The most common symptom from Lumbar Stenosis is leg pain. Patients experience what is termed Neurogenic Claudication - which most typically presents as increased pain in both legs when standing and walking is attempted. This pain most commonly is alleviated by leaning forward (Walking with a shopping cart) or sitting. Low Back Pain may also be associated with stenosis but is thought to generally be coming from the arthritis and the degeneration rather than from the constriction of the nerve roots.

Treatment of Lumbar Stenosis generally involved Non-Operative modalities. Anti-Inflammatory medication, Physical Therapy and time will usually alleviate some symptoms in the majority of patients. Lumbar Epidural Steroid Injections are often used to try to alleviate pain for those patients who failed to improve with non invasive treatments. The response to epidural steroid injections is unpredictable but they may alleviate leg pains for a significant percentage of patients suffering from Lumbar Stenosis.

An Operation for Lumbar Stenosis is generally reserved for those patients who have failed Non Operative treatments and have severe disabling leg pain when walking (neurogenic claudication). Patients had to have a complete work up which include X rays, MRI and sometimes a Lumbar Myelogram to confirm the diagnosis. The Gold Standard treatment currently for lumbar stenosis is a Lumbar Laminectomy. A Lumbar Laminectomy is a surgical procedure that removes the posterior bone in the spinal canal (Lamina) and the enlarged ligament (Ligamentum Flavum) that is commonly associated with it. This in turn increases the space available for the nerve roots which generally helps alleviate the pain in the legs. Alleviation of Back Pain from a Laminectomy is not consistent and generally is not on it’s own a good indication for a laminectomy.

Lumbar Stenosis may be associated with other conditions such as Spondylolisthesis (Slippage of one vertebra on the other) and/or Spondylolysis (a defect in the lumbar vertebrae) that may require different types of operative procedures. As always it is important to seek the advice of a board certified and preferably fellowship trained spine surgeon (Orthopedic spine or Neurosurgical spine) in order to get all the best options for maximizing a good outcome. We are fortunate to have several excellent Spine surgeons in the greater Princeton area and access to a surgeon with these qualifications is recommended.

The Disc itself is composed of two parts; Annulus Fibrosus and Nucleus Polposus. The nucleus is a gelatinous like material that is normally hydrated and is found in the central portion of the disc. The annulus is a thick avascular outer covering of the disc that contains the gelatinous central portion. When a disease process affects the integrity of the annulus, the gelatinous central material may escape or herniated into the spinal canal and cause compression to the nerve root (Radiculopathy), Spinal Cord (Myelopathy) or both (Myeloradiculopathy).

When a disc herniation happens in the low back and causes leg pain it is generally treated without an operation. Several studies have shown that up to 90 percent of people presenting with a disc herniation will have symptoms resolve non operatively within 6-8 weeks. Operative intervention is usually reserved for those patients that failed non operative treatment. A Lumbar Discectomy is a reliable surgery that generally yields excellent results in terms of alleviation of leg pain that is caused by a herniated disc. Generally Lumbar Disc herniations are treated from a posterior approach. There are several techniques for Lumbar Discectomy and when tailored to the individual patient, generally have an excellent outcome. Minimally Invasive Discectomy and Microdiscectomy as well as Open Discectomy all may be specifically tailored to the individual patient.

When a disc herniation happens in the Cervical Spine (neck) it usually manifests as intense arm pain, numbness and/or weakness in a specific distribution . Surgery is generally reserved for patients who do not respond to non operative treatments fro more than 6 weeks to three months. Depending on the location of the disc herniation several surgical options are available. Anterior Cervical Discectomy is an operation that is done from the front of the neck and is usually accompanied by an Anterior Cervical Fusion or recently a Cervical Artificial Disc Replacement. Cervical Disc Herniations may also be approached from a posterior approach with an operation that is called a Posterior Cervical Foraminotomy. A Cervical Foraminotomy now done with a minimally invasive approach using tube retractors and a microscope offers a great alternative to the traditional Anterior Cervical Discectomy and Fusion (ACDF) when applied appropriately.

