What is Spinal Stenosis?

I have an aching, pulsing feeling down my leg when I stand up and walk. What causes this?

You may have symptoms coming from a condition called spinal stenosis.

Symptoms include substantial back pain with variable leg pain and weakness associated with walking. The pain may become increasingly severe with standing and walking, and can usually be relieved by a short period of rest. The nerve deficit symptoms - weakness, pain, pins and needles, coldness or loss of sensation in the limbs - have a more generalized and irregular pattern than in disc herniation. Coughing, sneezing or straining while defecating may aggravate the discomfort. Unlike disc disease and other kinds of backache with an intermittent course, spinal stenosis generally becomes progressively painful over time.

This is a condition in which there is narrowing of the nerve openings either around the spinal cord or nerve roots - usually as a result of deterioration and aging of the spinal column. The leg pain, weakness and/or numbness are caused by the progressive narrowing that puts pressure on the spinal nerves. Your physician will suggest the best of several treatments for spinal stenosis, which include injections, medications and, sometimes, surgery (X-STOP® or laminectomy).

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What is spinal stenosis?

Spinal stenosis is a narrowing of the spinal canal. Some individuals are born with a lower than normal diameter of the spinal canal. Most individuals develop spinal stenosis with time. Just as the joints of the fingers become larger with age and wear and tear, the joints of the spine do as well. In the case of the spine, this enlargement of the facet joints and the intervertebral joints results in narrowing of the neural foramina and the spinal canal. The usual treatment is activity modification, anti-inflammatory medication and pain medication. Since the pain is intractable, epidural steroids are frequently used. If necessary, surgery may then be performed.

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What causes spinal stenosis?

The causes of stenosis vary. The condition may be either congenital or due to spinal degeneration. Anything that encroaches on the spinal canal can lead to stenosis. Examples are spur formation around the vertebral bodies, distortion around the vertebral joints or swelling of the joint's capsule; displacement of the yellow ligament or thickening of the vertebral body's lamina (thin bony plate). A herniated disc is a type of spinal stenosis, although it is not called by that name because the clinical picture is different. A few diseases can cause spinal stenosis. Among them are Paget's disease, a disease of unknown origin that causes abnormal growth and distortion of a number of different bones; and fluoridosis, due to excessive fluoride which can thicken bone and contribute to stenosis when there is a pre-existent narrowing of the canal. In some cases, scarring and other postsurgical problems, like overgrowth of a spinal fusion, can lead to stenosis.

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Is an MRI the only test used to determine if and what nerves are being compressed?

An MRI scan is definitely the best test, but there are other alternatives. A CT scan with myelography is just as effective as an MRI but is more painful because it involves a spinal injection. An EMG study of the leg (electromyography) can explore whether a muscle group is affected; but this is a non-specific test and does not find a lot of disc herniations.

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When is spine surgery usually necessary?

Surgery is recommended for spinal problems only after all appropriate conservative measures have been applied. If symptoms are not controlled effectively with medications, physical therapy and injections, then surgery can be considered, depending on the specific situation.

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What are the surgical treatment options for spinal stenosis?

Surgical treatment: Decompression

The most common surgical procedure for stenosis is a decompressive laminectomy sometimes accompanied by fusion. Often referred to as “unroofing” the spine, this procedure involves the removal of various parts of the vertebrae, including:the lamina, as well as the attached ligaments, that cause compression of the spinal cord and nerve roots, and/or enlarged facets, osteophytes and bulging disc material The goal of the surgery is to relieve pressure on the spinal cord and nerves by increasing the area of the spinal canal and neural foramen. Other types of surgery to treat stenosis include:

• Laminotomy - only a small portion of the lamina is removed to relieve local pressure on the spinal cord and nerve roots.
  
  Foraminotomy - the foramen (the opening through which the nerve roots exit the spinal canal) is enlarged to increase space for the nerves. This surgery can be done alone or with a laminotomy.
• Facetectomy - part of the facet joint is removed to increase space for the nerves.
• Interspinous Process Decompression (IPD®) IPD is a surgical procedure in which an implant, called the X-STOP device, is placed between two bones called spinous processes in the back of your spine.
  

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How long has the X-STOP device been used to treat spinal stenosis?

The X-STOP® IPD® device was approved for commercial sale in the U.S. in November 2005 and has been commercially available in Europe since 2002. Since introduction of the X-STOP® IPD® system, more than 15,000 X-STOP® IPD® devices have been implanted worldwide.

