Should I Have Surgery for Spinal Stenosis?

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Should I Have Surgery for Spinal Stenosis

As a doctor who helps patients avoid spinal surgery, I get asked this question several times a week: “Should I Have Surgery for Spinal Stenosis?” The answer is frequently “No”, so let’s delve into why I think that and go over the results of one patient who we helped avoid the surgery.

What Is Spinal Stenosis?

Before I answer the question, “Should I Have Surgery for Spinal Stenosis?”, let’s review the diagnosis. The term “stenosis” simply means a tight area. For example, you may have heard of coronary artery stenosis, which means a narrowed artery in the heart. Here the narrowing is in the spine. The spinal cord and nerves travel through holes in the bones called the spinal canal which the area we’ll be discussing.

The central canal is the big hole in the middle of the spinal bones (vertebrae). In the neck and upper back, the spinal cord travels through this hole. In the low back, there are only spinal nerves. When the facet joints or ligaments get big, arthritic, and swollen, the spinal canal can become narrowed and when this happens it’s called central canal stenosis.

What Are the Symptoms of Low Back Spinal Stenosis?

By far, the single biggest and most common symptom is the inability to stand for any significant length of time. Patients with central canal stenosis can usually measure their standing time in minutes. Meaning, they will commonly say that they can stand 5 to 20 minutes before they have severe back pain, numbness, and tingling, or weakness in the legs. When they sit down, all of this goes away quickly. They also to like to walk bent over, so for example, leaning over a shopping cart may feel more comfortable.

Why does this happen? To understand that we need to learn more about a ligament in the spine called the ligamentum flavum.

Meet the Ligamentum Flavum

lumbar stenosis treatment without surgeryIn Latin, “ligamentum flavum” means “yellow ligament”. It lives at the back of the spinal canal and it often becomes very thickened in patients with central canal stenosis. Since this makes up the back half of the space where the nerves travel and since the thicker ligament can buckle into the spinal canal when the patient stands, this ligament is a key player in causing the symptoms of spinal stenosis. In the images above, this ligament is red. Other factors making the central canal smaller can include facet joint arthritis, bulging discs, or slipped vertebrae.

To learn more about central canal stenosis, see my video below:

How to Make the Critical Decision, “Should I Have Surgery for Spinal Stenosis?”

While medications or physical therapy may help, once the spinal canal gets much smaller, surgery is often recommended (1). There are a couple of types of common surgeries:

  • Decompression – The surgeon removes the bony back wall of the spinal canal and the ligamentum flavum and usually part of the facet joint to “open up” the area. A bulging disc may be shaved down.
  • Fusion – The surgeon places screws, rods, and often cages where the discs go. This fuses the area solid so that nothing moves.
  • Artificial discs – This is instead of fusion. This is where the surgeon takes out one or more discs and replaces them with a prosthesis.

Often decompression is performed with either fusion or artificial discs. The downside of both of these procedures is what’s called Adjacent Segment Disease (ASD). This means the area above and below the surgery will get too much force and begin to break down. See my video below to learn more:

Does the research show that surgery for stenosis works? Maybe in the short run, but in the long run several years after the procedure, patients are about the same whether they had the surgery or not. Or the surgery result is no better than just getting physical therapy (3,5,6). Won’t you get paralyzed if you fall or get in a crash? Regrettably, this is also a common misconception as the risk of the surgery usually exceeds the risk of spinal cord or nerve injury due to trauma (6,7).

Are there situations where someone definitely needs the surgery? Yes, if there is significant weakness in the hands or legs and less invasive therapy as described below doesn’t work, then the patient may need spinal surgery despite the possible side effects.

What Are the Risks of Surgery for Spinal Stenosis?

One of the reasons you may want to avoid spinal stenosis surgery is complications. To take a deeper dive into that subject, it’s good to understand that some of what spine surgeons report in research studies on complications is often very different from what patients report. Meaning that spine surgeons can underestimate surgery complications (2). For example, in a recent analysis, the complication rate of spine surgery was 10-24% (3). That’s 1 in 10 to 1 in 4 patients who got the surgery! Those complications included infection, nerve damage, more pain, or the need for more surgery.

If I Don’t Have Surgery, What Else Is Available?

We have been helping patients avoid spinal stenosis surgery for years by using their own platelets or stem cells. How does that work? Watch my video below to find out:

Does it work? Below are the MRIs of an elderly woman who we treated. The top row of MRI’s hasn’t been altered. On the left are the “Before” images and on the right are the “After” images. Since I know it’s tough for a non-physician to read these images, I have outlined the spinal canal in the images in the second row. As you can see, the size of that yellow area (the spinal canal) is smaller on the left before the procedure and much bigger after several procedures. This might not seem like a huge difference, but this difference helped this woman be able to stand again for more than an hour.

The upshot? Spinal stenosis is a common problem for many people as they age. The answer to the question “Should I Have Surgery for Spinal Stenosis?” is now different. These days there are non-surgical options. So think twice before a big surgery!

