Condition: Spinal Stenosis

What is spinal stenosis?

Spinal stenosis is a narrowing of the spinal canal. Some patients are born with this narrowing, but most often spinal stenosis is the result of a degenerative condition that develops in people over the age of 50. Younger people with a spine injury or a narrow spinal canal are also at risk.

Spinal stenosis is the gradual result of aging and "wear and tear" on the spine from everyday activities. Degenerative or age-related changes in our bodies can lead to compression of nerves (pressure on the nerves that may cause pain and/or damage). This crowding of nerve fibers results in pain and numbness in the back and legs when standing or walking.

What causes spinal stenosis?

Your spine, or backbone, protects your spinal cord and allows you to stand and bend. Spinal stenosis causes narrowing in your spine. The narrowing can occur at the center of your spine, in the canals branching off your spine and/or between the vertebrae, the bones of the spine. The narrowing puts pressure on your nerves and spinal cord and can cause pain.

Spinal stenosis is the gradual result of aging and “wear and tear” on the spine from everyday activities. Degenerative or age-related changes in our bodies can lead to compression of nerves (pressure on the nerves that may cause pain and/or damage).

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As we age:

  • the ligaments of the spine can thicken and calcify (harden from deposits of calcium)
  • bones and joints may also enlarge
  • bone spurs, called osteophytes, may form
  • discs may collapse and bulge (or herniate)
  • one vertebra may slip over another (called spondylolisthesis)

What are the symptoms of spinal stenosis?

If you suffer from lumbar spinal stenosis you may feel various symptoms, including:

  • dull or aching back pain spreading to your legs
  • numbness and “pins and needles” in your legs, calves or buttocks
  • weakness, or a loss of balance, and
  • a decreased endurance for physical activities

Symptoms increase after walking a certain distance or standing for a time. Symptoms can improve when you:

  • sit
  • bend or lean forward (see Figure below)
  • lie down, or
  • put your foot on a raised rest
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How would I know if I had spinal stenosis?

Diagnosing Lumbar Spinal Stenosis
Before confirming a diagnosis of stenosis, it is important for your doctor to rule out other conditions that may produce similar symptoms. In order to do this, most doctors use a combination of techniques, including:

  • History - Your doctor will begin by asking you to describe any symptoms you have and how the symptoms have changed over time. Your doctor will also need to know how you have been treating these symptoms, including medications you have tried.
  • Physical Examination - Your doctor will then examine you and check for any limitations of movement in your spine, problems with balance, and signs of pain. Your doctor will also look for any loss of reflexes, muscle weakness, sensory loss, or abnormal reflexes.
  • Tests - After examining you, your doctor may use a variety of tests to confirm the diagnosis. Examples of these tests include:
  • X-ray - shows the structure of the vertebrae and the outlines of joints.
  • MRI (Magnetic Resonance Imaging) - provides a three-dimensional view of our back and can show the spinal cord, nerve roots, and surrounding spaces, as well as signs of degeneration, tumors or infection.
  • CAT Scan (Computerized Axial Tomography) - depicts the three-dimensional shape and size of your spinal canal and bony structures surrounding it.
  • Myelogram - highlights the spinal cord and nerves after a dye is injected into your spinal column, which appears white on an X-ray film

Precaution: Radiological evidence of stenosis must be correlated with your symptoms before the diagnosis can be confirmed.

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What are the treatment options for spinal stenosis?

Once a diagnosis of spinal stenosis is confirmed, the process of treating the condition usually begins with a regimen of non-invasive, “conservative” therapy.

Non-surgical Treatment of spinal stenosis

There are a number of ways a doctor can treat stenosis without surgery, including:

  • Medications, such as non-steroidal anti-inflammatory drugs (NSAIDs) to reduce swelling and pain, and analgesics to relieve pain.
  • Corticosteroid injections (epidural steroids) to reduce swelling and treat acute pain that radiates to the hips or down the leg. Pain relief from an epidural injection may be temporary and patients are usually advised to get no more than 3 injections per 6-month period.
  • Rest or restricted activity.
  • Physical therapy and/or exercises to help stabilize the spine, build endurance and increase flexibility.

While some patients obtain relief from symptoms with these treatments, others do not.

Surgical Treatment of spinal stenosis: Decompression

Non-surgical treatments may temporarily relieve pain. More severe cases of stenosis may require surgery.

The most common surgical procedure for stenosis is a decompressive laminectomy sometimes accompanied by fusion. Often referred to as “unroofing” the spine, this procedure involves the removal of various parts of the vertebrae, including:

  • illustration “unroofing” the spinethe lamina, as well as the attached ligaments, that cause compression of the spinal cord and nerve roots, and/or
  • enlarged facets, osteophytes and bulging disc material

    The goal of the surgery is to relieve pressure on the spinal cord and nerves by increasing the area of the spinal canal and neural foramen.

Other types of surgery to treat stenosis include:
  • Laminotomy - only a small portion of the lamina is removed to relieve local pressure on the spinal cord and nerve roots.
  • Foraminotomy - the foramen (the opening through which the nerve roots exit the spinal canal) is enlarged to increase space for the nerves. This surgery can be done alone or with a laminotomy.
  • Facetectomy - part of the facet joint is removed to increase space for the nerves
  • Interspinous Process Decompression (IPD) IPD is a surgical procedure in which an implant, called the X-STOP®, is placed between two bones called spinous processes in the back of your spine. It is designed to remain safely and permanently in place without attaching to the bone or ligaments in your back. Learn more abotu the X-STOP® devise and procedure below.
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What is the X-STOP® Device?

