After taking the medical history, in a patient with symptoms of spinal stenosis such as pseudoclaudication (increased leg pain with walking), there is a need for a definite diagnosis to make an effective treatment plan. The doctor takes a precise physical examination of the patient's back. He/she may push different areas to see if they hurt. The patient has to bend in different directions to see if there are any pains or limitations. There are also imaging tests as follows:
- X-rays: Apart from bone spurs, lack of disc height, spinal instability and aging changes, X-rays can help determine if the patient has spinal stenosis.
- Magnetic resonance imaging: MRI provides a better view of soft tissues such as spinal cord, nerves, and discs.
- Computed tomography scans: A CT scan with myelogram (injecting a dye into the spinal sack fluid to make the nerves more visible) can help determine whether the nerves are being compressed.
Types of spinal stenosis
There are three types of spinal stenosis:
• Lateral stenosis: This condition happens when a nerve root that has left the spinal canal is compressed beyond the foramen.
• Central stenosis: When the central canal in the lower back is choked, this condition may lead to the compression of the cauda equina nerve roots.
• Foraminal stenosis: This condition occurs when a nerve root in the lower back is confined by a bone spur in the foramen.
Non-surgical treatments for lumbar spinal stenosis
Restoring function and relieving pain are the main goals of non-surgical treatments which may relieve the pain to some degree. These treatments include:
- Activity modification: Postures such as leaning forward may relieve the pain.
- Physiotherapy:Strengthening and stretching exercises, massage, and exercises such as stationary biking can help control symptoms. A physiotherapist-supervised program of spinal stenosis exercises can prevent further debilitation.
- Anti-inflammatory medications: NSAIDs such as ibuprofen can reduce the inflammation around the nerves and relieve the pain.
- Steroid injections: Cortisone injections in the epidural spacecan lessen the inflammation, as well as the pain. Typically, the injection includes a local anesthetic for temporary pain relief.
Surgical treatments for lumbar spinal stenosis
In general, surgical treatments are performed on patients who are suffering from a poor quality of life because of severe pain or disabilities that havenot been controlled by non-surgical treatments. There are different surgical procedures to treat lumbar spinal stenosis including:
• Laminectomy:This surgical procedure, also called decompression, involves removing the lamina of a vertebra resulting in a nervedecompression. This is the most common surgery for treating spinal stenosis with a high rate of success. Patients are able to enjoy a pain-free lifestyle after the surgery. If arthritis has advanced to spinal instability, a combination of laminectomy and spinal fusion may be performed.
• Foraminotomy: In this procedure only a part of the facet is removed.
• Laminotomy:This is a microdecompression procedure in which there is a partial removal of thelamina to ease the pressure or allow access for adeeper operation.
• Interspinous process spacer: By spreading the backbones apart, these devices (inserted between the spinous processes) create a space for the nerves to function normally. The success rate is over 80%.
• Microendoscopic decompression: This procedure is done through a tube called microendoscopic surgery to minimize the trauma to the soft tissue.
How to Select a Surgeon
The following questions should be asked in order to help you select the right surgeon for the procedure.
- How many times have you done this procedure? In general, when it comes to surgery "practice makes perfect," so more is better. (However, if the doctor is recommending something that is not often done, such as multi-level fusions, more would not necessarily be better.)
- Are you board eligible or board certified? You can usually look on the wall and see a certificate.
- Are you fellowship trained in spine surgery? This is more important if the surgery is a fusion, artificial disc replacement, or other more extensive procedure.
- If I want to get a second opinion, who would you recommend? (Someone not in the same practice.)
- Statistically the success rate for this type of surgery is what percentage? What is your personal success rate, and how many of this type of surgery have you done?
- Can I talk to other patients who have had a similar procedure?
Any defensiveness on the part of the surgeon when you ask these types of questions may be a red flag. A surgeon with good results and appropriate qualifications will not be threatened by these types of questions and will respect your attention to these matters.
While getting discharged from the hospital, the patient would receive a discharge summary that would briefly describe his preoperative condition and the surgical procedure. Most importantly, it would give a detailed description of the medicines that would need to be taken after discharge, along with their dosage schedules. It would be beneficial for the patient to travel by an ambulance from hospital to home at the time of discharge. The surgeon would also give additional instructions as regards the dos and don’ts after discharge. Routine activity restrictions following a spine surgery include avoiding bending forwards, lifting heavy weights, traveling in two-wheelers and auto rickshaws, using Indian style of toilet commode sitting for prolonged times, etc. On reaching home, till the surgical stitches are removed, the wound dressing should not be allowed to get wet. Follow up visits will be scheduled to make sure your back is healing well. Off-the-schedule meetings can be arranged with the surgeon if the patient has soakage of the wound dressing, fever over 101 degrees F, increase in numbness or weakness in the legs, difficulty to pass urine.