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Spinal Stenosis occurs when the spinal canal has reduced in size so that the spinal nerves can no longer function properly. The actual cause of the malfunction in the nerves is not really understood but it is thought that it may be as a result of not enough blood getting to the nerve (arterial insufficiency) or blood not being able to flow away and chemicals building up that shouldn’t (venous occlusion). Either way the spinal canal has become narrowed and the nerves are affected. The symptoms felt are usually a numb aching cramp like pain brought on by walking and relived by stopping or leaning forward.
It is insidious in onset, which means it creeps up on you in a stealth-like manner and usually occurs after the age of 50. If severe it can cause Cauda Equina syndrome with disturbance of bowel and bladder function.
As the condition progresses the symptoms may come on simply by standing and with time your standing time may reduce. Progression of the disease is measured by a reduction in walking distance initially and as already mentioned by a reduction in standing time. The pain felt on walking is medically referred to as “claudication” and interestingly, not enough blood getting to the muscles of the leg can also cause these very same symptoms. This is known as peripheral vascular disease (PVD) or arterial insufficiency syndrome and this type of claudication is medically termed “intermittent claudication” as opposed to “spinal claudication”. The easiest way to exclude this as a cause is to see if you can feel the arterial blood vessels pulsating lower down the leg. If you can’t then it may be peripheral vascular disease, but it is important to remember that both spinal stenosis and PVD may co-exist.
My definition of Spinal Stenosis is “claudication with evidence of chronic nerve root compression or irritation in the presence of a spinal canal lesion on imaging and the absence of vascular insufficiency.”
Well you can be born with it. This is referred to as congenital spinal stenosis but more commonly it is acquired with time due to degenerative changes within the spine. Basically as the disc degenerates the disc loses height. As it loses height it causes the intervertebral disc to bulge into the canal. This causes a progressive narrowing of the canal from in front. As the disc loses height it also causes the facet joints behind the canal to load abnormally. This in turn, causes the facet joint to wear abnormally causing a degree of loss of articular cartilage within the facet joints. This is known as facet joint arthropathy or more simply osteoarthritis of the facet joint or spine. In osteoarthritis the body starts to form new bone we assume to try and stabilise the joint. This new bone is called an osteophyte. These osteophytes then grow into the canal narrowing the canal from the sides and back.
As this occurs very slowly patients do not have symptoms for many years until the point at which the spinal canal has lost all its reserve capacity and the nerves are finally affected. This is why it is referred to as insidious in onset. Even as it starts, patients will often ignore the symptoms or attribute it o something else until it becomes very obvious that their walking distance has reduced significantly.
Sometimes it can come on very abruptly but this is usually when the patient has suffered an acute disc herniation in an already narrow canal and the disc herniation takes up all of the reserve capacity in the spine very suddenly.
On these occasions it is important to be aware of the risk of developing cauda equina syndrome.
Surgical treatment options are either a spinal injection or spinal surgery to formally free the nerve roots. This may take the form of a laminectomy, a “flip” Spinous process osteotomy or a targeted decompression depending on the degree of spinal stenosis and its location relative to the canal.
Spinal injections can work by reducing the collective inflammation of the nerve roots at the point of compression as well as producing a degree of epidural fat atrophy thereby increasing the capacity within the canal.
The simplest analogy and please stay with me on this one….imagine lots of people standing in a room in which the walls are moving in “James Bond” style. The walls moving in relates to the spinal stenosis. Unfortunately the “baddie” has also lowered the temperature in the room but has provided big woolly coats for everyone to wear. The dilemma is by wearing the coats everyone is more swollen and therefore cannot move and suffocates. This relates to the nerves swelling within the canal secondary to the inflammatory response to the mechanical irritation of being compressed. Remember that Celsus’s cardinal signs of inflammation are redness, heat, pain and swelling.
By delivering a spinal injection with steroid we are reducing the swelling of the nerve roots in the canal by reducing the inflammatory process associated with the mechanical irritation of the nerve roots. This is just like increasing the temperature in the room so that everyone can take their big woolly cots off and leave them outside the room. We have the same number of people in the room but they are all individually less swollen so there is more space for them to move around and be comfortable in the room.
It is difficult to predict how long a spinal injection will last in these circumstances but often in my experience it can last up to 6 months or more and in elderly patients in whom surgery is not really an option it is a suitable temporising measure.
If you are offered an injection here is what to expect.
Spinal injections are performed as a day case procedure usually at The Priory Hospital under a light general anaesthetic. The procedure will be discussed with you once it has been agreed that an injection is required. Instructions for your admission will be received from the Reservations Team at the Priory Hospital. This will include your admission time and any instructions regarding being “nil by mouth”. Prior to the procedure it will be necessary to carry out some routine blood tests.