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Are there published clinical data to support the effectiveness of the X-STOP® IPD® procedure in treating lumbar spinal stenosis (LSS) patients?

Recently published clinical trial results support the clinical success of the X-STOP® IPD® procedure. In a pivotal trial used for U.S. marketing approval, patients suffering from LSS showed greater overall treatment success rates at two years when treated with the X-STOP® IPD® procedure compared to non-operative care⁴. Four-year follow-up of a subset of patients in this pivotal trial showed that the beneficial impact of the X-STOP® IPD® procedure on back function persists⁵. Additional studies^6,7, have shown similar effectiveness of the X-STOP® IPD® procedure to treat patients with LSS. Finally, a recent study using positional MRI documents that the X-STOP® IPD® procedure improves spinal canal and neural foramen anatomy⁸.

⁴ Zucherman, J.F., et al., A multicenter, prospective, randomized trial evaluating the X-STOP interspinous process decompression system for the treatment of neurogenic intermittent claudication: two-year follow-up results. Spine. 2005;30(12):1351-1358.

⁵ Kondrashov, D., et al., Interspinous process decompression with the X-STOP device for lumbar spinal stenosis: a 4-year follow-up study. J Spinal Disord Tech. 2006;19:323-327

⁶ Lee, J., et al., An interspinous process distractor (X-STOP) for lumbar spinal stenosis in elderly patients: preliminary experiences in 10 consecutive cases. J Spinal Disord Tech. 2004;17(1):72-7; discussion 78.

⁷ Siddiqui, Two-year clinical and positional MRI results of X-STOP interspinous device - a preliminary report. The Spine Journal 6. 2006;1S-161S:152.

⁸ Siddiqui, M., et al., Influence of X-STOP on neural foramina and spinal canal area in spinal stenosis. Spine. 2006; 31(25):2958-2962.

⁴ Zucherman, J.F., et al., A multicenter, prospective, randomized trial evaluating the X-STOP interspinous process decompression system for the treatment of neurogenic intermittent claudication: two-year follow-up results. Spine. 2005;30(12):1351-1358.

⁵ Kondrashov, D., et al., Interspinous process decompression with the X-STOP device for lumbar spinal stenosis: a 4-year follow-up study. J Spinal Disord Tech. 2006;19:323-327

⁶ Lee, J., et al., An interspinous process distractor (X-STOP) for lumbar spinal stenosis in elderly patients: preliminary experiences in 10 consecutive cases. J Spinal Disord Tech. 2004;17(1):72-7; discussion 78.

⁷ Siddiqui, Two-year clinical and positional MRI results of X-STOP interspinous device - a preliminary report. The Spine Journal 6. 2006;1S-161S:152.

⁸ Siddiqui, M., et al., Influence of X-STOP on neural foramina and spinal canal area in spinal stenosis. Spine. 2006; 31(25):2958-2962.

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What is a laminectomy?

It’s a moderate to major surgical procedure to remove the lamina – the part of bone in the spine covering the spinal cord and/or nerve roots. The purpose of this procedure is to gain access to the nerves, to treat spinal stenosis or remove a disc herniation.

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For decades, moderate to major surgery was the only effective treatment for spinal stenosis, why is the X-STOP different?

The X-STOP IPD offers several benefits compared to traditional surgery for lumbar spinal stenosis, including:

• the option of local anesthesia
• the potential to be an outpatient procedure
• usually no removal of bone or soft tissue allowing for potentially quicker recovery
• fully reversible procedure that does not limit any future non-surgical and surgical treatment options

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Do I need a fusion?

Although our physicians are trained and experienced in these techniques, a fusion is not a procedure to be taken lightly. Instability is the commonly accepted indication for fusion; in patients that meet the strict criteria for instability in the lumbar spine, a procedure with or without instrumentation will be discussed. An inordinate number of lumbar spinal fusions are currently being done in this country, with little agreement on indications and requirements for this procedure. What is known, is that the complication rates and failures in patients chosen with liberal criteria are quite high. These considerations are weighed very seriously before lumbar and cervical fusion is considered for treatment.

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Can I bend over if I have a fusion?

Yes. Most of the motion, when you bend at your waist, occurs in yours hips. Most likely, you’ll only have 1 or 2 levels of your spine fused. Sacrificing some motion may occur – but the alternative is less back pain, allowing you to have better motion than before. Generally, there is very little change in motion from this operation.

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Do you have other questions that have not been answered?