What is Spinal Stenosis?
The spinal cord is a structure located behind the vertebral bodies. It starts right under the head and spread downwards. In the spine, there are 5 different vertebrae groups as neck (cervical), chest (thoracic), low back (lumbar), sacral and coccygeal. Spinal stenosis is mostly seen in the low back and neck area. There are 5 vertebrae in the low back area. This area is where body weight is focused most. Other structures located in this area are disc (where herniation occurs) between the vertebrae, facet joints where vertebrae joint, ligaments passing behind the vertebral bodies and yellow ligament located behind the thecal sac.
Spinal stenosis is the narrowing of the spinal canal behind the vertebrae and thus compression on the spine and compression on nerve roots. Lumbar spinal stenosis is a degenerative process. Degenerative changes of all the above-mentioned structures contribute to this process and the patient experiences spinal stenosis after a while. The main factors of lumbar spinal stenosis include decrease in water content of the discs between the vertebrae by age, inward growing of facet joints, compression of the ligament behind the vertebrae as calcified on the spine and compression of yellow ligament by thickening.
WHAT ARE THE SYMPTOMS OF SPINAL STENOSIS?
Spinal stenosis is a process of developing slowly. Therefore, in the beginning, there may not be complaints and findings. However, as the disease gets severe, the life quality of the patients is destroyed and daily activities are significantly restricted. When this clinical table appears, generally diameter of the spinal canal has narrowed above a specified degree and the spine and nerve roots have been compressed.
The patients may experience back, low back pain, power loss, and numbness in feet. The most significant finding in patients is cramp and spas in the feet after walking. By the time, these findings are seen in a shorter time and in advanced periods, patients experience cramp and spasm during walking even at home. If the patients get rest while walking, the complaints decrease. Then, when they start to walk again, they face the same problems. The patients may have pain starting in the low back and hip and radiating to the feet. Patients having spinal stenosis may have difficulty while they lie back. In advanced period, they tend to walk by bending forward. Because the patient wants to make spinal canal wider by bending.
In spinal stenosis in the neck, weakness, tingling, and numbness may be seen in arms and&or hands, and in advanced cases weakness, function loss and inability in walking may be seen. If spinal compression is severe, patients may experience findings such as difficulty or inability in doing hand skills (such as button-up, tying laces).
In advanced cases where feet are affected, the patients cannot walk without support. Also, in advance cases, the patient may have urinary or fecal incontinence.
In the examination of the patients, increased reflexes may be seen in arms and legs, and power and sensation loss may be observed in hands and legs. In addition, abnormal findings called pathological reflex may be observed in hands and feet. Some or all of the findings may be seen in one patient.
In spinal stenosis in the neck, attacks are seen widely. The patient is relaxed or has fewer findings between the attacks. 25% of the patients have slow development, while 2% is observed to get worse instantly.
HOW IS IT DIAGNOSED?
Spine array and radiological anatomical structure, the diameter of the nerve roots, degenerative changes, any slip in the vertebrae are evaluated in x-ray imaging. Computed tomography or 3-D computed tomography of the vertebrae provide more detailed information. In addition, 3-D imaging provides a more detailed definition for spinal canal. Computed tomography is required to measure to determine the size of the systems to be used to fix the spine such as screws or rods which may be used during surgery. As computed tomography displays the bones and osteoarthritis better, it provides information on the location where bone growth- or osteoarthritis-dependent compression is present. However, in recent years, the golden standard diagnosis method is to examine this area with magnetic resonance (MRI). Magnetic resonance is an essential method to evaluate the anatomical structure of disc structures located between vertebrae, facet joints where vertebrae joint and ligaments connecting the vertebrae, thecal sac and nerve roots. In this examination, if the diameter of the spinal canal is below a specific level, it means that the disease is severe. Also, the view of spine damage (myelopathy) means that the disease is severe. Electrophysiological examinations are primarily electromyography (EMG) and somatosensory evoked potential (SSEP). With EMG, compressed nerve root and peripheral nerves, and with SSEP, spinal canal compression are evaluated. Sometimes, EMG is used as auxiliary diagnosis method in other diseases.