It is Important to have all the newest and traditional tools available to both the Patient and the Spine Surgeon in order to maximize the success of the treatment.

The Lumbar Disc serves many functions. It has a “shock absorber” function between the lumbar vertebrae. It also facilitates range of motion of the low back (i.e. flexion, extension, rotation and lateral bending) and acts as a spacer between the vertebrae which allows for the individual nerve roots to pass through their respective exit hole (Foramina). The Lumbar Disc is composed of two parts, the Nucleus Polposus (Central jelly like material) and the Annulus Fibrosus (Thick outer layer that surrounds the center). This unique arrangement is what allows the disc to serve its function.

The term Degenerative Disc Disease is a diagnosis that encompasses a wide variety of conditions that basically result from a dysfunction of the lumbar disc. Disc degeneration may be age related, activity related (i.e. repetitive abnormal stresses to the low back) or sometimes may be triggered by a traumatic event ( accident) that caused the vertebrae, disc or both to be injured (i.e. a Burst Fracture). Regardless of the mechanism the end result of Degenerative Disc Disease may present as different symptoms in different patients.

Low Back Pain is a common presenting symptom of Degenerative Disc Disease. The Disc itself has nerve fibers supplying the outer surface of the disc and they are thought to be part of the reason that patients have pain from isolated Disc Degeneration or Internal Disc Derangement (IDD, Discogenic Pain). Low Back Pain may also be coming from arthritis at the posterior Facet Joints that may be part of the degenerative cascade. Leg pain (Sciatica) may also accompany Low Back Pain when the degenerative process causes direct pressure on the nerve roots (Lumbar Stenosis, disc herniation or foraminal stenosis) or results in instability (Spondylolisthesis)

The testing to confirm degenerative disc disease as the cause of the symptoms may be extensive. It is difficult to pinpoint exactly where the pain is coming from. X-rays, MRI, CT Scan and Discograms may be used as a part of the diagnostic work up and are individually tailored depending on the patient history and physical exam.

The mainstay of treatment for isolated Low Back Pain stemming from Degenerative Disc Disease is Non-Operative. All modalities should be exhausted prior to considering surgical intervention. Anti-Inflammatory medications, Physical Therapy, Injections, Chiropractic treatment, acupuncture and alternative medicine may and should be utilized prior to consideration of surgery for Low Back Pain that comes from Degenerative Disc Disease. For those patients who have tried everything and spent a minimum of six months at non operative attempts, Surgery may be appropriate if the patient’s diagnostic studies and symptoms are consistent.

Different surgical options are available depending on the patient symptoms, physical status, health and diagnostic studies. Lumbar Fusion is currently the Gold Standard for the treatment of Low Back Pain stemming from Degenerative Disc Disease. Different surgical techniques are available. Minimally Invasive and Minimal Access Spine Surgery has made great progress in the past 10 years and allows for smaller incisions, less blood loss and often less post operative pain compared to traditional open approaches. Anterior Lumbar Interbody Fusion (ALIF) combined with a Posterolateral Spinal Fusion or Transforaminal Lumbar Interbody Fusion (TLIF) combined with a Posterolateral Spinal Fusion are both techniques that I utilize depending on individual patients. Artificial Disc Replacement (Total Disc Replacement) has been evolving as a possible alternative for the treatment of isolated Discogenic Pain. Artificial Disc Replacement is still in its infancy and may be a good alternative for fusion. Further U.S. long term studies are necessary to make an adequate assessment as to the long term results and most importantly Safety of this promising procedure.

Regardless of the technical options that are available to the surgeon for treatment of back pain from degenerative disc disease, Patient Selection is probably the single most important predictor of surgical outcome. It is important for patients to be aware that surgical outcomes vary and to understand that surgery for back pain is for the most part elective in terms of quality of life improvement. As always it is important to seek the advice of a board certified and preferably fellowship trained spine surgeon (Orthopedic surgeon or a  Neurosurgeon) in order to get all the best options for maximizing a good outcome. We are fortunate to have several excellent Spine surgeons in the greater Princeton area and access to a surgeon with these qualifications is recommended.

