When Does Spinal Arthritis Become SPINAL STENOSIS?

When Does Spinal Arthritis Become SPINAL STENOSIS?
By Dennis Crandall, M.D.

As a part of normal aging, the spine can develop arthritis. The discs lose their water content and begin to collapse, bone spurs form, and the ligaments around the joints of the spine begin to thicken. After age 50, these slowly growing bone spurs and thickened ligaments may begin to narrow the spinal canal and compress nerves. The result is slowly worsening pain into the buttocks, hips, thighs, and legs. Walking and standing are often worse than sitting. Feet or legs can become numb or tingle. Walking distances becomes more difficult as the legs begin to "feel heavy." Often, patients find themselves standing or walking in a stooped forward position in order to ease the pain. This process of spinal nerve compression is called spinal stenosis. Back pain may or may not be present. Over time, if signs and symptoms of spinal stenosis are ignored, bowel and bladder control can be lost.

NONOPERATIVE TREATMENT

Unfortunately, conservative care has not been very effective at providing lasting relief from pain caused by spinal stenosis or pinching of the spinal nerves. Early stenosis can be treated with arthritis medications with some success. Steroids pills or steroid injection into the spinal canal (epidural) can provide some improvement in symptoms if the nerves are not too badly pinched. However, the effect of the steroids usually wears off within several days, weeks, or months and the pain returns. Other treatment methods such as wearing a back brace, physical therapy, or spinal manipulation (Chiropractic) have not been shown to provide any lasting improvement when significant nerve compression is present.

SURGERY

Spinal stenosis most often requires surgery to decompress nerve roots and alleviate the pressure caused by the overly narrowed spinal canal. The surgery is called Laminectomy and is commonly done by spine surgeons all over the country.

  As with all surgery, a patient's decision to proceed is a very personal one. Surgery for this condition is usually elective in that it can wait until the patient decides it is time to get rid of the pain. A decision to avoid surgery is a decision to live with the symptoms a while longer. The only time surgery cannot wait is if significant leg weakness is present or if bowel or bladder control is lost.

RISKS OF SURGERY: The risk of infection is 1-2%. If the incision becomes infected, an additional trip to the operating room is usually required to wash out the infection. Antibiotics are required, sometimes through a vein.

  If nerves have been compressed for an extended time, return of function and relief of pain may not be as complete as hoped for. There is also a risk (less than 5%) that new numbness or weakness could occur. If this happens, it usually improves on its own.

  There is a risk that the fluid filled sack (dura), which surrounds the nerve roots, can adhere to the surrounding bone and ligaments being removed. If the dural sack is torn, it must be repaired during surgery. Rarely, an additional operation is required to repair a dural tear that hasn't healed.

   In some patients, adequate decompression of the pinched nerve roots requires removing some of the bone that contributes to spine stability. Fusion of the unstable segment would then be required to restore spinal stability and relieve back pain.
Other risks not listed here are even more rare and are not therefore listed. There are also medical risks as with any major surgical procedure.

SURGICAL PROCEDURE (LAMINECTOMY)

Patients enter the hospital the morning of surgery. The surgical procedure involves an incision along the spine and back muscles moved aside (not cut). Decompressing nerves involves removing arthritic bone spurs and thickened ligaments, which pinch nerve roots and cause pain. This can take 1-4 hours depending on the severity. If fusion is required to establish spinal stability, this involves removing some of the thick bone on the back of the pelvis and placing it along the side of the spine. Spinal instrumentation (rods and screws) is usually required to promote successful fusion. The incision is closed with self-dissolvable sutures covered with steri-strip tape. There are no staples or stitches that need to be removed later.

HOSPITALIZATION

Usually patients are up walking a day after surgery. Most people are ready to go home after 1 - 2 days depending on how quickly they become independent. When additional physical therapy is needed, a therapist can visit patients at home. Sometimes a short-term stay at a rehabilitation facility is required in order to obtain additional therapy and nursing care.

RECOVERY AFTER SURGERY

PAIN: Relief of leg and buttock pain is often immediate and can continue to improve for several weeks to months. By 4-6 weeks, the incision pain is mostly gone. Patients may return back to work around that time. A back and abdominal strengthening program is started in physical therapy at 3 - 4 weeks.

ACTIVITY LEVEL: Walking and swimming are excellent and can be resumed any time after week 3. Sitting is not usually a problem. Bending and lifting more than 10 pounds should be avoided until physical therapy can strengthen the back (starting week 4-6).

DRIVING: Before driving can safely be resumed (1 - 4 weeks), a practice session in a parking lot is needed to be certain that the patient can get from the accelerator pedal to the brake quickly enough for safe driving.

SEX: Intimate relations can be resumed after 6 weeks when the incision is well healed.

LONG TERM RESULTS

With adequate surgical decompression of pinched nerves, about 80% of patients get good to excellent relief from buttock and leg pain. Numbness and leg weakness usually improve to some degree, if not completely. If significant back pain was present before surgery, it will likely be present after surgery. Patients with spinal instability, listhesis (slipped vertebrae) or scoliosis (curvature of the spine) do not usually do well with decompression alone. Instead, fusion of painful vertebrae along with nerve decompression is required to address the causes of back pain.

About Dennis Crandall, M.D.
As a resident in Orthopaedics at St. Louis University, Dr. Crandall found it both challenging and gratifying to alleviate pain and restore function in patients with complex spinal disorders. After residency, he continued spinal fellowship training and served on the faculty of the University of Maryland. He taught the medical students and orthopaedic surgery residents about spinal diseases and surgery. Dr. Crandall chose to return to the Phoenix area because of the weather, lifestyle and family ties. He has been in practice in the Phoenix and East Valley area since 1994. In 1999, he founded the Sonoran Spine Center with a commitment to provide quality spine care to both children and adults with all types of spinal disorders. Furthering his focus on spinal research, he founded the Sonoran Spine Research and Education Foundation, a non-profit corporation that funds spinal research and educational seminars such as the annual Arizona Spine and Scoliosis Symposium.