Lumbar Spinal Stenosis

Hi, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today we're talking remotely with Dr. Joshua Auerbach. Dr. Auerbach is the Chief of Spine Surgery in the Department of Orthopedics at Bronx Lebanon Hospital Center, and an Assistant Professor of Surgery at the Albert Einstein College of Medicine in Bronx, New York. Dr. Auerbach attended medical school at Mt. Sinai School of Medicine in New York. From there he complete an orthopedic surgery residency at the University of Pennsylvania in Philadelphia. He completed a spinal reconstructive fellowship at Washington University School of Medicine in St. Louis. Thanks for joining us today Dr. Auerbach.

Dr. Joshua Auerbach: Thanks for having me.

Dr. Sechrest: Well, Dr. Auerbach I want to thank you today for joining us on eOrthopod.TV Remote, and what I thought we would discuss today is a condition that I think you are probably very familiar with, and that's spinal stenosis, or lumbar spinal stenosis. So first, can you start out by talking a little bit about what spinal stenosis is, so that patients can understand what we're going to be talking about.

Dr. Auerbach: So, spinal stenosis is basically a condition of your low back where the nerves that are exiting the spinal canal are being pressed. And when the nerves are being pressed, whether its from arthritis or from a disc herniation, then those nerves that are being pressed can cause pain that goes down your buttock and into your legs. And the kind of, other kind of symptoms that you can have when a nerve is compressed as it exits the spine, can be numbness and tingling, and difficulty with walking, and you may notice that you're walking shorter and shorter distances, this may also be accompanied by low back pain as well. These symptoms together are basically called uh, neurogenic claudication – in other words, these nerves that are being pressed cause this triad of pain, numbness, and tingling that can be very, very disabling and troubling for patients.

Dr. Sechrest: Now, what about danger. In terms of the signals that might uh drive me to come and see a spine surgeon. Is this something that I can decide when and if I want to pursue this? Or are there certain things I should be watching as a patient that should tip me off that it's time to see someone like you?

Dr. Auerbach: Well, most cases of spinal stenosis are able to be treated non-operatively. I mean the vast majority of patients are uh, will typically have complaints of low back pain with the leg burning and numbness and tingling. And usually it can be fairly well-tolerated with medications and sometimes we'll get patients started in a round of physical therapy. Ah, and usually with some of these more conservative treatments, the symptoms can be, for the most part, controlled. The time to be concerned and maybe to see your doctor a little bit more urgently is if you start to develop weakness in your legs, or an inability to bring your foot forward, or difficulty with walking – to the point where it's really interfering with your quality of life and certainly any and sort of change in your ability to hold your urine or hold your feces, certainly those could represent more significant and more severe compression of the nerve root. And that would certainly indicate that you should see your doctor much more urgently.

Dr. Sechrest: Well, lets talk a little bit about the evaluation of spinal stenosis. When I come to your office as a patient, what's the first thing that you're going to do during that visit?

Dr. Auerbach: Well, the very first thing that we do, we always sit down and we get a really good history. Spinal stenosis is a very, very common condition. It effects millions of patients per year and its the most common reason for older patient to seek out spinal surgery care. So, the most important thing is to get a really thorough and detailed history, to understand what brings the pain on, what makes it better, and what are the associated findings. So, for example, if a patient comes in and they describe a pretty clear history of “well , I used to be able to walk 5 or 6 blocks without having any pain, and now over the past few months or so, I've only been able to walk about 1 or 2 blocks or so before I have to strop, in fact I've even gotten a cane.” And some patients will come in with um, with the canes that have a seat on them because they know they can't walk for long distances before having to stop. That's a pretty clear picture of a progressive spinal stenosis. Because again, these patients will also complain of numbness, burning, tingling, and associated low back pain. So, the spectrum of, of disease that spinal stenosis encompasses is ah, is fairly uh, fairly clear. And you can usually get a lot of information from the patient just by taking a really detailed and careful history. Now the other things that we will do in addition to taking a good history and just talking with the patient, is to do a physical examination. So on physical examination, the most important thing I do, I actually watch the patient walk. Not just walk you know from the chair into the room, but we'll go out into the hallway and I will watch them walk up and down, to sort of see what kind of balance um, stability they may have. Are they favoring one leg or the other, are they pitched forward? Is there um other, maybe there's a problem with the hips, maybe there is a problem with the foot or the ankle. These are all things that orthopedic surgeons - it's really important as orthopedic surgeons to evaluate a patient's gait from top to bottom. We can't just be, as a spine surgeon I can't just look at their back. We have to be thinking about possible hip pathology, knee pathology, foot and ankle disease, balance problems. Maybe their walking is, uh a balance problem, as related to a cervical spine problem – or pressure on the spinal cord – which is a totally different kind of a problem. So, for me, the most important thing in the first evaluation that I do on a physical exam is to watch the patient walk and to really get a good sense of where is their discomfort coming from, if you're able to tell just from their walk. The other thing that we'll do in addition to the watching and evaluating their gait, is we'll do a strength examination and we'll see, make sure that all the nerve roots are firing strongly and there's no weakness. And we do a sensation examination. And we also always check the hips, make sure that there's no hip arthritis. And we'll look at the range of motion of the hips and at the knees. We'll also do examinations of the pelvis to make sure that there's no arthritis in the sacroiliac joint, because this can also mask as back pain, that could also potentially be causing leg pain as well. And we always check the pulses as well because we want to make sure that patient that patients that have back pain and leg pain, and weakness and difficulty with walking, sometimes these patients may have vascular claudication, or perhaps they have peripheral vascular disease, In which case their legs fatigue and tiredness is not actually coming from the spine nerve roots being compressed, but perhaps it's coming from vascular insufficiency, or peripheral vascular disease. So all these things all come together in the history and the physical examination so that at the end of the day we can come up with a good idea of where the patient's discomfort is coming from.

