Spinal canal stenosis in the lumbar spine

introduction

At a Spinal stenosis it is a narrowing of the spinal canal. The spinal canal is formed by the individual vertebral bodies and surrounds them Spinal cord. If there is a narrowing in this canal, the spinal cord and the nerve fibers running in it suffer. The consequences range from pain to paralysis and abnormal sensations.
In the course of life it occurs in the area of ​​the spine wear-related (degenerative) Changes. Depending on how severely these wear processes change the spine, more or less pronounced clinical pictures such as spinal canal stenosis can occur.
But how does such a degeneration of the spine express itself?

In the course of wear and tear, remodeling processes take place on the spine. Among other things, this leads to the formation of excess bone tissue ('osteophytic Cultivation "), arthrosis of the intervertebral joints and damage to the Band washers (Intervertebral discs).
Since these "additions" take up space that is not naturally available, it can be too Constrictions (Stenoses) of said spinal canal and intervertebral holes (Intervertrebral foramina) come. The narrowing leads to a Compression of the spinal cord in the spinal canal and to one Entrapment of the nerve roots the spinal cord nerves emerging from the intervertebral holes. The most common is Lumbar spine affected by such spinal stenosis. The simple reason for this is that the lumbar spine has to absorb a lot of weight and particularly high forces due to the upright gait and gravity. However, other parts of the spine, such as Cervical spine, to be affected.

The typical main symptoms of spinal stenosis to the lumbar spine are load-dependent Lower back pain. These usually radiate into the legs and make walking more difficult for those affected. Those affected can usually only walk a certain distance without restriction and pain-free (Spinal claudication).
In diagnostics, there are imaging methods such as Computer and magnetic resonance tomography in the foreground. The latter in particular shows the narrowing of the spinal canal very well. Both conservative and surgical methods exist for treating spinal canal stenosis of the lumbar spine. The therapy is individually adapted to the patient and his complaints.

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causes

Spinal stenosis is not a sudden occurrence in the spine. On the contrary, it arises after a creeping, mostly for years unnoticed and unrecognized process. This is a slow wear-related, degenerative remodeling the bony structure of the spine. Not all degenerative changes in the spine cause symptoms; on the contrary, they appear in almost everyone in old age. So they are ultimately something natural that occurs as a result of age.
Whether or not symptoms develop depends heavily on the extent of the change, the basic stability of the spine, the general condition of the person and, above all, the burdenthat the spine is exposed to, for example through sport or work.
But what exactly are degenerative processes? And how can you imagine this? A degenerative change is a kind Wear and tear or decay of tissue, which is usually associated with a functional limitation of the affected area, e.g. a joint. There are various changes in the context of a spinal stenosis of the lumbar spine. An important process to be mentioned in this context is the creation bony attachments. These are also called osteophytic additions or Spondylophytes designated. These are bony attachments that occur at various points on the vertebral bodies and the bony processes of the vertebrae. Since these extensions are space-consuming and occur in places where no space is provided for them, it can be used Narrowing other structures come. In spinal stenosis, there are bony attachments important nerve roots at their exit points in the intervertebral holes (Intervertebral foramina) as well as that Spinal cord in the spinal canal constricted.
Furthermore are Osteoarthritis-like Changes in Intervertebral joints a consequence of wear and tear. The intervertebral joints are the joints that connect the vertebrae with each other, they are also called facet joints.

In the course of degenerative wear and tear, the Band washers in height. This loss of height and elasticity of the intervertebral discs leads to greater stress on the individual vertebral bodies. In addition, the important ligamentous apparatus of the spine also loses its elasticity, as it is no longer taut due to the loss of height.

A possible consequence can be a so-called Vortex sliding (Spondylolisthesis), in which the vertebral bodies slide against each other. Ultimately, all these degenerative changes result in constrictions in various parts of the spine. Strong back muscles can help to stabilize the spine and cushion forces and loads. People whose back muscles are not well trained are more likely to develop symptoms.
In addition to the changes in the spine caused by wear and tear, there are also other primary diseases that can trigger spinal stenosis of the lumbar spine. However, these are very rare. An example of such a disease is the Paget's disease (Ostitis deformans), which is a bone disease that promotes the appearance of bony attachments on the lumbar spine. Also disorders of the hormonal balance, like that Cushing's Syndromeat which increased Cortisone levels present in the blood can cause spinal stenosis. Ultimately, spinal stenosis of the lumbar spine can also occur as a complication in the course of operations on the spine.