Like Low Back Pain, Neck pain affects a large portion of the population. For most people with Acute Neck Pain, symptoms will resolve within four to six weeks with some simple treatments. Physical therapy, anti inflammatories, exercises and certain activity modifications will alleviate symptoms for most patients. Neck pain that lasts for longer than 6 weeks-3 months is no longer termed Acute Neck pain. Patients suffering from Chronic Neck Pain may benefit from certain Pain Management Modalities, depending on the specific cause for their pain.

Neck Pain can be due to a variety of causes. Cervical Degenerative Disc Disease (Spondylosis, Arthritis) may manifest itself as neck pain and/or Arm Pain (as a result of a “ pinched nerve”). The cervical discs act as shock absorbers between the bones in the neck (vertebrae). With aging or a specific injury (acute or chronic) the discs may become dehydrated, degenerated and loose their biomechanical properties that allow them to do their job. As the discs degenerate they may loose their height and /or cause a Disc Bulge or a Disc Herniation. This in turn may lead to the joints in the neck (Facet Joints) to become arthritic and form bone spurs. The Ligaments In the cervical spine may also in turn change in composition and become calcified and thickened. All these processes may manifest in different conditions depending on the anatomy of the individual patient.

Herniated Disc (Disk), Pinched Nerve, Bulging Disc (Disk) and bone spurs all may cause a Cervical Radiculopathy. Cervical Radiculopathy is pain, numbness and / or weakness along a specific nerve root that is being irritated by the disease process. Cervical Myelopathy is a more serious condition that is caused by compression of the Spinal Cord itself (rather than the nerve root) and an internal damage to the spinal cord “wiring”. Cervical Myelopathy may or may not be accompanied with neck pain, but the main symptoms involve overall motor dysfunction.

There are many conditions that cause neck pain; for the most part patients should exhaust non operative modalities prior to considering surgery. Certain conditions that cause neck pain such as Spinal Tumors, Fractures and Myelopathy may require more urgent intervention. It is important to seek advice from a physician that has all the diagnostic and treatment capabilities in order to make the best choice. A Fellowship Trained Spine Surgeon (Orthopedic Surgeon or a Neurosurgeon) who devotes all of his/her time to the treatment of spinal conditions has the latest tools and techniques to allow for the best treatment of spinal conditions.

Low back pain is a very common condition affecting up to 80 percent of the population in the United States. Fortunately the majority of patients suffering from low back pain will resolve their symptoms with simple treatments such as physical therapy, exercises, healthy living and sometimes anti-inflammatory medications. Certain conditions affecting the Lumbar Spine may cause low back pain that fails non operative treatments. There are conditions such as Degenerative Disc Disease, Spondylolysis, Spondylolisthesis, Stenosis, Arthritis and Internal Disc Derangement that may require more intensive treatments. Certain modalities such as Interventional Pain Management may offer temporary or permanent alleviation of pain by integrating different modalities. Interventional Pain Management may utilize Epidural Steroid Injections, Facet Injections, Rhizotomies, Sacroiliac Injections and other modalities that will decrease the inflammatory reaction from the pain generator in the lumbar spine. Patients that do not respond to any of the modalities that are available today to alleviate their low back pain may be candidates for Spine Surgery.

Spinal Surgery for Low Back Pain, for the most part is elective (i.e. not life threatening). There are very few conditions that cause low back pain that mandate surgery (Lumbar Epidural Abscess, Cauda Equina Syndrome, Tumor conditions of the lumbar spine and certain Fractures to name a few). There are many different surgical options that are available. It is important for patients with low back pain that requires surgical intervention to seek care from a physician that specializes in Spine Surgery only. Different surgical techniques such as Minimally Invasive Spine Surgery, Artificial Disc Replacement, and Lumbar Fusion have evolved to offer patients a safe and reliable surgical option for their specific condition when applied correctly.

