Treatment of lumbar spinal stenosis

As we age, our spine loses a lot of its youthful vitality. Discs compress, muscles, ligaments, and tendons weaken. With the spine weakened, the boney structures of the vertebrae begin to overgrow (osteoarthritis) as a means to stabilize the structure. The new boney mass begins to encroach on the openings in the spine that the nerves and spinal canal pass through. As the openings begin to narrow, the spinal canal and nerves rub against the bone causing irritation, inflammation and the symptoms of stenosis mentioned above.

As a chronic pain specialist, many patients come into our office with a date for surgery or, and more unfortunate, a diagnosis of failed back surgery. For the patients who had put off surgery, they have explored their options and have discovered that surgery is not the answer for them. For the patients who had the surgery, they need more options than before.

In the recommended surgical procedures for spinal stenosis, two choices are the most favored. A Decompression procedure where the surgeon will shave and cut away the bone narrowing the spainal canals. The second, a fusion procedure to limit the movement between two vertebrae and hopefully stop the compression of nerves.

Many of the patients we see are looking for alternatives to spine surgery. Many of these people are told that surgery is the only option because the MRI shows narrowing and possible compression on the nerves and spinal cord. Surgery for spinal stenosis should always be considered only after other conservative therapies have been exhausted because it is usually not as successful as hoped and leads to a new diagnosis “failed back surgery syndrome,” where symptoms continue to deteriorate. It is important to note that in instances where stenosis is so severe that the patient has lost circulation to the legs or bladder control – a surgical consult should be made immediately.

Many studies insist that surgical treatment is the best option for lumbar spinal stenosis. Is that really true?

Despite the fact that many studies insist that surgical treatment is the best option for lumbar spinal stenosis, a startling study was published in the medical journal Spine (1) which offered a different opinion.

“We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. . . However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment.

In the above research it should be pointed out the comparison between lumbar surgery and conservative treatments  included the traditional conservative treatments including physical therapy, cortisone injections, pain medications and others listed below.

Understanding the surgical options for stenosis

In the recommended surgical procedures for spinal stenosis, two choices are the most favored.

  • A Decompression procedure where the surgeon will shave and cut away the bone narrowing the spinal canals.
  • The second, a fusion procedure to limit the movement between two vertebrae and hopefully stop the compression of nerves.

A team of  researchers found that patients with lumbar spinal stenosis who do not improve after nonsurgical treatments are typically treated surgically using decompressive surgery and spinal fusion surgery. Unfortunately the researchers could not determine if the surgery had any benefit either.(2)

When fusion causes stenosis

A December 2021 (3) study suggested surgical treatment options for lumbar spinal stenosis (LSS) based on adjacent segment disease (ASD) after spinal fusion typically involve decompression, with or without fusion, of the adjacent segment. The clinical benefits of microendoscopic decompression for lumbar spinal stenosis based on adjacent segment disease have not yet been fully understood as far as effectiveness is concerned.

Now let’s go to another paper that has more of an opinion: From Dr. Nancy Epstein of Winthrop University Hospital:

  • “The incidence of nerve root injuries following any of the multiple minimally invasive surgical techniques resulted in more nerve root injuries when compared with open conventional lumbar surgical techniques. Considering the majority of these procedures are unnecessarily being performed for degenerative disc disease alone, spine surgeons should be increasingly asked why they are offering these operations to their patients.”(4)

A 2019 study (5) provided the results of a survey sent to surgeons to examine factors influencing surgeons’ definition of instability in grade 1 degenerative spondylolisthesis (DS) and assess treatment preferences for both stable and unstable degenerative spondylolisthesis.

  • Degenerative spondylolisthesis treatment options are broadly classified as decompression with or without fusion. In surgical decision-making, “instability” is frequently considered as a key factor. However, no consensus on the definition of instability exists. Yet, decompression with fusion was the preferred treatment method for unstable DS in 99% of the respondents. For stable degenerative spondylolisthesis, 40% would still perform fusion, whereas 60% preferred treatment with decompression-alone.

Conclusions: Clear consensus regarding the definition of instability does not exist.

People still have pain, even after successful surgery.

In the medical journal Public Library of Science one, a November 2019 study (6) from a combined group of 22 medical researchers look at post-surgical patients with degenerative lumbar spinal stenosis from 13 surgical spine centers. The patients were deemed to be good surgical candidates. Following pain and disability testing in the follow up periods post surgery, the researchers concluded that.

“Although most patients experienced important reductions in pain and disability, 29% to 42% of patients were classified as members of an outcome trajectory subgroup that experienced little to no benefit from surgery. These findings may inform appropriate expectation setting for patients and clinicians and highlight the need for better methods of treatment selection for patients with degenerative lumbar spinal stenosis.”

A June 2022 study (9) went looking for risks factors and the odds of needing a revision spinal surgery to treat lumbar stenosis. Patients who had revision surgery were classified as immediate complications of the initial operation with infections, neurological deficits and hematoma being the most common. Within this group only 22 patients had fusion surgery in the first place, while 29 were treated by decompression.

  • Revision surgery was indicated by 53 patients at a later date.
  • While 4 patients decided against surgery, 49 revision surgeries were planned.
  • 28 were performed at the same level, 10 at the same level plus an adjacent level, and 10 were executed at index level with indications of adjacent level spinal stenosis, adjacent level spinal stenosis plus instability and stand-alone instability. Pain and ability to walk improved significantly in all patients.

