Care at CNSO – Understanding Lumbar Stenosis
THE LOWER PART OF your spinal column is the lumbar spine and it contains 5 vertebral bodies each with a distinctive reference name: L1, L2, L3, L4 and L5. These lumbar spine vertebrae are inter connected by joints, called facet joints, and intervertebral discs. Within the column of bone and joints is a tunnel, the spinal canal, containing spinal fluid, and through which the spinal cord and nerves travel. Under normal conditions, the spinal canal is large enough for the spinal cord and nerves to pass freely without any pressure or obstruction from any structures that form the spinal canal.
Lumbar stenosis, or canal stenosis, is a narrowing of this spinal canal in your lower back, resulting in pressure on the spinal cord or spinal nerves. At the location where the spinal nerve exits the spinal cord, it is called a nerve root. The nerve roots in the lumbar spine share the same reference name as the vertebral bone above it. For example, between the L4-L5 vertebral bones, exits the L4 nerve root. Each lumbar nerve root exits the spinal cord and travel down into the legs. When pressure is placed on the nerve roots by the surrounding structures within the spinal canal, it may cause symptoms such as pain, numbness, or tingling in the low back and legs. This condition is colloquially referred to as a pinched nerve and most commonly occurs at the L4-L5 level of the lumbar spine. The second most common level to develop a pinched nerve is lower down the lumbar spine at L5-S1. A pinched nerve at this level causes symptoms in the low back, buttock, and back of the leg that are referred to as sciatica. In more severe cases, especially when there is severe lumbar spinal stenosis placing pressure on the spinal cord, the patient may experience leg weakness or difficulty with bladder control. At Centers for Neurosurgery, Spine & Orthopedics, our multidisciplinary team helps patients across Northern New Jersey have relief from their spinal stenosis or pinched nerve and returns patients to their daily activities.
The usual cause of lumbar stenosis is age-related wear and tear (arthritis) on the joints and ligaments of the spinal column. As these structures experience degenerative changes, they can become deformed, overgrown by calcium deposits from arthritic bone growth, or misaligned, crowding into the already narrow spinal canal and further reducing this space where the spinal cord and nerves travel. The resulting canal stenosis can cause pressure on the nerves and spinal cord. Lumbar stenosis can also be caused by disc herniations or fractures of the spine. Rarely, stenosis can be congenital. Lumbar stenosis, as well as canal stenosis at any level of the spine can be easily seen on Cat Scan or MRI by a neurosurgeon or orthopedic spine surgeon.
Risk factors for lumbar stenosis are the same as risk factors for any degenerative condition of the spine. Intrinsic to the aging process is repetitive use, overuse, or overburdening joints and bones over extended periods of time. Lack of movement, lack of use, and poor nutrition prevents bones and joints for the supply of nutrients and activity needed to remain healthy and free from limitations. Otherwise, muscles become weak and unable to support the skeletal structure for any movement including simple daily activities like carrying groceries, or walking up and down stairs. Family genetics, poor nutrition, and smoking cause bones to become demineralized at an earlier age leading to microfractures and disorganized bone growth. The inflammatory process associated with overuse, misuse, and traumatic injury also causes the disorganized bone growth all of which can lead to spinal stenosis. Specific risk factors include:
- Family history of spinal arthritis
- Sports Injury
- Motor Vehicle Injury
- Work Related Injury
- Fall Injury
- Physically strenuous work, repetitive bending, and lifting
- Repetitive trauma (collision sports)
- Sedentary lifestyle, especially excessive sitting
- Poor posture
- Muscular imbalance
Signs & Symptoms
The classic symptom of lumbar stenosis is leg pain or weakness made worse by standing upright or walking and relieved by bending over or sitting. This is known as neurogenic claudication. Typically, patients find it more comfortable to walk while stooped over, or while leaning on a cane or shopping cart.
Pain, numbness, and tingling can affect one or both legs. When severe, the legs may become weak after prolonged standing or walking. In extreme cases, there can be a loss of bowel or bladder control.
Lumbar spinal stenosis requires a thorough evaluation by a spine-specialized practitioner such as a neurosurgeon or orthopedic spine surgeon. This evaluation will include a detailed history, physical exam, and neurological assessment.
History taking will identify when your symptoms started, inciting events (such as trauma or heavy lifting), relieving factors, symptom severity (numeric pain scale or visual analog scale), associated neurological symptoms (sensory loss, numbness/tingling, abnormal gait, bowel/bladder dysfunction, weakness), and attempted therapies (oral/topical medications, physical therapy, acupuncture, chiropractic, etc.). A complete history helps your doctor recognize the pattern of your symptoms that can point to a likely diagnosis.