Dr. Sechrest: Well, I'm particularly glad that you went into the detail about the vascular claudication and the difference. Because this is sometimes confusing, not only to primary care physicians but also patients and even some other specialists. I think that the problem that we as orthopedists always face is we see a condition that we think is an orthopedic condition, it's not always the case that it is. It can be coming from the spine. And as you pointed out, it can be coming from the blood vessel disease, it can be coming from another part of the musculoskeletal system, like the hip. So I'm, I'm very glad that you went in and explained that very well for patients. I think that's sometimes a very difficult thing for patients to really understand.

Dr. Auerbach: Sure.

Dr. Sechrest: What's the first radiologic test, or some type of scan that you would typically order?

Dr. Auerbach: Right. Well, what I'll commonly do, in fact if the patient's history is fairly suggestive and fairly clear, that the problem is in fact coming from the spine and that it is a spinal stenosis related problem, in most cases, unless there's a red flag – unless I'm concerned about unexpected weight loss or some sort of – maybe there's ah, you know, signs or symptoms suggestive of a triple A or aneurysm, or infections, or a fracture, in most cases of back pain with associated leg and buttock pain that I believe is consistent with spinal stenosis and neurogenic claudication, very commonly we will go ahead and just get them started in a conservative treatment program – even before the imaging is done. So if this is a patient that's never sought out medical treatment for this problem, you know, if they've come in there, they've already done a bunch of physical therapy and medications, and things, and other sorts of treatment, then we would jump to the imaging studies. But, if a patient is just coming on for the first time and being evaluated, most likely we will get them started in a round of physical therapy, and try different medications, and those sorts of things. And then the vast majority of symptoms, excuse me, in the vast majority of patients, we get those symptoms under control, and don't need any further imaging or workup. But, if they've gone through these imaging – sorry, if they've gone through this initial round of treatment whether it be with medications, or rest, anti-inflammatory medications, muscle relaxants, pain medications, – if they've already gone through this first round of treatment, then the first step I'll do is go ahead and get an x-ray. A lumbar spine x-ray. And typically we'll get a lumbar spine flexion/extension x-ray as well. And what that x-ray shows us is it shows us the architecture of the spine, and of the vertebral body. And we want, what we want to see is what is the alignment of the spine. We know that as we get older we tend to lose our normal natural curvature of the spine, which is called lordosis. And we tend to get a little bit more straight and a little bit more kyphotic. Which again means that the spine itself is straight and it can actually reverse into the opposite curvature. And some of that is due to arthritis related changes, and some of its due to loss of height of the discs. And as we get older, we know that the discs shrink a little bit and lose the water and lose their supportive cushioning. So the first step is we'll look at the sagital alignment of the x-ray. We'll also look for whether or not there is the presence of a fracture. And we also may want to look and see if there is something called a spondylolisthesis – which is where the two vertebral bodies may have a sense of instability. Where one vertebral body is slipping in front of the other. These are very important um hallmark findings of spinal stenosis and it's the spectrum of spinal stenosis which includes spondylolisthesis. So these are really important um things to note on the x-rays to help us figure out what's the next treatment step.

Dr. Sechrest: And do you go ahead and start treatment based on x-rays? Do you, do you feel the need to go to any further more advanced imaging? Or is this usually enough for you to to make plans for treatment?