Conclusions: “While looking for predictors of revision surgery due to re-stenosis, instability or same/adjacent segment disease none of these were found. Within our cohort no significant differences concerning demographic, peri-operative and radiographic data of patients with or without revision were noted. Patients, who needed revision surgery were older but slightly healthier while more likely to be male and smoking. Surprisingly, significant differences were noted regarding the distribution of intraoperative and early postoperative complications among the 6 main surgeons.”

Treatment with PRP

Spinal stenosis is the result of bone growth in the spine. The bone growth is occurring because the bone is trying to stabilize the spine from excessive movement or laxity, a state of vertebrae slipping out of place. Fusion surgery is recommended as a means to stop the bone spur growth and vertebrae instability by quickly replacing the slow natural fusion with a rapid surgical fusion.

Regenerative medicine including PRP works in a completely different way. These treatments stabilize the spine by strengthening the often forgotten and underappreciated spinal ligaments and tendons. These techniques help stabilize the spine, which is imperative as unstable joints can lead to – or further exacerbate – the arthritis that causes spinal stenosis.

In the medical journal Insights into imaging, researchers wrote of the four factors associated with the degenerative changes of the spine that cause spinal canal stenosis:

  • disc herniation.
  • hypertrophic facet joint osteoarthritis, (an overgrowth of bone)
  • ligamentum flavum hypertrophy (inflammation of the spine’s supporting ligaments – the ligamentum flavum).
  • and spondylolisthesis (stress fractures causing the vertebrae to slip out of place)

The same research suggests that these conditions can prevent the formation of new tissue (collagen) which can initiate repair.(7)

Collagen is of course the elastic material of skin and ligaments. Here the association between collagen interruption and spinal stenosis can be made to show spinal instability can be THE problem of symptomatic stenosis.

A study on what damaged spinal ligaments can do

A study in the Asian Spine Journal investigated the relationship between ligamentum flavum thickening and lumbar segmental instability, disc degeneration, and facet joint osteoarthritis. Ligament thickening is the result of chronic inflammation. Chronic ligament inflammation is the result of a ligament injury that is not healing.

What these researchers found was a significant correlation between ligamentum flavum thickness, spinal instability and disc degeneration. More so, the worse the degenerative disc disease, the worse the ligamentum flavum thickness.(8)

PRP can address the problem of ligament damage and inflammation. Addressing these problems address the problems of spinal instability. Addressing the problems of spinal instability can address the problems of spinal and cervical stenosis.

Medical references for this article

1 Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical Versus Nonsurgical Treatment for Lumbar Spinal Stenosis. Spine (Phila Pa 1976). 2016 Jul 15;41(14):E857-68.
2
 Inoue G, Miyagi M, Takaso M. Surgical and nonsurgical treatments for lumbar spinal stenosis. Eur J Orthop Surg Traumatol. 2016 Oct;26(7):695-704. doi: 10.1007/s00590-016-1818-3. Epub 2016 Jul 25.
3 Murata S, Minamide A, Nakagawa Y, Iwasaki H, Taneichi H, Schoenfeld AJ, Simpson AK, Yamada H. Microendoscopic Decompression for Lumbar Spinal Stenosis Associated with Adjacent Segment Disease following Lumbar Fusion Surgery: 5-year Follow-up of a Retrospective Case Series. J Neurol Surg A Cent Eur Neurosurg. 2021 Dec 12. doi: 10.1055/s-0041-1739206. Epub ahead of print. PMID: 34897616.
4 Epstein NE. More nerve root injuries occur with minimally invasive lumbar surgery: Let’s tell someone. Surg Neurol Int. 2016 Jan 25;7(Suppl 3):S96-S101. doi: 10.4103/2152-7806.174896. eCollection 2016.
5 Spina N, Schoutens C, Martin BI, Brodke DS, Lawrence B, Spiker WR. Defining instability in degenerative spondylolisthesis: surgeon views. Clinical spine surgery. 2019 Dec;32(10):E434.
6 Hebert JJ, Abraham E, Wedderkopp N, Bigney E, Richardson E, Darling M, Hall H, Fisher CG, Rampersaud YR, Thomas KC, Jacobs B. Patients undergoing surgery for lumbar spinal stenosis experience unique courses of pain and disability: A group-based trajectory analysis. PloS one. 2019;14(11):e0224200-.
7 Kushchayev SV, Glushko T, Jarraya M, et al. ABCs of the degenerative spine. Insights into Imaging. 2018;9(2):253-274. doi:10.1007/s13244-017-0584-z.
8 Yoshiiwa T, Miyazaki M, Notani N, Ishihara T, Kawano M, Tsumura H. Analysis of the Relationship between Ligamentum Flavum Thickening and Lumbar Segmental Instability, Disc Degeneration, and Facet Joint Osteoarthritis in Lumbar Spinal StenosisAsian Spine Journal. 2016;10(6):1132-1140. doi:10.4184/asj.2016.10.6.1132.
9 Melcher C. Lumbar spinal stenosis–surgical outcome and the odds of revision-surgery: Is it all due to the surgeon?. Technology and Health Care. 2022 Jun 10(Preprint):1-2.

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