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Identifying Spinal Stenosis, Pathology and Appropriate Treatment Options

On the hardwood floor at his local Y, John McFadden was engaged in a game of pick-up basketball. Moving across the court during one sequence, the 64-year-old longtime recreational player crossed paths with a player on the opposing team. They made contact, and the other player immediately fell to the ground in pain. Thinking the other player had tripped over his foot, John continued up and down the court without a second thought.

As their casual game ended and the other player limped over to him with an incredulous mien, the 64-year-old was in for a surprise. He was to discover the reason behind the other player’s abrupt fall to the ground and his shock in finding his opponent without any noticeable damage in the aftermath. During that sequence of the game when the two players crossed paths, they had, in fact, slammed their knees together.

The strange thing was, he never felt a thing.

Creeping Sensations

While John McFadden, a retired vice president of sales for Motorola Communications who lives in Wayne, Pa., stays active and keeps in shape, he
is not a man of steel, nor a superheroic figure oblivious to the pain of mortal men. No, the explanation is far simpler. And much more dangerous. The hard kernel of it is this: he has spinal stenosis.

At its most basic, spinal stenosis is known as a narrowing of the spine. This could mean a narrowing at several points, including the center of the spine, in the canals diverging from the spine, or in the spaces between the 26 vertebrae that make up the spinal column. As the osteal fortress around the spinal cord and emerging nerve roots, the spine plays a crucial role in our daily movements and motion, and any degradation or aberrance of it can carry severe consequences.

With spinal stenosis, these problems are characterized not by a single, specific disease presentation but by a host of outcomes that can occur due to the disease state’s tendency toward narrowing, according to Dr. Rolondo Puno, an orthopaedic surgeon at the Leatherman Spine Center in Louisville, Ky.

“Stenosis is a term we use where it’s not just the disc,” says Puno. “It’s kind of like a global problem. There are ligaments. There are bone spurs digging into the nerve. And sometimes there is what we call instability, where the ligaments get loose and the bone slips and you have movement of the vertebra in relation to another vertebra.”

Alternatively, some conditions, in the symbiotic fashion common to orthopedic maladies, can themselves lead to a diagnosis of spinal stenosis. In John McFadden’s case, he’s not sure what caused his condition. But unlike his wife, who also has spinal stenosis and saw a gradual progression with her disease, his symptoms appeared with a fury. About 10 years ago he was standing in line at a sporting goods store when a sudden jolt of pain shot down the back of his leg. It was severe enough that it made him consider ditching the store without checking out. As soon as he sat down in the driver’s seat of his car outside, the pain disappeared. But back at the office, standing up again, it returned.

The pain was enough to prompt a visit to his doctor, who performed an MRI and confirmed the condition. Since then he has been struggling with the condition day to day, though he has been able to maintain an active lifestyle, including tennis and basketball. But he does not know how much longer that will remain true.

“It’s becoming more and more of a problem,” says McFadden, who is wary of surgery and views it, like his doctors, as a last recourse. “It hurts basically all the time, at a low level.”

His wife, Mary Joe, after suffering from persistent back pain, had her condition diagnosed by an orthopedist about a dozen years ago. Since that time she has endured alternating cycles of pain and, with treatment, symptom-free living.

“When I first had it, and for several years after, I was almost crippled by the pain,” she says. “There were times when I couldn’t even walk. Where I needed help getting out of the chair. This severe pain was really debilitating when it was at its worst.”

Over the past decade, her treatment regimen has cycled through physical therapy, a chiropractor, a spinal decompression machine, steroids and pain medication. For the time being the treatments have worked, and she is without symptoms. “I’m free as a bird,” she says.

A Closer Look

Spinal stenosis typically affects men and women over the age of 50, though it can affect those who are born with a narrow spinal canal or who have suffered injury to the spine. As follows, there are several factors that can result in stenosis.

