Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're highlighting new and emerging therapies for spinal stenosis. Joining me is Dr. Thomas Staner. He's a Clinical Professor of Neurosurgery at UAB Medicine. Dr. Staner, it's a pleasure to have you join us. As we get into this topic, please speak about the current state of back pain today, the prevalence, the economic impact. What have you been seeing in the trends and what is really the scope of what we're discussing here today?

Dr. Thomas Staner: This certainly is one of the most common conditions that we have. It's a condition that affects us in the workplace because, of course, so many people can be injured with a simple condition like back pain. Specifically, we'll be talking about stenosis, which is of course a subcategory, if you will, of that. But back pain, per se, can include many, many things, including a typical strain that goes away easily. Stenosis is a little bit different now, and we addressed that once before in a podcast, and we're here to kind of update that, including a little review on a literature which I did in a famous site called Google.

Melanie Cole, MS: It's certainly a famous site, yes. So, let's speak about clinical indicators and imaging findings you rely on when you're diagnosing spinal stenosis. As you said, this is kind of under the umbrella of back pain. It's its own subcondition. So, how do you differentiate between something like this and other causes of similar symptoms?

Dr. Thomas Staner: Well, a good MRI scan is really essential. You can use a CAT scan sometimes and certainly a CAT myelogram could be indicated as well. But what we do at Greystone, we're part of the department of Neurosurgery for UAB, is we try to get patients in faster and we have ways of doing that. In addition, besides myself, there's an advanced nurse practitioner and also a physician assistant who all are oriented to care for the spine, and they're very familiar with that condition. Stenosis, of course, just by way of reviewing is the narrowing of a tube. So, it could be a stenosis of an artery, of course, but we're talking about the spine here.

And if I may just to review one more time about stenosis, think

about a Christmas tree. So, the trunk of the Christmas tree, that's the spinal canal. The spinal cord goes through that way down to about L1-2, where it becomes the cauda equina. Then, there's the neuroforamen, the branches of the Christmas tree, where nerves come out. And finally, especially in the lumbar area, there's the lateral recess stenosis that can also cross nerves and cause symptoms. And symptoms can come related to either spinal cord or peripheral nerves. They can come from the cervical, the thoracic, or lumbar area. And differential should also occlude in our minds the possibility that we may be dealing with a shoulder problem or a hip problem in addition or instead of the problem of stenosis. They're commonly associated with one another.

So, the treatment has not changed much in a way, but I have to tell you, before this podcast, i of course went into, what I said, Google and tried to find out, was there anything that I should be aware of someplace in this world that we should talk about? And well, yes, there is. For instance, I went into WebMD and I found out that, and this is in quotation marks in regards to stenosis, "Nothing can cure it." Well, that's a quote. I think that's terribly wrong. The first laminectomy was done in 1814. And by the way, the last 40, 50 years, at least, this has been routine to treat patients with stenosis by way of a laminectomy.

There's all sorts of other beautiful websites out there now I want to mention. They're alternative websites. So, we see stem cells from Thailand, And although they show pictures of patients that have laminectomy, maybe Chinese prolotherapy, acupuncture, acupotomy, which is kind of like an invasive acupuncture, all these new things are coming out, well, relatively old, that are being tried now that may not be readily accepted in our community.

The gold standard has not changed very much, despite attempts at devices like interspinous distraction, which caught on maybe about 15 years for a while, I think, in part because no surgeons could perform this like pain management specialists with safety. It just started having problems, especially between the spinous processes, especially in the lumbar area we're talking about.

But there's been many ways of treating this condition, and we have to be careful that we avoid the fantastic and that which is vogue. And, you know, 50 years ago, I remember this long enough that lasers were really what it was all about. And lasers worked out well for some specialties, less well for others. Laser was a tag that everybody wanted to join with them and have laser therapy. It's still very useful, again, for some specialties, probably much less so for neurosurgery in the spine. Nowadays, stem cells, I should say, be cautious about reading these sites and caution your patients that look at the source. If it's from Mayo Clinic, the Cleveland Clinic, places that are reliable, you can trust, but you have to be very careful because I've seen some wonderful, wonderful websites now, beautifully designed, where 90% of what they're saying is perfectly correct. But somehow, it's a sell mission, so we have to be careful about this.

