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Back pain can be disabling and can arise from many conditions such disc herniation, disc protrusion, and spinal stenosis. Today we’ll be concentrating on Spinal Stenosis. How is it treated?  Is surgery needed? Are there alternatives to Back Surgery for Spinal Stenosis?

What Is Spinal Stenosis?

Lumbar stenosis is narrowing of the spinal canal and is sometimes referred to as central canal stenosis (1). The spinal canal is important as it is a hole that runs through the spinal bones from the top of the neck to your low back. It’s located directly behind each disc and contains the spinal cord, spinal fluid, and spinal nerves.

 

Cross section of lumbar spine.2.snip  266x300 - Are There Alternatives to Back Surgery for Spinal Stenosis?

To better understand stenosis, please watch the video below on the neck stenosis.  The same concepts apply to the low back.

 

What are the Causes of Spinal Stenosis?

The spinal canal is outlined by the red line. The disc is in front of the spinal canal whereas the ligamentum flavum and lumbar facet joints are behind the spinal canal.   Any structure that pushes or extends beyond the red line can narrow the spinal canal thereby creating stenosis. (2)

Cross Section of lumbar spine with Spinal Canal identified 243x300 - Are There Alternatives to Back Surgery for Spinal Stenosis?

 

There are three principles structures that can encroach upon the spinal canal thereby causing spinal stenosis:  the disc, the facet joints and the ligamentum flavum

Cross section of lumbar spine with Disc protrusion 295x300 - Are There Alternatives to Back Surgery for Spinal Stenosis?

  •     Disc protrusion. The disc is in front of the spinal canal.  A  disc protrusion can extend into the spinal canal and narrow the diameter of the spinal canal creating stenosis as illustrated below by the blue arrow.

 

 

 

Cross section of lumbar spine with Facet Overgrowth. 300x282 - Are There Alternatives to Back Surgery for Spinal Stenosis?

 

  • Overgrowth the lumbar facets. The facet joints are behind the spinal canal and in the presence of trauma, overloading or instability can beef up in size and encroach on the spinal canal thereby causing spinal stenosis as illustrated by the green arrow

 

 

 

Cross section of lumbar spine with overgrowth of ligamentum flavum. 271x300 - Are There Alternatives to Back Surgery for Spinal Stenosis?

  • The ligamentum flavum is in the back of the spinal canal and is a thick elastic tissue that connects the vertebral bodies.  In the illustration below it is the thick yellow band that is identified by the two blue arrows.   In the presence of instability, the ligamentum flavum can become thickened pushing forward on the spinal canal creating stenosis illustrated below by the purple arrow.

 

 

 

 

What are the Treatment Options?

Conservative treatment options include physical therapy (3), medications, lifestyle modifications, steroid injections, and rehabilitation. (4).  When these treatment options fail many consider surgery.  Current surgical options include:

  • Lumbar decompression whereby a piece of bone(lamina) and supporting ligaments is removed to open the narrowed spinal canal (5).  The major drawback of lumbar decompression surgery is that it creates instability in the low back as a result of removing important bones and ligaments.  This instability oftentimes leads to additional degenerative changes in the spine.

laminectomy . lumbar 300x117 - Are There Alternatives to Back Surgery for Spinal Stenosis?

  • Lumbar fusion where two or more of the vertebral bodies are bolted together (6). There are significant complications associated with lumbar fusion which include infection, nerve injury, escalation in pain and adjacent segment disease (ASD). The job of the disc is to absorb the forces of daily living. When one of more discs are surgically fused the forces of daily living are then transferred to the lumbar disc and facet above and below the fusion which can result in injury, degeneration and in many cases pain. A recent study found 11.7% in patients who had lumbar fusions developed adjacent segment disease at 28 months. (7).

Lumbar Fusion 2 level with hardware x.ray .a.p view 291x300 - Are There Alternatives to Back Surgery for Spinal Stenosis?

  • Interspinous process spacers are thin implanted spacers designed to create more space more space in the spinal canal without removing the bone. (8)

Interspinous spacers - Are There Alternatives to Back Surgery for Spinal Stenosis?

 

How Effective is Spinal Stenosis Surgery?

