The clinical picture of the disease is initially blurred, there are no characteristic symptoms.
Functional disturbances, as well as pain or irritation of the sciatic nerves, can be due to very different painful changes in the lumbar spine.
A typical symptom for the narrowing of the spinal canal is spinal claudication (Claudicatio spinalis). The patient complains of pulling pains in the front or back of the lower extremities when walking a short distance. The pains are relieved if he sits down or bends over his upper body. At the moment of inclination, the spinal canal expands, thus reducing irritation of the nerve structures. In extreme cases, where patients cannot walk even 100 meters, further diagnosis and therapy is required.
Normal x-ray diagnostics does not give any unambiguous indications with which you can make a diagnosis. In most cases, the diagnosis is made only after a CT scan - computed tomography. In many cases, magnetic resonance imaging is today a priority choice for diagnosis, which can be supplemented, in the case of severe multi-segment stenosis, with lumbar (lumbar) myelography, and after it with the use of computed tomography (CT).
The physique of a person contributes to the fact that the lower lumbar spine is constantly subjected to high mechanical loads. This results in very frequent degenerative changes. In this case, it is not the question “do they develop at all?” that matters more, but the question “how fast do they develop?”
With instability, which leads to slippage of the vertebrae, the spinal canal is deformed - it becomes oblong. If the cross section in the normal state usually resembles a “cocked hat”, then after deformation it becomes narrower and sharper.
Mechanical stress in this spinal segment causes the formation of spondylophytes as supporting elements. Perhaps, in response to such instability, the “yellow ligament” (Ligamentum flavum) also thickens.
The cavity at the disposal of the dural sac becomes smaller and can lead to irritation or damage to the nerve roots.
In many cases, the reason for such changes is mechanical instability. The musculature of the spine can be strengthened by appropriate gymnastics and, through this, instability and its consequences can be improved. As an accompanying therapy, the entire spectrum of pain management can be used. This is often necessary if only to make targeted training possible at all. The main emphasis of treatment is on exercise therapy, relaxation exercises, electrotherapy and skilled acupuncture, rather than the use of pain medication. In the absence of the therapeutic effect of the above therapeutic methods or with constant complaints, surgical expansion of the bony spinal canal is required. In this case, the corresponding nerves of the segment are released from bone pressure. Therapy for spinal stenosis is mostly conservative.
Operative methods of treatment can help with severe nerve damage or with the described clinical picture and unbearable pain that can lead to disability that is not amenable to other types of treatment.
Since there is no therapy for progressive degenerative disease of the spine that eliminates the cause of the disease, physical therapy and pain therapy are at the forefront of treatment. These include:
- Medication for pain relief (NSARP, opiates, etc.)
- Anti-pain plaster
- Implanted pumps for pain relief
- Physiotherapy pain relief treatment (electrotherapy, ultrasound, heat and so on)
- Infiltration therapy (nerve blockade, periradicular therapy, trigger point infiltrations)
- Mobilizing, stabilizing physiotherapy exercises
- back school
- Support corsages
Accurate diagnosis, determination of optimal therapy and sufficient analgesic treatment of advanced forms of the disease are possible only with inpatient treatment.
The greatest non-invasive therapeutic effect of pain relief is injections, when the drug is injected directly into the spinal canal (epidurally or epidurally).
For spinal stenosis localized in the upper lumbar region, the epidural infiltration method is suitable. With the help of sacral infiltration, it is usually possible to achieve an analgesic effect only up to the level of the 4th lumbar vertebra.
Epidural infiltration, in turn, is very flexible in terms of height. The level of injection corresponds to the approach used by anesthesiologists for spinal anesthesia.
With the help of a long needle, the space of the spinal canal is reached and, according to the principle of "no resistance", the needle is advanced until its tip falls into the cavity of the spinal canal, after which, as in the case of sacral infiltration, a mixture of local anesthetic and cortisone is injected. Pain therapeutic effect corresponds to the effect of sacral infiltration. In the case of repeated administration of medications, it is possible to connect a catheter system that provides constant access to the spinal canal.
Surgical treatment is used in very severe cases of spinal stenosis. Reasons for surgery may include:
- Unbearable pain that cannot be treated conservatively
- neurological atrophy
- Tendency towards disability/inability to move
- Spinal stenosis
- Young age of the patient
When narrowing the spinal canal, the most correct, priority method is, perhaps, open microsurgical decompression.
Microsurgery is understood as an open operation with a very small skin incision, using operating microscopes, as well as special, calibrated instruments.
Parts that are responsible for stenosis of the spinal canal and stenosis of the nerve roots are removed under microscopic magnification, that is, they are decompressed (parts of the vertebral arches, parts of the "yellow ligaments", parts of the vertebral joints). At the same time, the traumatism of the operation is minimized as much as possible.
The advantages of the microsurgical method are:
- a small surgical injury, as a result of which there is insignificant blood loss and the formation of small scars.
- Possibility of earlier mobilization and rehabilitation.
- Reducing damage to nerves and blood vessels.
- Achieving stability in the motion segment with dynamic implants (DIAM, X-Stop, Wallis, Aperius)
dynamic implants, as, for example, the X-Stop system and the DIAM system offer the opportunity to relax the pinched nerve roots and at the same time correct unfavorable movement dynamics without resorting to surgical intervention and opening the spinal canal. Mobilization after surgery is possible in most cases even in the evening of the same day, pain relief in the back and lower extremities is noticeable after a short time.
For spinal stenosis involving several vertebrae, the surgical incision should be widened accordingly. Then, for the individual steps of decompression, the operating microscope is again used.
If at the same time there is a pronounced instability of the vertebrae, then the unstable segments of the spine must be additionally stabilized. This can happen in various ways, in some cases, a second operation is necessary with intervention from the front and back (from the side of the abdomen and back). Sometimes it is enough to perform a separate operation on the back. The end result of such an operation is spinal fusion - the creation of immobility of the spine in the damaged section.