Spinal Stenosis

Surgical Management of Spinal Stenosis

Overview

Spinal stenosis is a fairly common problem caused by constriction of the spinal cord or nerves exiting from the spinal cord. This can occur in the neck (cervical) as well as the lower back (lumbar) and on rare occasion, in the central (thoracic) spine.

The symptoms associated with central stenosis (or stenosis of the spinal cord) are usually an aching in the legs, loss of balance, or loss of bowel and bladder control. 

The symptoms associated with foraminal stenosis (or tightening of the exiting nerves or nerve roots) are numbness, tingling, burning, or weakness in a particular area of the arm or leg.  This is sometimes called radiculopathy. 

Sometimes symptoms can be alleviated in the early phases of spinal stenosis with anti-inflammatories, lifestyle modification, or injections into or around the spinal column.  When these steps are no longer sufficient or adequate, surgery can be used to alleviate the symptoms. 

Surgery can be beneficial by enlarging the canals or tunnels through which the spinal cord or nerve roots run. Sometimes surgery can be relatively simple and easy, and a procedure similar to those a Roto-rooter (TM) is used. Sometimes the surgery is more complex and will require a more extensive procedure, such as a fusion. The surgery complexity depends on what is causing the stenosis.

Symptoms & Diagnosis

Characteristics of

Individuals with central spinal stenosis (either the cervical, thoracic spine, or lumbar spine) will present with symptoms of claudication (aching in the legs) or myelopathy (damage to the spinal cord itself). These symptoms can vary from aching in the legs to loss of bowel and bladder or sexual control to balance and coordination issues.

Patients with foraminal stenosis (tightening of the nerve roots as they are trying to exit the spinal cord) usually present with symptoms referred to as radiculopathy. These symptoms are localized to a particular area of the arms or legs and can manifest as weakness, burning, numbness, aching, or sciatica (pain radiating down the leg).

Types

The first differentiation that needs to be made is whether there is central stenosis or foraminal stenosis. Central stenosis is tightening in the spinal canal of the spinal cord.  Foraminal stenosis is tightening of the openings of the exit points for each nerve as it is exiting the spinal column.

The second thing that must be determined is what is causing the central or foraminal stenosis. There are many causes, including arthritis, disc herniations, spondylolisthesis (malalignment of vertebral bodies), spine curvature (scoliosis), fracture, tumor, or infection.

Similar conditions

Spinal stenosis usually does not cause back or neck pain, although these symptoms may be associated with the condition, depending on the cause. Spinal stenosis usually does not have back pain as its main symptom. In addition, stenosis must be differentiated from degenerative disc disease.

Incidence and risk factors

Spinal stenosis can have many causes. It is most commonly seen in the elderly with arthritis or in younger people as a result of a disc herniation.

Approximately 250,000-500,000 Americans have symptoms of spinal stenosis due to degeneration. This represents about 5 of every 1,000 Americans over 50.

The prevalence of symptomatic herniated lumbar disc is about 1 to 3 percent, depending on age and sex. The highest prevalence is among people age 30 to 50, with a male to female ratio of 2:1. In people ages 25 to 55, about 95 percent of herniated discs occur in the lower lumbar spine.

Diagnosis

Spinal stenosis can usually be determined with a thorough clinical history and examination of the patient. It is then confirmed with an MRI (Magnetic Resonance Image) or a CT (Computerized Tomography) with dye injected around the spine. Either one of these will show the problem. X-rays can be helpful in suggesting the cause of the problem, however, since the nerves, spinal cord, and discs do not show up on x-ray, this is not a definitive study.

 

Treatments

Medications

Medications can help spinal stenosis and often the symptoms will resolve of their own accord, or go through waxing and waning periods. This comes back to the cause of the stenosis. Sometimes medication is all that is needed, but sometimes the actual cause of the stenosis needs to be managed more aggressively. Anti-inflammatories and muscle relaxants are usually the first line of treatment.

As a more invasive option, steroids and local anesthetics can be injected around the site of the problem. These are usually administered by a physiatrist or an anesthesiologist. Such injections can provide lasting relief and can occasionally be all that is needed.

