Back Surgery for Spinal Stenosis
Spinal stenosis is a condition where the spaces in the spinal canal have become obstructed or narrowed leading to pressure being placed on the spinal nerves and the spinal cord. This can occur in the lumbar spine, the thoracic spine, and the cervical spine and many patients often have evidence of Spinal stenosis at a number of levels. This is particularly true in cases where the degeneration is due to age-related wear and tear rather than acute injury. Compression of blood vessels, and problems with the intervertebral discs, spinal ligaments, and other important tissues and structures can also be both the cause and effect of spinal stenosis. Lumbar spinal stenosis is the most common form of spinal stenosis and is suffered by a huge number of people. Symptoms include mild, occasional aching in the back or the buttocks, acute shooting pain down into the feet, numbness, weakness, mobility problems, bowel and bladder incontinence, and paralysis.
Thoracic Spinal Stenosis
Spinal stenosis in the thoracic spine is less common, only accounting for around 1% of those with the condition. This is mainly due to the anatomical differences between the cervical, lumbar, and thoracic spine and the latter’s relative rigidity compared to the neck and lower back. However, the thoracic spine is actually much narrower than the spinal canal in the cervical and lumbar spinal regions making any obstruction more likely to cause problems. Those with a congenitally narrow thoracic spinal canal are also liable to suffer spinal cord compression from relatively minor trauma to the spine. Inflammation, vertebral fracture, osteophyte (bone spur) growth, or disc herniation can occur, along with synovial cysts, and ligament calcification, all of which reduce the space available for the spinal nerves to travel through and the spinal cord itself. Thoracic spinal stenosis may remain asymptomatic for many years until a patient begins to experience mild middle back pain. As the condition develops there may be pain in the lower back, down the legs, and a progressive loss of bowel and bladder control. In some cases the ability to walk may be affected, and muscle weakness and atrophy, along with paralysis can occur.
Cervical Spinal Stenosis
Cervical spinal stenosis is also fairly common, as the neck is more mobile than other regions of the spine and is, therefore, more liable to incur damage due to simple wear and tear. The cervical spine may also be injured through acute trauma, such as whiplash or a contact sports injury and this may cause spinal stenosis through structural abnormalities and hypermobility. As with other forms of spinal stenosis the treatment is usually conservative initially, with patients given medication and physical therapy to manage their condition. If, after six months or so, the patient shows no improvement or is unable to manage daily activities due to pain or disability they may be advised to consider back surgery. Back surgery for spinal stenosis usually involves two elements; decompression, and fusion to restore stability to the spine. If nerve compression is isolated and easily accessible then there may be no need for spinal fusion. If, however, there is a considerable degree of material obstruction of the nerves and spinal cord across one or more levels the likelihood of fusion being necessary is increased.
Types of Back Surgery for Spinal Stenosis
Spinal stenosis treatment largely depends on the degree of narrowing in the spinal canal and the cause of that pathology. Conservative treatment is usually attempted for at least six months prior to surgery being considered. Stenosis may be due to a disc herniation, rupture, or bulging disc, in which case traction, endoscopic discectomy, or open traditional discectomy may be indicated. Developments in both surgical technique and hardware mean that patients may also be able to have an artificial disc replacement in order to preserve movement in the spine. Traditionally, the removal of an intervertebral disc has meant that the spine needed extra support through fusion surgery, which increases the risk of complication over more minimally invasive procedures.
Fusion surgery in itself may, however, be indicated, as this can restore the correct alignment of the spine and prevent spinal curvature or slippage from putting pressure on the spinal nerves or cord. Alternatively, a portion or section of the lamina may be removed in order to decompress the back of the spine, with or without fusion. More minimally invasive surgeries, such as the X-Stop implant procedure may be helpful for patients with isolated stenosis in the lumbar spine. Not all patients are able to have minimal access procedures due to anatomical variation and other health conditions and patients should endure they discuss their options with their surgeon to appreciated the risks and benefits of each operation.
Choosing a Back Surgery for Spinal StenosisPatients with spinal stenosis require a detailed anatomical diagnosis prior to any back surgery being carried out. A major reason for failed back surgery syndrome is the simple fact of a patient’s symptoms being attributed to an anatomical defect that is not actually causing their symptoms. Selective nerve root blocks and contrast dye X-Rays can help isolate the dysfunctional nerves, ensuring that the vertebral level operated on is responsible for the symptoms of back or neck pain and radiculopathy. The surgery may need conducting from the anterior, posterior, or both the front and back of the spine and this can affect the availability of certain procedures for many patients. Spinal stenosis surgery aims to decompress the spine whilst maintaining stability and this means that a surgeon should aim to remove the minimal amount of material necessary to achieve decompression without creating a new problem such as nerve injury or spinal instability. Some patients may be unable to undergo the more extensive procedures, many of which can take several hours to perform, due to the risks of long-term anaesthetic exposure. Less invasive procedures performed in a shorter time under local anaesthetic may provide a significant degree of relief without the risks of respiratory or cardiovascular complication that are associated with general anaesthetic.
Patients who have additional medical problems, such as diabetes, respiratory issues, adrenal dysfunction, or cardiovascular problems need to ensure that these are addressed prior to surgery particularly as some medications can cause an increased risk of bleeding, hypoglycaemia, or respiratory difficulty. Smokers are advised to quit several weeks in advance of any back surgery, particularly surgery involving spinal fusion. This is because smokers have a considerably lower success rate for achieving a solid bone fusion and are at increased risk of failed back surgery syndrome and general complications from surgery. Any medications, prescribed or not, that the patient is taking should be brought to their physicians’ attention as these may need discontinuing prior to surgery and avoiding for a brief period afterwards. NSAIDs, which many back pain sufferers take to manage their condition, can reduce the success of spinal fusion by inhibiting the formation of new bone and are usually to be avoided after such back surgery.
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