Q: I have been to a spinal surgeon who said I have spinal stenosis and degenerative spondylolisthesis and recommends surgery. I am in constant pain in my butt and legs. I am very limited to doing anything or walking much and just do small things around the house. Would you recommend surgery, too? I have heard so many stores about not getting back surgery because it doesn’t work. What are your thoughts?
A: Spinal stenosis refers to a narrowing of the spaces within the spine that can put pressure on the spinal cord and surrounding nerves. It is most common in the neck and lower back. While some individuals have no signs or symptoms and the condition is discovered on X-rays that may be performed for other issues, the condition may cause pain, muscle weakness, numbness, and bladder/bowel control issues. When the cervical spine is involved, numbness, weakness and tingling of the extremities is common; stenosis in the lumbar region can result in cramping and pain that often follows walking or standing for extended periods of time.
The causes for this condition include injuries such as major trauma from an auto accident, a herniated disk which affects the shock absorber between the vertebrae that tends to dry with age, tumors inside the spinal cord/within the covering of the spinal cord/between the cord and the vertebrae, ligaments that thicken and become stiff as an individual ages, and Paget’s disease of the bone that complicates the body’s normal recycling process. This disease is common in the skull, spine, pelvis and legs.
Diagnosis may be made through MRI or CT myelogram. An X-ray won’t likely confirm the condition but could be a first step in evaluating a back problem or look for diseases or conditions such as spondylosis. Symptoms will depend on the portion of the body that is affected. In the pelvis, hip pain is common. In the spine, pain, tingling and numbness of an arm or leg may occur as nerve roots become compressed. In the leg, bones weaken and become misshapen, causing arthritis of the knee or hip.
Degenerative spondylolisthesis is a spinal condition in which one vertebra slips either forward or backward over the one below it. It generally occurs as a consequence of the aging process when joints, ligaments and bones become weaker and less able to hold the spinal column in its proper position. Spondylolisthesis can lead to spinal deformity and a narrowing of the spinal canal. The most common symptom is lower back pain that worsens following exercise, followed by decreased range of motion, numbness, tingling, and more.
Diagnosis may be made by a lateral X-ray film from the side which will show the slippage of the vertebrae as compared to the alignment of other vertebral bones. Based on the X-ray results, an MRI might be ordered for additional assistance to determine the severity of the disorder.
Treatment may begin with non-surgical options to include ice or heat, pain medication such as OTC ibuprofen or acetaminophen, and a modification of activities that includes rest, avoiding bending backwards/standing or walking for extended periods and more. If these measures provide relief, you may have found an answer to the problem. If not, manipulation by a chiropractor, osteopathic physician, or other appropriately trained health professional might be considered. Then there is the epidural steroid injection to consider. These injections may help curb pain while increasing your ability to function; and, the epidural can be administered up to three times a year, yet there is debate regarding long-term benefits. Without sufficient relief, surgery comes to mind, yet according to some reports, surgery for degenerative spoldylolisthesis is rarely needed; however surgery for spinal stenosis with spondylolisthesis is a different problem. For spondylolisthesis a laminectomy does have limited support in written reports but if the spinal stenosis is at the same level as the spondylolisthesis, the decision to operate is more complicated because it involves which procedure and the possible complications. This decision may require a tertiary care second opinion. . Surgery goals are to realign the segment of the spine to alleviate nerve pressure and provide stability of the area that should be considered if the pain is disabling and the surgeon determines your quality of life will be appreciably increased. Decompression (laminectomy) alone is usually not advisable and in up to 60% of all cases, fusion will be needed.
Have an in-depth discussion with your surgeon regarding conservative non-surgical/ surgical approaches to your condition. Bring a family member with you for the talk.