Exercises

Usually exercises are not beneficial for spinal stenosis. It is very important to maintain good core strength with strong back and belly muscles, as well as flexibility of the legs and trunk. These will be beneficial in avoiding many of the causes of spinal stenosis in the first place, but once a person has stenosis, these usually cannot reverse the cause.

Possible benefits of laminectomy, decompression, fusion

Stenosis can be improved with surgery by providing a larger opening or canal for the nerves and spinal cord. Surgery is usually beneficial in alleviating the pain and weakness caused by the nerves being pinched.

Sometimes the canal can be enlarged with something as simple as a laminectomy in which the roof of bone on the back in removed to allow the spinal cord to have more room. This is one of the simplest operations to alleviate these symptoms. 

If the stenosis is caused by a disc herniation, then sometimes all that is needed is a discectomy in which part of the disc is removed.

If the stenosis is caused by spine instability or fracture or tumor, sometimes a spine reconstruction, such as a fusion needs to be done along with the decompression or laminectomy or discectomy. Otherwise further problems may develop. 

With these surgical approaches, most people do well in recovering use of their limbs and in relieving the symptoms of pain, burning, tingling, or numbness.

Types of surgery recommended

The type of surgery recommended depends on the cause of the stenosis. Usually no surgery is required. In the case of stenosis of the canal due to arthritis and aging, usually a laminectomy is all that is required.  For foraminal stenosis due to a disc herniation, a discectomy may be all that is needed.  If the stenosis is caused by a more severe condition, a fusion or more intricate spine reconstruction may be needed.

Who should consider laminectomy, decompression, fusion?

Surgery should be considered for individuals who have failed conservative treatment with medications and injections, or those with symptoms that are so severe that they are starting to lose significant function and are at risk for permanent nerve damage.

What happens without surgery?

Most people do not have surgery to correct spinal stenosis and their symptoms either resolve or they learn to live with them. However, without surgery, there is a risk of permanent nerve damage and possible paralysis.

Surgical options

The surgical options for spinal stenosis are based on the cause of the stenosis.

For stenosis of the canal due to arthritis and aging, or due to a small spinal canal from birth, usually a laminectomy is all that is required. 

For foraminal stenosis due to a disc herniation, a discectomy may be all that is needed.

If the stenosis is caused by a more severe condition, such as spondylolisthesis, fracture, tumor or scoliosis, then a fusion or a more intricate spine reconstruction may be needed. 

Effectiveness

In the hands of an experienced surgeon, the outcomes of laminectomy, decompression, and fusion surgery are usually effective in relieving leg and arm pain caused by the stenosis. Usually it takes many months for the strength and sensation to return to normal and this may never occur, but the pain usually decreases rapidly.

Urgency

Surgery for spinal stenosis is almost always elective, except in some very unusual cases in which permanent spinal cord damage may occur. Usually these cases are not treated surgically until time and other more conservative options have proven to be ineffective. 

Risks

The most frequent risks associated with spinal stenosis surgery, include:

• Infection.
• Stiffness.
• Tear of the lining of the sac surrounding the spinal cord (dural tear).
• Nerve root or spinal cord injury.
• Anesthetic complications.

These risks can be minimized by optimizing the medical status of the patient before surgery. For example, the use of tobacco products increases the risk of adverse events occurring, therefore, patients are encouraged to stop smoking or using other tobacco products.

Managing risk

Most of the risks can be managed with medications, or on occasion (such as with infection), with a repeat surgery. The most important thing is to identify the problem and address it.

Preparation

Before surgery, patients should consider the limitations, alternatives and risks of surgery. Successful surgery depends on a partnership between the patient and the surgeon. Patients should optimize their health so that they will be in the best possible condition for this procedure. Smoking should be stopped a month before surgery and not resumed for at least three months afterwards.

The surgeon needs to be aware of all health issues, including allergies and the non-prescription and prescription medications being taken. Some of these may need to be modified or stopped. For instance, aspirin and anti-inflammatory medication may affect the way the blood clots.

The patient needs to plan on being less functional than usual for six to 12 weeks after the procedure. Driving, shopping and performing usual work or chores may be difficult during this time. Plans for necessary assistance need to be made before surgery. For individuals who live alone or those without readily available help, arrangements for home help should be made well in advance.

Timing

In most cases of spinal stenosis, there is no rush to have surgery. Generally, more conservative options are used first and only after these have not worked is surgery performed. Surgery can be done on an elective basis when timing is favorable for the patient and medical conditions are optimized.

