LifeCare Chiropractic

The Best Chiropractic Care in Mesa, Arizona

Spinal Stenosis

Trends in Surgery for Lumbar Spinal Stenosis

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Technically, “stenosis” is shrinking of an opening.  When we refer to “spinal stenosis” this means a shrinking of the openings of the spinal column where your nerves run through it.

There are two flavors: lateral recess stenosis and central canal stenosis. In lateral recess stenosis, the nerves exiting the spinal cord are affected, usually resulting in pain down one leg, most often aggravated by standing or walking.

In central recess stenosis, the column where the spinal cord runs through is compromised, more often resulting in cramping, pain, numbness and tingling in both legs (numbness and tingling starting in the feet and moving up over time), again aggravated by standing or walking.

Lumbar spinal stenosis (occurring in the lumbar region, as opposed to the cervical, or neck, region) is a slowly progressive condition associated with arthritis of the spine. Over time, the enlargement of the bones in the region of the openings where the nerves exit essentially chokes off the healthy function of the nerves or spinal cord.

However, there are also ligaments that get thickened and hard over time that also contribute to the shrinking of the opening, most notably the ligamentum flavum. These ligaments, I believe, can be stretched and loosened up to help with the symptoms of lumbar spinal stenosis.

In my experience, back strengthening exercises for spinal stenosis don’t seem to really help all that much. Spinal epidural injections have not been shown to help in the long run either, and may increase the need for surgery later on.

Flexibility is a definitely plus, so yoga and specific stretches for the lumbar spine can be good. I am a very big fan of inversion tables for this condition as well (you can read about this more in a older blog article by clicking here).

In our office, we have been very successful using a technique called the Cox Flexion-Distraction technique. While we don’t fix everyone, the vast majority of patients do well with this treatment, especially when combined with a home inversion table and yoga.

But what about surgery? Is surgery for lumbar spinal stenosis a good idea?

I guess that depends.

There are different procedures that have been used for lumbar spinal stenosis. They range from “simple” decompressive laminectomies to complicated fusions. As always, simple is the best approach and, in general, the patients who I know who had this procedure done years ago seemed to do well. Complicated fusions, on the other hand, are a toss up.

Here’s the kicker: the outcomes are usually equivalent while the complications are far greater with the more complicated surgeries. That being said, fusions are likely a better option for those patients who also have instability present (usually from a condition called spondylisthesis) or patients with a higher curvature scoliosis of the spine.

One other little tidbit—there was a huge push for a period of time to use an artificial compound mixed in with bone, called bone morphogenetic protein – BMP, for spinal fusions. The problem is that the bone grew too fast and couldn’t be controlled, leaving a much higher complication rate. Luckily, the company that made BMP did a great job of paying off doctors to promote its use and hiding the concerns.

So, with this in mind, you would think that most of the surgeries done for lumbar spinal stenosis should NOT be fusions, right?

This particular study gives us some enlightening answers. Researchers looked at the data from 2004-2009. They looked at 3 situations:

  1. Lumbar spinal stenosis without any other factors
  2. Lumbar spinal stenosis with spondylolisthesis
  3. Lumbar spinal stenosis scoliosis

Surgical treatment was then divided into 3 groups:

  1. Decompression only (laminectomy, discectomy)-the “simple” option.
  2. Simple fusion (1–2 disc levels, single approach.
  3. Complex fusion (>2 disc levels or a combined front and back approach).

Here’s what the researchers found:

  1. The rate of decompressions dropped from 58.5% to 49.2%.
  2. The rate of simple fusions increased from 21.5% to 31.2%.
  3. The use of a compound called BMP more than doubled from 14.5% to 33.0% of all fusions.
  4. The use of interbody devices increased from 28.5% to 45.1%.
  5. In 2009, 26.2% of patients with stenosis without instability had a fusion procedure.

The bottom line is that, in a period of 5 years, while the numbers of procedures did not increase greatly, there was a shift from simpler surgeries that were cheaper with less complications, to more complicated procedures that were far more expensive and used a compound that was known to further increase complication rates.

No wonder our healthcare system is going broke.

If you have stenosis, I would STRONGLY recommend that you find a chiropractor that does Flexion Distraction, buy a home traction unit and get a 2nd and 3rd opinion on whether you really need that surgery.

 

Steroid Injection Epidurals For Spinal Stenosis–Boon or Bane?

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Epidurals are handed out like candy in this country. We assume that, much like surgery and medications, that there are hordes of research studies documenting the effectiveness of this intervention.

Regular readers of the Rantings and any chiropractor out there will tell you this couldn’t be further from the truth.

Yet this doesn’t seem to stop primary care doctors from referring patients out for epidurals long before they would consider a referral to a chiropractor (data from a major insurance company in the US notes that a measly 6.6% of non-surgical spine episodes that do not begin with a chiropractor will ever be referred to one for care, and even then this is VERY late in the episode).

Possibly this lack of referral is because primary care doctors don’t think there is research supporting chiropractic care (not true).  But this doesn’t seem to halt the referral to pain management centers to perform expensive, invasive procedures with evidence actually against their use that carries a much higher risk than manipulation.

Just seems strange to me.

That’s not to say that I don’t believe epidurals have a place in medicine, because I do. I have referred non-responsive patients out for them in the past, but they are few and far between and always for leg pain that is consistent with a disc herniation.  This scenario is a far cry from what is happening in the arena of low back pain in mainstream medicine today.

I can’t tell you how many times I’ve had patients sent for epidurals for isolated low back pain with no leg pain involvement.  Ugh!!

But what about leg pain associated with spinal stenosis-a condition where advanced arthritis of the spine begins to choke off the room for the nerves going into the leg?

Just recently I had just such a case.  After the 2nd visit using Flexion-Distraction he had absolutely no response to treatment.  So on the 3rd visit I really ramped up the agressiveness of the treatment with instructions to only return for additional treatment if he noted improvement after this visit.

I was fully expecting to have a discussion about a referral to pain management for this patient.  Luckily, that last treatment broke through the barrier and he had a pretty substantial improvement.  His outcome is going to be good.

But what if it wasn’t?  What if the 3rd visit didn’t help?  I’ve had stenosis patients in the past who did not have a strong response.  They are few, but they happen.  An epidural would seem to me to be a better option than referring that patient out for a surgical consult.

At least that’s what I thought until I came across this particular article.

The premise of this study was that the use of an epidural spinal injection for spinal stenosis patients would lower the need for, or at least delay, surgery.  Boy, were they surprised.

In looking at a group of patients who had an epidural spinal injection in the first 3 months of the trial versus those who did not, there were some enlightening findings:

  1. Those who received the epidurals had a much higher preference for avoiding surgery (62% versus 33%).
  2. In those who got the epidural but ultimately ended up in surgery there was a 26-minute increase in operative time and an increased length of stay by 0.9 days.
  3. Over 4 years, there was 34% less improvement in overall quality of life (measured using the 36-Item Short Form Health Survey (SF-36) Physical Function) among the epidural patients that ended up having surgery.
  4. There was less improvement in the epidural patients (56% less on Body Pain and 64% Physical Function).
  5. Of the patients who were initially in the non-surgery group, those who had an epidural were 45% more likely to switch to the surgical group.
  6. On the only positive note, the patients who were originally in the surgery group who got the epidurals were 1/3 less likely to actually follow through with surgery.

Wow!  Talk about nullifying a hypothesis!

I think that we, as a society, need to really rethink what steroids might be doing to our ability to heal, and accept the fact that the use of steroids applied directly to sensitive spinal structures may very well be doing far more harm than good.

Just my two cents (and a lot of medical research, too…).