Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole and joining me today is Dr. Thomas Staner. He's a Clinical Professor of Neurosurgery at the Greystone Neuroscience Center Office of UAB Medicine, and one of the few neurological specialists in the country, who's board certified in both neurosurgery and neurology. Today, we're giving an update on spinal stenosis, helping patients receive faster treatment.

Dr. Staner can help with this, by seeing patients in the clinic at Greystone and directing them to the appropriate care. Dr. Staner it's a pleasure to have you join us again today. Tell us a little bit about some of the changes in spinal stenosis and give us some recent updates on the impact on the quality of life for patients.

Thomas Staner, Jr. (Guest): Well spinal stenosis is a topic that is becoming more relevant because of our aging population. Stenosis, you know, Greek word is to narrow is kind of comparable to having wires in a big pipe in a normal person or wires and a straw in a person who has some compression. And these could be the spinal cord or the nerves themselves. There is many symptoms. We're going to discuss the changes in our approaches to spinal stenosis during this topic. But I want you to be aware that again, this is a topic that is becoming more and more seen by our specialists and by the general population because of the aging. Now, people can have, if you will, all sorts of symptoms from spinal stenosis.

And that's because it can occur in the neck, the thoracic area or the lumbar, while the thoracic area is the least important by way of frequency, it still can occur even in the thoracic area. So, we look for stenosis or narrowing that can cause symptoms. The symptoms can be of varying nature. That could be a sciatic pain, for instance, that could be back pain, especially on extension, that could be paresthesias or numbness either in your upper or lower extremities. One of the things we hear is that sometimes patients are developing paralysis and they don't know it. They describe it as a heaviness in an extremity. And that is even with physicians that they themselves have this condition. They may not recognize that they're becoming paretic; they may complete a balance problems or even incontinence. And then there's the various syndromes that we have that we're all familiar with in medicine, I presume, central cord syndrome. Where you have weakness in the upper extremities and tingling. I seen a man this week that had a severe central cord syndrome, and yet he was undiagnosed. Cauda equina syndrome. I think we're all familiar with that. Patients have profound pain in the lower extremities, one or both, they could have loss of incontinence. They could have saddle anesthesia, sudden abrupt sexual dysfunction, but especially pain and numbness or weakness in both legs. And finally, there's even a Brown-Sequard syndrome where it's kind of a hemi section of the cord you get the spinal cord. We can have a loss of sensation on the contralateral side, through motor paralysis. So, there's a lot that you can be seen with spinal stenosis, depending upon where it occurs. It's affecting the spinal cord, which goes all the way down from the bottom of the occiput all the way down to the L one, two area, or if it's in regards to the cauda equina, distal to it. I tell patients that you can consider stenosis affecting you several different ways.

Think of a Christmas tree. The trunk of the Christmas tree holds, if you will, the spinal cord, until we get down to the cauda equina. It's the main pipe, if you will, for the spinal contents and where the nerves come out on the side, you can think of as the branches of the Christmas tree, that's the neuroforamen, that can also be tight.

And finally, especially in the lumbar area, you could have what we call lateral recess stenosis. The joints, the facet joints becoming somewhat larger and pressing on the nerves as they come round, if you will, to shoulder. The shoulder of the Christmas tree is where they come out. So, all these things are important for patients and they could have one or more of these conditions affecting them. And it's more important of course, if it's spinal cord, but still, it could be very important, even if it's, they cauda equina, that they could still develop immense paralysis. And it seems to run in families at times. And if one patient has it in, in the lumbar area, they may also have in the cervical area, we have to be aware of that.

Now, how do we diagnose this? Well, first of all, there were other clinical findings, right? And we diagnose it by imaging, MRI scan is ubiquitous now, and it's an excellent study, if we can use it for most patients to look and see if they have this compression. And also in the case of the cervical area and thoracic, you could see if they have myelomalacia or the spinal cord being directly affected.

We can see inside the spinal cord MRI scan. The CAT scan of course its strength is bony abnormalities. So, let's see maybe the neuroforamen where the nerves come out sideways, the branches of the Christmas tree. You could probably see that better than MRI scan. If we have concerns that we have, the neuroforamen been somewhat narrowed, then we might want to get a CAT scan after the MRI scan.

Not always, depending upon the quality, of course, the MRI scan. Generally as a rule, open MRI scans are not as useful as closed MRI scans, but some of our patients are clastrophobic. And if they can't take sedation well, that's, that's certainly an option. Even a moluck on the CAT scan are still used to clarify the area of compression. Plain spine films, generally are not very useful for evaluating stenosis.

So, I don't know if you're following with me so far, but if you're willing, I want to go over some of the costs of this for you.

Host: I would love that Dr. Staner it's absolutely fascinating. And you're making such great points for other providers about clinical findings and things they might not even consider as related to spinal stenosis. So, I would love for you to continue and to explain to other providers how you're helping patients receive faster treatment.

Dr. Staner: Well, we do the evaluations and the, as you can imagine, neurosurgeons are busy people. And in my practice, I did 36 years of surgical practice. In the last five years, I've been doing evaluations for other neurosurgeons. I find this particularly rewarding because I can be there for the patients when they need me most during the evaluation period.

