15-12-2019

What is lumbar stenosis?

Lumbar spinal stenosis is a disease that causes pain or numbness in the legs. The Instituto Clavel medical team explains exactly what this condition consists of, its origin and possible treatments.

This pathology consists of the narrowing of the lumbar spinal canal, which causes compression of the nerve roots that transmit stimuli to the lower extremities. This canal is formed by the internal canal of the vertebrae, the intervertebral discs and the ligaments that give the spine stability

In some cases of lumbar spinal stenosis it will be necessary to resort to spinal surgery, but as we will see below, there are also other treatment alternatives depending on how far advanced the disease is.

Causes and symptoms of lumbar spinal stenosis

This disease can be a congenital conditions that doesn’t show any symptoms until adulthood. However, in most cases, it appears as a result of bone degeneration or osteoarthritis, so its prevalence in the population increases as age increases. 

It can manifest in different ways such as lumbalgia, radiculopathy (pain in the territory of a specific nerve root) or loss of strength in the legs, among others. 

However, the most commonly associated symptom is so-called neurogenic claudication. This consists of the increasing inability to walk, from medium distances at first, to being unable to take even a few steps in advanced cases. The sensation is of pain in both legs, although it may also be a sensation of numbness, tingling (“pins and needles”), or feeling of loss of strength. 

Symptoms are usually relieved when the affected person sits down, as this enlarges the diameter of the lumbar canal by flexing the lumbar spine. As it is a degenerative pathology and, most of the time, slowly progressive, there are many degrees of severity, from mild to very limiting.

How is it diagnosed?

To begin with, the doctor interviews the patient in-depth, to discover if there is any indication for a neurological origin of the symptoms the patient is suffering, that might correspond to symptoms caused by other pathologies of the joints or nerves.

As mentioned previously, it is important to note if the patient has found his ability to walk is limited to shorter and shorter distances, and if they feel the need to bend over forward, or sit down to get relief from the symptoms.

In the physical examination, the doctor evaluates the patient's strength, sensitivity, and osteotendinous reflexes in the lower extremities. The spinal column, especially the lumbar segment, is also examined. Once there is clinical suspicion of symptomatic spinal stenosis, the next step is to request imaging tests to confirm the diagnosis:

  1. Magnetic resonance: this is the main tool that we have at our disposal to visualize the soft parts (nerves, discs and ligaments, among others) in detail, and in this case confirm the lumbar stenosis.
  2. Scan or CT: this test gives us detailed information on the bone structures of the spine. It is useful for evaluating the degree of bone involvement in stenosis and detect the existence of other anomalies, such as osteoarthritis, osteophytes, spondylolysis or others, that may affect the treatment decision.
  3. Dynamic and functional lumbar x-rays: these are conventional flexion and trunk extension x-rays in profile. They allow us to see if there is instability in the vertebral segment.
  4. Telemetry x-ray with EOS scanner: Full-body standing x-rays that make it possible to detect if there are problems of spinal imbalance or curvature that contribute to the condition and need to be corrected. One of the great advantages of the EOS scanner is that it reduces the patient's exposure to radiation by up to 85% compared to conventional x-rays. 
  5. Electromiography: This test is used when necessary to assess the degree of nerve involvement. In some cases, it makes it possible to determine if the origin is neurological or not, if the cause is compressive or not (and therefore if it has a surgical solution) and, if there is actually compression of a nerve, if the problem is in the nerve root in the spine or is it a peripheral problem in the limb.

The results of these tests, combined with the information gathered during the patient interview and physical examination, will determine the doctor’s diagnosis.

Treatments of lumbar stenosis

As we mentioned at the beginning, while many cases of milder degree can improve through conservative treatment, others will require more aggressive treatments. We describe below what those involve. 

To begin with, among the conservative treatments, the following are fundamental: 

  • Maintain a healthy body weight for our height and build. 
  • Make changes in personal and professional habits: use ergonomic furniture, correct posture, and practice moderate physical activity on a regular basis. 
  • Additional support and guidance, especially at the beginning, until the acute phase of the symptoms has passed and the healthy habits are fully acquired.

In the absence of specific techniques for this type of individual pathology, at Instituto Clavel we decided to create a specialized protocol of physical therapy and exercises to address the various problems of the spine and evolving according to the different phases of the process. As a result, FisioSpine was born, to carry out a method created by our team of expert physiotherapists in spinal care together with our team of neurosurgeons, who guide and assist in the recovery process.

We know, however, that sometimes the compression pathology of the spine, such as lumbar stenosis, is too far advanced and severe to expect improvement with conservative treatment alone. Some rebellious cases, without special structural problems apparent in the imaging tests, will need to be referred to the Pain Clinic for palliative treatment, but, fortunately, many of the severe cases have the possibility of improvement through surgery.

At Instituto Clavel, our team of spine surgeons is trained in different techniques and surgical access routes to the spine so they can choose the treatment that best suits our patient with the least possible risk. Treatment of lumbar spinal stenosis will usually consist of direct posterior decompression surgery using laminectomy, that is, removing the vertebral bone and ligament that forms the back of the spinal canal in order to give the sufficient width for passage of the nerve roots.

In some cases with very localized narrowing and compression, we will be able to perform minimally invasive decompressions using microsurgery (MIS surgery), performed with state-of-the-art surgical microscopes. Sometimes the patient may suffer from some other structural problem of the lumbar spine, such as degenerative discopathies, facet arthropathies, spondylolisthesis, etc., which will make it necessary to combine decompression with the use of implants

With techniques such as the lateral approach we can access the spine to elevate the collapsed disc and return the ligament, which was folded and compressing the space needed by the nerve roots, to its original position inside the canal, in a minimally invasive way, promoting fast recovery. 

There are also cases with associated spinal instability or very advanced degeneration that will require fusion surgery, since we will need to open an important part of the vertebra and the ligament to ensure good decompression that will remain after the tissues heal.

When it is necessary for the patient's safety and the success of the surgery, a posterior approach will be used to implant the screws. For this we have several high-tech tools, such as the O-Arm 2, a state-of-the-art intraoperative scanner that allows real-time imaging in the operating room in order to implant the transpedicular screws using virtual navigation and to optimize their placement, as well as checking the correct positioning of the implants before the end of surgery. With this system we can perform minimally invasive instrumented surgeries, since the opening we need is the minimum needed for the introduction of the material. 

In addition, to guarantee patient safety, surgeries with significant neurological risk are always carried out under intraoperative neurophysiological monitoring, through which the team's neurophysiologist performs continuous monitoring of nerve activity during each minute of the surgery to prevent nerve injury.

Given the wide range of resources that we can make available to the patient at Instituto Clavel, we consider that it is essential to study each case individually to offer the treatment option that guarantees the greatest probability of success, the least surgical risk, and the swiftest recovery.

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