Lumbar Canal Stenosis Surgery

Where does spinal stenosis occur?

Spinal stenosis can occur anywhere along the spine but most commonly occurs in two areas:

• Lower back (lumbar canal stenosis).
• Neck (cervical spinal stenosis).

What is lumbar canal stenosis?

Lumbar canal stenosis is the narrowing of the spinal canal or the tunnels through which nerves and other structures communicate with that canal. Narrowing of the spinal canal usually occurs due to changes associated with aging that decrease the size of the canal, including the movement of one of the vertebrae out of alignment.

The narrowing of the spinal canal or the side canals that protect the nerves often results in a pinching of the nerve root of the spinal cord. The nerves become increasingly irritated as the diameter of the canal becomes narrower.

Symptoms of lumbar canal stenosis include pain, numbness or weakness in the legs, groin, hips, buttocks, and lower back. Symptoms usually worsen when walking or standing and might decrease when lying down, sitting, or leaning slightly forward.

Who gets spinal stenosis?

Spinal stenosis can develop in anyone but is most common in men and women over the age of 50. Younger people who are born with a narrow spinal canal can also have spinal stenosis. Other conditions that affect the spine, such as scoliosis, or injury to the spine can put you at risk for developing spinal stenosis.

Herniated disks and bone spurs are two common causes of spinal stenosis.

• Thickened ligaments: Ligaments are the fiber bands that hold the spine together. Arthritis can cause ligaments to thicken over time and bulge into the spinal canal space.
• Spinal fractures and injuries: Broken or dislocated bones and inflammation from damage occurring near the spine can narrow the canal space and/or put pressure on spinal nerves.
• Spinal cord cysts or tumors: Growths within the spinal cord or between the spinal cord and vertebrae can narrow the space and put pressure on the spinal cord and its nerves.
• Congenital spinal stenosis: This is a condition in which a person is born with a small spinal canal. Another congenital spinal deformity that can put a person at risk for spinal stenosis is scoliosis (an abnormally shaped spine).

What are the symptoms of spinal stenosis?

You may or may not have symptoms when spinal stenosis first develops. The narrowing of the spinal canal is usually a slow process and worsens over time. Although spinal stenosis can happen anywhere along the spinal column, the lower back (number one most common area) and neck are common areas. Symptoms vary from person to person and may come and go.

Symptoms of lower back (lumbar) spinal stenosis include:

• Pain in the lower back. Pain is sometimes described as dull ache or tenderness to electric-like or burning sensation. Pain can come and go.
• Sciatica. This is pain that begins in the buttocks and extends down the leg and may continue into your foot.
• A heavy feeling in the legs, which may lead to cramping in one or both legs.
• Numbness or tingling (“pins and needles”) in the buttocks, leg or foot.
• Weakness in the leg or foot (as the stenosis worsens).
• Pain that worsens when standing for long periods of time, walking or walking downhill.
• Pain that lessens when leaning, bending slightly forward, walking uphill or sitting.
• Loss of bladder or bowel control (in severe cases).

Symptoms of neck (cervical) spinal stenosis include:

• Neck pain.
• Numbness or tingling in the arm, hand, leg or foot. (Symptoms can be felt anywhere below the point of the nerve compression.)
• Weakness or clumsiness in the arm, hand, leg or foot.
• Problems with balance.
• Loss of function in hands, like having problems writing or buttoning shirts.
• Loss of bladder or bowel control (in severe cases).

Symptoms of abdomen (thoracic) spinal stenosis include:

• Pain, numbness, tingling and or weakness at or below the level of the abdomen.
• Problems with balance.

Can spinal stenosis cause permanent paralysis?

While the narrowing of the spine can cause pain, it usually doesn’t cause paralysis. However, if a spinal nerve or the spinal cord is compressed for a long period of time, permanent numbness and/or paralysis is possible. This is why it is especially important to see your healthcare provider right away if you experience numbness or weakness in your arms or legs.

How is spinal stenosis diagnosed?

Your healthcare provider will review your medical history, ask about your symptoms and conduct a physical exam. During your physical exam, your healthcare provider may feel your spine, pressing on different area to see if this causes pain. Your provider will likely ask you to bend in different directions to see if different spine positions bring on pain or other symptoms. Your provider will check your balance, watch how you move and walk and check your arm and leg strength.

You will have imaging tests to examine your spine and determine the exact location, type and extent of the problem. Imaging studies may include:

• X-rays: X-rays use a small amount of radiation and can show changes in bone structure, such as loss of disk height and development of bone spurs that are narrowing the space in the spine.
• MRI: Magnetic resonance imaging (MRI) uses radio waves and a powerful magnet to create cross-sectional images of the spine. MRI images provide detailed images of the nerves, disks, spinal cord and presence of any tumors.
• CT or CT myelogram: A computed tomography (CT) scan is a combination of X-rays that creates cross-sectional images of the spine. A CT myelogram adds a contrast dye to more clearly see the spinal cord and nerves.

MANAGEMENT AND TREATMENT

What are the treatments for spinal stenosis?