Dr. Auerbach: Well, I think once the screening x-ray is done, again, once we've either ruled out that again that there's no fracture, there's no other, you know, ah, large structural problem that could be causing the symptoms, then most likely we're going to go to an MRI. So an MRI of the lumbar spine is a magnet where the patient lies flat on the tube and they're in a magnet for about 30-45 minutes and the images that are captured by the MRI machine allow us to see in two different planes where the nerves could potentially be pinched. And based on the source and the location and the degree of nerve compression, if there is nerve compression, then we are able to dictate our treatment accordingly, and either recommend either a surgery, or injection, or continued physical therapy and medical management.

Dr. Sechrest: Now you've mentioned physical therapy and you've also mentioned medications as a part of the treatment plan. Can you give us a little bit of information about what you're expecting from physical therapy and also what type of medication that you're going to prescribe?

Dr. Auerbach: Sure. The first line treatment for medical management of spinal stenosis, again is typically Motrin, Ibuprofen, other anti-inflammatory agents. Ah, most of which um, do a really good job for a first line treatment. Those patients that have more back-related symptoms than leg-related symptoms, they may benefit from a muscle relaxant – like a Flexeril or some other sort of muscle relaxant. The second medication that we typically recommend is a nerve medication. Either Neurontin or Lyrica, Both of which help calm the inflammation around the nerve root. And in more, in patients with more severe pain, sometimes we have to go to narcotics, such as Percocet or Vicodin or Tylenol with Codeine and some of these more stronger medications where the patient's pain really is quite severe and disabling. And in those cases we do have to use these stronger agents.

Dr. Sechrest: And what about physical therapy. What are you hoping to gain with physical therapy?

Dr. Auerbach: Well, physical therapy can really help a lot of different patients in a lot of different ways. What we typically prescribe is a program of core strengthening. Where we really work on strengthening the patients core muscles on the belly side of things, and also working on strengthening their back muscles. One of the other great things that the physical therapists are able to do is work on ah, um, pain modalities. They can provide heat, ice, ultrasound, electrical stimulation, um, and then the other thing is we just get them on the treadmill and get them walking. And to help them with their gait, and sometimes we'll end up prescribing, at the recommendation of the physical therapist, we may end up prescribing a cane or even in more severe cases, a walker, depending on the level of severity of their disease. But what the main goals of physical therapy are really to provide pain relief and to help restore functionality and to really get them walking to the level that they are uh, require, and are hoping to achieve.

Dr. Sechrest: Now, lets talk a little bit about injections. You mentioned injections as part of a little bit more invasive treatment for spinal stenosis. What type of injections are we talking about? And again, what are you trying to achieve with those injections?

Dr. Auerbach: Right. So again, if you remember the source of patient's buttock and leg pain from spinal stenosis is a pressed nerve. Again, that nerve can either be pressed from arthritis in the spine or from a disc herniation pinching on those nerves. So, the way that we try to alleviate those symptoms are again, either with the medications, or potentially with the physical therapy, and with the injections what we are trying to do is try to calm the inflammation down. Now there are two main routes through which the medi – through which the injection can provide patient symptom relief. The first example is an interlaminar epidural steroid injection, where the pain management physician provides a needle into the interlaminar space and provides medication which goes down the entire thecal sac, and that will help calm the inflammation down around any of those nerves that are being pinched. The second type of injection is called a transforaminal injection. This is a little bit more selective. This is where the pain management physician uses a fluoroscopy, or an interoperative x-ray to localize the exact site on the nerve root where that, where the medication is injected. So if the physician thinks that the L3,4 nerve root on the right side, for example, is the pinched nerve that is causing the patient's symptoms, we can selectively inject a medication around that nerve root which again should help provide a strong dose of helping medication right onto the effected nerve root as opposed to an interlaminar injection where it may be more dissipated, and may have a lesser effect. So, um, the transforaminal injections are a little bit more precise. And perhaps they can provide more medications to the effected nerve root, but they don't get the global effect that an intralaminar injection can have, which does sort of help all the nerve roots in the distal lumbar spine.

Dr. Sechrest: Now, if I'm a patient, what should I expect from these injections? Is this something that I get once, do I get it multiple times? And how long can I expect these to help when I do have an injection?

Dr. Auerbach: Well, that's something that the patient is going to have to discuss with their pain management physician, because a lot of docs have a different, or have their own protocols, that seem to work best. Sometimes an injection will provided one time, in order to assess whether or not the patient is going to be provided any relief. Sometimes they are provided a series of three injections or even more. And again, that's all very ah, ah, practitioner specific. But, what a patient can expect from this, again, whether it's one injection, or a series of injections over time, is that if the nerve is being pressed, if the medication is provided to this nerve, the patient can expect almost immediate pain relief. Again, sometimes even within the hour, and hopefully this pain relief will be for as short a period of hours, but sometimes it can last even up to months. And certainly there are patients that that um, that get a lot of injections, and are doing everything they can to try and avoid a surgery. Which also again, if they can get their symptoms under control, is a very reasonable option to do. Um, so again, it's hard to predict who will get that extended and long-lasting relief from an injection, but we do expect that in most patients they'll get some form of pain relief, whether it be hours, or days, or weeks to months. That's really more on case by case basis and its hard to predict ahead of time.

