Transcription:
Non-Operative Treatments of Low Back Pain from Lumbar Spinal Stenosis

Joey Wahler: Lumbar spinal stenosis is a condition that causes back pain and can significantly diminish daily quality of life. So we're discussing this condition and its treatment options. Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. Thanks for listening. I'm Joey Wahler. Our guest, Dr. Brian Block, anesthesiologist and pain management expert at Maryland Pain Specialists and the University of Maryland St. Joseph Medical Center, a member of the UM Spine Network. Dr. Block, thanks for joining us.

Brian Block: Happy to be here.

Joey Wahler: So first, in a nutshell, what is lumbar spinal stenosis and what are its symptoms?

Brian Block: Stenosis in general is a medical term that just means narrowing. So lumbar spinal stenosis is narrowing in the lumbar spine, kind of the low back. It happens commonly as we get older as the connective tissues in the spine just kind of overgrow. I kind of describe it as the changes that we all see in our hands as we age. The tissues in the spine enlarge, and then they fill up some of the space in between the bones. And in that space, there are nerves that run down from your brain to your feet and those nerves are in the space, but now the space is smaller and that causes pain. So we call the space getting filled spinal stenosis. The tissues that overgrown are kind of ligaments and joints, you know, facet joints, and bulging discs, and also a specific ligament, so it's kind of a connective cartilage tissue in the spine.

Joey Wahler: So you mentioned older people being prone to this. Is anyone more predisposed because of genetics or anything else?

Brian Block: So in terms of who's more affected than others, it is still mostly age-related. But some people are going to develop it at a younger age and some people at an older age. So the main risk factors are a little bit of genetics, but primarily smoking and diabetes mellitus. There's something like 2 million people in the US alone with complaints of painful lumbar spinal stenosis.

Joey Wahler: And so you started to touch on it. Expand a little bit more, if you would, doctor, on what lumbar spinal stenosis affects most?

Brian Block: Most patients will complain of pain and fatigue and weakness in the legs, really when they stand or walk. When you stand up, the stenosis actually gets worse because some of the overgrown tissues start to bulge and really squeeze on the nerves. And then, when you sit down or if you were to lean over a shopping cart or a walker even, that stretches the tissue out and gives the nerves a bit more room to breathe, so to speak, and they feel better and have less pain.

So that description of pain with standing or walking has a specific medical term called claudication. Spinal stenosis is not the only cause of claudication, but is by far the predominant reason why people would have that kind of pain in the legs with standing or walking. Sometimes people with bad vascular disease will have vascular insufficiency and they'll have similar symptoms. So whenever I evaluate a patient, we do talk about that as the other thing to think about. But like I said, with the decrease in smoking rates in the US which has been wonderful, people have less vascular disease, but there's plenty of spinal stenosis out there.

Joey Wahler: Is this something that a patient can ever just tough out and live with or does it at some point have to be treated in some way?

Brian Block: Patients can tough it out. And some people clearly do. The fact that the pain gets better when you sit or if you lean over a walker means that patients always have the ability to just sit down. But that dramatically limits people's function. The inability to walk through the grocery store without sitting down, or really draping yourself over a cart limits people's functions in day to day life. So they do tend to seek care because it is debilitating

Joey Wahler: So speaking of treatment then, regarding nonsurgical options, can you discuss things like pain medication, steroids, physical therapy, and there's also something called complementary therapies?

Brian Block: Certainly. In general, in all of medicine, good medical practice is always to start with the simplest most conservative care. And so the first thing we'll do is some activity modification. Sometimes people just need to walk. They can kind of modify how they walk, go to physical therapy, get a little bit stronger and have a reduction in symptoms. So that's ideal.

In terms of medication, there are some oral medications that are useful. Simple over-the-counter medications, like, you know, Tylenol or ibuprofen are a little helpful. Sometimes that's enough and like other conditions, if the stenosis is severe, you end up doing more. And if the stenosis is mild, often people can be better with, you know, just some over-the-counter Tylenol.

For folks who don't get enough relief from activity modification or medications, either prescription or over-the-counter, we will do an epidural steroid injection, which is injecting anti-inflammatory medicine right into the tight area in the spine. The epidural injection doesn't relieve the stenosis, but it makes the nerves less irritable because the stenosis isn't what hurts, it's the nerves being pinched. And so if we can make the nerves less irritable, patients will have less pain. Some patients respond really well to epidural injections and they can be repeated, assuming that they're helpful for a long enough period of time, you know, months to years. For those who aren't sufficiently better, then we talk about more invasive treatments, minimally invasive decompression, or actual full spine surgery.

Joey Wahler: So speaking of which, when is surgery necessary in this condition and what does that involve?

