What is spinal stenosis?
Spinal stenosis – Lumbar spinal stenosis
Stenosis is a Greek word that means “narrowing or constricting space” or “chocking.” In a medical sense, spinal stenosis is the narrowing or constricting of the space in the spine where the spinal cord and nerve roots are located that causes them to be pressed on and irritated, and in this sense chocked. Simply, spinal stenosis is a narrowing within the spine that “pinches” or otherwise irritates a part of the nerve system. This nerve pressure is usually caused by osteoarthritis in a deeper area of the spine, giving rise to symptoms in whatever part of the body the irritated nerves travel to, like the arms, neck, legs and low back.
Types of spinal stenosis
There are two primary types of spinal stenosis; lumbar spinal stenosis and cervical spinal stenosis. Lumbar spinal stenosis occurs in the lower part of the spine and is the most common type of spinal stenosis. Cervical spinal stenosis occurs in the neck region of the spine. Although the locations are different each type of spinal stenosis arises in a similar manner, affects the spine and nerve roots in a similar way, and cause similar symptoms.
Lumbar spinal stenosis vs. Cervical spinal stenosis
When lumbar stenosis compresses the lower back nerve roots pain will occur along the pathway of the major low back nerve network, called the sciatic nerve, resulting in sciatica. The symptoms of sciatica are pain, numbness, tingling and weakness that can radiate down from the low back and into the buttocks and back of the legs to the toes. Sciatica problems are easily triggered in lumbar spinal stenosis with any activity that compresses the spine – prolonged standing, carrying a heavy, weight, prolonged forward flexion.
Approximately 75% of spinal stenosis occurs in the lumbar spine (low back), with the most of the other 25% occurring in the neck or cervical spine; rarely does spinal stenosis affect the upper back or thoracic spine.
When cervical stenosis compresses the spinal cord and nerve roots it is far more dangerous because the spinal cord in the neck is much larger, and carries more important parts of the nerve network (nerve supply to and from the heart and lungs, the vagus nerve, etc.). If the spinal cord is compressed in the neck it can have dire consequences only slightly less dramatic than when someone is executed by hanging – because being hung with a rope around the neck severely compresses on the spinal cord of the neck and stops all heart and lung function. Since the spinal cord ends in the upper part of the lumbar spine, the spinal cord is not in jeopardy by lumbar spinal stenosis.
Spinal stenosis, the development of degenerative arthritic changes within the spine that presses on nerve tissue, usually becomes significant after 50 years of age and slowly progresses as a problem as the arthritis of the spine also progresses. Since lumbar spinal stenosis is a much more common problem, most of this discussion will focus on this area.
Lumbar spinal stenosis symptoms
Some symptoms of lumbar spinal stenosis symptoms are rather consistent from patient to patient. Because spinal stenosis is the expression of arthritis pressing on nerves from within the spinal column it does not begin rapidly or after trauma, as many other lower back pain problems do; it develops slowly over a period of time, and increases frequency and severity as the spinal osteoarthritis progresses. The pain of lumbar stenosis will come and go, depending on activity levels of the individual and anything the person might do that is favorable or unfavorable to aggravate the spinal arthritis; spinal stenosis pain is not continuous, as a rule. Symptoms will occur typically during certain activities such as walking or prolonged standing, or any other action that stresses the area of the lumbar spine where the osteoarthritis is located . Lastly, lumbar spinal stenosis symptoms typically can be controlled by simply lying down or sitting. The pain will slowly disappear as the reduction of weight bearing allows the irritated tissue to calm down and no longer press on the delicate nerve structures of the sciatic nerve.
Spinal stenosis treatment
Surgery is usually not necessary to treat a spinal stenosis problem. This is good because spinal stenosis surgery can be complex and dangerous since it involves going within the spinal structure very close to the spinal cord. Depending on the location and degree of spinal osteoarthritis and the severity of symptoms that results, spinal stenosis can usually be managed well using non-invasive, non-drug methods with three common methods.
Three common non-surgical spinal stenosis treatments include:
- Ice/Heat applications
Apply straight ice to the area of the lower back at the level of greatest pain and where the sciatica seems to start (where the spinal stenosis is located), following the instructions for applying cold/heat.
- Activity modification
This treatment for stenosis usually turns out to be an exercise in becoming aware of what aggravates the spinal stenosis and what makes it feel better. Thus you should avoid whatever aggravates the back pain and do what feels better to the back. The primary observation that people with spinal stenosis make is that they feel less pain and their back is more relaxed while holding the low back, or neck, flexed forward.
Examples of activity modification as treatment of spinal stenosis: first thing in the morning lean on the bathroom sink before washing to get ready for the day by stretching the lower back and relaxing it; sleep on your left or right side while bringing one or both knees up toward our chest like your body is rolled up into the shape of a ball; leaning forward at the hips on a walker or shopping cart instead of walking upright; leaning forward and bent over on the handlebars of a stationary bike or other exercise equipment instead of walking for exercise; sit in a recliner that is flattened out a bit instead of on a straight-back chair; when sitting on a couch periodically bring your feet off the floor as you bring your knees up toward your chest and snuggly wrap your arms around your knees.
With this treatment for stenosis, patients are usually counseled to avoid activities that cause adverse spinal stenosis symptoms. Patients are typically more comfortable while flexed forward. Examples of activity modification for treatment of spinal stenosis might include: walking while bent over and leaning on a walker or shopping cart instead of walking upright; stationary biking (leaning forward on the handlebars) instead of walking for exercise; sitting in a recliner instead of on a straight-back chair.
- Spinal stenosis exercise
Spinal stenosis exercises (strengthening) – Spinal stenosis exercises are very helpful, but they cannot do more than control and minimize the problem – not cure it. These exercises are a critical part of treatment because of the importance of remaining as active as the condition will allow.