The goal of physical examination is to further clarify and isolate the cause of your symptoms. Leg pain and dysfunction can result from lumbar stenosis. But leg pain can also be caused by a variety of other derangements in your body, including in your brain, cervical spine stenosis, hips, knees, or the muscles, tendons, and ligaments of your legs. After carefully listening to a history of what the patient has been experiencing and assessing the likely pain generators, a detailed physical exam will test likely nerve root distributions, neural networks within the brain and throughout the body, individual joints, muscles, ligaments and tendons that maybe malfunctioning.
Depending on the history and physical, diagnostic imaging such as an X-ray, CT scan, or MRI may be indicated for further evaluation. If symptoms are mild, diagnostic images will not be authorized by insurances unless the patient has had physical therapy and non-steroidal anti-inflammatory medications for 6 weeks and there has been little to no improvement in symptoms.
For those patients who have moderate to severe symptoms, or symptoms lasting more than 4 to 6 weeks, especially after attempted conservative therapies, diagnostic imaging such as MRI (magnetic resonance imaging) or CT scan (computed tomography scan) may be considered to provide guidance for additional types of therapy such as an epidural or transforaminal nerve block. MRI without contrast is generally the best imaging study initially. If spinal stenosis is present, the MRI will show strictures limiting the space within the spinal canal. For patients who cannot get an MRI, a CT scan can be obtained instead. On the CT scan, the cross-sectional view will clearly show whether spinal stenosis exists. The neurosurgeon or orthopedic spine surgeon will then correlate the patient’s symptoms with the findings on either the MRI or CT.
When patients come to CNSO, it is because they cannot function and are in pain. The majority of patients with lumbar stenosis do not have a severe enough condition to warrant surgery. These non-operative cases can return to normal function but would significantly benefit from physical therapy and conditioning. The techniques learned by spending six weeks with a physical therapist, a couple of times a week, should continue to be used at home and for the life of that patient. It will prevent the pain and disfunction from reoccurring.
Whether non-operative or operative, the initial non-surgical treatment may include:
- Temporary reduction of activities that aggravate their condition to reduce ongoing irritation of the nerve roots or spinal cord
- Medications to relieve the inflammation of the nerves and any resulting muscle spasms:
- Inflammation (Ibuprofen, Naproxen, steroids)
- Muscle spasms (Flexeril, Valium, Skelaxin)
- Nerve irritation (Neurontin, Lyrica)
- Pain (Morphine, Percocet, Dilaudid)
- Physical therapy to strengthen the core and improve postural biomechanics
- Epidural steroid injections or Transforaminal steroid injections to reduce inflammation at the spinal nerves
In the cases where the spinal stenosis is moderate to severe and significantly symptomatic:
Surgical treatments are solutions in which the neurosurgeon and orthopedic spine surgeon make the narrow spinal canal wider by removing the boney overgrowth and degenerative changes. This can be accomplished a number of ways depending on the location of the problematic spinal stenosis but in the majority of the cases, a posterior laminectomy approach is all that is necessary. Only in cases where there is lumbar stenosis plus other specific spine conditions affecting the anterior portion of the spine, is it necessary to perform an Anterior-Posterior surgical decompression. The CNSO surgical approach is determined based on the location of the spine pathology, which procedures need to be performed to remove the pathology, and always with the goal to minimize the disruption of the surrounding tissue, the invasiveness, and to minimize any scarring. At CNSO, this is accomplished by the use of minimally invasive spine surgery techniques which range from dilators to robotics for more complex cases. These techniques allow the CNSO neurosurgeons and orthopedic spine surgeons to have only a 2 cm surgical incision size which helps patients quickly recover from spine surgery and no longer need pain medications within one month. For spinal stenosis, the procedure chosen will restore the space within the spinal canal thereby relieving any pressure on the spinal cord and/or nerve roots. If the spine is unstable because of an existing spondylolisthesis or advanced degenerative or rheumatoid arthritis, a spine fusion will be necessary and should be performed during the same surgical session as the decompression of the spinal cord and spinal nerves.
The dedicated team at Centers for Neurosurgery, Spine, and Orthopedics (CNSO) understands how lumbar stenosis can impact your daily life and how to cure it. By working with the CNSO team of board-certified neurosurgeons, orthopedic spine surgeons, physiatrists, nurse practitioners, rehabilitation specialists, and certified physical therapists, patients receive comprehensive and coordinated care. CNSO offers multiple convenient locations across northern New Jersey, including offices in Bergen, Passaic, Morris, Essex, Hudson, and Sussex Counties. Northern NJ patients can learn more about effectively treating lumbar stenosis either non-operatively or surgically by contacting CNSO today.