WHAT ARE TREATMENT METHODS FOR LOW BACK SPINAL STENOSIS?
In no-advanced cases, non-surgical methods such as bed rest, medication treatment physical therapy, spinal injections may be applied to the patient. For medication treatments, medications from simple pain killers to narcotic group pain killers may be used. However, the need and dose of these medications are determined bu the physician. Epidural injection treatment is also a non-surgical treatment method. In this application, the corticosteroid is administered to the epidural cavity out of the membrane layer surrounding the nerves. If it is successful, it can be applied again. With physical treatment application to be carried out upon the decision of physical therapy specialist, it is aimed to stop or ease the pain, to strengthen the muscles and to provide movement.
However, if there is a decrease in walking distance of the patient by time, called neurogenic claudication and there are cramp and spasm, power loss in the legs, if bladder and intestine problems are present and life quality of the patient is decreased, surgical treatment should be applied. Surgical treatment is carried out in a more comfortable and successful way thanks to developed technological opportunities and increases the use of microscope in neurosurgery. Our aim in the surgery is to remove the compression thecal sac and the nerves contained in it. The name of this surgery in the medical literature is lumbar decompression. Thecal sac is relieved by removing the bones at the both sides, forming the posterior structure of the spine. In suitable cases, intervention is carried out on one side to prevent damage to the spine, in other words, bone tissue is removed from the back of the spine however, expanding operation is carried out on both sides under microscope. As lumbar spinal stenosis is a degenerative process, in some patients, vertebrae may slip on each other. Sometimes, if stenosis is severe, single or both sides restricted relieve may not be sufficient and whole of posterior bone structure and facet joints should be removed. In that case, in addition to spinal cord relieve operation, screw, cage application may be required to fix the vertebrae. However, it does not mean that screw, cage application is necessary for all patients. Patients should pay attention to low back health after the operation and avoid activities causing low back pain. The other 2 factors affecting low back health in the future is to maintain the recommended exercise program and to pay attention not to gain weight.
WHAT ARE TREATMENT METHODS FOR CERVICAL SPINAL STENOSIS?
Damage caused by the compression depending on canal stenosis in the spine, called myelopathy is one of the most important factors in determining the operation. If myelopathy is not present, and weakness and sensation loss are not severe in arms, hands and legs, non-surgical methods (such as physical therapy, medication treatment) may help to solve the problems of the patient in part. The operation is based on removal of the factors causing compression on the spinal cord, osteophyte formation, calcification of strong ligament passing behind the vertebrae, growth of the yellow ligament behind the spinal cord becoming apparent, inward degenerative growth of facet joints where vertebreae unite, rarely, slip of the vertebrae. This operation is called decompression surgery. It is possible to remove this compression with the operation carried out as anterior and posterior. However, type of the operation is determined by the neurosurgeon after examinations. In operations carried our as anterior, if the compression is caused by a disc, surgery can be applied directly to the said disc without intervening to the adjacent vertebrae. Sometimes, the compression may be caused by the osteoarthritis of the strong ligament laying behind the vertebrae. In that case, spinal body/bodies and the disc tissue are removed. These are replaced by bone graft or cage-shaped prosthesis to replace the spine., Afterwards, fixation procedure (fusion) is carried out with plaques and screws. However, it does not mean that screw, cage application is necessary for all patients. However, in operations, it may be required to remove the yellow ligament and the structure forming the back of the spine (lamina). In that case, it will be suitable to carry out fixation procedure (fusion) by placing screws and rods to the spine in order to strengthen the spine. Also, it is possible to extend the spinal canal with laminoplasty carried out with the aid of prosthesis material placed after a part of lamina is removed and separated.