Treatment of Lumbar Spinal Stenosis

Lumbar spinal stenosis is a chronic pathological condition in which a narrowed spinal canal exerts pressure on the structures within it. The pathology progresses slowly, but there can be no improvement without treatment. As time passes and the situation worsens, the patients already at the time of diagnosis require a surgical intervention. Spinal stenosis mainly affects elderly patients, and its most frequent localization is the lumbar spine. When untreated, stenosis steadily develops and causes disability.

Content

1. Why does it occur?
2. Clinical manifestation
3. Conservative treatment
4. Surgery
5. Risk and prognosis after surgical treatment
6. European hospitals for effective treatment
7. The cost of treatment in European hospitals

Why does it occur?

The disease occurs due to congenital or acquired influences. Some people already have a congenitally narrow spinal canal, which puts pressure on the nerves, soft tissue or ligaments, thereby creating a very high probability to develop stenosis.

Spinal stenosis is most commonly caused by degenerative changes due to aging. However, degenerative changes can be due to morphological changes or an inflammatory process. As the body ages, the ligaments thicken and calcify (form calcium salt storages within the ligaments). There is also overgrowth in the vertebrae and joints (these overgrowths are called osteophytes). When one part of the spine is affected, there is increased stress on the intact part of the spine.

The age-related degenerative changes in the spine are the most common cause of spinal stenosis and they are usually presented in two forms of arthritis (osteoarthritis and rheumatoid arthritis).

Osteoarthritis is the most common form of arthritis and usually occurs in middle-aged and elderly individuals. It is a chronic, degenerative process that can involve many joints in the body. This disease is characterized by both wear and thinning of the surface layer of the joint cartilage. It is also often accompanied by excessive bone overgrowth and decreased joint functionality. When the facet joints and discs are involved, a condition called spondylosis occurs. Spondylosis can be accompanied by disc degeneration or by bone overgrowths, which can lead to both narrowing of the spinal canal and intervertebral foramen.

Rheumatoid arthritis usually affects people at an earlier age than osteoarthritis and implies the presence of joint soft tissue inflammation. Although rheumatoid arthritis does not often cause spinal stenosis, damage to the joint ligaments can be quite a serious precondition for spinal stenosis. Rheumatoid arthritis primarily affects the segments with excessive mobility (including cervical).

Other causes of spinal stenosis are spinal tumors and injuries.

Clinical manifestation

The narrowed spinal canal can be asymptomatic. However, if the formation suppresses the spinal cord, some symptoms slowly progress anyway. More commonly, patients notice that something is not right with the arms or legs: they can experience pain. If nerve roots are suppressed, patients may experience lumbosacral radiculopathy. Squatting or bending the spine can reduce the painful manifestations.

The patients with more severe lumbar spinal stenosis may have intestinal and bladder dysfunction, or lower extremity dysfunction.

The diagnosis is made after the collection of anamnesis and a diagnostic examination. Additional diagnostic methods used may include:

• Computed tomography (CT) of the spine.
• Magnetic resonance imaging (MRI) of the spine.
• X-ray of the spine.
• Myelography, scintigraphy, and electroneuromyography (if clinically indicated).

Conservative treatment

In cases with moderately aggressive conditions, non-surgical symptomatic treatment with high-quality physical therapy is used.

Conservative therapy implies using medications for pain management. These may be NSAIDs, corticosteroid injections, and injections with anesthetics.

Physical exercises are chosen individually by a physician to facilitate movement in the spine, strengthen the abdominal muscles and muscles of the back, which helps stabilize the spine. Aerobic exercises may sometimes be recommended to patients as well.

Corsets may help. But generally, corsets are designed to relieve pain and improve the spine condition only for a short period of time. As a rule, corsets are relevant for elderly patients with low degree of muscle strength and degenerative changes in several areas of the spine.

Chiropractic treatment acts on the deterioration of function responsible for the pain in the spinal segments. Such medical manipulations aim to restore the range of movement in the spine and remove muscle pressure. Chiropractic treatment uses traction techniques (spinal traction) to release spinal nerves from compression. Research has shown that chiropractic care is as effective as other conservative treatments.

Acupuncture is used as a conservative therapy method. It involves the stimulation of specific areas of the body with a variety of medical techniques, most commonly the insertion of fine needles through the skin. The practice has shown that it can achieve good results, especially for low back pain.

Surgery

The common efficiency of surgical intervention is linked to the development of microsurgical techniques. For example, 20 years ago, the most widespread option that doctors chose for the surgical treatment of stenosis was laminectomy, which resulted in vertebral instability at the area of manipulation and frequent recurrence of pain syndrome. Currently, microsurgical techniques allow radical decompression with minimal surgical trauma and preservation of all spinal support structures.

Here are several types of surgery for spinal stenosis elimination:

• Segmental stabilization (facilitates restoration of the correct vertebrae position, and stops the lesion of neighboring areas).
• Resection (removal of a part of the arch to enable decompression).
• Arthrodesis or spondylodesis (fusion of two or more vertebrae when they are unstable).
• Endoscopic lumbar foraminotomy (minimally invasive surgery aimed at the elimination of nerve root compression and fast elimination of the pathological process).
• Microdiscectomy (minimally invasive surgical procedure with a minimal recovery period).