Costs

The surgeon’s office should provide a reasonable estimate of:

• The surgeon’s fee
• The hospital fee and
• The degree to which these should be covered by the patient’s insurance.

Surgical team

Most spine surgery is done by either a fellowship trained orthopedic surgeon or a neurosurgeon. These surgeries generally require the patient be admitted to the hospital after surgery so they are usually done in a hospital as opposed to an outpatient center.

Finding an experienced surgeon

There are many ways to find an experienced spine surgeon. One of the best ways is through word-of-mouth from family members or friends who have had positive experiences with a surgeon. The majority of the most qualified surgeons are known in the medical community so a referral from a primary care physician is a reasonable means of finding a qualified surgeon.

In addition, surgeons specializing in spine surgery may be located through university schools of medicine, county medical societies, or state orthopedic societies.

Facilities

Stenosis surgery is usually performed in a major medical center, although stenosis from a disc hernia may be dealt with in an outpatient surgery center. In major medical centers, there are specially trained teams involved in the care, including the surgeon, an anesthesia team, as well as nurses and technicians.

Technical details

There are various approaches to treat stenosis, depending on the cause.

Most stenosis in the cervical spine is operated on through the front of the neck with very little muscle damage.  The major structures are pushed and pulled to the side, without having to cut much tissue and allowing access to the bones on the front of the neck. The bones and discs can then be accessed to remove any compression on the nerve roots and spinal cord. Usually a fusion or disc replacement is then performed to maintain the stability of the neck. 

Depending on how many vertebral segments are involved, occasionally a back side (posterior) approach needs to be used on the cervical spine. This tact is much less common and is a more invasive procedure, causing more pain due to all the muscles on the back of the neck having to be peeled away from the bones to obtain access. 

Most lumbar surgery is done through the back.  The patient is face down on the operating table. If a disc is all that needs to be removed, this can be done through an incision measuring about 2 centimeters. A pathway is made down to the lamina (roof of the bone over the back of the spinal cord) and a small window is made in the bone allowing the surgeon to see the spinal cord. The spinal cord is gently pulled to the side and an instrument is used to reach down the side of the cord and remove the disc that is out of place. Most patients have significant relief of leg pain following this type of procedure. 

If the cause of stenosis is due to arthritis and a generalized tightening of the cord, then a larger incision is required. The whole lamina is exposed on both sides and then typically the whole lamina and the overlying spinous process (see figure) is removed.  Sometimes only one segment needs to be decompressed and sometimes multiple levels need to be addressed. 

If there is spinal instability, such as a spondylolisthesis or scoliosis associated with the stenosis, then sometimes screws and rods need to be placed to provide stability so the pain and nerve compression does not recur or persist.

Anesthetic

Patients undergoing spine surgery will usually be administered a general anesthetic causing them to be completely asleep during the procedure. A tube is inserted in their throats and into their lungs to assist with breathing.

Length of laminectomy, decompression, fusion

Spinal surgery can take anywhere from one hour to about eight hours depending on what is being done. A discectomy or laminectomy can usually be done in one to three hours depending on the complexity.  If a fusion is required, this will usually take three to eight hours, depending on how many segments need to be addressed and whether the procedure is a revision of a previous surgery.

Pain and pain management

Surgery through the front of the neck and discectomies are usually not especially painful and often patients will go home from the hospital the day after the procedure with good pain control on oral pain medications.

The more invasive lumbar spine surgeries with laminectomies and fusions are some of the most painful operations one can have. The muscles on the back are very large and during the procedure, must undergo extensive manipulation, causing significant pain after surgery. The pain is usually managed by epidural catheters, patient controlled analgesia (PCA), or combinations of medications.

Use of medications

For simple discectomies, oral pain medication is all that is usually required.

For any other surgery for stenosis, such as laminectomies or fusions, usually a patient controlled analgesia (PCA) pump, or an epidural is used to control pain for one to three days before switching to oral pain medications. When they go home, most people are taking Oxycontin, MS Contin, Percocet, Vicodin, Oxycodone, or a combination of narcotic and muscle relaxant.