Now, the gold standard still is a lumbar laminectomy. When do we think about doing that? Well, we start at the point of saying, we try to treat this conservatively first. We look at the patient. Is the patient 20 years old or nine years old? Do you have cancer recently, a heart attack recently, or is he in training for some kind of a marathon? There's a big difference between these. And what is the cause of for stenosis or narrowing of this tube. So, we might start off by saying take NSAIDs, anti-inflammatory, if it's a pain down the hip and leg.

One thing that has been in literature for a long time is to stretch the hamstring muscles, and I would disagree with that entirely. We tell patients not to stretch the sciatic nerve. Don't cause pain. Avoid that. Let that nerve heal. So, no hamstring stretching. Gabapentin, other medications can be very useful. Physical therapy, as long as we don't stretch the hamstring muscle, especially for back pain, can be very, very helpful, at least on a temporary basis. And sometimes we tell our patients, for instance, if it's just back pain from your stenosis, indeed, we could treat that conservatively. For instance, if you are fairly young or if you don't have blood pressure problems, you could try an inversion table. Just go down 10 or 15 degrees with your head down Trendelenburg. And that can alleviate the pain on a temporary level. But as we progress, we go further to pain management, epidural steroid injections, different type of blocks, facet injections, radiofrequency. All those have been, I believe, proven to help many, many patients through the years. So, non-surgical treatment can be tried.

Let's say a person has a bad condition and his pain is up there, but he's got a wedding next month with his daughter. Okay, we can still give him some pain medicine, tell him to try to avoid situations that cause his pain, give him physical therapy blocks, something like that. I think all that is you have to see the patient and treat the patient.

Now, the symptoms, this goes without saying that they can be very severe or very mild. In the first case of back pain with stenosis does not mean we should jump in and be very aggressive. Surprisingly, in the last two weeks, I've seen four quadriparetic patients. I think three were in a wheelchair. And all four of them could be improved by decompressive surgery, and probably a couple of them should have had it before it occurred. People ignore signs and symptoms many times. For instance, you're not going to ignore severe pain, maybe down the hip or leg or arm. You may not ignore that. But people may ignore paresthesias or heaviness in your arms. I'm talking about physicians may ignore it themselves on your own body, not realizing that they may be developing something called a central cord syndrome or compression in the cervical spine by stenosis.

Now, most of the time, stenosis probably indeed is caused by arthritis, degenrative condition. We get that as we get older. It's very common. It's one of the commonest things we treat, certainly, as the patient ages. So, we have to look at the whole patient and decide what to do. If a surgical approach is an option and advised, the prognosis are generally very good. That goes without saying that it hasn't changed very much in the last 20, 30 years or so, but that doesn't matter because the prognosis has been good throughout that time. Perhaps the only thing I see more now is that there is a tendency for neurosurgeons and spine specialists to perhaps fuse more. And we fuse, of course, if we think the spine is unstable, like something called spondylolisthesis, or if it might be unstable with the patient, for instance, having a decompression, and then we make him unstable androgenically.

So, it's a very fascinating topic, and the best part about it is it's almost always treatable. We can almost always help a person. We have patients that are 90 years old, and they say, I remember one in particular, she was going paralyzed, and I followed her, kept her on a cervical collar because this is a cervical stenosis. She kept on getting worse and worse, and eventually we had to have a talk. And I said, "You want to go for this?" She couldn't feed herself, she couldn't move. Surgery was an option, but she was 90. And she knew that, "Well, I might not make it through surgery or afterwards," but she couldn't live like that, she told me so. We did the decompression, she walked out of the hospital. There's wonderful stories like that, ad infinitum.

So, stenosis isn't a bad thing to have necessarily, and we don't want to rush to surgery of course. But the symptoms of paresthesias, of paralysis, especially noting it may be a heaviness, pain, all these should be looked at and that should be considered, especially the differential we mentioned. It may not be coming from the spine. And sometimes people can have several conditions causing the complaint they have. They can have a neck pain from arthritis, a cervical radiculopathy, shoulder problem, and a carpal tunnel in one person. So, we just have to keep an open mind about that.

Melanie Cole, MS: Wow. Such an interesting topic, Dr. Staner. And as you mentioned, there are conservative measures to treat and the advancements have come so far in your field with ultrasound-guided and intraoperative imaging. And when you're doing various facet, whatever you're doing, injection procedures, there's just been so many advances. But when you were talking about conservative measures, I'd like you to speak about the importance of this multidisciplinary collaboration, because as you are a neurosurgeon and doing what you do, then there are all these other people that are also involved in the PT and the exercise. I'm an exercise physiologist, and I know that I have worked with many of you for spinal stenosis specifically in some of those conservative measures. Speak about your team a little bit.