Treating sciatica from spinal stenosis requires use of forward flexion or bending exercises. This posture increases the size of the compressed nerve passageways, allowing the irritation or impingement to subside. For this reason people with spinal stenosis will flex at the hips to feel sciatic pain relief as well as lower back pain relief.
In many ways spinal stenosis causes the nerves to become pressed upon, or compressed, resulting in what some people would call a pinched nerve, whether in the low back or the neck. There are a series of simple and effective things a person with a pinched nerve can do that can be very helpful in many cases. Review some of these ideas for pinched nerve treatment to learn how to help yourself and reduce or eliminate the need for more aggressive medical treatment.
Discuss these exercises with your doctor, chiropractor or therapist:
Lumbar spinal stenosis exercise
- Strengthening the muscles that bring the spine into flexion (forward bending). Using two of the same exercises that were used for strengthening the low back, it is possible to stretch the lower back muscles and other soft tissue that hold the spine in a backward bending position. These stretches are usually held in a gentle and easy posture that does not provoke any back or leg pain, for 30 seconds .
Back flexion. Comfortably lie on a padded surface face up, on the back, gently pulling both knees toward the chest until a comfortable stretch is felt. After 30 seconds, slowly return to the starting position. Do about 3-6 repetitions. As an alternate, try pulling just one knee toward the opposite shoulder until a comfortable stretch is felt. After 30 seconds, slowly return to starting position. Do about 3-6 repetitions.
Back flexion. Using a padded surface, get down on the hands and knees. Rock
back so you are sitting back down on your heels, allowing your chest to come
down close to the floor and your arms outstretched in front of you. Do not
bounce on heels. After 30 seconds, slowly return to the starting position. Do
about 3-6 repetitions.
Abdominal muscle and core strength. Lie face up on a padded surface, with
both knees bent and feet flat on floor. Tighten abdominal muscles. Slowly
raise one foot off the floor about 4-6 inches and hold that position for 5-10
seconds; over time increase time that foot is held up off floor to 30 seconds.
Return to starting position. Do about 3-6 repetitions.
Back extension. Comfortably lie on a padded surface face up. Tighten the low back and buttock muscles while allowing the low back to flatten firmly against the floor. Hold that position for 5-10 seconds; over time increase time that foot is held up off floor to 30 seconds. Return to starting position. Do about 3-6 repetitions.
Spinal stenosis treatment with epidural injections
An injection of cortisone into the space outside the dura (the epidural space) can temporarily relieve symptoms of spinal stenosis. While injections can seldom be considered curative, these spinal stenosis treatments can alleviate the pain in about 50% of cases. Up to three injections over a course of several months can be tried. Although they are not considered diagnostic in and of themselves, generally, if the pain caused by spinal stenosis is relieved by an epidural steroid injection, then the patient can also be expected to have a good result if they later choose to have spinal stenosis surgery.
Spinal stenosis surgery
The primary goal of spinal stenosis surgery is to remove those spinal structures that are compressing the nerves in the spinal canal or vertebral foramen. The procedure used is commonly referred to as lumbar decompression surgery (foraminotomy, laminectomy and laminotomy).
Spinal stenosis surgery is best indicated for anyone who does not improve with conservative measures (rest, exercise, hot/cold applications, stretching, chiropractic, etc.) or if severe and rapidly progressive weakness or loss of bowel or bladder function occurs. Depending on the results of physical examination findings and imaging studies, various surgical procedures can be used to treat the non-responsive lumbar spinal stenosis patient, from laminectomy to multiple fusion procedures.
Generally, stenosis surgery is more reliable for relief of sciatica leg symptoms and less reliable for relief of lower back pain symptoms.
It is critical that as a patient you discuss these basic points with your doctor before you agree to spinal stenosis surgery:
- 1. Get a sense of the level of confidence that the surgeon has a clear and detailed understanding where your spinal stenosis is located. The doctor must know exactly what he/she is going to do and where the problem is located during stenosis surgery. This is especially true if yours is a complex problem with more than one location that is being impinged upon, or if both sides of the spine must be opened. If your doctor cannot speak with confidence about the surgery then the results might not make you pleased. You might want to find a doctor to do the spinal stenosis surgery who more clearly understands your lower back pain problem.
- 2. Ask about the possibility that the stenosis surgery might cause new problems or worse problems for you than you now have. It is good to discuss the possibility of injury to nerves in the area, or if the surgery will cause instability and weakness of the spine that you currently do not have now. Along this same line of thought you want to assure that this stenosis surgery should not cause a situation that might require an additional surgery later. If you learn that there are other techniques of spinal stenosis surgery that will cause fewer problems later, then you should find another surgeon who does this kind of operation. .
- 3. Ask the surgeon if the method that will be used to correct or relieve your spinal stenosis is the least invasive technique that is available and used. Ask if the method of spinal surgery will be minimally destructive of normal structures in the area and near important nerve structures. Ask if the technique and method of stenosis surgery will leave as much as possible of the normal or slightly abnormal tissues alone. If you are told that there are other methods that destroy less normal tissue, then you need to determine who can do that kind of surgery.
- 4. Ask if the surgery can be done under an epidural anesthetic instead of general anesthesia. Spinal stenosis surgery for decompression of nerve tissue when done under general anesthesia is stressful for the patient since it is often a many-hour procedure. Some patients cannot tolerate this kind of metabolic and physical stress. If you are learn that this surgeon prefers to work with a patient under general anesthesia, be sure to find out why, what would be the reasons that you could be an exception, and this risk is justified in your case. If you are not satisfied with the answers then it might be better to find a different surgeon who can safeguard you during your stenosis surgery.