Effectiveness of medications

Pain medications can be very powerful and effective. Their proper use lies in the balancing of their pain relieving effect and their other, less desirable effects. Effective pain control is an important part of the post-operative management. Being psychologically prepared is also helpful. Patients who have been on high dose pain medications before surgery usually have a harder time gaining acceptable pain relief than patients who are not on narcotics. 

Important side effects

Pain medications can cause drowsiness, slowness of breathing, difficulties in emptying the bladder and bowel, nausea, vomiting and allergic reactions. Patients who have taken substantial narcotic medications in the recent past may find that usual doses of pain medication are less effective. For some patients, balancing the benefit and the side effects of pain medication is challenging. Patients should notify their surgeon if they have had previous difficulties with pain medication or pain control.

Hospital stay

After surgery, the patient spends an hour or so in the recovery room. For significantly complicated or long cases, the patient may need to spend a night or two in the intensive care unit (ICU).

A drainage tube is often used to remove excess fluid from the surgical area. The drain is usually removed on the first or second day after surgery. Bandages cover the incision. They are usually changed the second day after surgery.

Generally, the patient is up walking the day after surgery with assistance from a physical therapist. 

Patients are discharged as soon as the incision is dry, he or she is comfortable with oral pain medications, can perform the usual activities of daily living with minimal assistance, and a home support system is in place.

Recovery and rehabilitation in the hospital

Recovery from spinal surgery for stenosis depends largely on what surgery was done to alleviate the stenosis.

Most patients having discectomies will feel pretty well within hours after surgery and will go home the day of or the day after surgery. These patients usually see a therapist while in the hospital to review any precautions and make sure they can perform the usual requirements of daily life. 

Patients undergoing anterior cervical spine decompression and fusion also recover fairly rapidly and are ready to go home a day or two after surgery.  Some patients experience hoarseness of the voice and difficulty swallowing.These patients will require assistance by therapists to be cleared for discharge. 

Patients undergoing laminectomies and fusions will recover more slowly.  Therapists will try to get these patients up and walking the day after surgery, but these patients are generally slower to mobilize and to regain their strength and independence. 

Occasionally, the elderly or those who undergo extensive surgery, will not be able to go home after their surgery and may need to spend a period of weeks to months recuperating in a rehabilitation center or skilled nursing facility.

Hospital discharge

At the time of discharge, the patient should be relatively comfortable on oral medications, should have a dry incision, should understand their limitations and should feel comfortable with the plans for managing the surgical site.

Most patients do not need to see a therapist for exercises after discharge. The main mode of therapy for the first few weeks is walking. Patients should not lift more than 5 to 10 pounds.

Convalescent assistance

Many patients may require help after surgery with daily activities, such as putting on shoes and socks. This depends on what type of surgery they had. Before patients can go home, they need to demonstrate their ability to perform most daily activities, such as dressing, getting out of bed and walking to the toilet, etc. If they are unable to do these things, they may need to go to a skilled nursing facility or a rehabilitation facility to get more care.

Physical therapy

After surgery, it is advisable to walk as much as possible. A more involved physical therapy or exercise program is usually not needed for the first few weeks. It is imperative that patients do not lift more than 5 to 10 pounds. 

Once everything is healed, sometimes trunk strengthening and stretching are needed. Depending on how debilitated the patient is, this may need to be done under the guidance of a therapist.

Rehabilitation options

After surgery, the main therapy is walking. This can usually be done by the patient on his or her own schedule. If the patient is significantly debilitated, he or she may require the help of a therapist.

Can rehabilitation be done at home?

Therapy following spinal stenosis surgery can usually be done at home when it is convenient for the patient to do so.

Usual response

In general, patients gradually regain strength and stamina after surgery and most feel better than they did before surgery. Some mild to moderate stiffness may occur depending on what procedure was done.

Risks

The main risk with rehabilitation is when patients are too aggressive in their rehab and do too much too soon. For example, patients may lift or twist more than they should following surgery. It is best to follow the prescribed steps precisely to avoid problems and to ensure a safe and steady recovery.

Duration of rehabilitation

It may take up to a year for complete recovery from spinal stenosis surgery, depending on the procedure performed. An issue many patients complain about is feeling fatigued. Rehabilitation can take many forms.