Symptoms

The main symptom of spinal stenosis of the lumbar spine is load-dependent low back pain. Since spinal canal stenosis mainly occurs in the lumbar spine, this is where the pain is usually located. The pain does not suddenly develop overnight, but is much more the expression of a creeping process in the context of the degenerative changes in the spine. The pain occurs mainly when walking. The pain can suddenly radiate to the legs, forcing the person to stop moving. Pain-free walking is then only possible over a short distance.
This pain-related limp in the context of a spinal stenosis of the lumbar spine is known as Claudicatio intermittens. The load-dependent pain is caused by compression of the nerve roots in the lumbar spine that supply the leg. You may also feel numb in your legs. Walking downhill or sitting for long periods of time increases the discomfort because the lumbar spine is increasingly brought into the hollow back, which increases the narrowing.
The complaints decrease when the lumbar spine is bent, for example when walking uphill or cycling.
Spinal stenosis of the lumbar spine can lead to further symptoms such as tingling or burning sensations in the legs. These sensory disorders can also show up in the genital area.

More on this: Symptoms of spinal stenosis

diagnosis

When diagnosing spinal stenosis of the lumbar spine, the doctor uses various diagnostic tools. First of all there is the patient interview anamnese, in the foreground. Typical complaints of spinal stenosis of the lumbar spine, such as load-dependent lower back pain, are queried and already provide a sound suspicion.
Nevertheless, further important investigations are being carried out to safely rule out other diseases and to confirm the suspicion of spinal canal stenosis. There is a physical examination the spine and a Blood collection. In the blood collection, for example. Inflammation values certainly.
This is followed by imaging diagnostics, which are absolutely necessary to determine the exact location of the narrowing. Usually one is done first X-ray in two levels, which can make changes in the spine visible. In particular to exclude other diseases such as tumors, fractures, Abscesses and other processes it is very well suited.
Probably the most important and best method for assessing spinal stenosis of the lumbar spine is the Magnetic resonance imaging (MRI) of the lumbar spine because they can be used to evaluate ligaments, nerves, intervertebral discs and soft tissues particularly well. Degenerative processes and constrictions are particularly beautiful to see. However, that too Computed tomography (CT) a widely used diagnostic tool. The CT is particularly useful for assessment more bony Structures are important and clearly superior to other procedures in this respect. The CT is also often used in surgical planning.

In addition to these non-invasive examinations, there is also a somewhat more invasive diagnosis, namely the Myelography or the Myelo-CT. This examination is done through a puncture needle Contrast media injected into the spinal canal. The point of the contrast agent is, one better judgment of constrictions and compression. Myelography is particularly important when planning surgery if insufficient information is obtained from CT or MRI.

Do you suspect that you may have lumbar spine syndrome? To do this, carry out our self-test "lumbar spine syndrome":

MRI of the lumbar spine

The MRI (Magnetic resonance imaging) is an important diagnostic tool in the field of imaging to make changes in different structures such as the intervertebral discs, nerves, ligaments or the spinal cord visible. It is therefore the most important diagnostic tool in spinal stenosis of the lumbar spine. The narrowing of the spinal canal, which contains the spinal cord, and the intervertebral holes, which serve as exit points for the nerve roots, can be made visible.
Degenerative changes in different structures can also be assessed in this way. These include, for example, a decrease in the height of the intervertebral discs or abnormalities in the ligamentous apparatus. However, it should not be assumed that every change in the spine that can be seen on an MRI also causes symptoms. Not every abnormality in the imaging also has a consequence for the person examined.
The interplay of symptoms, such as pain, numbness and the like, and the extent of the abnormalities in the MRI is important. A weak point of the MRI is the assessment of the bony apparatus. In this point, the MRI is inferior to the CT. Therefore, a CT examination can be a useful addition to an MRI.

Read our articles on this

• MRI of the lumbar spine
• MRI vs. CT - What's the Difference?

therapy

Both surgical and conservative, i.e. non-operative, treatment options are used to treat spinal stenosis of the lumbar spine.

Conservative therapy

In the conservative treatment of spinal stenosis of the lumbar spine, there are various approaches that are briefly summarized here. Usually a versatile approach is in the foreground. Before considering any surgical measure, all conservative measures should be attempted.
An important cornerstone of conservative therapy for spinal stenosis of the lumbar spine is the Pain therapy Pain reduction is important to improve the patient's wellbeing and quality of life.

