Spinal stenosis is similar the lime build-up on the inside of a garden hose. Over time, it narrows the diameter of the hose, just as spinal stenosis narrows the spinal canal. Another analogy which patients often find useful is picturing a garden hose which is intentionally bent or “kinked.” While the diameter of the hose is maintained on either end of the bend, at the site of the bend the diameter of the hose is narrowed or “stenotic”. Similarly, the lumbar spinal canal can be stenotic at one segmental level with the adjacent levels having a more preserved and patent central canal.
What are the symptoms of spinal stenosis?
The symptoms arising from spinal stenosis are classically, but by no means exclusively, worse with standing or walking and improved with sitting or bending forward. These symptoms may be intermittent and can vary in severity when they recur. Other symptoms may include pain, cramping or numbness, or a sensation of fatigue affecting the back and or legs. Less commonly, and in more concerning neurological cases, weakness or bowel and/or bladder problems can result.
However, spinal stenosis does not necessarily cause symptoms. Many people can have significant stenosis on imaging studies without any symptoms. The spine literature confirms the importance of identifying which radiographic findings correlate with symptoms and which are clinically less relevant.
Other conditions, such as peripheral vascular disease (narrowing of the arteries in the legs) and osteoarthritis of the hip, can also cause similar complaints and mimic symptoms of spinal stenosis.
How Is Spinal Stenosis Diagnosed?
As described, a complete history and a thorough physical examination will be performed by your treating phsyiatrist. The physicians at Long Island Spine Rehabilitation Medicine will perform an extensive spine and musculoskeletal evaluation to assure that your condition is accurately diagnosed. Through a detailed history, examination, and review of your radiographs, your physiatrist will attempt to isolate which film findings are in fact resulting in your clinical symptoms. Such efforts can ultimately result in more targeted and appropriate therapies and improved clinical outcomes.
Usually, an MRI study will be obtained to optimally assess your spinal anatomy. Sometimes, a Computed Axial Tomography (CAT) scan and/or a lumbar myelogram may be advised if you are unable to undergo an MRI exam for any reason or if additional anatomic information is needed. Each of these studies can provide information about the presence, location and extent of spinal stenosis and nerve root compression. As mentioned before, many patients with evidence of spinal stenosis on imaging studies may not develop symptoms.
In select cases where diagnostic uncertainty should remain, nerve studies, also referred to as nerve conduction studies or EMG (electromyography) studies may be performed. These studies can detect evidence of nerve damage that can result from more longstanding and symptomatic stenosis. Such testing can also help to rule out a non-spinal process such as a peripheral neuropathy which might mimic a primary spinal process. In our practice, these tests are performed with the latest diagnostic equipment and in a fashion which maximizes patient comfort. The physiatrists of Long Island Spine Rehabilitation Medicine have also completed extensive training in performing these studies and are either board certified in Electrodiagnostic Medicine or board eligible for subspecialty certification in Neuromuscular Medicine.
An important part of your treatment plan is an exercise therapy program is specially designed to reduce your back or leg symptoms. Patients with spinal stenosis often benefit from a “flexion biased” spine stabilization and rehabilitation approach.
Our physicians at Long Island Spine Rehabilitation Medicine work closely with therapists certified by the McKenzie Institute and are specially trained to treat spinal disorders. While McKenzie therapists are often thought of as particularly skilled in the treatment of acute disc herniations, their understanding of the lumbar spine also situates them as excellent therapists and educators for patients with symptomatic stenosis.
Medications used to control pain are called analgesics. Most pain can be treated with nonprescription medications such as aspirin, acetaminophen, naproxen, or ibuprofen. If you have severe persistent pain, you may be prescribed stronger analgesics for a short period of time. Sometimes your doctor will prescribe muscle relaxants to help with pain control, particularly during evening hours. With any medication, the goal in prescribing is to maximize benefits realized through as low a dosage as possible, while minimizing adverse side effects (such as constipation and drowsiness). All medications should be taken only as directed. Medications are prescribed by your treating physiatrist in an individualized fashion and only after a careful consideration of your past medical history and current medication regimen.
The scientific literature has shown that non-surgical treatments for spinal stenosis are a safe, recommended and often effective approach for this condition. The physicians of Long Island Spine Rehabilitation Medicine, experts in the field of non-surgical spinal care, are uniquely trained to evaluate and treat patients presenting with the full spectrum of symptoms arising from lumbar spinal stenosis.
Selective transforaminal epidural injections performed with fluoroscopic guidance may be recommended if you have severe leg or back pain. These are targeted injections of a corticosteroid and local anesthetic mixture into the epidural space immediately surrounding the inflamed and compressed spinal nerve.
These injections are performed in a target and diagnosis-specific fashion and are offered to aggressively control the acute inflammatory phase of injury and as a component of a comprehensive rehabilitation program. Both our experience and the spinal literature suggest that patients with debilitating limb pain arising from spinal stenosis can realize significant and lasting relief from a transforaminal injection approach, even when previous therapies have failed. The more fixed mechanical nature of spinal stenosis, as opposed to an acute disc herniation, may present a more notable compressive insult to the affected nerves and a greater treatment challenge.
The physiatrists of Long Island Spine Rehabilitation Medicine have particular expertise and dedicated fellowship training in both Spine Medicine and interventional spinal procedures. Such experience is essential when performing injection procedures in the degenerative and stenotic lumbar spine. Injection procedures are performed in our practice by your treating physiatrist, utilizing the latest in imaging technology, and in a comfortable office setting with a skilled and seasoned medical team.
Successful outcomes realized without surgery support the notion of transient exacerbations in patients with stenosis which may result from superimposed inflammatory or compressive components of injury. Long term outcome studies often describe moderate and lasting relief from symptoms in symptomatic stenosis patients who choose a non-surgical treatment approach.
What About Surgery?
If your symptoms fail to respond to a reasonable trial of non-surgical approaches, the physiatrists at Long Island Spine Rehabilitation Medicine may refer you to a surgical colleague. Surgery is reserved for that small percentage of patients whose pain cannot be relieved by non-surgical treatment methods and whose quality of life is notably compromised by ongoing leg symptoms. Surgery is also indicated for patients with pronounced or progressive neurological deficits, such as weakness or numbness in the lower limbs, or for patients with cauda equina syndrome (a rare neurological deterioration which includes loss of bladder or bowel control).
As spinal stenosis results in a narrowing of the bony canal, the goal of the surgery is to open up or decompress the canal to increase the available space for the nerves. This decompressive procedure is often referred to as “laminectomy.” Surgery, when necessary, will very often relieve the leg pain associated with stenosis and, less reliably, pain complaints localized to the lumbar region. Postoperatively, patients are graduated to their previous activities over a period of weeks, and postoperative rehabilitation is often necessary.
In those stenosis cases in which a spondylolisthesis, a slippage of one vertebrae upon another, is evident or if excessive motion (instability) is observed, spinal fusion surgery may be concurrently recommended. A fusion is performed along with decompression to provide stability to the surgical segment. A fusion is performed by placing bone graft, bone substitute, and/or instrumentation between the vertebrae being fused. Fusion procedures can be performed from the front (anterior approach) or from the back (posterior approach), or may require both an anterior and posterior approach. The choice of approach is influenced by many technical factors including the extent of decompression achieved, anatomic variation between patients, and degree of instability.