Dr. Thomas Staner: I'd like to first of all agree with you and say perhaps the biggest advances in my specialty for spine work really is imaging. Imaging is so much better now, and that applies to robotics and what we do at the time of surgery. Of course, we're the final solution, perhaps. And before that, we really encourage our patients to have treatment that's conservative. And usually, it's not just one thing like an NSAID. It usually is something like physical therapy, which by the way, some insurance companies say you have to have six weeks before they will agree to doing an MRI scan. So, they're a team approach. We have pain management at our facility. We've had it for many years. And there's a number of good pain management specialists across the Birmingham. We're very fortunate in that regards.

So, the different type of blocks they do, there's something in the last few years that we have come across by way of spine care, not directly related to stenosis. But sometimes associated with it, and that's called Modic changes and Schmorl's nodes. And these are things that, of course, may respond to physical therapy and anti-inflammatories. But they're found especially on the MRI scan. And in the past, we have ignored these. Radiologists don't even report them many times. But now, we find that there's something new the last couple of years, especially, I know we do this at the University Hospital, and I'm not sure it's done anywhere else, certainly not in Birmingham, I don't know anywhere else in Alabama, but it will be done, that's basically vertebral nerve ablation, where we put a large needle or trocar inside a vertebral body, thread an electrode, and coagulate a nerve inside the bone. And that's for Modic changes where there's edema, and we've had very good luck with patients that have had midline pain now, for some time. Schmorl's nodes, on the other hand, is like a disc herniation that goes downward, not back into the canal, but into the bone. We have been seeing that, I've seen that for decades, and we have not made much of it. We've ignored it to a harm, because we now found that many patients, especially if there's swelling of the bone around that area, can benefit from an old procedure called vertebroplasty or kyphoplasty.

So, things are moving ahead, especially with imaging and our analysis of imaging, and we must rely on our conservative partners who treat these patients, because if we jump a step, if we go right to the extreme, I don't think that's best medicine, when they may live an eternal life, especially if they're 70s, for instance, with stenosis, and never have a problem again.

Melanie Cole, MS: Dr. Staner, as we get ready to wrap up, it's so enlightening, this conversation, and you're giving us a lot to think about in this field that is such a burgeoning field. I mean, now we're involving pain management specialists and so many other of our colleagues. Now, how do you engage patients in their own care for spinal stenosis? Because that is also complex. And briefly explain to us how that works because we're looking at other factors and comorbidities of obesity and smoking. And I mean, there's all these things that can come into play when someone's dealing with spinal stenosis. So, I'd like you to speak to other providers about how you engage patients to be involved in their own care and help their own back issues so that they can have a higher quality of life.

Dr. Thomas Staner: Well, that's important. We have more options now. First of all, I mentioned Interventional Radiology, especially at UAB, has come a long way in the last few years in managing this, and with neurosurgery and with physical therapy and pain management, and they are their own separate entity in a way, because they provide things that are not necessarily provided by these other groups.

 I see a very large patient and they have back pain. And in the past, it was a catch 22. Well, I can't do exercise. Because I hurt my back, and if I don't, I get bigger. Well, nowadays, with these new drugs are out at the present time, I certainly would recommend that people speak to, if not their bariatric surgeon, their primary care surgeon, who has access to new medications that can help weight reduction. And this is a great opportunity now for our patients that are overweight. My partners downtown won't take a BMI over 40 and there's one person over 37, I believe. Well, that excludes a large number of our population. So, we have to give them some medication. It's seldom we can say to them, stop eating or exercise.

If they're adults, it's very hard after a certain age, middle age, to lose weight, but now we have options. We have opportunities, and GLP 1s, other things are available that make it so possible for them to say, "Look, we'll come back in a few months where I've lost the necessary weight and let's treat it then, unless there's, of course, emergency by way of paralysis.

We do indeed have great improvement in our capabilities, especially with our partners, what they have done, and of course, imaging and surgery. So, things are moving along. We just have to say a word of caution. Don't believe everything you read on the internet. Look at the source. Look at the source.

Melanie Cole, MS: What a great message and key takeaway from this discussion, Dr. Staner. Thank you so much for joining us. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. Thanks so much for joining us today.