Lumbar spinal stenosis in Tunisia
Lumbar Spinal Stenosis
The lumbar spine (lower back) consists of five vertebrae in the lower part of the spine, between the ribs and the pelvis. Lumbar spinal stenosis is a narrowing of the spinal canal, compressing the nerves traveling through the lower back into the legs. While it can affect younger patients due to developmental causes, it is more often a degenerative disease that affects people typically aged 60 and older.
The narrowing of the spinal canal usually occurs slowly, over several years or decades. Discs become less spongy with aging, leading to loss of disc height and may cause bulging of the hardened disc into the spinal canal. Bone spurs may also appear and ligaments may thicken. All of these can contribute to narrowing of the central canal and may or may not produce symptoms. Symptoms may be due to inflammation, compression of the nerve(s), or both.
Symptoms may include
Pain, weakness or numbness in the legs, calves or buttocks
Calf cramps with walking, requiring frequent short rests to walk a distance
Pain radiating into one or both thighs and legs, similar to the lay term "sciatica"
In rare cases, loss of leg motor function, loss of normal bowel or bladder function
Pain may improve when bending forward, sitting or lying down
Degenerative spondylolisthesis and degenerative scoliosis (curvature of the spine) are two conditions that may be associated with lumbar spinal stenosis. Degenerative spondylolisthesis (slipping of one vertebra over another) is caused by osteoarthritis of the facet joints. Most often, this involves L4 slipping over the L5 vertebra. It is generally treated with the same non-surgical ("conservative") and surgical methods as lumbar spinal stenosis.
Degenerative scoliosis most often occurs in the lower back and more frequently affects people aged 65 and older. Back pain associated with degenerative scoliosis usually begins gradually and is activity-related. The curvature of the spine in this form of scoliosis is often relatively minor. Surgery may be indicated when non-surgical measures do not improve the pain associated with the condition.
Non-surgical treatment of lumbar stenosis
A combination of time, medication, posture management, stretching and exercise may be helpful for many patients during pain flare-ups. Weight management, smoking cessation and bone strengthening efforts may also be indicated.
Anti-inflammatory medications may be used to reduce swelling and pain, and pain relievers may be used to relieve pain. Most pain can be treated with over-the-counter medications, but if pain is severe or persistent, prescription medications may be provided.
Epidural injections of medication may be prescribed to help reduce swelling.
Physical therapy and/or prescribed exercises may help stabilize and protect the spine, build endurance and increase flexibility. Therapy can help the patient return to a normal lifestyle and activities. Typically, four to six weeks of therapy are encouraged.
Surgical treatment of lumbar stenosis
A doctor may recommend surgery if non-surgical management (as described above) does not improve symptoms. There are different types of spine surgeries and, depending on the specific case, a neurosurgeon will help determine which procedure might be appropriate for the patient. As with any surgery, a patient's risks include age, overall health and other issues, all of which are taken into consideration beforehand. A patient may be considered a candidate for surgery if:
Back and leg pain limits normal activity or impairs quality of life.
Progressive neurological deficits develop (leg weakness, foot drop, limb numbness).
Loss of normal bowel and/or bladder functions.
Difficulty standing or walking.
Medications and physical therapy are not effective.
The patient is in reasonably good health.
There are several different surgical procedures that may be used, with the choice influenced by the severity of the case. In a small percentage of patients, spinal instability may require spinal fusion - this decision is usually determined before surgery. Spinal fusion is an operation that creates a solid union between two or more vertebrae. Spinal fusion can help strengthen and stabilize the spine, and may thus help relieve severe and chronic back pain.
Types of lumbar spinal stenosis surgeries
The most common surgery in the lumbar spine is called decompressive laminectomy, in which the laminae (roof) of the vertebrae are removed to create more space for the nerves. A neurosurgeon may perform a laminectomy with or without fusion of the vertebrae or removal of part of a disc. Spinal fusion with or without spinal instrumentation may be used to enhance fusion and support unstable areas of the spine.
Other types of surgeries or techniques/methods to treat lumbar spinal stenosis include:
Laminotomy: creates an opening in the bone (in the lamina) to relieve pressure on the nerve roots.
Foraminotomy: surgical opening or enlargement of the bony exit for the nerve root as it leaves the spinal canal; may be done alone or with laminotomy/laminectomy.
Medial facetectomy: Removal of part of the facet (bony joint) that may be overgrown, to create more space in the spinal canal.
Anterior Lumbar Interbody Fusion (ALIF): Removal of the degenerative disc through the lower abdomen. A structural device, made of bone, metal, carbon fiber or other materials, is placed to take the supporting place of the removed disc and filled with bone, so that fusion between the bone (vertebral bodies) above and below eventually occurs.
Posterior Lumbar Interbody Fusion (PLIF): removal of the degenerative disc through the skin of the back, removal of the posterior bone of the spinal canal, retraction of the nerves to access the disc space. A structural device, made of bone, metal, carbon fiber or other materials, is placed to take the supporting place of the removed disc and filled with bone, so that fusion between the bone (vertebral bodies) above and below eventually occurs. Similar to TLIF, this is often done on both sides of the spine.
Transforaminal Lumbar Interbody Fusion (TLIF): removal of the degenerative disc through the skin of the back, removal of the posterior bone of the spinal canal, retraction of the nerves to reach the disc space. A structural device, made of bone, metal, carbon fiber or other materials, is placed to take the supporting place of the removed disc and filled with bone, so that fusion between the bone (vertebral bodies) above and below eventually occurs. Similar to PLIF, this is often done on one side of the spine.
Instrumented fusion: Use of "hardware" (hooks, screws, other devices) to add stability to the construct for fusion.
The potential benefits of surgery must always be carefully weighed against the risks of surgery and anesthesia. While a large percentage of patients with lumbar spinal stenosis who eventually undergo surgery report significant pain relief after surgery, there is no guarantee that surgery will help every individual.