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References:

(1) Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. BMJ. 2016 Jan 4;352:h6234. doi: 10.1136/bmj.h6234.

(2) Ratliff JK, Lebude B, Albert T, Anene-Maidoh T, Anderson G, Dagostino P, Maltenfort M, Hilibrand A, Sharan A, Vaccaro AR. Complications in spinal surgery: comparative survey of spine surgeons and patients who underwent spinal surgery. J Neurosurg Spine. 2009 Jun;10(6):578-84. doi: 10.3171/2009.2.SPINE0935.

(3) Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev. 2016;2016(1):CD010264. Published 2016 Jan 29. doi:10.1002/14651858.CD010264.pub2

(4) Lurie JD, Tosteson TD, Tosteson A, et al. Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2015;40(2):63–76. doi:10.1097/BRS.0000000000000731

(5) Delitto A, Piva SR, Moore CG, Fritz JM, Wisniewski SR, Josbeno DA, et al. Surgery Versus Nonsurgical Treatment of Lumbar Spinal Stenosis: A Randomized Trial. Ann Intern Med. 2015;162:465–473. doi: 10.7326/M14-1420

(6) Cheung, Jason Pui Yin, and Keith Dip-Kei Luk. “Complications of Anterior and Posterior Cervical Spine Surgery.” Asian spine journal vol. 10,2 (2016): 385-400. doi:10.4184/asj.2016.10.2.385

(7) Murphy, Donald R et al. “Cervical spondylosis with spinal cord encroachment: should preventive surgery be recommended?.” Chiropractic & osteopathy vol. 17 8. 24 Aug. 2009, doi:10.1186/1746-1340-17-8

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5 thoughts on “Should I Have Surgery for Spinal Stenosis?

  1. William Wertman

    How well do plates and stem cells work for cervical spinal canal stenosis? Your information only addressed lumbar. I am a chiropractor and do a lot of power lifting at age 54. I had both knees done with platelets and stem cells at Regenexx with Dr Newton, with moderate to great results. I have moderate degeneration all over my cervical spine. I have mild left C6 radiculopathy with noticeable weakness in the C6 myotome with lifting heavy. Can not detect the weakness with normal daily activities or manual muscle testing. MRI also reveals moderate stenosis in the central canal from C5 to C7. Is it worth a trip back to Dr Newton.
    PS the weakness is improving slowly.

    1. Chris Centeno, MD Post author

      Yes, definitely worth a trip back to Dr. Newton to see if you’re a good fit. See https://regenexx.com/blog/living-with-neck-stenosis/

  2. Bridgette Lang

    It’s AMAZING to not need the shopping cart! It was my, “walker”-standing in lines were challenging, after a period of 20+ – screaming, tight muscles, pain/burning-I always tried to find the shortest line, closest parking spot, or best seat. (Seats with cushions). Yuck! Never again!! Makes me mad thinking about it- dealing with it- Years taken! Don’t do it too! Don’t deal, heal!!
    Now- I park the farthest. I enjoy walking and standing in lines! I hate the shopping cart! Poor hubby is now the cart driver, as I refuse! (Go him!)
    Rgxx- scolioplasty changed my Life!! I have, for sure, a better quality Life due to the brilliant mind of Dr Centeno and those who follow in his footsteps, science, and Love- the love to see people gain back their quality of Life, continue being active and happy!
    You can’t go back once cut; why advanced precise needle placement Injections with my own body helping ME out in mass numbers-is all I need to continue being MEEE!! Be PROACTIVE!! Keep active! Yay, to a body in motion!!

  3. Neil K Hersh, M.D.

    Another terrific presentation, Chris….as a fellow physician very interested in regenerative therapies, I wanted to express my appreciation & gratitude for your measured, logical approach. And your citing data from the literature is greatly appreciated. Sincerely, Neil K Hersh, M.D.

  4. Lance Wolrab

    This is precisely why I went to Grand Cayman in February. Measured performance using both crankset and pedal based power meters on my bicycle showed a shift over and 8 month period from 49/51% L/R balance, to 39/61% shortly before I had the reinjections. Mine were C3 – C7 facet joints 18 months after PRP here in the US and L3 – S1 intradiscal. I won’t say it was all fun. The first 36 hours post-injection were pretty tough, but the recovery is surprisingly quick. I had instant results – split stream urination ended, balance improved as noted by my Egoscue therapist, and now approaching 6 months later, I am seeing 45/55% L/R balance on my bicycle power measurement devices. Still some numbness in my toes, but I know nerve regeneration can take a long time and I have patience. Every day is a bit better. My lumbar MRI was so bad I didn’t need Dr. Williams’ opinion, I could see it for myself (I’ve been getting regular MRIs for over 10 years now, so I have some idea what to look for) the lumbar region had degenerated significantly since the previous MRI. I am expecting, based on results, the MRI at 12 months will show substantial improvement, and having my stem cells in storage for future use is a real bonus. I could not be happier.

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