As of Wednesday, May 8, 2013
DEAR DOCTOR K: I’m a man in my 70s with spinal stenosis. What are my surgical options?
DEAR READER: Your spine is made up of a column of bones called vertebrae. The vertebrae are separated by tough little shock-absorbing disks that keep the bone of the vertebra on top from rubbing against the bone of the vertebra beneath it. The vertebrae and disks have a circular space in the center, called the spinal canal, through which your spinal cord (the long nerve that extends from your brain down your back) passes. For much of your life, your spinal canal is wide enough that it doesn’t touch or push on your spinal cord.
However, as the bones and disks grow older, in some people they begin to break down. The disks may bulge out and push on the spinal cord, or pinch a nerve root coming out of the spinal cord. Ligaments, which connect your vertebrae to one another and allow them to move flexibly, may thicken, or small bony growths may develop and protrude into the spinal canal. Spinal stenosis is a narrowing of the spinal canal caused by the problems with aging disks, ligaments or bones that I just mentioned. (I’ve put an illustration depicting spinal stenosis on my website, AskDoctorK.com.) It causes low back pain and discomfort in the thighs or lower legs when you stand up straight, bend backward or walk even short distances. You’re probably more comfortable sitting or leaning forward.
For some people, symptoms improve substantially over time without treatment. If your stenosis is fairly recent, give yourself some time to see if your symptoms improve on their own.
If you are overweight, weight loss can help. The heavier you are, the more pressure one vertebral bone puts on the bone below it.
Exercises and physical therapy are the most widely used treatments. My impression, and that of most of my colleagues, is that they are effective. However, there aren’t many large, rigorous scientific studies to confirm that opinion.
Exercises that are less likely to cause the vertebral bones to pound on each other are preferred. So rather than jogging, try swimming, bicycling or using equipment such as an elliptical cross-trainer.
If your symptoms don’t improve, surgery to remove the structures that are pressing on your spinal cord is often successful. People who have this surgery can usually be physically active, with few or no restrictions, for a long time. However, up to one in four patients need a second surgery within 10 years of their initial surgery.
Sometimes the changes that cause spinal stenosis cause a vertebra to slip forward. If that’s true in your case, you might consider spinal fusion surgery. This fixes the position of the vertebrae permanently, preventing future displacement. By reducing motion in the affected area of the spine, spinal fusion relieves the pain caused by abnormal movement.
So even though you asked about surgery, you should know that most people with spinal stenosis never need it. Fortunately, simpler approaches work for most people.
Dr. Anthony L. Komaroff is a physician and professor at Harvard Medical School. To send questions, go to AskDoctorK.com, or write: Ask Doctor K, 10 Shattuck St., Second Floor, Boston, MA 02115.