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Lumbar Spinal Stenosis

What is Lumbar Spinal Stenosis?

Lumbar spinal stenosis is a condition where the tube in the middle of the spine (spinal canal) is narrowed. Since the important neurological structures, the spinal cord, cauda equina and spinal nerves are located in this spinal canal, this condition can affect them. The lumbar spine has the spinal cord present only at the upper most levels (L-1, L-2). Below that level, the cauda equina (large bundle of nerves) is located in the spinal canal and can be affected by spinal stenosis.

How does Lumbar Spinal Stenosis develop?

This condition is quite common as the spine ages. Contributing factors are:

  1. Discs which bulge, protrude, or herniate into the spinal canal from the front.
  2. Bone spurs which develop on the vertebral body or facet joints from the back.
  3. One of the spinal ligaments can thicken (ligamentum flavum) from overuse and also takes up space in the spinal canal
  4. Some patients have a small spinal canal from birth and are at a higher risk to develop spinal stenosis.

How much smaller does the Spinal Canal get in Lumbar Spinal Stenosis?

A normal size for a spinal canal in the neck is 17 to 18mm in diameter, about the size of a penny. When the canal narrows to 13mm or less, spinal stenosis exists. When the diameter is reduced to 10mm or less, the stenosis is deemed to be severe.

What is Cauda Equina Syndrome?

Cauda Equina Syndrome is a condition where there is an acute loss of the function of the lumbar and sacral spinal nerves, below the level of the spinal cord.  This is commonly a neurological emergency, and may require emergency surgery.

Cauda Equina Syndrome can happen in extremely severe cases of spinal stenosis, where the spinal canal only has a few mm of space remaining.

What are the symptoms of Lumbar Spinal Stenosis?

In cases of severe Lumbar Spinal Stenosis and Cauda Equina Syndrome some of these symptoms can be seen:

  1. Leg pain, numbness when arching backwards
  2. Weakness in the legs when walking distances
  3. Numbness and tingling in the legs when walking distances
  4. Problems emptying the bladder
  5. Problems with controlling bowel movements
  6. Unstable gait
  7. Spasms in the leg muscles
  8. Loss of muscle mass in the legs

How is Lumbar Spinal Stenosis diagnosed?

This condition is diagnosed by combining information from the patient history, physical examination, and special tests:

  1. History

The diagnosis revolves around asking the patient questions about some of the common symptoms of spinal stenosis. Here are some:

  1. Do you have a difficult time walking a certain distance?
  2. Do your legs feel weak and cramping after walking a certain distance?
  3. Do you feel better walking when bending forward?
  4. Do you feel like you are having problems with your balance?
  5. Do you have weakness in the legs?
  6. Do you have numbness or tingling in your legs?
  7. Do you have trouble emptying your bladder?
  8. Do you ever lose control over your bowels?

 

     2. Physical Examination:

The spine specialist often examines the following:

Gait for stability

  1. Reflexes testing of the legs
  2. Ankle clonus
  3. Strength testing (motor) of the legs
  4. Sensation testing (sensory) of the legs
  5. Babinski test

 

      3. Imaging

a. X-Ray

X-Rays can be helpful to establish the anatomy of the low-back. However, they cannot offer information about the spinal canal or spinal cord. They cannot show spinal stenosis clearly.

b. MRI

MRI information is critical and the best study when evaluating severe spinal stenosis. It can show the spinal cord and spinal nerves in detail and can accurately assess how much compression of each exists. It can also determine if there is swelling present in the nerve or spinal cord (gliosis). The latter can be a sign of impending damage or existing damage to the spinal cord.

c. CT scan

Regular CT scans can show the spinal canal and foramen accurately. However they have the disadvantage of not being able to show the spinal nerve and spinal cord in detail.

d. CT Myelogram

A CT Myelogram involved an injection of Contrast Dye into the Spinal Fluid of the Low Back. A CT Scan is then performed to shpw where the dye has traveled. This can show spinal stenosis in detail.

How is Lumbar Spinal Stenosis treated?

The treatment of lumbar spinal stenosis is dependent on the severity of the case. Surgery is reserved for severe conditions not responding to non-surgical care.

1. Non-Surgical Care

A. Alternative Health Care

Alternative Health care options can often complement conventional medical care. Massage Therapy, Acupuncture, Meditation exercises and Herbal Remedies can all help with the pain from this condition. Massage therapy techniques can help with the muscle components of this condition.

B. Nutrition and Weight Loss

Proper nutrition and weight loss can have a positive impact on many spine conditions. Excess weight on the spine often contributes to the symptoms of pain and spasms (Spine and Obesity).

C. Chiropractic Care

Chiropractic care including manipulation and adjustments of the spine can help with the pain and spasms from this condition.

D. Spine Exercises

Spine exercises can help with the muscle pain and tightness from this condition. Exercise also increases the amount of oxygen delivered to the spine which can help with healing. Pilates, Yoga and T’ai Chi can help maintain the spine’s flexibility.

E. Physical Therapy (PT)

PT has many modalities to offer for this condition. They can range from Manual Therapy and Exercises to Traction and Ultrasound Treatments. Traction can help with compressed spinal nerves, but not the compression of a spinal cord per se. Ultrasound and Electrical stimulation can help with muscle spasms. Certain PT exercises such as conditioning exercises can help maintain the muscle tone and function in the legs.

F. Self Help Tools

Self Help Tools are items which can be purchased to help with back pain. They range from Back Braces to Back Mattresses and Ergonomic Devices such as chairs and computer accessories. Braces can provide some comfort and prevent patients from bending backwards too far. Bending backwards can worsen the symptoms of spinal stenosis in severe cases.

G. Spine Medications

Here are some of the common groups of medications which are available for this condition:

1.Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)

2.Steroids

3.Muscle Relaxants

4.Pain Killers

5. Antidepressants

H. Injections

Lumbar Epidural steroid injections can help with cases of lumbar spinal stenosis without cauda equine syndrome. It may not be recommended to perform injections in a patient with extremely severe spinal stenosis due to the pressure the injected fluid can place on the cauda equina.

Here are types of epidural injections for Lumbar Spinal Stenosis:

1. Lumbar Interlaminar Epidural Steroid Injections

2. Lumbar Transforaminal Epidural Steroid Injections

3. Caudal Epidural Steroid Injections

 

      2. Surgical Care

Here are some of the surgical procedures offered for cases of severe Lumbar Spinal Stenosis:

  1. Lumbar Laminectomy Decompression
  2. Lumbar Laminotomy and Foraminotomy
  3. Lumbar Interspinous Process Spacers.
  4. Lumbar Fusion