The choice of the type of surgery is guided by the clinical picture of the specific case and the data obtained through instrumental examination methods. In case of central stenosis due to hypertrophy, methods of microsurgical decompression of the central spinal canal are sufficient. In the case of lateral stenosis and radicular compression, microsurgical decompression with the implantation of a prosthesis is indicated. A prosthesis lifts up the spinal structures and disables rotational motion in the operated vertebral segment, which is the prevention of lateral spinal stenosis recurrence.

Spinal canal decompression and implantation of a stabilizing system is indicated in cases of the affected segment instability. The possibility of osteoporosis must be excluded prior to such surgery, otherwise vertebral fractures are possible during implant placement and in the postoperative period. Considering that lumbar spinal stenosis is more common in elderly patients, some studies have been conducted to investigate the effectiveness of surgical treatment of this age group. It was found that in patients aged between 75 and 80 a positive effect of surgery for lumbar spinal stenosis was observed in 80%.

Surgery is indicated for paralysis and numbness, as well as for functional disorders that limit active lifestyle, such as walking or moving a lot. In these cases, conservative spinal stenosis treatment methods alone are, unfortunately, insufficient.

Spinal stabilization surgery is another surgical option that has been performed for many years in European hospitals. It can be conducted independently or in conjunction with various manipulations. When performing a spinal stabilization procedure, surgeons create the conditions that will allow for the vertebrae to stabilize and heal over time.

A doctor inserts a bone graft (often the patient's own tissue) or a substance that is supposed to stimulate the bone growth. Fusion (spondylodesis) is going to stop destructive displacement of the vertebrae, which will ensure the stability of the spine. As a result, the patients are usually free of pain after such a surgical procedure.

The postoperative treatment of spinal canal stenosis mostly takes a long time and, in many cases, depends on the stage of the lumbar spinal stenosis and the neurological changes that have already occurred. Recovery can take place both on an outpatient and inpatient basis. It can be also supplemented by home physical procedures.

Risk and prognosis after surgical treatment

Any surgical intervention is associated with risks because of the common use of general anesthesia and the overall high risk of intervention in elderly people. The liability of surgical intervention includes possible impairment of the dural membranes, infectious complications, or thrombosis. The presence of concomitant somatic pathology is a factor influencing the decision of whether to conduct surgical treatment.

As a rule, surgery enables a rapid regression of clinical manifestation due to the elimination of compressed nerve structures. But there are cases, where the symptoms persisted even after surgery. This is often the case in the presence of prolonged compression in the preoperative period, and significant damage to the nerve structures. Generally, the long-term results of surgical treatment are influenced by the degree of pathological processes in the spine and the quality of rehabilitation.

European hospitals for effective treatment

European hospitals provide therapy for different kinds of spinal diseases. The strict quality control and continuous advancements of European medicine makes qualified and effective treatment available to foreign patients.

High-quality and comfortable treatment in European hospitals is possible due to various conservative therapies using modern medications along with sparing surgical techniques. European doctors perform the most complex types of treatment of lumbar spinal stenosis with maximal therapeutic effect, which is achieved thanks to the modern diagnostic technology, microscopic equipment, and the latest generation medications.

The following medical facilities offer the cheapest spinal stenosis treatment in European hospitals:

• Hospital Waldbrol Oberberg, Germany.
• Academic Teaching Hospital Luisenhospital of the Aachen University, Germany.
• Hospital Neuwerk Moenchengladbach, Germany.
• Academic Hospital zum Heiligen Geist Frankfurt am Main, Germany.
• University Hospital Oldenburg, Germany.

The cost of treatment in European hospitals

The cost of treatment in European hospitals is calculated based on the pricing system approved by the local Ministry of Health for each diagnosis. The prices for all medical procedures, related services, and medications are regulated by both the Ministry of Health and insurance companies.

Based on the status of the medical facility and the type of treatment prescribed (inpatient or outpatient), the room chosen, and the position of the doctor, the full cost of treatment is formed.

The final calculation of the cost of treatment is made after discharge at the end of the course of therapy. At this stage, the pre-agreed fee may change depending on the additional therapeutic and diagnostic services performed. If less was actually spent than originally planned, the cost is recalculated, and the difference is returned to the patient.

• The price of diagnostics starts at 498 EUR.
• The price of laminectomy and discectomy starts at 3,670 EUR (depending on the number of segments involved in the treatment).
• The price of laminectomy and stabilizing surgery starts at 8,781 EUR (depending on the number of segments involved in the treatment).

The price of neurological rehabilitation starts at 540 EUR.

Authors: 

The article was edited by medical experts, board certified doctors Dr. Vadim Zhiliuk and Dr. Sergey Pashchenko. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!

Sources:

National Spine Health Foundation

SPINE-health

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