Spinal stenosis: Doctor responses to patient questions

The doctor is in!

Peter Ullrich, MD

The following explanations, insights and advice about spinal stenosis - including diagnosing the source of the pain, non-surgical treatments and surgery - are provided by Peter F. Ullrich, Jr., MD, an orthopedic spine surgeon and Medical Director for Spine-health.com.

Patients frequently e-mail us questions about spinal stenosis, and while we don’t provide individual responses, periodically, Dr. Ullrich will take time to respond to the more frequently asked questions and we publish the responses in this section of the site.

Please understand that the following responses to spinal stenosis questions represent the opinion of one physician, and are intended for informational purposes only and not as a substitute for professional medical help or advice.

Spinal stenosis questions and physician responses

Question: My 65 year old mother has had spinal stenosis and sciatic pain down her left leg for 6 years. She is otherwise in stable health. She experiences some numbness, coldness, tingling in her left leg and foot but mostly just horrific pain that doesn't respond to any treatment. She has nerve compression at L4/L5, and fusion surgery at one level with decompression has been recommended by a surgeon. She has tried all of the conservative measures to avoid surgery, including multiple steroid injections, to no avail. She has mild osteoporosis and osteoarthritis in her spine. She also has scoliosis in her thoracic spine. She also has lumbar disc disease. The surgery would address only her pinched nerve and would not attempt to correct her spine in any way (due to the severity and complexity of her conditions). It would only be to relieve the leg pain, which is debilitating. She is only able to walk/stand for minutes at a time.

I have 2 specific questions. Would my mom be a candidate for an artificial disk with the decompression instead of the fusion? Next question - I read that waiting too long for surgery can be a mistake. We avoided surgery based on recommendations of the first surgeons we consulted. I want to know if you can give me any indication about the chances that the nerve down her left leg has been compressed so long (6 years) that even after the decompression is done, the nerve will continue to cause extreme pain. This is my biggest concern - if she goes through the risk of the surgery, will it be for nothing if the nerve is severely damaged? Thank you so much for any guidance you can provide.

Doctor’s response: She would not be a candidate for an artificial disc. Artificial discs are designed only to treat pain due to degenerative disc disease. They do not stabilize the spine (as a fusion would) and do not provide for decompression of the nerve roots. They are absolutely contraindicated in anyone with osteoporosis or in patients over 65 years old as they will subside into the vertebral body.

From the information in your e-mail, it does sound as though a decompression would be reasonable at this time. In spinal stenosis cases, it is rare to see permanent nerve damage. The majority of time, the surgery for spinal stenosis works as well if it is done now or at a later date, and that is why a lot of physicians will encourage patients to wait until their pain becomes debilitating. The main goal of surgery is to relieve the pain and allow the patient to function better. In general, it is usually not necessary to do surgery to prevent nerve damage from spinal stenosis.

However, there is always a small chance that any surgery will not work. The most important thing is that the potential benefits of surgery outweigh the risks. A one level decompression and fusion is a reliable surgery for the most part, and if your mother has already had all other conservative treatments, and is now debilitated, I would think the potential benefits far outweigh any risks. Good luck.

Question: Had 2 back surgeries to remove a synovial cyst @ L4 and L5 on right side (in 2000 and 2002). The surgeries were to remove the cyst only. Now, I still have pain in my back, hip, butt and leg. Right leg cramps up and feels dead and numb. I also started having pain on my left side and is starting to go down my left leg. Recent MRI showed: bony 38; discogenic degenerative changes at L4-5 with moderate to severe proximal foraminal stenosis on left and moderate right sided foraminal stenosis. Do you think a fusion is in order? What type of Dr. - neuro or orthopedic? I tried everything!

Doctor’s response: In general, I have found patients who have had a synovial cyst will eventually require a spine fusion. This is not always true, but it is fairly common that a fusion will be required. I believe this is the case because the synovial cyst comes off the facet joint as it degenerates. Although a decompression can remove the cyst, the facet joint degeneration continues, and this eventually leads to instability at the affected joint. Either an orthopedic surgeon or neurosurgeon can perform this type of surgery. The best situation is to find a surgeon who has done a spine fellowship and/or concentrates their practice on spine fusions.

