsuccessful and further surgery is not recommended.
We cannot prevent the physiological changes of aging that sometimes cause pain and affect our level of functioning. Fortunately, most patients are able to successfully manage spinal stenosis with conservative measures and are able to continue living an active and fulfilling life. Patients that are experiencing symptoms of spinal stenosis should see their healthcare provider for further evaluation and recommendations. A referral to a spine-specialized physician or physiatrist offers an expert approach to spinal conditions and can help facilitate treatment options.
Andrew J. Will, M.D. is a physiatrist at Twin Cities Pain Clinic in Edina, Minnesota.
|
