What is spinal stenosis ?

Spinal stenosis is a condition where the space for neural elements in spinal column is narrowed. This leads to narrowing of channels where spinal cord and nerve roots travel resulting in compression of the neural elements.

What is the causes of spinal stenosis ?

• Primary / Developmental spinal stenosis- which means you’ve had it since birth although the symptoms appear in later part of the life. This is a form of inherited stenosis called short pedicle syndrome. These patients are more prone to develop symptoms in midlife. Primary spinal stenosis isn’t common.

• The second category is the commonest and happens due to wear and tear or degeneration process . This results from degenerative changes in the ligaments of the canal or due to some disease or injury to the spine. The most common direct cause of spinal stenosis is osteoarthritis of spine coupled with degenerative changes in the disc and facet joints.

•Aging : as a part of the normal age related degenerative process.

•Life style: Stress and emotional tension, poor posture -standing for long periods of time or sitting incorrectly—can cause spinal stenosis , heavy physical work, lifting or forceful movement, bending, or awkward positions can really hurt your back.

•Injuries and Accidents : Injury to muscle , ligaments , or soft tissue can lead to spinal stenosis .Fracture in spinal bone in a fall or a car accident also is a common cause

• Obesity :Being overweight puts pressure and stress on the back, especially the low back. Carrying excess weight aggravates other health conditions such as osteoporosis (weak bones), osteoarthritis (joint pain), rheumatoid arthritis (an autoimmune disease), degenerative disc disease (described above in the aging section), spinal stenosis, and spondylolisthesis.

Specific conditions can present with secondary stenosis
• Large Slip disc,
• Facetal arthritis,
• Primary spinal tumours,
• Spinal Metastatic tumours,
• Infections,
• Spinal Fracture

What are the symptoms are spinal canal stenosis ?

This depends on the level at which the stenosis is in the spine. Lower spine (lumbar) stenosis can present as –

• Neurogenic claudication –
Pain or cramping in legs during standing stand for long periods of time or when you walk. The discomfort usually eases if you bend forward or sit down, but comes back when you stand upright. Symptoms which appear on walking and subside when you bend forward is typical of lumbar spinal stenosis. This type of pain is called neurogenic claudication. Patients with this condition may find walking uphill or climbing stairs more comfortable than walking straight.
• increased frequency of urination or
• urgency of urination
• inability to control urine.

Depending on the location the spinal stenosis has been classified into cervical spinal stenosis or lumbar canal stenosis

Cervical Spinal Stenosis:
Spinal stenosis in neck (cervical spine) can cause
neck pain,
• shoulders pain ,
• vertigo, giddiness,
• arm pain ,
• pain in nape of neck,
• forearm pain.
• difficulty in walking,
• imbalance during walking,
• numbness in hands,
• difficulty in finer functions of hand such as holding a glass, change of signature etc.
• headaches,
• numbness, or muscle weakness.
• Loss of balance, which can lead to clumsiness or a tendency to fall.

When do i need to have a physician opinion ?

Seek medical attention if your symptoms persists and seek immediate attention if you have any of the following emergency signs (RED FLAGS ):

1. Pain is getting significantly worse
2. Pain affects every day activities
3. Severe symptoms
4. Associated Fever or constitutional symptoms
5. Groin or leg weakness or numbness
6. Arm or hand weakness, tingling, or numbness
7. Loss of bowel or bladder control.

What are the treatment options for spinal stenosis ?

There are different options to treat spinal stenosis depending on the severity and duration of symptoms . They may comprise of one or many

1. Drugs & Medications
2. Physical Therapy
3. Spinal Bracing
4. Spinal Injections
5. Spine surgery
6. Physiotherapy

Drugs, Medications, to Relieve Spinal stenosis :

Medication alone is not the ultimate solution to your back pain, however during emergency or during severe pain these medicines may help you curb the suffering.

Acetaminophen :

Your doctor may call this an analgesic, but most of us refer to acetaminophen medications as painkillers. They don’t help reduce inflammation, though.

NSAIDs (non-steroidal anti-inflammatory drugs) :

These will help reduce swelling (or inflammation) while relieving your pain; that’s how NSAIDs differ from acetaminophen. If an over-the-counter NSAID is an option for you, you have plenty to choose from. You can use ibuprofen, aspirin; however seek medical advice before you take any medicine.

Muscle Relaxants : If you have chronic spinal stenosis caused by muscle spasms, you may need a muscle relaxant, which will help stop the spasms

Anti-depressants :
As surprising as it may seem, anti-depressants can be effective drugs for treating pain because they block pain messages on their way to the brain. They can also help increase your body’s production of endorphins, a natural pain killer.

Opioids : In the most extreme cases, and only under careful supervision, you doctor may also prescribe an opioid, such as morphine or codeine.

Medication Warning : As with all medications, you must follow your doctor’s advice precisely. Never mix over-the-counter and prescribed drugs without consulting your doctor.

Physical Therapy to Relieve Spinal stenosis :

(A) Passive Therapy
i. Massage
ii. Heat Therapy /Cold /Ice Packs
iii. Local Ointments application
v. Traction

(B) Active Therapy – exercises
1. Endurance exercises
2. Strengthening exercises for back and abdominal muscles
3. Core stability Exercises

Passive Treatments :

• Deep Tissue Massage :
Deep tissue massage relieves deep muscle tension and spasms, which develop to prevent muscle motion at the affected area.