Literature for lumbar stenosis is not very encouraging. One high-level randomized trial followed patients for 8 years. Patients were randomized to surgery or non-operative care.  At 8 years surgery was not found to be superior to non-operative care. (9)  Another study followed 169 patients from 2000-2007 who were randomly assigned PT or surgery (10). Surgical decompression had a similar effect as physical therapy (9). A different study critically reviewed 26 studies and 5 randomized control studies and was unable to demonstrate surgery to be the superior treatment to non-surgical for lumbar stenosis.
(11). What was interesting was the number of side effects in the surgical cases ranged from 10-24 % vs zero in the non-surgical group. Complications included stroke, respiratory distress, heart attack and death due to a blood clot.

Are There Alternatives to Back Surgery for Spinal Stenosis?

Yes!

The Regenexx DDD procedure uses precise injections of platelets into the lumbar spine. The Centeno-Schultz Clinic pioneered the procedure and has successfully treated many patients.   Specifically, the platelets are injected:

  •  Into facet joints to reduce swelling and overgrowth.  Overgrowth as illustrated above can cause stenosis.
  •  Around spinal nerves to reduce swelling and increase blood flow. This allows for a better electrical signal to the muscles.
  • Into spinal muscles to improve stability.  Stability is critical in the lumbar spine and provided by ligaments and muscles.
  • Into the ligamentum flavum to improve the stability and reduce thickening.  Ligamentum flavum thickening as illustrated above can cause stenosis.

To better understand Regenexx DDD click on video below.

Spinal stenosis is the narrowing of the central spinal canal and is a cause of significant pain and disability.  Common causes of spinal stenosis include disc protrusion, facet overgrowth and ligamentum flavum thickening.  Surgery is often chosen when conservative therapies fail despite the lack of convincing evidence that it is a superior treatment option.  Are there alternatives to back surgery for spinal stenosis?  Yes. Regenexx DDD utilizes precise platelet injections into the facets, muscles, and ligaments to treat the lumbar stenosis, treating all of the components of the issue, which is crucial.

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References:

1.Lee GY, Guen YL, Lee JW, et al. A new grading system of lumbar central canal stenosis on MRI: an easy and reliable method. Skeletal Radiol. 2011;40(8):1033-9.DOI: 10.1007/s00256-011-1102-x

2.Arabmotlagh M, Sellei RM, Vinas-Rios JM, Rauschmann M. [Classification and diagnosis of lumbar spinal stenosis]. Orthopade. 10.1007/s00132-019-03746-1.DOI: 10.1007/s00132-019-03746-1

3.Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical Versus Nonsurgical Treatment for Lumbar Spinal Stenosis.Spine. 2016;41(14):E857-68. https://www.ncbi.nlm.nih.gov/pubmed/27128388

4. Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis.BMJ. 2016;352:h6234. DOI:10.1136/bmj.h6234https://www.ncbi.nlm.nih.gov/pubmed/26727925

5. Overdevest GM, Jacobs W, Vleggeert-Lankamp C, Thomé C, Gunzburg R, Peul W. Effectiveness of posterior decompression techniques compared with conventional laminectomy for lumbar stenosis.Cochrane Database Syst Rev. 2015;< Missing volume number >(3):CD010036. https://www.ncbi.nlm.nih.gov/pubmed/25760812

6.Försth P, Ólafsson G, Carlsson T, et al. A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis.N Engl J Med. 2016;374(15):1413-23. https://www.ncbi.nlm.nih.gov/pubmed/27074066

7.Zhong ZM, Deviren V, Tay B, Burch S, Berven SH. Adjacent segment disease after instrumented fusion for adult lumbar spondylolisthesis: Incidence and risk factors. Clin Neurol Neurosurg. 2017;156:29-34.DOI: 10.1016/j.clineuro.2017.02.020

8. Nunley PD, Shamie AN, Blumenthal SL, Orndorff D, Block JE, Geisler FH. Interspinous Process Decompression: Expanding Treatment Options for Lumbar Spinal Stenosis.Biomed Res Int. 2016;2016:3267307. https://www.ncbi.nlm.nih.gov/pubmed/27819001.

9.Lurie JD, Tosteson TD, Tosteson A, et al. Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT).Spine. 2015;40(2):63-76. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4288009/

10.Delitto A, Piva SR, Moore CG, Fritz JM, Wisniewski SR, Josbeno DA, et al. Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis: A Randomized Trial. Ann Intern Med. 2015;162:465–473. doi: 10.7326/M14-1420.

11.Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus non-surgical treatment for lumbar spinal stenosis.Cochrane Database Syst Rev. 2016;(1):CD010264. doi: 10.1002/14651858.CD010264.pub2