And then afterwards, if they need conservative care or surgical care, expedite this quicker than probably a local physician can just because of my specialty. Now the different causes, generally speaking, we're talking about the aging spine. So, we're talking about the genesis of joint disease. However, there could be a congenital predisposition people with narrow spinal canals from birth are more liable to have this problem though that's not common.

So, what happens when you have a degenerative back? Well, you know, we all think about the joint disease affecting 80 and 90 year olds, but really, your spine starts changing after you're two years old and start walking. And by the time you're 30, you might see some changes in your spine, bulging discs, that are not causing problems.

Even the annular tears by the time you're 40, in that disc. Remember we're talking about a pipe. So, there's many sides to the pipe. It's a 360. It may be one side from a disc herniation. It may be on the other sides, posteriorly in the sides from the ligamentum hypertrophy. Usually occurs again, in the older spine, but there's other causes as well, tumors, trauma, even adipose.

Some people have adipose to the spine, which can cause stenosis. So, there's a lot that can cause this and it's best evaluated by obviously a specialist, in this condition, but a lot of general physicians should be aware of the primary symptoms that occur and can do the initial evaluation as well.

Especially if they see a patient who was complaining of those problems that we've mentioned and is older. What about treatment, et cetera? You know, I've been through many years of seeing treatment and I think fashions come and go and somethings stay that are valuable. I'm going to mention one thing that's of interest because this is a big topic, nowadays. Minimally invasive surgery. Arguably minimally invasive surgery was done in the 1960s, by some people. People don't know that. Endoscopic decompression is fairly recent, but things like Chymopapain for a disc herniation was used in the late 1960s and 1970s. In the 1980s, we had something called a percutaneous nucleotome for a disc herniation, looked like a large trochar with a guillotine on the side of it, so it would slice off and suck parts of the disc inside.

These did not stand the test of time, but the compressive laminectomies have. What has been added to the decompressive laminectomy's in recent years is something called laminoplasty's especially in the cervical spine. We move the lamina, and then decompress it. We put a wedge in there, make the opening in the canal bigger and then reapply it with wires or what have you. So, the canal is bigger and keeping the lamina intact. That has sought some favor in recent years. And especially there seems to be a great trend in the last 10 or 15 years towards fusion. People, I guess of my age, saw little need for fusion unless the spine was unstable or we were creating instability. But I realized that this is the present, if you will, gold standard, many times fusing, and this is where the surgeon's decision comes into scope. Still more recently, even I'm reading an article here in May of this year. Going back to endoscopic decompression, which is favored over fusion by some surgeons. So, we may be going back again to a smaller approach.

We'll see. But in any case, whatever your surgeon chooses, and there's more reasons that I can give in this talk the outlook for surgery on the spine for stenosis is excellent. Even when there's some paralysis, it can help frequently. Certainly, pain is one of the easiest things to help. And the question is what they have to decide on is when to do something.

And when is it necessary? What to do is, not as, maybe as quite as important. Again, there's many alternatives that we have available. At one time, we also had even interspinous devices. Pulling these spinous processes apart, creating more room inside the spine. This seems less favored nowadays.

I think people are getting a little bit away from that, but the gold standard is the decompressive laminectomy with, or without the fusion. And results are really, always have been very good. So the question will be then at an older person, are they able to have the surgery? Are they clinically stable? Are they an anti-coagulants?

What do we have to do with, to prepare them for a surgery? Are they massively overweight? These are questions we have to ask ourselves in the evaluation state.

Host: And are you using ERAS protocols too? As you're telling us how these landscapes have changed and how some of it hasn't changed. Really a fascinating talk, Dr. Staner are you incorporating ERAS? Are you seeing changes in that direction? Kind of give us a summary of what you'd like other providers to know about spinal stenosis and these patients receiving faster, more efficient treatment.

Dr. Staner: I suppose that there has to be a decision along the way about how to treat this, but the first decision is made as to whether or not they do have the condition by way of imaging. And again, I would encourage a closed MRI scan to start with, for most patients. This could be performed by the local physicians and they could come up with a diagnosis most of the time.

Now I would tell you this, that when you say spinal stenosis, remember we're talking about a pipe and you could have spinal stenosis and still have plenty of room for the nerves or spinal cord. So just having spinal stenosis by itself is not that relevant, unless there's compression on the nerves or the spinal cord. But this can all be evaluated frequently by the MRI scan. And then the next step might be to decide what the patient needs by way of treatment. The local physician, they start off with pain medications, with simple pain medication, not prolonged, but for a sudden episode anti-inflammatories, muscle relaxants can all be used.

And then the next stage after that would be a good pain management specialist, board certified in that topic who's an interventionalist who can give some spinal blocks. That might be the next stage, especially important if a person it has to do something the following month and he can't take time off for possible elective surgery, or he's just not a candidate for elective surgery because of his medical condition. Pain management partners with us and can be very helpful.

Host: What a great guest you are. You have a wealth of knowledge, Dr. Staner to impart to both patients and other providers. I can't thank you enough for joining us today. And a physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician.

That concludes this episode of UAB Med Cast. I'm Melanie Cole.