• Hot and Cold Therapy :Both hot and cold therapies offer their own set of benefits, and your physical therapist may alternate between them to get the best results. This reduces inflammation, muscle spasms and pain.

• TENS (transcutaneous electrical nerve stimulation) :
Uses electrical current to stimulate your muscles and reduces muscle spasms and is generally believed to trigger the release of endorphins, which are your body’s natural pain killers.

• Traction :Reduce the effects of gravity on the spine. the intent is to reduce the disc herniation and is usually performed in the cervical or lumbar spine.

• Active Treatments :Help to reduce recurrent pain but will also benefit your overall health.

• Core stability :Many people don’t realize how important a strong core is to their spinal health. Your core (abdominal) muscles help your back muscles support your spine. When your core muscles are weak, it puts extra pressure on your back muscles. Your physical therapist may teach you core stabilizing exercises to strengthen your back.

• Flexibility :Learning proper stretching and flexibility techniques will prepare you for aerobic and strength exercises. Flexibility helps your body move easier by warding off stiffness.

• Muscle strengthening :Strong muscles are a great support system for your spine and better handle pain.

Spinal Injections : (A)Injection techniques
1. Root Block Injection
2. Epidural Injection
3. Caudal Block Injection
4. Facet Block Injection

• Epidural Steroid Injection :
An epidural steroid injection sends steroids—which are very strong anti-inflammatories—right to the nerve root that’s inflamed. This is a pain management therapy, so it’s best to have a well-trained pain management specialist do the injection. You’ll probably need 2-3 injections; generally, you shouldn’t have more than that because of the potential side effects of the steroids.

Spinal Bracing :Spinal bracing is often advised for pain relief in patients with
• back pain
neck pain
• slip disc
• stenosis
• spondylolisthesis
• Spinal Trauma
• Herniated Disc
• Spinal tuberculosis with pain

Spinal bracing utilises these primary objectives:

Controlling back pain by limiting motion and unloading discs, vertebrae and other spinal structures by compressing the abdomen.
Stabilising weak or injured structures by immobilising the spine.
• Providing three-point force systems to provide correction or prevent progression of a deformity.

Different type of braces are classified based on the rigidity and are – Flexible, Rigid or Semi-rigid

• Flexible orthoses or corsets are prescribed for relief of low back pain associated with degenerative disc disorders, trauma, or postural deformities. Rigid stays and inserts can be added to restrict motion and act as a postural reminder.

• Rigid orthoses are commonly custom fabricated and provide the most support to the area being treated. A body jacket or TLSO controls motion in all planes.A two piece front and back design is commonly used post operatively for ease of application while a front or back opening single piece design is commonly utilised when treating scoliosis.

Different types are :

• Corset braces
• Hyperextension braces
• Moulded jackets
• Neck braces
• Rigid braces
• Sacroiliac and lumbosacral belts
• Trochanteric belts
• Thoracolumbosacral orthoses (TLSO)

Long time usage of corsets / belts can lead to muscular atrophy due to disuse.
Please consult your specialist before using a corset/ belt for your spinal problem.

• Surgery for Spinal stenosis :
• Only 5% of people need surgery to treat back problems. Your pain may be severe, but most sprains and strains do not require surgery. Surgery is reserved for the most severe cases of spinal stenosis (spinal cord impingement, structural deformity, severe cases of spinal stenosis)

(A) Surgery- Surgery is often required for patients whose symptoms are worsening over 2-3 weeks, and patients are not responding to conservative treatment. Emergency surgery is required for patients who have lost bowel / bladder control – Cauda Equina syndrome.

The options of surgery are
• Decompression
• Spinal Fusion

The spine surgery advised for Spinal stenosis can be performed in many different ways. The success rates of surgery in slip disc/ herniated disc / sciatica is 99 % and with invention of modern technology and minimal invasive surgery techniques it nears 100 %. Spine surgery can be performed in different manners;-

• Conventional Open surgery
• Minimal Invasive Spine surgery – Key hole spine surgery
• Endoscopic Spine Surgery
• Microscopic spine surgery
• Micro endoscopic spine surgery

Decompression includes

•Facetectomy :A procedure that removes a part of the facet (a bony structure in the spinal canal) to increase the space.

•Foraminotomy :A procedure that removes the bony compression over foramina (the area where the nerve roots exit the spine) to increase the size of the nerve pathway.

Laminoplasty :A procedure make more room for the spinal canal.

•Laminotomy :A procedure that removes only a small portion of the lamina (a part of the vertebra) to relieve pressure on the nerve roots.

• Micro-discectomy :A procedure that removes a disc through a very small incision using a microscope.

Laminectomy :A procedure for treating spinal stenosis by relieving pressure on the spinal cord.

• Spinal Fusion: The surgery intends to stabilise a unstable segment responsible for pain , this may involve putting some screws in your spine to increase stability.

• Various options of doing spinal fusion are PLF /PLIF/TLIF/ ALIF/XLIF