Lumbar Spinal Stenosis

What is spinal stenosis?

Spinal stenosis happens when the space inside the backbone is too small. This can put pressure on the spinal cord and nerves that travel through the spine. Spinal stenosis occurs most often in the lower back and the neck.

What causes spinal stenosis?

Spinal bones are stacked in a column from the skull to the tailbone. They protect the spinal cord, which runs through an opening called the spinal canal. Most spinal stenosis occurs when something happens to reduce the amount of open space within the spine. Aging and age-related changes in the spine happen over a period of time and slowly cause loss of the normal structure of the spine. 

Causes of spinal stenosis include:

• Bone spurs. Wear-and-tear damage from arthritis can cause extra bone to grow on the spine. These are called bone spurs. They can push into the spinal canal. Paget's disease also can cause extra bone to grow on the spine.

• Herniated disks. Disks are the soft cushions that act as shock absorbers between your spinal bones. If part of the disk's soft inner material leaks out, it can press on the spinal cord or nerves.

• Thick ligaments. The strong cords that help hold the bones of your spine together can become stiff and thick over time. Thick ligaments can push into the spinal canal.

• Tumors. Rarely, tumors can form inside the spinal canal.

• Spinal injuries. Car accidents and other trauma can cause spinal bones to break or move out of place. Swelling of nearby tissue right after back surgery also can put pressure on the spinal cord or nerves.

What are the symptoms of spinal stenosis?

The narrowing of spinal stenosis creates pressure on the spine and related structures, causing symptoms. When symptoms do occur, they start slowly and get worse over time.

The symptoms you experience depend on the location of the narrowing in your spine. Symptoms of spinal stenosis in the lower back can include:

• Pain in the lower back.

• Burning pain or ache that radiates down the buttocks and into the legs, that typically worsens with standing or walking and gets better with leaning forward (flexion).

• Numbness, tingling, or cramping in the legs and feet. These may become more pronounced during standing or walking.

• Weakness in the legs and feet.

Walking, standing, or extending the lumbar area of the spine can cause symptoms to worsen. Sitting or flexing the lower back or neck may relieve symptoms. The flexed position “opens up” the spinal column, enlarging the spaces between vertebrae at the back of the spine.

How is spinal stenosis diagnosed?

To diagnose spinal stenosis, we must obtain your medical history and conduct a physical exam to assess your pain and symptoms. We also use an imaging test, such as a magnetic resonance imaging (MRI) scan, or computerized tomography (CT) scan.

What are the possible complications from spinal stenosis?

Spinal stenosis can lead to the slow but steady loss of strength in the legs. The severe pain caused by this condition can be quite disabling, even if you have no muscle weakness, since it greatly affects your ability to work and enjoy life. The natural course of the disease is one of slow progression over time.

People with more severe stenosis may also have problems with:

• Bowel function.

• Bladder function.

• Sexual function.

What are the first-line treatments for spinal stenosis?

Treatment for spinal stenosis depends on how severe your symptoms are. First-line treatment for spinal stenosis include physical therapy and over-the-counter medications before thinking about something more involved, such as surgery.

• Physical therapy has been shown to be very effective, and a physical therapist can teach you exercises that may help build up your strength and endurance, improve the flexibility and stability of your spine, and improve your balance.

• Medications which may be suggested include NSAIDs, antidepressants (amitriptyline), and anti-seizure or neuropathic drugs (gabapentin, pregabalin). Opioids are usually not necessary and only used as a last resort due to their poor safety profile and potential for abuse and addiction.

• An epidural steroid injection (ESI) around the pinched nerves may help reduce the inflammation and relieve some of the pain. However, steroids can be associated with serious side effects. Repeated steroid injections can weaken nearby bones, tendons and ligaments. That's why a person often must wait many months before getting another steroid injection.

What if these treatments fail? Then What?

If you fail to achieve sufficient and prolonged pain relief from the conservative therapies above, you may be a candidate for more advanced interventions.

1. Vertos Minimally Invasive Lumbar Decompression (MILD) is a procedure designed to debulk an enlarged ligament at the back of the lumbar spine with the goal of relieving neural compression causing symptoms of neurogenic claudication. The MILD procedure selectively removes small portions of ligament and leaves no implants behind. Most people can go home the same day.

2. Surgery can create more space within the spinal canal. Options may include Laminectomy (removes the back part, or lamina, of the affected spinal bone) or Laminotomy (removes only part of the lamina), or implantation of spinal distraction devices. In most cases, these operations help reduce spinal stenosis symptoms. But some people's symptoms stay the same or get worse after surgery. And some patients may not be candidates for surgery due to medical issues.

3. Neuromodulation with spinal cord stimulation (SCS) has been shown to achieve sustained improvement of symptoms of LSS for at least a 2-year duration regardless of previous history of lumbar decompre