Dr. Sechrest: Well, as a spinal surgeon, when do you si, when do you decide that conservative care has failed and it's time to have a discussion about surgery with a patient?

Dr. Auerbach: Well, spinal stenosis is a very, very disabling disease in some patients. But most importantly, and the thing I always tell my patients, is that they need to know that it's usually not a life-threatening condition, and its not a surgical emergency. So, we always try to exhaust conservative treatment modalities, to the best of our abilities, which again includes doing nothing, medications, physical therapy, and epidural injections. Or repeating that sequence. If uh, if that's what's warranted. And really we let the patient decide when the conservative treatment has failed. If a patient's pain continues to persist, despite these conservative treatment modalities, and certainly if the patient's pain is getting worse in the presence of these conservative treatment modalities, and and certainly if the patient should develop any more concerning signs or symptoms such as a foot drop, or weakness, or change in their urinary or bowel or bladder habits, this obviously represents a progression of their neurological signs and their their neurological disease, and may warrant a surgical decompression more urgently. So we try these conservative treatment modalities, but if the patient's pain continues and it's severe and disabling, then we typically recommend a surgical treatment. If we get the patient's pain from an 8 out of 10 down to about a 4 out of 10, or a 5 out of 10, and it's not getting any better, but the patient is okay with that and doesn't really wish to pursue a surgery, then, by all means that's a very, very reasonable ah choice. We don't have to do a surgery if the conservative treatment doesn't bring their pain down to zero. What we want is for the patient to be able to live their life comfortably, to be able to do the activities of daily living that bring them joy to their life – in their lives – and really the surgery is reserved for those patient for whom this conservative treatment has not worked, and for whom the spinal stenosis is causing severe disabling pain that's interfering with their quality of life. Once it gets to that point, and again, that's not a decision that any surgeon can make, that's really a patient-specific, um, ah, outcome. Um, ah, at that point the surgeon and the patient have a discussion and say listen, this is where you are, this is what we've tried, and now we need to discuss what are our options. Either continue on with these conservative treatments or we can start discussing possible surgical options.

Dr. Sechrest: Lets talk a little bit about those surgical options. When I'm a patient who , who is suffering from spinal stenosis, what are you going to recommend in terms of a spine, of a surgical operation that could help alleviate those symtpoms?

Dr. Auerbach: When it comes to discussing surgical options for a patient, there are several components of a potential surgical intervention that need to be discussed. The first component, and the requisite component of any surgery for spinal stenosis is a decompression. So, whether it's an indirect decompression, with a less invasive procedure like an X-STOP, or if it's a direct decompression, where you are performing either a laminectomy or bilateral laminotomy, where you are preserving the posterior ligamentous structures, either way, the goal of that surgery is to take the pressure off of the nerve root. The most effective way to do that is to perform a direct decompression where we're again removing either the arthritis or the disc tissue that is pressing on the nerve root so that after the surgery the nerve root is no longer being pressed, which should alleviate the patient's buttock and leg symptoms. So that's the primary goal or almost any spinal stenosis surgery – is either a laminectomy or a laminotomy in order to decompress the spinal nerve. Now, whether or not the patient also requires some form of stabilization, i.e., a spinal fusion, is really up to what the x-rays and what the MRI looked like. If there is instability in the spine, meaning a spondylolisthesis, or again, like we discussed earlier, where two of the vertebral bodies are unstable and one may be slipping forward in front of another, that is very commonly a situation that requires a surgical stabilization with a lumbar fusion. And the reason why we need need to do a fusion in this situation is because we know that if we just do the decompression and take the pressure off the nerve roots, that the vertebral body may continue to slip forward and cause persistent back pain and leg pain, possibly leading to another surgery down the road. So the most efficient and effective way to provide great patient relief from both their back pain and their leg pain is to decompress the spinal nerve root, with the decompression, and then again, depending on if there's any instability, to maybe also adding a stabilization procedure, such as a lumbar spinal fusion.

Dr. Sechrest: Well, I think that's both good advice and encouraging for patients. So I want to thank you for that and look forward to further discussions in the future. Thanks a lot.

Dr. Auerbach: Thanks for having me.