Choice of stenosis treatments depend on what is causing your symptoms, the location of the problem and the severity of your symptoms. If your symptoms are mild, your healthcare provider may recommend some self-care remedies first. If these don’t work and as symptoms worsen, your provider may recommend physical therapy, medication and finally surgery.

Self-help remedies include:

• Apply heat: Heat usually is the better choice for pain due to osteoarthritis. Heat increases blood flow, which relaxes muscles and relieves aching joints. Be careful when using heat – don’t set the settings too high so you don’t get burned.
• Apply cold: If heat isn’t easing your symptoms, try ice (an ice pack, frozen gel pack, or frozen bag of peas or corn). Typically ice is applied 20 minutes on and 20 minutes off. Ice reduces swelling, tenderness and inflammation.
• Exercise: Check with your healthcare provider first, but exercise is helpful in relieving pain, strengthening muscles to support your spine and improving your flexibility and balance.

Non-surgical treatments include:

• Oral medications: Nonsteroidal anti-inflammatory medications (NSAIDs) can help relieve inflammation and provide pain relief from spinal stenosis.
• Physical therapy: Physical therapists will work with you to develop a back-healthy exercise program to help you gain strength and improve your balance, flexibility and spine stability. Strengthening your back and abdominal muscles — your core — will make your spine more resilient. Physical therapists can teach you how to walk in a way that opens up the spinal canal, which can help ease pressure on your nerves.
• Steroid injections: Injecting corticosteroids near the space in the spine where nerve roots are being pinched or where worn areas of bone rub together can help reduce inflammation, pain and irritation. However, only a limited number of injections are usually given (typically three or four injections per year) because corticosteroids can weaken bones and nearby tissue over time.
• Decompression procedure: This outpatient procedure, also known as percutaneous image-guided lumbar decompression (PILD), specifically treats lumbar spinal stenosis caused by a thickening of a specific ligament (ligamentum flavum) in the back of the spinal column. It is performed through a tiny incision and requires no general anesthesia and no stitches. The procedure is guided by an X-ray and a contrast agent that is injected during the procedure. The surgeon uses special tools to remove a section of the thickened ligament, which frees up space within the spinal canal, reducing compression on nerve roots. Some of the advantages of this procedure are that the bony architecture of the spine is left intact and there is little disruption in the mechanics of the spine so people recovery quickly. People usually go home a couple hours after the procedure and begin walking and/or physical therapy soon thereafter. Compared with before the procedure, you will be able to walk and stand for longer periods of time and experience less numbness, tingling and muscle weakness.

When is spinal stenosis surgery considered?

Because of the complexity of spinal stenosis and the delicate nature of the spine, surgery is usually considered when all other treatment options have failed. Fortunately, most people who have spinal stenosis don’t need surgery. However, talk with your healthcare provider about surgical options when:

• Your symptoms are intolerable, you no longer have the quality of life you desire and you can’t do or enjoy everyday life activities.
• Your pain is caused by pressure on the spinal cord.
• Walking and maintaining your balance has become difficult.
• You have lost bowel or bladder control or have sexual function problems.

What are the surgical treatments for spinal stenosis?

Surgery options involve removing portions of bone, bony growths on facet joints or disks that are crowding the spinal canal and pinching spinal nerves.

Types of spine surgery include:

Laminectomy (decompression surgery): The most common type of surgery for this condition, laminectomy involves removing the lamina, which is a portion of the vertebra. Some ligaments and bone spurs may also be removed. The procedure makes room for the spinal cord and nerves, relieving your symptoms.

In a laminectomy, the lamina portion of the vertebral bone is removed.

Laminotomy: This is a partial laminectomy. In this procedure, only a small part of the lamina is removed – the area causing the most pressure on the nerve.

Laminoplasty: In this procedure, performed in the neck (cervical) area only, part of the lamina is removed to provide more canal space and metal plates and screws create a hinged bridge across the area where bone was removed.

Foraminotomy: The foramen is the area in the vertebrae where the nerve roots exit. The procedure involves removing bone or tissue this area to provide more space for the nerve roots.

Interspinous process spaces: This is a minimally invasive surgery for some people with lumbar spinal stenosis. Spacers are inserted between the bones that extends off the back of each vertebrae called the spinous processes. The spacers help keep the vertebrae apart creating more space for nerves. The procedure is performed under local anesthesia and involves removing part of the lamina.

Spinal fusion: This procedure is considered if you have radiating nerve pain from spinal stenosis, your spine is not stable and you have not been helped with other methods. Spinal fusion surgery permanently joins (fuses) two vertebrae together. A laminectomy is usually performed first and bone removed during this procedure is used to create a bridge between two vertebrae, which stimulates new bone growth. The vertebrae are held together with screws, rods, hooks or wires until the vertebrae heal and grow together. The healing process takes six months to one year.

Is spinal surgery safe? What are the risks of surgery for spinal stenosis?

All surgeries have the risks of infection, bleeding, blood clots and reaction to anesthesia. Additional risks from surgery for spinal stenosis include:

• Nerve injury.
  
• Tear in the membrane that covers the nerve or spinal cord.
• Failure of the bone to heal after surgery.
• Failure of the metal plates, screws and other fasteners.
• Need for additional surgery.
• No relief of symptoms/return of symptoms.