X-STOP deviceThe X-STOP® is a titanium metal implant designed to fit between the spinous processes of the vertebrae in your lower back. It is designed to remain safely and permanently in place without attaching to the bone or ligaments in your back.

The oval spacer fits between the spinous processes and the wings are designed to prevent the implant from moving.

Patients can gain relief from chronic lower back pain, and may walk out of the hospital the same day, thanks to this innovative new surgical implant that recently was approved by the FDA.

The X-STOP® Interspinous Process Decompression System implant is inserted through a small incision in a patient's back. It separates the ligaments and bone, which prevents pressure on nerves and immediately relieves pain. The procedure takes less than one hour and typically requires a local anesthetic. Many patients are able to stand upright and walk the same day of the surgery.

[Please note: The X-STOP® implant is manufactured from a titanium alloy of metal. Please inform your doctor if you think you are allergic to titanium or titanium alloy. It is also known to produce artifacts if you undergo an MRI exam. If you have an MRI exam, after you have had X-STOP® surgery, inform your doctor that you have the X-STOP®.] Failure to inform your doctor may affect the quality of diagnostic information obtained from these scans. The X-STOP® is MRI safe.

What What is IPD®?

Interspinous Process Decompression (IPD) is a surgical procedure in which an implant, called the X-STOP®, is placed between two bones called spinous processes in the back of your spine. With IPD surgery or X-STOP® spinal stenosis surgery there is no removal of bone or soft tissue. The X-STOP® implant is not positioned close to nerves or the spinal cord, but rather behind the spinal cord between the bony spinous process.

How is the X-STOP® procedure performed?

Using local anesthesia and with the help of X-ray guidance,the X-STOP® Interspinous Process Decompression System implant is inserted through a small incision in a patient's back.

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Alternatively, your surgeon may elect to use general anesthesia. It separates the ligaments and bone, which prevents pressure on nerves and immediately relieves pain. The procedure takes less than one hour and typically requires a local anesthetic. Many patients are able to stand upright and walk the same day of the surgery.

Specialized spinal surgeons such as James S. Hamada, M.D. perform this procedure, which is just one of the minimally invasive surgical treatments offered by Tri-City Medical Center for back and spinal conditions. Minimally invasive techniques are performed whenever possible so that patients can benefit from smaller incisions, faster recovery and less post-operative pain. 

You will be placed on your side during the procedure so that you can bend your spine when the X-STOP® is inserted. The surgery to implant the X-STOP® typically lasts 45 minutes to an hour-and-a-half. During this time you may be awake and able to communicate with your doctor.

Patients may experience rapid relief from their symptoms and enjoy improvement of physical function. The unique design of the X-STOP® implant enables it to be inserted using a minimally invasive approach, resulting in very little tissue disruption. Also, the X-STOP® implant's unique design allows it to be implanted without fixation to bones or ligaments so to provide a reversible procedure that should not limit future treatment options. Due to its minimally invasive nature, the procedure can typically be performed in less than an hour, and as demonstrated during the clinical trial, with a low rate of procedural complications.

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Am I a candidate for X-STOP® spinal surgery?

You may be a candidate for the X-STOP® spinal surgery if you have primarily leg pain rather than mostly back pain and your pain is due to spinal stenosis/ foraminol stenosis. Your leg pain is worse with prolonged standing and bending backwards. You must get significant relief of your pain when you sit down and bend forward or stand and bend forward.

According to an independent market research organization, there are approximately 1.4 million individuals in the United States with a primary or secondary diagnosis of lumbar spinal stenosis. The X-STOP® device may be a treatment alternative for approximately 220,000 of these individuals who would have otherwise been treated with conservative non-operative therapies or with a surgical procedure called a laminectomy.

What are the benefits to being treated with the X-STOP® IPD®?

IPD offers several benefits compared to traditional surgery for lumbar spinal stenosis, including:

  • the option of local anesthesia
  • the potential to be an outpatient procedure (often walking out of the hospital on the same day as surgery)
  • usually no removal of bone or soft tissue allowing for potentially quicker recovery
  • fully reversible procedure that does not limit any future non-surgical and surgical treatment options
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  • the implant can be removed
  • virtually no chance of dural tear or neurologic complication
  • does not create instability
  • insignificant blood loss
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X-STOP® IPD®: Clinical Study Results

The X-STOP® IPD System was tested in a carefully controlled research study that took place in nine hospitals across the United States. In this study, 100 patients with lumbar spinal stenosis had x-stop spinal surgery with the X-STOP® device. These patients were compared to 91 patients who did not have surgery, but were treated by their doctors in other ways (for example, with medications, corsets, physical therapy, etc.).

Approximately half of the patients who received the X-STOP® device in this two-year research study experienced a degree of pain relief and ability to increase their activity levels that was sufficient to be considered a successful outcome at two years after the surgery. The clinical benefit beyond two years has not been measured.

The likelihood of needing an additional operation during the study was low. Overall, 90% of patients had significant improved clinical outcome.

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