Spinal Stenosis

Spinal stenosis is a narrowing of the spinal canal that results in pressure on nerve roots. It is a chronic disorder that can worsen over time, causing back and leg pain and difficulty walking. While it almost always occurs in the lower back, it may develop in the neck area. Spinal stenosis is a common problem in patients over the age of 45, and it usually is related to arthritis. It can also be caused by disease or injury or can be the eventual result of having been born with a smaller spinal canal.

In patients with arthritis, spinal stenosis arises from inflammation, swelling of vertebral joints, and surrounding tissues. The swelling of joints narrows the spinal canal and pinches nerves. Also, bone spurs accumulate inside the spinal canal, resulting in pressure on nerve roots.

This pressure on nerves causes pain, which can radiate down the leg. The pain results from nerves not getting enough oxygen. This is often described by patients as cramping or discomfort or “worms crawling on my legs”. The distribution of discomfort is often in the calves along the course of the fifth lumbar nerve root. The pain is usually worse with walking.

Spinal stenosis arising from arthritis is accompanied by spondylolisthesis in 1 in 10 cases. Spondylolisthesis is a slippage of the vertebrae, in which one vertebra slips forward on top of another, leading to instability and misaligned vertebrae in the spinal column.

Characteristic Symptoms

Patients may experience a variety of symptoms when suffering from spinal stenosis. The most common symptoms are listed below. In my 20 years of medical experience taking care of patients with spinal stenosis, the best predictor of success with surgery is the answer to the following McAfee Checklist. If you answer “YES” to four of the following symptoms, then you will have an 80% chance of relief with surgery, five questions then you will have an 85% chance of relief with surgery, six questions affirmative, then you should have a 90% chance of relief. If you have seven out of the following seven symptoms then you have a 95% expectation that spinal stenosis surgery will alleviate your symptoms.

McAfee Spinal Stenosis Checklist (Write out either YES or NO or Sometimes):

1) Back pain radiating down the thighs, buttocks, or calves

2) Leg pain that is worse than back pain

3) Numbness and tingling down the legs

4) Leg cramps, with or without leg pain

5) An ability to straighten up

6) Relief by bending forward or lying down to relieve pressure on nerves (Do you bend forwards over a shopping cart to get relief while at a grocery store?)

7) Difficulty walking (Write down a distance you can walk without discomfort)

If you are experiencing any of these symptoms, spinal stenosis may be the cause. It is important to get an accurate diagnosis and seek treatment. If it goes untreated, it can lead to bladder and bowel control difficulties and even paralysis. With the proper treatment, you will achieve relief.

Accurate Diagnosis

Physical Exams allow your doctor to examine your spine and posture while sitting, standing, moving, and lying down. Your doctor also performs flexibility and range-of-motion tests to check strength, weakness, numbness, reflexes, and motor abilities.

Medical Histories help your doctor to uncover details about your back and leg pain, past medical problems, injuries, medication, and exercise and job factors.

X-Rays are standard tests that show degenerative changes in bones and tissues. Taken while lying down and standing up, x-rays show injuries and problems related to spinal stenoses, such as spondylolisthesis, but do not lead to a definitive diagnosis of spinal stenosis.

Myelograms are injections of dyes in the spinal column to provide more detailed views of the inner workings of spinal structures.

MRI and CT scans are detailed, three-dimensional pictures of soft and bony tissues for complete information about nerve compression. CT scans are often performed in conjunction with myelograms (contract injections to outline nerve roots), in both flexed and extended positions, to pinpoint the exact location of the narrowing in the spinal canal. MRI can also pinpoint the exact location of the spinal stenosis.

Effective Treatments

Occasionally, conservative approaches, such as nonsteroidal anti-inflammatory medication, exercise programs to strengthen stomach muscles and reduce arching of the back, and even more stimulation through the skin for acute attacks, provide relief for spinal stenosis pain. Almost always we prescribe at least 3 months of core strengthening physical therapy, core strengthening balance ball with abdominal crunches, swimming, yoga, flexibility exercises, etc.

After this first phase of treatment, if your symptoms progress we often will have you see a physical medicine and rehabilitation specialist for epidural steroid injections to help target the relief of spinal inflammation.

Surgery is usually the recommended approach for lasting results. Listed below are some indications that surgery may be the best solution:

• Intolerable pain in everyday activities despite medical treatment
• Difficulty walking or standing
• Major, progressive neurologic deficits

Decompression Laminectomy or removal of all or parts of the flat plates that form the vertebral arch in one or more vertebrae, is the recommended surgical procedure. This enlarges the opening between the vertebrae to make more space for nerves and relieves pressure when discs bulge.

Fusion Surgery is often performed at the same time. In this procedure, your doctor fuses the affected vertebrae to add to the long-term success of the surgery. Particularly in patients with spondylolisthesis, posterior stabilization with screws or rods is required to stabilize the spine. The standard fusion method involves the placement of bone along the sides of the bones of the spine. This bone can be obtained from your pelvis (sometimes referred to as the hip) or it can be obtained locally. All fusions require material to stimulate your body to heal the fusion. This is usually called a demineralized bone matrix, DBM. This material stimulates your bone to heal better and faster. While this procedure is safe the success of the fusion is dependent on the stability of the spine, quality of the bone graft, and other factors such as tobacco use, or the use of steroids.

A fusion with spinal instrumentation is a technique that is used to increase the rate of successful fusion. Pedicle screws and rods are utilized to provide stability of the spine. This screw system becomes part of a fixed triangle within the vertebral body providing immediate stability to the spine. Patients may require back support or corset for six weeks after fusion surgery. Surgery usually lasts for 2 to 3 hours and may require a blood transfusion. Most patients are out of bed the next day and begin physical therapy on the second postoperative day. Most patients are able to go home within three days after surgery.

Typically patients are able to resume many light activities and distance walking after 3 to 6 weeks. After six weeks most patients can resume many normal activities including driving. The pace of your activity and your endurance may take several months to recover. Your postoperative level of activity is frequently dependent on your physical limitations before surgery. Following surgery, many spinal stenosis patients are able to walk a quarter of a mile each day without pain.

“I was having trouble walking at all, before my surgery”, says Jordan Wheeler, 69, “seven years after surgery, I'm still walking 3 miles a day five days a week”.

“Before my surgery, I was on my hands and knees; now I can walk half a mile," says Joan Brent, 42, three weeks after surgery.

Paul C. McAfee, MD, MBA

St. Joseph's Hospital

O'Dea Medical Arts Building

7505 Osler Dr.

Suite 104

Towson, MD 21204

Phone number: 410-337-8888

Fax number: 410-823-4833

MACK8132@gmail.com