Brian Block: Surgery is really only necessary when the pain is overwhelming, when the amount of function that someone is able to do is completely not enough to meet their quality of life. And then, you start looking at surgery. For the most part, most patients with lumbar spinal stenosis never reach the point of requiring surgery, otherwise they would be unable to walk. It's just they can't walk very far. If you were to be stenotic so severely that you were having actual weakness or foot drop or incontinence of urine or stool, that would be a dramatic surgical indication, but would be pretty uncommon.

Joey Wahler: So, doc, let's talk about MILD as it's called, which stands for M-I-L-D, minimally invasive lumbar decompression. What's that?

Brian Block: It's a great new procedure really designed to treat lumbar spinal stenosis. It's been in development for the last 10 years. But in the last two years, it has really become a big part of my practice. And I kind of situate it as more than an injection, but less than a formal surgery. Some patients do need surgery, but there are lots of folks who this can be, you know, plenty of enough treatment to improve them. It's very minimally invasive, hence the name. It uses just a little five-millimeter tube to use some small tubes and kind of scrape out that tissue that's overgrown that we spoke about to begin with. It doesn't remove as much of the tissue as a laminectomy, which is a spine surgery, instead just removes the most overgrown part, the part that's really causing the trouble in many folks, that's called the ligamentum flavum. Data on this has been really positive in my own hands and our practice. And, you know, the studies that have looked at this are showing, you know, 75% success with, you know, a 30-minute outpatient procedure. So it's really, really very intriguing.

Joey Wahler: So while surgery is needed only for the minority of patients with this condition, what is involved when that's needed?

Brian Block: Surgery definitely plays a role in the treatment of spinal stenosis. I'm not a surgeon, but, you know, I work with plenty of excellent surgeons. Mostly, they'll do, for this condition, something called a laminectomy, which removes the overgrown ligament, but also the overgrown bone and creates really a lot of room. It really does relieve the compression of the nerves. But it is a more invasive procedure and has a little bit more recovery and takes a bit more of the tissue out, which is both, you know, good and bad. So for patients who are having trouble, and we talked about not giving up hope, you know, it's a whole continuum of everything from over-the-counter, you know, acetaminophen, all the way to spine surgery, with things like injections and MILD and prescription medication, all in between.

Joey Wahler: So generally speaking, how often would you say using the non-surgical treatments we've discussed is this curable?

Brian Block: It's not curable as much as it's treatable. Love the term cure, love to, you know, cure disease forever. But in this category, we're really just going to treat it to reduce the symptoms and improve the function. And I would say almost everyone can be treated to the point where their function improves. Obviously, if you're 75, you're still going to have some limitations, because you're not 25. But we can dramatically improve things. Specific percentage-wise, it kind of depends on which treatment you're speaking of.

Joey Wahler: Gotcha. So you being involved in pain management, it sounds like you're really talking about doing just that here. Couple of other things, what daily activities would you say are usually best or worst for those suffering from this?

Brian Block: So the worst activities are going to be anything with prolonged standing or walking. So the patients who end up seeing me tend to be more, you know, severely affected, and those are the folks who can't even grocery shop. You know, they have to get a motorized cart just to get through the grocery store. So anything with standing or walking, particularly outdoors. You know, indoors, you might be able to hold onto something, but you know, if you have severe stenosis, you can't go for a walk in the park because there's no place to stop and rest. In terms of best activities, it's anything that's sedentary, which can get old after a while. But anything seated is generally fine. Patients have no pain with being seated. So they're perfectly happy to sit and read, watch TV, go to a movie, that sort of thing

Joey Wahler: So for someone that, as you said often helps people that can't even go grocery shopping without being in severe pain and then you see this dramatic change in them, how would you describe that change in terms of not just physically, but how emotionally that really changes their lives?

Brian Block: Oh, it's tremendous. It's very gratifying to be able to treat patients and have that kind of effect on their life. Patients can grocery shop, which seems kind of benign, but they can also walk from the car to the stands to watch their grandchildren play soccer or baseball. So it's more emotional than just routine daily activities. It's the ability to function in life with everyone else.

Joey Wahler: And so in summary, you've talked about the non-surgical treatment options that are usually right at hand for this and how successful they tend to be. So overall, what's your message for those listening that are suffering from this condition?

Brian Block: That they don't really need to suffer. They might need treatment, but we have plenty of great options. Whether it's medications minimally invasive procedures or full surgery, we have plenty of ways to really treat this and create a good quality of life.

Joey Wahler: Sounds like it indeed. Well, folks, we trust you're now more familiar with lumbar spinal stenosis and what can be done about it. Dr. Brian Block, thanks so much again. And you can find more shows just like this one at umms.org/podcast. Again, that's umms.org/podcast. And thanks for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again. Helping your health is good health. I'm Joey Wahler.