One possibility is offered by drug pain therapy. For this purpose, a level scheme of the World Health Organization (WHO) can be used, which specifies certain drug groups and their dose depending on the patient's complaints.

Another possible therapy for pain is the acupuncture Although the benefits of acupuncture are controversial, they are occasionally used.

Pain management is important for the patient for a number of reasons. You try that with good pain therapy Chronic pain develops as part of a Pain memory to prevent. In addition, usually only a largely pain-free patient can carry out further therapy options, such as sports exercises or physiotherapy. Good pain relief enables the patient to cooperate well.

Also Movement therapies and muscle relaxing Procedure as well as a Posture training are important for patients with spinal stenosis of the lumbar spine. Another important therapeutic approach is physical therapy. This makes use of different therapy modalities like the Heat therapy or Electrotherapy. They are designed to help relax muscles and relieve pain.

There are many exercises that can help with back pain. Exercises can be performed under the guidance of a physiotherapist or physiotherapist. However, simple exercises can also be performed well at home. However, they are by no means a substitute for adequate therapy and should rather be seen as a supportive measure. Above all, exercises in a slightly bent position help to widen the spinal canal and thereby reduce the stress on the crushed nerve root and the spinal cord. Below are a few simple exercises that can provide relief, especially for lumbar spinal stenosis.

• 1. „Cat hump“: For these exercises you should put a mat or a light blanket on the floor. Now kneel on the floor and come into the Quadruped. Your hands and knees are touching the floor. Now take a deep breath and make a "cat hump". The head hangs loosely. Hold the position for a few breaths. Then let your back sag loosely. Repeat the exercises 10 to 15 times, several times a day.
• 2. Kneel on the floor again and sit loosely with your buttocks on your calves. Now bend your upper body forward and place it on the floor. They stretch their arms away from themselves. Try to keep your buttocks on your calves. Repeat the exercises 10 to 15 times.
• 3. Step storage: For this exercise, lie on your back on the floor. Then place the lower legs on a stool so that the upper and lower legs form a right angle. To strengthen the abdominal muscles, you can now pull your upper body towards your knees in small movements. They stretch their arms forward. Repeat the exercises 15 to 30 times.
• 4. Lie flat on your back. Now pull your knees to your chest and hug them with your arms. They also pull their heads down to their knees. Make yourself whole "round". Hold this position for a few breaths.

In addition to such stretching exercises, certain types of sport are also gentle on patients with spinal canal stenosis. These include sports that come with an easy Torso forward tilt accompanied. A very good example of this is cycling, which many patients with spinal stenosis even find significantly easier than walking. Other back-friendly sports for people with spinal stenosis are Nordic walking or rowing.

In addition to the procedures mentioned, there are also psychological and psychotherapeutic approaches to coping with pain. The focus is on learning skills in order to achieve pain reduction and relaxation.
Often times, different approaches are in so-called Back schools combined. These represent a kind of comprehensive therapy concept in which back-friendly behavior is to be learned. Targeted strength training of the back and abdominal muscles is often combined with other therapeutic approaches.

Finally, there is also the option of treatment with local anesthetics (Local anesthesia). These are injected by an experienced doctor near the nerve root exit points in the spine. They are used to numb local pain. The infiltration of the intervertebral joints represents a similar therapeutic approach. In this form of therapy, a local anesthetic, mostly mixed with cortisone, is injected into the joint capsule of the intervertebral joints (facets). In order to hit the right area, the infiltration is done under vision with a CT.

Surgery for spinal stenosis of the lumbar spine

In addition to conservative therapy, surgical therapy is also an important pillar in the treatment of spinal stenosis of the lumbar spine. Risks of the operation must always be carefully weighed so that surgical intervention is usually only considered if conservative measures do not provide sufficient improvement.
There are many different surgical procedures that can be used for spinal stenosis of the lumbar spine. Two goals are in the foreground, namely discharge as well as the stabilization of the vertebral canal or the spine.
In order to ensure relief of the spinal canal, the excess bone tissuethat narrows the spinal canal, worn away. Depending on the extent to which bone is removed, a distinction is made between different surgical procedures:

