LUMBAR SPINAL CANAL STENOSIS

Spinal cord is a structure located in the vertebral canal behind the vertebral bodies. It extends downward from the base of the brain. There are 4 different vertebral groups on the spine as cervical, thoracic (chest), lumbar and sacral regions. Spinal canal stenosis is mostly seen in the lumbar and cervical regions. There are 5 vertebrae in the lumbar region, the spinal region that carries the most of the body’s weight. Other anatomical structures in these regions are the discs between the vertebrae (lumbar disc herniation arises from this structure), facet joints connecting vertebrae to one another, the strong connective tissue passing behind the vertebral bodies, and the yellow ligaments behind the thecal sac.

Spinal canal stenosis is the narrowing of the spinal canal (the passageway that houses the spinal cord) located just behind the vertebrae, which squeezes the spinal cord (at various levels) as well as the nerve roots. Lumbar spinal canal stenosis is a degenerative process. Degenerative changes of all the above mentioned structures contribute to this process, and the patient may encounter a stenosis problem after a while. The main factors for lumbar spinal canal stenosis include the facts that the water content of the discs between the vertebrae decreases with increasing age, the facet joints grow inward in over-weight patients, and the lumbar spinal canal becomes narrow when the ligament at the back of the vertebrae gets calcified, applying pressure from the front, while at the same time the yellow ligaments at the back of the vertebrae becomes thick and apply pressure from behind.

Symptoms

Lumbar spinal canal stenosis is a slowly developing process. Therefore, it may initially progress without causing complaints and symptoms. However, as the disorder progresses, it impairs the quality of life and significantly restricts the daily activities. When this clinical condition appears in patients, diameter of the spinal cord canal is usually narrowed to a certain extent, while the spinal cord and the nerve roots extending from it are compressed.

Patients may experience back pain, lumbar pain, and also loss of strength and numbness in the feet. The most obvious finding in patients is the cramps and spasms that they feel in their legs after walking a certain distance. In the course of time, these symptoms appear after walking shorter distances and patients suffer from cramps and spasms in their legs even when they walk at their homes. The symptoms get milder if patients get rest when they feel cramps and spasms. However, the same problem reappears when patients start walking again. Patients may have pains extending from the lumbar and hip regions to the feet.

Patients with lumbar spinal canal stenosis may have difficulty in lying on their backs. Such patients tend to walk by leaning forward in later periods because they want to make their spinal cord canals a little bit wider by leaning forward intentionally.

Diagnostic Methods

Alignment and radiological anatomical structures of the lumbar vertebrae, diameter of the canals from where the nerve roots extend, degenerative changes, whether there are any vertebral slippage and the anatomical relationship of the lumbar vertebrae and the sacral region are evaluated with a directed graph. Computed tomography of the lumbar vertebrae or their computed tomography 3D reconstruction provides more detailed information about these. 3-D images also help defining (in a visual sense) the inner structure of spinal cord canal in more detail. Computerized lumbar spinal cord tomography is also required for performing measurements intended for determining the extent to which the fixating systems such as screws and rods (sometimes need be used in surgical operations) will be used. However, the gold standard diagnostic method in recent years is to examine the region with magnetic resonance imaging. Magnetic resonance imaging (MRI) is an indispensable diagnostic method for evaluating the disc structures located in the intervertebral distances, the facet joints connecting the vertebrae to one another, the connective structures keeping the vertebrae together, the thecal sac as well as the anatomical condition of the nerve roots extending from it. Diameter of the spinal cord canal measured below a certain value can be considered to be an indication of that the disorder has highly progressed. When we mention about electrophysiological examination, the first thing that comes to mind is electromyography (EMG). EMG is used to evaluate peripheral nerves and to determine which nerve roots extending from the spinal cord are under compression. EMG is sometimes also used as an auxiliary differential diagnostic tool for other diseases.

Treatment Options

Non-surgical procedures such as bed rest, pharmacotherapy, physiotherapy, and spinal injections can be performed in non-advanced cases. In pharmacotherapy, various medicines from simple analgesics to strong narcotic medicines can be used. However, whether they are needed and what doses can be given should be determined by the physician. Epidural injection is one of the non-surgical treatment methods, as well. In this procedure, corticosteroid (cortisone) is applied to the epidural space outside the nerve-lining membrane layer that covers the nerves. If success is achieved, then it may need to be repeated. Physiotherapy procedures to be performed after the decision of a physiotherapist are intended to eliminate or reduce the pain to tolerable levels, strengthen the muscles, and provide ease of movement.

