Episode Transcript
Dr. Miller: Spinal stenosis. Do you have that, and what do you about it if you do have it? We're going to talk about that next on Scope Radio.
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Dr. Miller: Hi, I'm here with Dr. Darrel Brodke and I'm Dr. Tom Miller, and Darrel is a professor of orthopedic surgery at the University of Utah. Darrel, what is spinal stenosis?
Dr. Brodke: Well, spinal stenosis, Tom, is a narrowing of the spinal canal. The spinal canal is where the nerve roots coming off of the spinal cord come down through the remainder of your spine and then out to form nerves that go down your leg. This can also happen in the cervical spine, by the way, or the neck, but classically it's in the lumbar spine. So spinal stenosis is a narrowing in the space, like a pipe that had sediment built up so that the space is now so narrow that it's compressing the nerves.
Dr. Miller: So the spinal cord, the main nerve, is compressed. Now does this happen because of trauma, does it happen in younger patients or older folks? What causes it?
Dr: Brodke: Spinal stenosis is largely a disease of older folks, although we can see congenital stenosis in younger folks. Classically it would be an older person who started having problems with pain radiating from their buttocks down their legs, particularly when they walk.
Dr. Miller: And does it come on suddenly? What kind of a pain is it? Is it burning, is it sharp, is it lancinating? I mean, is there a type of pain that one typically experiences when they have spinal stenosis?
Dr. Brodke: Sure. So the pain, it can vary in nature from person to person, but it's common, most commonly, a pain that feels like pressure or a pain that feels fairly sharp and searing down the legs. It can also take the form of fatigue in the legs rather than actually frank pain and it commonly limits the distance that a person can walk or a time that they can stand.
Dr. Miller: So when they stop walking the pain gets better, then they start walking again and it recurs.
Dr. Brodke: Often they have to sit down or bend over for the pain to actually get better because that posture of flexion allows for increased space for the nerves and therefore better blood flow, better nutrients, and the nerves start feeling better. As soon as they stand up again, they start getting that compression of the nerves and then after a short period of time the nerves start responding by hurting.
Dr. Miller: Darrel, is there a particular place in the spine that is more common to see spinal stenosis?
Dr. Brodke: Yeah, most commonly we see spinal stenosis in the lumbar spine, that is the low back, and therefore it most commonly affects the buttocks and legs. We can see spinal stenosis in the cervical spine as well where it's actually pressing on the spinal cord causing problems with balance or stability or fine motor dexterity in the hands, but most commonly we see it in the low back.
Dr. Miller: How does one treat this? Are there conservative ways to treat it? Do you go to surgery?
Dr. Brodke: So we will often try to treat spinal stenosis, particularly in the lumbar spine, conservatively first. That means physical therapy, anti-inflammatory medications, changing . . .
Dr. Miller: Things like ibuprofen, Motrin?
Dr. Brodke: Exactly. We'll also have them change the way they do activities. In physical therapy we do exercises, for example, bent over inflexion because that opens the space for the nerves. So it's a specific kind of physical therapy.
Dr. Miller: So the conservative therapy is something that you would prescribe for a patient. They would generally go to a physical therapist who would then carry out the type of exercise and treatment that you had recommended?
Dr. Brodke: Yes.
Dr. Miller: Now how often is that effective?
Dr. Brodke: That's effective quite a fair amount of time. It's hard for me to estimate but I can quote you statistics from the literature in which maybe half the patients really feel like that was very effective, another third of patients feel like it was somewhat effective, and then there are a fair number of patients where that didn't work at all and we end up talking about surgery.
Dr. Miller: And what percentage of patients would maybe need to go on to surgery, and if that is the case, tell me a little bit about that.
Dr. Brodke: That's a number that's a little hard to get to because the total number of patients with spinal stenosis is not well identified, but if we look at studies in which only spinal stenosis patients are enrolled and we look at operative and non-operative treatment options, somewhat under half of the patients end up in surgery, and those patients that end up in surgery do extremely well. In fact, they do better than the non-operative patients do.
Dr. Miller: So what's important is to go to someone who is a particular specialist in spine surgery so that they could actually select the patient for surgical procedure after having gone through rather conservative therapy.
Dr. Brodke: Exactly. We'll often try conservative therapy whether you're seeing the surgeon first, or your primary care physician, or a physiatrist. All of those types of physicians are certainly well-capable of prescribing the physical therapy and anti-inflammatory medications, ibuprofen for example, that are the beginning of treatment for spinal stenosis. But as the disease progresses and for those patients that that actually doesn't work on, the next step would be to see a surgeon whose specialty is treatment of lumbar spinal disease.
Dr. Miller: So for our listeners, if you're having burning pain radiating down from your buttocks down the sides of your legs that causes you to stop, you rest, it goes away, it starts again when you walk any distance, it's relieved when you're bending forward, you might have spinal stenosis. You'd probably see your primary care provider who can then refer you on to a spine specialist who might start with conservative therapy, likely would start with conservative therapy and that would generally do the trick in a number of patients, and if not, they would best advise you on what the next steps are and that might include surgery.
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