On the day of the injection you are allowed to have breakfast but cannot eat after 9am. You are however allowed water until 11.30am. Mr Ishaque usually operates on a Monday afternoon so you will be admitted onto the ward at about 12.00pm. On admission Mr Ishaque and Dr E J da Silva will see you in order to go through the consent and talk you through the procedure.
You will then be taken down to the anaesthetic room where you will greeted by the theatre team and all the necessary checks will be performed for your safety. At this stage Dr Da Silva will place a small cannula in the back of your hand to allow him to deliver the anaesthetic agents during the procedure.
You will then be walked into the theatre itself and shown how to climb onto the operating table in order to get comfortable.
Mr Ishaque will then mark your back with a marker pen using the x-ray machine to guide him regarding the entry point for the spinal injections. Mr Ishaque will then clean your back using standard surgical iodine and the procedure is carried out using a sterile technique.
You may feel a slight sharp sensation like a pinch which last a few seconds before Dr Da Silva administers the intravenous general anaesthetic which is the local anaesthetic being placed at the needle entry point but often you will already be asleep at this point. You will not feel the actual spinal injection which is much more comfortable and safer for yourself and Mr Ishaque, as he can be sure you will not move at a crucial point during the injection.
Please be aware that if you are needle-phobic (very scared of needles) then Dr Da Silva can make sure that you will not even feel this initial injection just under the skin.
Mr Ishaque routinely performs an epidurogram using either Omnipaque or Niopam in order to confirm correct placement of the spinal needle after using x-ray guidance in two planes, taking x-rays from both side to side and from front to back.
Once you have had your injection you will be helped back onto your bed and transferred to the recovery suite. As you have has an epidural injection it is standard practice to monitor your blood pressure for about half an hour before being sent back to the ward.
Once back on the ward you will be able to eat and drink in order to get your blood sugar levels up and you will be asked to rest for 90 minutes to allow the sensation to return to your legs and the effects of the general anaesthetic to wear off.
Usually you will be discharged by about 7pm and you will need to be picked up, as you will not be fit to drive on the day of the injection.
Following your injection a follow up consultation will be arranged for you, this will be arranged for you 4 weeks following your procedure.
Immediately after the injection it is not unusual to have a slight increase in back pain but often the leg pain is immediately relieved. I would advise you take a few days off after the injection to rest and during this time it is important to keep taking your anti-inflammatory (Diclofenac, Ibuprofen or Naproxen) medication as well as any painkillers. It is fine to drive the following day but I would limit journeys to less than 40 minutes. I have had a number of patients who have flown short haul within 1 week of the injection which although is not recommended, is possible provided you keep well hydrated, keep mobile during the flight and keep wearing your compression stockings to reduce the chances of a deep venous thrombosis (DVT) and more importantly a Pulmonary Embolism (PE). In the weeks immediately following the injection I would advise you to walk regularly as your symptoms allow and to avoid any strenuous exercise and in particular excessive bending, lifting or twisting. Swimming is an ideal exercise as you are supported and if you can’t swim then walking widths in the pool at progressively increasing depth provides increasing resistance helping to build strength and stamina.
In the majority of cases any discomfort associated with the injection should have passed within 2 weeks and the effects of the steroid should be becoming more apparent. I usually advise patients to wait 4 weeks before starting physiotherapy, which will also help with the longer-term recovery.
When to operate ?
Being a surgeon, like all surgeons, I enjoy operating, however it is much more important skill to know when not to operate.
It is the “decision rather than the incision” that is most important.
Obviously there are times when an operation cannot be avoided and this is referred to in medical terms as an absolute indication. The only real absolute indication for surgery in spinal stenosis is when a patient has “cauda equina syndrome”.
There is however a graduation of symptoms which make the need for surgery more pressing. We refer to these as relative indications. These include loss of neurological function or progressing loss of neurological function. By this I mean worsening motor function or weakness with associated pain. If the stenosis compresses the lower lumbar nerves enough to give a patient weakness then surgery may well be necessary.
I will however be able to guide you towards a decision about surgery but I feel very strongly that surgery should be the last resort unless absolutely necessary.
I also believe that in the majority of cases the final decision about surgery has to be made by yourself with the best possible information to hand to help you make the right decision.
Mr Ishaque is highly experienced and widely recognised as a leading Consultant Spinal Surgeon. He is one of the few surgeons to have been awarded both the British Orthopaedic Association's Robert Jones Gold Medal and a Hunterian Professorship from The Royal College of Surgeons of England. He is one of the youngest surgeons to have achieved this, having been awarded both honours, before the age of 40.