However, surgical treatment should be considered in cases where the patient can walk gradually shorter distances in the course of time while also suffering from cramps, spasms and loss of strength in the legs, where he/she has urinary bladder and bowel problems, and where his/her quality of life deteriorates. Surgical treatment is now performed more comfortably and successfully, by means of the developed technological possibilities and especially the increased use of surgical microscope in neurosurgery. Surgical treatment is intended to eliminate the pressure on the thecal sac and the nerves in it. This surgical procedure is called “lumbar decompression surgery” in the medical literature. The thecal sac is relieved by removing the yellow ligament and the bones at the both sides, which constitute the posterior structure of the spine. In cases where applicable, one-sided approach is used to prevent further impairment of the spine’s dynamics. In other words, bone tissue is removed from one side at the back of the spine but an expansion surgery is performed under a microscope on both sides. Since lumbar spinal canal stenosis is a degenerative process, a vertebra can slide over the vertebra below it in some patients. Such cases may require fixation screws to be applied to the slipped vertebrae, in addition to spinal cord release surgery. Patients should care about their lumbar health in post-operative period, and avoid activities which are likely to cause lumbar pain. Sticking to the recommended exercise programs and taking care not to gain weight are the two other important factors affecting the lumbar health in the future.

After Surgery

  • I will instruct you to stand up at 15:00 if your surgery will be performed in the morning or at 22:00 if it will be performed after 17:00. Then, you will stay in the hospital for a period of 1 or 2 days, depending on your condition.
  • There will be no problem with going back your home by sitting in a vehicle. If possible, travelling on the front seat and tilting the seat backward at an angle of about 110 degrees will minimize the risk of pain.
  • If you need to use stairs in the first 2 postoperative weeks, please climb the steps one by one and bring your foot next to the other one at each step.
  • You can have your meal while sitting. If possible, please pay attention to ensure that you have a back support while sitting on a chair for eating.
  • Please take care to act as instructed to you when sitting and standing up.
  • You may feel pain and burning and stinging sensation in the lumbar region in the initial postoperative days. Do not worry about that. Take a bed rest in such cases.
  • Please make sure that your bed is suitable for lumbar health. Do not lay on armchairs, sofas etc. for the rest of your life.
  • When you intend to get out of bed, first completely turn to the side-lying position, consequently turn to the sitting position by getting support from the sides using your hands, and then stand up.
  • Please come for the control examination on the day of your postoperative appointment. I will give you the required information about bathing during the control examination.
  • When you consume the medicines that I will prescribe for you at the time of your discharge, you will not need to take the same medicines unless told otherwise.
  • You must definitely use a closet (not a squat-toilet) to meet your toilet needs.
  • Take care to wear your shoes while sitting. Do not wear extremely high-heel or flat shoes. With middle-heels, you will feel more comfortable.
  • When taking something from a high place, try to take it after you get an appropriate height.
  • Do not plop down on a chair or armchair when sitting, as if you are falling down. Place yourself in a sitting position slowly and in controlled way.
  • Take support from your knees and the armrests while standing up.
  • Go out and start walking after the 7th day. Start initially with short distances (20 to 30 min) and go on walking by adding 5-10 minutes after each day.
  • If you work at a desk job, you will be able to return to work 15 days after surgery. Those who work under more difficult conditions can return to work 45 days after surgery.
  • Pay attention to avoid carrying heavy things in the first 45 postoperative days, and then carrying things totally heavier than 5 kg in your both hands. When lifting something heavy, crouch down and hold it as close to your body as possible.
  • Avoid weight gain, and try to lose weight if you are overweight. For doing so, it would be appropriate for you to get professional support from the dietary department.
  • Avoid sports involving physical contact after surgery. Prefer walking, swimming (if possible) etc.
  • Do not drive any vehicle in the first 20 postoperative days. Afterwards, you can do short-distance driving in the city. You can make long-distance journeys, by driving the vehicle yourself, after the 30th postoperative day. However, have a break for 10 minutes once every 1.5 hour for taking a short walk, and then get back on the road.
  • You can make short-distance journeys by plane after the first 7 postoperative days. Longer journeys (transoceanic) should be made after the first 30 postoperative days, and the patient should take a short walk in the plane once every 1.5 hour.
  • Those working at desk jobs should use orthopedic chairs with back support, and take a walk for 5 minutes once every hour.
  • You should start doing the lower back exercises prescribed to you after the 60th postoperative day. You may initially feel a mild pain, but the exercises will be painless in the course of time.
  • You can call me for any problem related to your surgery.
    Hope to meet you in healthy days…