There are other conditions in the Low Back that may manifest themselves as buttock or thigh pain, Sciatica or pinched nerve and leg cramps. Lumbar Herniated Disc (slipped disc, disc bulging, pinched nerve) may be as a result of Degenerative Disc Disease or an isolated process as a result of a twisting injury. Herniated Discs usually manifest as Radiculopathy, pain and numbness or weakness along a specific nerve root that is being affected by the herniation. Lumbar Stenosis, a narrowing of the spinal canal that usually causes Neurogenic Claudication, pain radiating to the legs when standing or walking. These conditions also usually respond to non operative treatments and surgical intervention is usually reserved for those with continued symptoms despite extensive attempt at non operative modalities.

Stenosis is a term describing narrowing of the spinal canal. In the Low back, Lumbar Stenosis causes narrowing of the space available for the lumbar nerve roots and often results in bilateral leg pain that is termed Neurogenic Claudication. When stenosis occurs in the cervical spine (Neck) it is usually the result of a slow degenerative process by which the Cervical Disc (the cushion between the bones in the neck) becomes worn down. As the disc degenerates and bulges in the spinal canal, the posterior Facet Joints and Ligaments become enlarged and may also intrude into the spinal canal. As a result, the space that is available for the Spinal Cord itself becomes smaller, hence the Cervical Stenosis. Cervical stenosis may also be due to other causes such as Congenital Stenosis (small spinal canal from early childhood), OPLL (calcification of the ligament behind the vertebral bodies and discs), Spinal Tumors (cancer that either originates in the cervical spine or metastasized to the spine) and Spinal Trauma (fractures and dislocations that cause a traumatic stenosis).

The most common cause of cervical stenosis is degenerative and this discussion will be limited to the diagnosis and treatment of this particular condition.

Degenerative Cervical Stenosis on its own does not necessarily warrant treatment. Patients that are asymptomatic generally do not require any particular symptoms. When cervical stenosis becomes symptomatic, treatment depends on which symptoms are caused by the condition. When stenosis affects mainly the actual nerve roots and causes isolated nerve root pain or weakness (Radiculopathy), treatment is mainly directed towards non operative modalities that will decrease the pain. Modalities such as Physical Therapy, Anti-inflammatories and occasionally injections may alleviate the nerve root symptoms. These modalities however will not change the anatomic Stenosis.
When the spinal cord itself is affected, cervical stenosis may result in a condition called Cervical Myelopathy.

Cervical Myelopathy- Signs and Symptoms

Hand Dysfunction – Patients often complain of their hands “not feeling right”. Clumsiness that manifests itself by difficulty with buttoning a shirt, holding on to small objects and dropping things unknowingly are common complaints.

Handwriting – patients often notice a definite worsening of their handwriting over a specific amount of time

Walking Difficulty – Balance is often affected with advanced myelopathy. Patients complain of unsteadiness on their feet when attempting to walk. Family members often notice this symptom. Leg weakness may also be noticed and patients may use walking aids to help with their balance

Neck Pain – Only about half of patients with cervical myelopathy will have neck pain; usually due to the degenerative process rather that as a result of the stenosis itself

Urinary Complaints – Urinary Urgency is often associated with myelopathy however urinary incontinence may happen with advanced cases

Cervical Myelopathy - Diagnosis

Cervical Myelopathy- Treatment

There are several different surgical options for the treatment of Cervical Myelopathy. Several factors influence the surgeon when making the appropriate surgical planning. The alignment of the cervical spine (Kyphosis or Lordosis), the location of the spinal cord compression (behind the disc or behind the vertebrae), the length of the spinal cord compression (single level or multiple levels in the neck) and the patient’s medical condition are all critical factors in making the right decisions.

Anterior Cervical Discectomy and Fusion (ACDF), Cervical Corpectomy and fusion, Cervical Laminectomy (with or without fusion) Cervical Laminoplasty are all procedures utilized in the management of this complex condition

It is important for patients to make sure their surgeon is experienced with all of these techniques and is able to customize a treatment that is aimed at maximizing the benefit of the surgery and minimizing the complications.