My wife was just diagnosed with spinal stenosis after a long period of back pain that was just getting worse and worse. I'm really concerned because I've never seen her like this. The doctor doesn't seem in a big hurry to do anything more than send her to a physical therapist. Should we be pushing for surgery?
Spinal stenosis refers to narrowing of the spinal canal or the intervertebral foramina of the lumbar spine. The spinal cord travels down the spinal canal, so anything that narrows that space can compress the cord. The spinal nerve roots exit the spinal cord through an opening in the vertebral bones called the intervertebral foramina. There are many anatomical changes that can result in pressure or compression on the spinal cord or nerve roots. Most of these have to do with degenerative processes linked to aging. For example, osteophyte (bone spurs) can form around the facet (spinal) joints, thereby covering up the foramina (hole) where the nerve roots exit. The discs narrow and may even bulge. Loss of disc height compresses the facet joints together. The joints rub together and start to hypertrophy (build up tissue around them to protect them). These changes can also narrow the foraminal openings where the spinal nerve roots leave the spinal cord. At the same time, the major ligament down the back of the spinal cord (inside the spinal canal) called the ligamentum flavum starts to thicken. There's just enough room in the normal, healthy spinal canal for the spinal cord and the ligament. A ligament that's larger than normal adds to the pressure on the spinal cord. The first place to start is with conservative (nonoperative) care. This is the most appropriate approach for patients with mild to moderate symptoms. Since the progression of stenosis is usually slow, there's time to try conservative care. There's no need to rush into surgery, especially for older adults who have other health concerns. Pain relief and improved function in daily activities are the main goals of treatment. These are accomplished by activity modification and rest when necessary to keep symptoms from getting worse. Patients are advised NOT to stay in bed for long periods of time. Staying active without aggravating the symptoms is the way to go. The best way to do this is to avoid heavy lifting or movements that increase the symptoms (e.g., back extension). Physical therapy can help patients recover faster with less long-term disability. The therapist will teach your wife how to do a series of flexion exercises. She will also be given a program for cardiovascular fitness and both flexibility and strengthening exercises. A total program of this type can increase the area inside the spinal canal and help improve blood supply to the spinal cord. Weight loss is an added benefit to any consistent exercise program. The therapist will also provide instructions regarding posture and conserving energy during daily activities. If your wife's symptoms persist after six to 12 weeks of conservative care, then surgery might be a possibility. There are some other alternative ways to treat this problem. Your physician will know how to advise you based on the results of tests, X-rays and other imaging studies, and response to nonoperative treatment.