Spinal Stenosis

Lumbar Spinal Stenosis is the loss of space inside the spinal canal. It can occur anywhere in the spine but is most common in the lumbar spine, or the lower back.

Some people are born with a congenital form, but most develop spinal stenosis as part of the degenerative cascade. A few do not feel any effects of the narrowing, but as part of the aging process, most people will eventually notice radiating pain, weakness, and/or numbness secondary to the compression of the nerves or spinal cord.

While the narrowing may occur at different parts of the spine, the symptoms of nerve compression are often similar. That is why specialists often will perform testing to determine the cause and location of the narrowing.

Lumbar vs. Cervical Stenosis

The lower back develops lumbar stenosis, while the neck develops cervical stenosis.

Lumbar Spinal Stenosis

 

In lumbar stenosis, the spinal nerve roots in the lower back become compressed and this can produce symptoms of sciatica—tingling, weakness or numbness that radiates from the low back and into the buttocks and legs—especially with activity.

Common Spinal Stenosis Symptoms

Overall, spinal stenosis symptoms are often characterized as:

  • Developing slowly over time, or slow onset

  • Coming and going, as opposed to continuous pain
  • Occurring during certain activities (such as walking for lumbar stenosis, or biking while holding the head upright) and/or positions (such as standing upright for lumbar stenosis)
  • Feeling relieved by rest (sitting or lying down) and/or any flexed forward position.

Lumbar Stenosis Symptoms

When stenosis has developed in the lower back (lumbar spine), leg pain with walking may develop.

Leg pain with walking is medically known as claudication, and it can be caused by either arterial circulatory insufficiency (vascular claudication) or from spinal stenosis (neurogenic or pseudo-claudication). Leg pain from either condition will go away with rest, but with spinal stenosis the patient usually has to sit down for a few minutes to ease the leg and often low back pain, whereas leg pain from vascular claudication will go away if the patient simply stops walking.

For lumbar stenosis, flexing forward or sitting will open up the spinal canal by stretching the ligamentum flavum and will relieve the leg pain and other symptoms, but the symptoms will recur if the patient gets back into an upright posture. Numbness and tingling can accompany the pain, but true weakness is a rare symptom of spinal stenosis.

surgical treatment options

In most cases of advanced claudication (spinal or vascular), a decompression surgery is required to treat the symptoms of spinal stenosis.

Surgical treatment of spinal stenosis is indicated if non-operative care fails or if there is neurologic loss or deficit, especially if the neurologic loss is progressive. Examples of typical neurologic loss or deficit include symptoms of numbness, weakness, loss of coordination or tingling in the arm or leg.

Posterior decompression (laminectomy or partial laminectomy)
Also called a lumbar laminectomy, this surgery has long been considered the standard treatment for lumbar stenosis. The surgery removes the bone and soft tissue narrowing at a single or multiple affected levels, with the goal of relieving the pressure on the nerve root(s). The success rate is generally over 90% and it is considered a very reliable surgery.

Minimally Invasive Surgical (MIS) Decompression
This is a decompression procedure done through an endoscope or small tube. The surgery is designed to accomplish the same relief of nerve compression as an open laminectomy (discussed above), but with less tissue dissection, blood loss, and post-operative pain. The recovery from surgery is faster.

Combined with modern surgical technique, multiple levels of the spine and bilateral decompressions (on both sides) can be accomplished with one or two portals to access the operative site. This procedure is usually a day surgical procedure with rapid recovery and—with an experienced surgeon and the right indications—is considered a reliable surgery with good results.

Posterior Partial laminectomy with Coflex (interlaminar fixation) Motion Device
This approach combines a laminectomy surgery with a device that is added after the decompression with the goal of providing stability and preventing re-stenosis. Preventing re-stenosis is done to reduce the potential risk of needing an additional surgery in the future.

The device is indicated in stenosis secondary to arthritis and degenerative (arthritic) grade I spondylolisthesis (spine slip). In level I studies, the results are similar to a posterior fusion surgery, but with a more minimally invasive technique that has less blood loss, tissue dissection, and pain. Also, the potential secondary problems of fusion (adjacent level disease) are minimized. The patients typically return to activity faster than patients who have had a lumbar fusion.

Indirect Decompression
There are several options for an indirect decompression, including:

Far lateral Interbody Fusion or Oblique Interbody Fusion
Both techniques decompress the spine by opening up, or distracting, the disc space, thereby alleviating pressure on the nerve by opening the foramen where the nerve root is located. This is generally used when a fusion is also required to treat the particular spinal condition. Both techniques are done as minimally invasive approaches using a tubular retractor.

Anterior Interbody Fusion
Also called an ALIF, this surgery is done as more of an open surgical technique but using small incisions and minimal dissection, so the recovery time is relatively fast. An ALIF also decompresses the nerve by opening up, or distracting, the disc space and inserting a fusion implant to maintain the space in the foramen for the nerve to pass through.

Decompression and Fusion
Sometimes the spine needs additional strength and stability, which can be achieved with a spinal fusion that may be done as part of the same operation as a laminectomy. For example:

Posterior laminectomy and Fusion, Posterior lumbar Interbody Fusion (PLIF), or Transforaminal Interbody Fusion (TLIF)
These procedures are performed when the spine is de-stabilized by the decompression (e.g. lumbar laminectomy), which is sometimes because a large amount of the bone has to be removed and/or bone at multiple levels needs to be removed.

They may also be done if the spine is unstable prior to surgery, such as from a spondylolisthesis, or has a deformity that requires correction.

These types of fusion can all be done with open or minimally invasive surgical techniques. The particular technique depends largely on the patient's spinal condition, anatomy, and the surgeon’s experience and preference.

 

All of the techniques described can be done separately or in combination with minimally invasive surgical (MIS) techniques utilizing-high powered surgical microscopes, endoscopic cameras, intra-operative CT navigation, robots, and intra-operative monitoring.

If you'd like to discuss this condition with one of our doctors, we would be more than happy to contact you.  You don't need a primary care physician referral for us to see you. 

 

 

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