• Elderly patients without support may need extended care in a skilled nursing or rehabilitation facility.
• Many patients engage in outpatient physical therapy on a regular basis.
• Whereas other people, depending on surgery, don’t need any rehabilitation at all.

Returning to ordinary daily activities

In general, patients are able to perform the majority of daily activities within two to three weeks after surgery. Walking is strongly encouraged. Driving should wait until the patient can perform the necessary functions comfortably and confidently and is off high narcotic medication dosages.

Lifting of more than 10 pounds should be avoided for at least two months. If a fusion was performed, than the patient may have other permanent lifting restrictions.

Long-term patient limitations

For patients undergoing simple discectomies or laminectomies, there will be no long-term limitations. Patients undergoing fusions of the cervical spine may be able to return to their daily life without restrictions.

Patients who undergo fusions associated with decompression of their stenosis may require permanent limitations on activities and may need to consider career changes.  

Costs

The surgeon and therapist should provide the information on the usual cost of the rehabilitation program. The program is quite cost-effective, because it is based heavily on activities the patient can do on his/her own.

Summary of laminectomy, decompression, fusion for

1. Stenosis (a narrowing around the spinal cord or nerve roots) can be caused by many things. Some of the causes, include disc herniation, disc degeneration, arthritis, congenital narrowing, fracture, tumor, scoliosis, or spondylolisthesis.
2. The surgical management is based on the cause of the stenosis and not the stenosis itself. 
3. Stenosis surgery is usually very effective if done for the right condition. Surgeries for spine issues are generally more successful than spine surgery for arthritis or back pain.
4. Central stenosis will cause more general symptoms and can cause damage to the spinal cord itself (myelopathy). This is more significant than foraminal stenosis.  Foraminal stenosis is a narrowing of the canals where the nerve roots exit the spinal cord. These conditions cause symptoms in a particular region of the arm or leg and are referred to as radicular symptoms. 
5. Most patients with stenosis will not need surgery and the condition can resolve on its own with time, or with the help of medications and injections.

Types of surgery recommended

The type of surgery recommended depends on the cause of the stenosis. Usually no surgery is required. In the case of stenosis of the canal due to arthritis and aging, usually a laminectomy is all that is required.  For foraminal stenosis due to a disc herniation, a discectomy may be all that is needed.  If the stenosis is caused by a more severe condition, a fusion or more intricate spine reconstruction may be needed.

Who should consider laminectomy, decompression, fusion?

Surgery should be considered for individuals who have failed conservative treatment with medications and injections, or those with symptoms that are so severe that they are starting to lose significant function and are at risk for permanent nerve damage.

What happens without surgery?

Most people do not have surgery to correct spinal stenosis and their symptoms either resolve or they learn to live with them. However, without surgery, there is a risk of permanent nerve damage and possible paralysis.

Surgical options

The surgical options for spinal stenosis are based on the cause of the stenosis.

For stenosis of the canal due to arthritis and aging, or due to a small spinal canal from birth, usually a laminectomy is all that is required. 

For foraminal stenosis due to a disc herniation, a discectomy may be all that is needed.

If the stenosis is caused by a more severe condition, such as spondylolisthesis, fracture, tumor or scoliosis, then a fusion or a more intricate spine reconstruction may be needed. 

Effectiveness

In the hands of an experienced surgeon, the outcomes of laminectomy, decompression, and fusion surgery are usually effective in relieving leg and arm pain caused by the stenosis. Usually it takes many months for the strength and sensation to return to normal and this may never occur, but the pain usually decreases rapidly.

Urgency

Surgery for spinal stenosis is almost always elective, except in some very unusual cases in which permanent spinal cord damage may occur. Usually these cases are not treated surgically until time and other more conservative options have proven to be ineffective. 

Risks

The most frequent risks associated with spinal stenosis surgery, include:

• Infection.
• Stiffness.
• Tear of the lining of the sac surrounding the spinal cord (dural tear).
• Nerve root or spinal cord injury.
• Anesthetic complications.

These risks can be minimized by optimizing the medical status of the patient before surgery. For example, the use of tobacco products increases the risk of adverse events occurring, therefore, patients are encouraged to stop smoking or using other tobacco products.

Managing risk

Most of the risks can be managed with medications, or on occasion (such as with infection), with a repeat surgery. The most important thing is to identify the problem and address it.