Question: My CT and discogram show that once again, I have spinal stenosis. I am a 53 year old female. 10 years ago I had a laminectomy/discectomy that made things worse. My new surgeon was appalled at the amount of material taken. He performed a pedicle screw fusion L-4, L-5, S-1 9 years ago (I had 3 other opinions that strongly recommended the same surgery). Now, 9 years later, the pain is back. He suggests first an epidural to see if it helps with the pain from spinal stenosis; second an L-3/L-4 fusion. He felt that a laminectomy might not work and that I would then require another surgery for the fusion. Also, he said that in over 20 years of practice, he has had this result (the L3/L4) only 15 times and that a fusion had 50-50 success with leg pain and less with back pain. My pain is 90% leg pain. I cannot drive more than 5 miles, have trouble walking, and my stomach is getting to be a problem, due to taking non-narcotic drugs. My weight is good and I am doing all non-invasive therapies.

Is this development of spinal stenosis at the L3/L4 typical in such cases? What is your sense of success with laminectomy vs. fusion at the higher level? Will the problem continue to return over the years (I am only 53)? Will it continue creep up the spine? Does stenosis pain just get worse and worse as the facet area increases?

Doctor’s response: It is not typical to get a transfer lesion to the level above a fusion, but it definitely happens. The only two choices for treating your spinal stenosis are either further surgery, and a spine fusion is usually necessary, or continued conservative treatment. The problem with further surgery is that it then creates an even longer lever arm to transfer stress to the next (L2-L3) level in the spine. My own experience is that the results are probably slightly better than 50-50, but the real problem is that you are taking another joint and further changing the biomechanics of the back.

I usually will advise my patients to maximize their conservative treatment for spinal stenosis (including epidural injections, therapy and even chiropractics), and if they cannot live with their activity limitations anymore, then consider surgery only as a salvage procedure. It is possible to do only a decompression surgery if there is no associated instability (i.e. degenerative spondylolisthesis). Obviously, the risk with a decompression surgery alone is that a spine fusion surgery may be necessary in the future. Basically, there is risk either way.

A spine fusion surgery may lead to further breakdown at the next level, and decompression surgery alone may lead to instability at the affected level and require a fusion in the future. In general, if a patient has mostly leg pain, and there is no instability, I will counsel him or her to have the decompression alone.

Question: After 7 weeks of X-Rays, MRI's and a bone scan, I have been scheduled for surgery. I have Grade 2 spondylolisthesis of the L4-L5 level, degenerative disc disease, spinal stenosis and osteoarthritis. I am in a lot of pain when not taking 800mg of Motrin and Percocet, especially in the morning. Until June 15th, I walked 3 mornings a week and played 6-8 hours of tennis every week. I have been doing nothing since the pain started. Are there any exercises I can do for the next 6 weeks? Swimming? Upper body weight exercises? I need to try to maintain my weight because I will not be able to do much after the operation either. I've always used exercise as a means of reducing my weight. I don't know how to eat less...and I'm bored, in bed when not working, sitting, watching TV, movies. Help!

Doctor’s response: Generally, patients with spinal stenosis and spondylolisthesis are more comfortable if they are sitting than when they are standing. Therefore, most are able to exercise best if they are in a sitting position. Either a recumbent or an upright stationary exercise bike is usually well tolerated, as you would then be in the sitting position. The other thing to try is water walking (or aqua therapy or pool therapy). In the water, your joints are unweighted; therefore, exercising in the water does not usually create as much pain as exercise on solid ground.

If you have questions about your spinal stenosis or other back problems, please use this site to find peer-reviewed health information about spinal conditions, diagnosis and treatment options. The quickest way to locate information on the site is to use the “keyword search” box located in the upper left hand corner of each page. Also, if you want to talk online with others who may be in a similar situation or exchange information with other patients with spinal stenosis, please go to the Spine Forum Message Boards.

Additional disclaimer: Spine-health.com does not offer medical advice or treatment. This information does not replace the physician-patient relationship, and the information is not medical advice or treatment. It should only be considered as one physician's opinion based on an extremely limited amount of information. Patients should always seek the advice of a trained health professional for back pain or any health condition. Please note that the contents of this section have not been peer reviewed by Spine-health.com’s Medical advisory board