Spinal Stenosis and pain

One of the most common issues that people have to deal with is what is termed spinal stenosis. The term stenosis generally refers to “a narrowing” and can be applied to numerous locations of the body. In the issue of spinal stenosis, there is a narrowing of the spinal canal. The spinal canal extends from the brain down to the sacrum and this is where the spinal cord and its rements live. Nerves live in this canal and they depend on having enough room to exist so that they aren’t squeezed or restricted. A good example of how nerves don’t like to be compressed would be when someone hits their “funny bone”, not so funny and quite painful. This is the ulnar nerve which lives in a groove by the elbow region which when hit will s no pain down the arm. Well, spinal stenosis causes a similar issue in that the nerve is pinched near its origin in the spinal canal. This causes pain from the point of the compression down the extremity, be it arm or leg. People often refer to this as sciatica but it is really a very vague term and usually not used by those who regularly deal with this issue. Instead of sciatica, many of utilize the term spinal stenosis or radiculopaty to describe the pain. The reason for the use of these other terms is that sciatica refers to the sciatic nerve which is created by several nerves while spinal stenosis or radicular issues often involve one or two nerves. For example, spinal stenosis at the L4-5 level might affect the L4 or L5 nerves but it wouldn’t affect the nerves above it. Spinal stenosis is often caused by either disc or bone issues. Disc issues involve herniated or bulging discs while bony changes often from calcification so of the facet joints or other adjacent bony tissues leads to narrowing of the the canal. Depending on where the disc or bone protrudes into the canal will dictate which nerve or nerves are affected. For example if the disc is very laterally protruding then it would be affecting the nerve as it leaves the spinal column (foraminal canal) and this affects the exiting nerve, which at the level of L4-5 is the L4 nerve. On the other hand if th disc or bone is affecting the central canal at L4-5, it would affect the defending or traversing nerve which is L5. Therefore, the MRI findings are very helpful in determining which nerve is the affected nerve. Where the stenosis is located and the nerve affected dictate where the pain is. We are all wired somewhat the same and thus nerves generally go down arms and legs in the same area (for the most part). Now that we understand the reasons for the pain, the next important question is what to do about it. Ironically, in most people, ninety percent, who develop nerve pain will improve on their own within six months no matter what treatment is done for them. For those who the pain is severe or doesn’t improve there is a multitude of therapy options which go from physical therapy to injections to surgery. Surgery is generally the last thing considered. Many insurance companies now require physical therapy to start since they realize most people will improve on their own. After physical therapy, which I also include chiropractic in these modalities, people generally progress into pain management modalities. These modalities include steroid injections or other injections to attempt to reduce the inflammation of the nerve and eliminate the pain. These modalities help in some of the patients but definitely not all. For those who continue to suffer from pain, surgery would be the next option. Surgical options include decompression and or fusion type surgery. Examples of decompression type surgeries would include discectomies or laminectomies where either disc or bone is removed to open up the spinal canal. These modalities preserve the regular flexibility of the spine whilst removing the pressure on the nerves. Many Doctors prefer these for younger people who have herniated discs and otherwise have patent canals. Fusion type surgery is more utilized for what is termed instability. Instability is a really vague term and often two people will have different versions of what instability means. Some doctors consider the simple fact that you have a pinched nerve to imply that your spine is not stable while others would imply that some degree of shifting of the bones imply instability and there are degrees I between these. Fusions thus lock the bones to correct the instability. If the bones don’t move then they cannot be unstable. There are “flexible” fusions or even artificial disc which are beyond the discussion of this article but they try to maintain some degree of motion of the spine unlike the fusion. Success rates of these other modalities tend to be similar to conventional fusions. Thus, with spinal stenosis there are a multitude of options for treatment. Generally, surgery Is comsidered quickly for weakness or numbness since these imply nerve damage. If the problem is just pain then time is on your side. I generally only encourage surgery for patients who don’t get better with other modalities and either can’t live with the pain or require pain medications to deal with the pain. When looking at a MRI, the degree of spinal stenosis noted may not correlate with the pain. For instance, I have seen severe stenosis in people with no pain and others with mild stenosis are incapacited. Pain is a very personal experience. Thus, as a pain management physician, we are between conservative modalities and surgery. I hope this helps in your understanding of stenosis and options. I also apologize for any typos or grammatical errors since I don’t proofread these. Enjoy

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