Spinal Information - Spinal Conditions
Lumbar Spinal Stenosis
In the United States, Lumbar Spinal Stenosis ("LSS") remains the leading preoperative diagnosis for adults older than 65 years who undergo spine surgery (see Current Diagnostic Methodologies). The cost of LSS surgeries performed each year exceeds $1.0 billion. According to published scientific material by Willén, J. et al (1) (one of the Inventors of DynaWell L-Spine), Schöllhammer, M. et al (2), Westesson, P.L. et al (3), CT and MRI examinations with axial loading using the DynaWell L-Spine Device considerably increases the diagnostic specificity in patients with lumbar spinal stenosis. According to Westesson et al (3), this might change the treatment of the patient from non-surgical to surgical.
Facet joints tend to get larger as they degenerate. This process is the body's attempt to decrease the stress per unit area across a degenerated joint. Unfortunately, as the joint enlarges, it can place pressure on the nerves as they exit the spine (see below Figure B, Point #2 and #4). Standing upright further decreases the space available for the nerve roots, and can block the outflow of blood from around the nerve. In LSS, congested blood then irritates the nerve and the pain travels into the legs.
Generally, patients with spinal stenosis are comfortable if they are sitting, but have more pain down their legs when they walk, and the pain increases with more walking ("neurogenic claudication"). Walking while leaning over a supporting object (such as a walker or shopping cart) can help ease the pain, and sitting down will cause the pain to recede.
Treatment options for conservative treatment for LSS include activity modification and epidural injections.
- Activity modification. Since patients are more comfortable when they are flexed forward, they can concentrate their activity in that position and exercise can include stationary biking and using a cane or walker for walking while flexed forward.
- Epidurals. Approximately 50% of patients will experience good relief after an epidural injection, although the results tend to be temporary. If the injection is helpful it can be done up to three times annually. The action of the injection is not clearly known, but is probably a combination of the anti-inflammatory effect of the steroid and a flushing effect due to injecting a volume of fluid.
In chronic cases, spinal surgery is needed.
- Spine surgery (an open decompression or laminectomy) is the only way to change the anatomy of the spine and give the nerves more room. Decompressing the nerves by removing a portion of the enlarged facet joint prevents the nerve pinching when the patient stands up. It is effective in approximately 80% of cases, although over a 5-year period of time the results tend to deteriorate. Part of this deterioration is due to the progressive nature of osteoarthritis, and part is due to the overall aging process.
In the United States, sciatica and related pain remains the principal reason for doctor visits (affecting more than 10 million people annually), and the principal ailment cited in worker's compensation claims in the United States, and is a leading cause of employee absenteeism in the United States. Sciatica and related back pain is a principal cause for health care expenditures in the United States, with more than $100 billion in annual direct and indirect medical expense (see Current Diagnostic Methodologies). According to published scientific material by Willén, J. et al (1) (one of the Inventors of DynaWell L-Spine), Schöllhammer, M. et al (2), Westesson, P.L. et al (3), CT and MRI examinations with axial loading using the DynaWell L-Spine device considerably increases the diagnostic specificity in patients with sciatica. According to Westesson et al (3), this might change the treatment of the patient from non-surgical to surgical.
Sciatica is classified as pain along the large sciatic nerve that runs from the lower back down through the buttocks and along the back of each leg and is the most common form of back pain. Sciatica is usually caused by pressure on the sciatic nerve from a herniated disc (also referred to as a bulging disc, ruptured disc or pinched nerve). The problem is often diagnosed as a "radiculopathy", meaning that a disc has protruded from its normal position in the vertebral column and is putting pressure on the radicular nerve (nerve root).
For some people, the pain from sciatica can be severe and debilitating. For others, the pain might be infrequent and irritating, but has the potential to get worse. Usually, sciatica only affects one side, and the pain often radiates through the buttock and/or leg. While sciatica can be very painful, it is rare that permanent nerve damage (tissue damage) will result. Most pain syndromes result from inflammation and will get better within two weeks to a few months. Also, because the spinal cord is not present in the lower (lumbar) spine, a herniated disc in this area of the anatomy does not present a danger of paralysis. Symptoms that may constitute a medical emergency include progressive weakness in the legs or bladder/bowel incontinence.
Any condition that causes irritation or impingement on the sciatic nerve can cause the pain associated with sciatica. The most common cause is lumbar herniated disc. Other common causes include lumbar spinal stenosis, degenerative disc disease, or isthmic spondylolisthesis.
Nerve pain is caused by a combination of pressure and inflammation on the nerve root, and treatment is centered on relieving both of these conditions. Treatments include:
- Manual treatments (including physical therapy and osteopathic or chiropractic treatments) to help relieve the pressure.
- Medical treatments (such as NSAID's, oral steroids, or epidural steroid injections) to help relieve the inflammation.
- Surgery (such as microdiscectomy or lumbar laminectomy) to help relieve both the pressure and inflammation may be warranted if the pain is severe and has not been relieved with appropriate manual or medical treatments.
Treatment options for conservative treatment for sciatic pain include, heat/ice, medications and epidural steroid injections.
- Heat/ice: For acute pain along the sciatic nerve, heat and/or ice packs are most readily available and can help alleviate the pain, especially in the acute phase. Usually ice or heat is applied for approximately 20 minutes, and repeated every two hours. Most people use ice first, but some people find more relief with heat.
- Medications: Over-the-counter or prescription medications may also be helpful. Non-steroidal anti-inflammatory drugs (NSAIDs) or oral steroids can be helpful in reducing the inflammation and pain.
- Epidural steroid injections: If the pain is severe, an epidural injection can be performed to reduce the inflammation. An epidural is different from oral medications because it injects steroids directly to the painful area to help decrease the inflammation that may be causing the pain. While the effects tend to be temporary (providing pain relief for as little as one week up to a year), an epidural can be very effective in providing relief from an acute episode of pain. Importantly, it can provide sufficient relief to allow a patient to progress with a conditioning program.
If the pain is severe and has not gotten better within six to twelve weeks, it is reasonable to consider spine surgery. Depending on the cause and the duration of the pain, one of two surgical procedures may be considered: a microdecompression (microdiscectomy) or an open decompression (lumbar laminectomy).
- Microdiscectomy: (microdecompression) In cases where the pain is due to a disc herniation, a microdiscectomy may be considered after 4 to 6 weeks if the pain is not relieved by conservative means. Urgent surgery is only necessary if there is progressive weakness in the legs, or sudden loss of bowel of bladder control. A microdiscectomy is typically an elective procedure, and the decision to have surgery is based on the amount of pain and dysfunction the patient is experiencing, and the length of time that the pain persists.
- Lumbar laminectomy: (open decompression) Lumbar spinal stenosis often causes pain that waxes and wanes over many years. Surgery may be offered as an option if the patient's activity tolerance falls to an unacceptable level. Again, surgery is elective and need only be considered for those patients who have not gotten better after conservative treatments.