AGING. Changes that occur to the spine as people age are the most common cause of spinal stenosis, according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). This is true for several reasons. For one, the tissue that supports the spine may change, becoming thicker and harder. Secondly, bones and joint may enlarge. And finally, bone spurs, or surfaces of bone that bulge outward, are more likely to occur.

ARTHRITIS. In certain people, the degenerative condition of arthritis can lead to stenosis. Osteoarthritis is a more common cause than rheumatoid arthritis, but both can cause severe damage to the body’s joints. Mary Joe McFadden has been diagnosed with high-grade arthritis in addition to her spinal stenosis. “The stenosis is literally and figuratively an outgrowth of the arthritis,” she says.

OTHER CONDITIONS. Rounding out the list of conditions that can lead to spinal stenosis include osteophytes, which are the formation of bone spurs related to osteoarthritis; a herniated disk, which is a protrusion of cartilage between vertebrae; cancer malignancy; an abscess, or a localized
infection; a condition called spondylolisthesis, which occurs when one vertebra shifts from an adjacent vertebra; and bone diseases like Paget’s disease.

Where Does It Hurt?

The emergence and nature of John McFadden’s symptoms are not unusual. According to Dr. Puno, the legs are a common area in which the symptoms of spinal stenosis manifest.

“Patients come in with pain. They complain of leg pain, and sometimes they complain of numbness or tingling in their legs,” Dr. Puno says. “And sometimes they lose walking endurance and feel weakness in their legs.”

The manifestation of symptoms in the legs is normal for patients who present with spinal stenosis in the lumbar, or lower, spine. In the area of the cervical spine, on the other hand, the manifestation more commonly occurs in the hands. Patients may feel that their hands have become “clumsy,” and they may see changes in their writing patterns. Walking can be a notable sign in patients suffering from stenosis in the cervical area as well.

“Their walking pattern can change,” says Dr. Puno. “They walk like they’re drunk, like they’re losing their balance.”

Symptoms in Brief
• Pseudoclaudication, or difficulty in walking.
• Paresthesia, or abnormal skin sensations like numbness or tingling.
• Muscle weakness.
• Localized or radiating pain.
• Loss of bladder or bowel control.
• Paralysis.

Paralysis can occur in severe cases. It can present as loss of control of one or both legs, according to Dr. Puno. In those rare cases, surgery would be the recommended recourse. “If there is imminent paralysis or if the patient fails to respond to conservative treatment and it’s really affecting their normal lifestyle, then we recommend surgery,” he says. “The good thing is, most people don’t need surgery for it. They need symptomatic treatment.”

This course can take the form of medication, including those that limit swelling and reduce pain, as well as physical therapy, epidural injections, back braces, and a suggested limitation on activity. The latter treatment has not been embraced entirely by John McFadden, who continues to play basketball and tennis through the pain. McFadden, who has visited a chiropractor in the past and derived benefits from the treatment, primarily sticks to a regimen of over-the-counter pain medicine. Still, he has noticed restrictions to his lifestyle.

“It slows you down,” he says. “There are a lot of thing you can’t do because you’re always conscious that it hurts.”

Yet even with the pain, he does not view surgery as a viable option at this point in time. “I’m not interested in doing surgery unless it’s so severe that I can’t get around,” he says. “I don’t like the idea of back surgery. It scares me.”

Dr. Puno estimates that 80 percent of the patients he sees can live with spinal stenosis without ever undergoing surgical treatment. Most patients, he says, actively respond to medical management. For the 20 percent that must undergo a surgical procedure, several options exist, the goal of which, for any procedure, is to remove pressure from the spinal cord or nerve roots. One of them, known as decompression surgery, works by removing portions of the bone spurs and opening up the spinal canal to free the nerves. Another procedure, which may be coupled with a decompression technique, is a spinal fusion, which maintains the structural support of the spinal column through the insertion of rods and grafts.

There are many effective options for treating spinal stenosis effectively. The key is finding the right match. “It varies on the individual and it varies on the type of pathology,” Dr. Puno says.