Trends in Surgery for Lumbar Spinal Stenosis



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.

 

James Bogash

For more than a decade, Dr. Bogash has stayed current with the medical literature as it relates to physiology, disease prevention and disease management. He uses his knowledge to educate patients, the community and cyberspace on the best way to avoid and / or manage chronic diseases using lifestyle and targeted supplementation.







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Categories: Chiropractic Care, Low Back Pain, Osteoarthritis
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