• 1. Laminectomy: Special bony structures of the vertebrae, especially the vertebral arches, are removed in order to create space and the Eliminate constriction. A hemilaminectomy is a similar procedure, in which only half of the vertebral arch is removed. Nowadays, however, these interventions are almost exclusively carried out in modified form, as they can cause instability of the spine.
• 2. Windowing: A fenestration is a type of modified laminectomy. It is a microsurgical technique in which some material from the spine is removed through mostly bilateral, very small accesses. The procedure does not follow a uniform technique. The structures that are removed in the course of fenestration include parts of the intervertebral joints and the vertebral ligaments. In contrast to laminectomy or hemilaminectomy, the spinous processes and the vertebral arches are spared. This means that the risk of spinal instability after the procedure is lower than with a pure laminectomy or hemilaminectomy.
• 3. Interspinous spacers: This procedure is a kind of mixed option between conservative and surgical therapy. It can be used for patients with milder symptoms. Interspinous spacers or interspinous implants can be thought of as a kind of placeholder that is placed between the processes of two vertebrae. This creates a Expansion of the room reached.
• 4. Stabilizing procedures: As already discussed at the beginning of this section, in addition to relieving the load on the spinal canal and the nerve roots, stabilizing the spine is very important for the success of the therapy. A distinction is made between one solid merger a spinal column section and one dynamic fixation, in which individual vertebral bodies are splinted by a rod system and thus stabilized.

Please also read our article on this Surgery for spinal stenosis

OP follow-up care

Operations are always a burden for the patient, no matter how small it may be. In general, the surgical procedures used to treat spinal stenosis of the lumbar spine in the Keyhole technology (minimally invasive), i.e. with the smallest possible access points and wounds. Therefore, they are much gentler than operations with large surgical wounds and scars.
Immediately after the operation, the wound must be spared in order to ensure good healing. However, showering is usually possible with one on the first day after the operation special shower plasters possible. In the first 6 to 12 weeks after the operation, you should Lifting heavy loads, such as Turning movements the spine or other stresses are avoided.
Sports activities should only take place after Consultation with a doctor to be resumed. Depending on the surgical procedure used, full loading of the spine can only be guaranteed after half a year or even after a year. However, everyday skills can be easily performed.
After such an operation you should start with a Aftercare can be started in the form of physiotherapy, back training or physiotherapy. This should be recorded after 6 weeks at the latest. This also depends on the success of the operation and the general condition of the patient. This type of follow-up treatment is particularly important for the mobility and functionality of the spine and has good effects on patients with spinal stenosis of the lumbar spine.

Osteopathy

Also the Osteopathy is occasionally used in the treatment of spinal stenosis of the lumbar spine. After a confirmed medical diagnosis, a conservative attempt at therapy with osteopathic measures is carried out in some cases. These are e.g. Mobilizations of the spinal column. Among other things, hand movements are used to relax the muscles and unblock various joints. In the case of severe discomfort and instability of the spine, caution is advised, as osteopathic manipulations are occasional also damage on the spine.

Classification according to the degree of disability (GdB)

In which GdB it is the "degree of disability". This term is part of the Severely handicapped rights and represents a unit of measurement for the degree of disability. In the case of spinal column damage, which also includes spinal stenosis of the lumbar spine, the degree of disability is determined using the Restriction of movement, the extent of Spinal instability and the expansion of the affected area determined by the spine.
So there are different values ​​for the same clinical picture. In the case of spinal stenosis of the lumbar spine, values ​​of 0 to 100 surrender. The most important values ​​are briefly listed:

• GdB 0: It lies no functional limitation, restricted mobility or instability.
• GdB 20: There are moderate functional limitations in one Section of the spine. These are, for example, movement restrictions, persistent pain or a moderate Instability.
• GdB 40: There are moderate to severe functional limitations in two Sections of the spine.
• GdB 50-70: There are very severe functional limitations. This can be, for example. Stiffeners long spinal column sections (e.g. after operations).
• GdB 80-100: There is one severe restriction the spine so that hardly any stress is possible. This extends to the inability to walk or stand, for example in the context of movement failures or paralysis.

forecast

The prognosis of spinal stenosis varies from patient to patient, depending on the extent of the symptoms and the changes in the spine. In the case of mild symptoms, a satisfactory result can usually be achieved with conservative therapy. If pain and paralysis have existed for a long time, surgical procedures are preferred. However, these cannot guarantee absolute freedom from pain. Therefore, it is important to treat early and consistentlyto avoid long-term damage and irreversible consequences.