This condition could be caused by many processes that decrease the space available for nerves in the spinal canal, writes Dr SATNAM SINGH CHHABRA

Back pain might be more than just that — it can sometimes be life devastating pain. A 55-year-old patient, Ramkumar Shandilya, used to get small back pain and took some medicines to get him through the day. But this pain gradually increased and his left toe went numb. He struggled to get around the house and could not walk more than 50 metres at a stretch; he had to stop and rest before he could walk any further. This was affecting his professional life as he couldn’t concentrate on his job due to the pain. He started feeling hopeless and thought he would never be able to live a pain-free life.

On seeing him in constant pain for more than a year, his colleague referred him to a neurosurgeon. He went to a clinic, where he was examined and advised an MRI. The MRI showed severe lumbar canal stenosis at two levels in the spine and the patient was advised surgery as it was too late for non-surgical treatment.

UNDERSTANDING SPINAl PAIN

Spinal stenosis is a disorder that is caused by narrowing of the spinal canal. This narrowing happens as a result of the degeneration of both the facet joints and the intervertebral discs. In this condition, bone spurs (also called osteophytes) grow into the spinal canal. The facet joints also get enlarged as they become arthritic, which contributes to a decrease in the space available for the nerve roots. This condition is known as facet arthropathy. Technically, spinal stenosis is a condition of the narrowing of the spinal canal, which puts pressure on the spinal cord and nerves. About 75 per cent of cases of spinal stenosis occur in the low back (lumbar spine). In most cases, the narrowing of the spine causes pain, heaviness, tingling or numbness in the legs.

WHAT CAUSES lUMBAR PINIJ

Spinal stenosis may be caused by a number of processes that decrease the amount of space in the spinal canal available for the nerves. Aging is one of the most common causes. Degenerative processes occur throughout the body as we age, and stenosis can occur in individuals who were born with a spinal canal smaller than normal (congenital stenosis) or have rare conditions, such as tumors and metabolic conditions. Tissues in the spine may start to thicken, and bones may get bigger, compressing the nerves.

Conditions like osteoarthritis and rheumatoid arthritis may also contribute to spinal stenosis. The inflammation they cause can put pressure on the cord. Other conditions that may cause spinal stenosis includes heredity, spinal defects at birth, tumors of the spine, or accidents and injuries that may dislocate the spine.

IDENTIFYING SPINAl STENOSIS

Pain in the buttocks or leg, which is a common symptom of lumbar spinal stenosis, may be associated with the compression of the microvascular structures carrying blood flow to the nerve roots. At the same time, the symptoms of spinal stenosis may be the direct result of physical compression of the nerve roots. Each of these processes may interfere with the normal function of the nerve roots and decrease the effectiveness and endurance of the spinal nerves leading to:

• Weakness in the legs or arms
• Pain in the lower back while standing or walking
• legs or buttocks getting numb
• Falling frequently and having balancing problems
• loss of urine and bowel control, in extremity

Sitting in a chair usually helps relieve these symptoms, which return with periods of standing or walking.

HOW DO DOCS CONClUDEIJ

Usually, people who develop stenosis have no history of back problems or any recent injury.  First, simple treatments are provided for the suspected diagnosis. If postural changes or non steroidal anti-inflammatory drugs do not relieve the problem, then spinal imaging using X-ray, MRI or a CT scan will be helpful to confirm a suspected diagnosis.

TREATMENTS AND SURGERIES

If diagnosed, depending on the severity of spinal stenosis, the treatment may include either or combination of options like postural changes, which gives relief from pain and discomfort, medications and surgery to relieve the pressure on affected nerves. There are several types of surgeries that can be performed to treat spinal stenosis:

1. laminectomy and foraminotomy are the most common types of surgeries. Part of the vertebrae is removed to provide more room for the nerves. Usually, this is done as an open procedure. The patient undergoes Micro-endoscopic Decompression (MED), wherein the entire procedure is performed through small key-holes. This has several benefits in terms of better cosmesis, less pain, limited days of admission, early discharge, cheaper costs, and more.

This is a spinal surgery that has become a specialised revolutionary technique in which the routine spinal surgeries are performed using a key-hole. The most common spinal afflictions are disc herniations (slipped disc), lumbar canal stenosis and spinal instability. Generally, an open surgery is done to tackle most of these conditions. However, with the micro-endoscopic techniques, the objectives of the surgical procedure are achieved without any significant collateral damage to the soft tissue (muscles and ligaments) or the bony skeleton. Tubular retractors are passed through the key-holes to perform the procedures based on the indication of surgery.

Advantages: Apart from the elegance and cosmetic appeal, this technique has several advantages:

• The scar is miniscule (1.5-2 cm-long) and appears like an ordinary scratch
• No muscle or bony trauma, the contours of the back are well preserved
• Minimal painkillers required
• No stress on the metabolic system
• Swift and painless recovery as older patients may carry conditions of diabetes, hypertension, and heart problems
• Very small incision is made that heals (problem especially for the obese)
• Minimal blood loss. The patients are made to walk within a few hours after surgery and can go home the next day
• Post-operation easiness; a water-proof dressing is applied such that the patient can take bath as early as he/she wishes

2. Spinal fusion is typically performed in more severe cases where spinal stenosis is accompanied with spinal instability. Bone grafts or metal implants are used to attach the affected bones of the spine together. The goal of this surgery is to stabilise or lock two or more bones so they can’t move. This is done with metal hardware or bone graft from the pelvic bone. You may need to stay in the hospital for a few days following spinal fusion. The procedure of spinal fusion is done in a minimally invasive fashion using small key-holes (Minimally Invasive TlIF). After any type of back surgery, your doctor may recommend physical therapy for a short time. The right exercises can help you gain strength and flexibility.

POST-OPERATIVE EXERCISES

Your doctor or physical therapist can recommend exercises specifically designed to strengthen your back and abdominal muscles. They can also instruct you on how to do them safely. One might feel as though exercise would be too painful, but movement is crucial to your overall health. Try to perform some stretching exercises several times a day. If you haven’t exercised in a while, start slowly, even if it’s only for a few minutes a day. Ideally, you should exercise for 30 minutes at least three times a week. If exercise is particularly difficult, try exercising in a pool. The buoyancy of the water makes it easier to move and get full range of motion. But before you take up any form of exercise, consult your doctor.

The writer is Head Neuro and Spine Surgeon, Sir Ganga Ram Hospital, New Delhi