Melanie Cole (Host):  Welcome to Back to Health, your source for the latest in health, wellness and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I’m Melanie Cole and today we’re discussing minimally invasive spine treatments for spinal stenosis. Joining me is Dr. Neel Mehta. He’s the Medical Director of Pain Management and Co-Director of Weill Cornell Medicine’s Center for Comprehensive Spine Care. Dr. Mehta, thank you so much for joining us today. This is such a pervasive problem. So many people suffer from back pain of all sorts. Tell us a little bit about what is spinal stenosis. How does it develop?

Neel Mehta, MD (Guest):  Well first of all Melanie, thank you for having me and making me a part of your listening audience. It’s a pleasure to talk about something that I am passionate about in the treatment of spinal stenosis. Let’s take a moment to define what it is. The word stenosis means narrowing. So, people may have heard of carotid artery stenosis or coronary artery stenosis. That’s the narrowing of blood vessels that can lead to strokes or heart attacks. Fortunately, it’s not as severe of a problem in the spine but it can still lead to challenges with pain.

So, stenosis is the narrowing of a spinal canal that has led to the pressure on the nerve roots in the spine, leads to pain. The areas that cause stenosis can be from a number of reasons. Number one, you can have development of extra soft tissue such as ligaments or bone that encroaches into this canal. You can also have discs that are in between the bones in our spine that also encroach into the spinal canal putting pressure on these nerve roots. And then finally, bones can shift over time in what was once a straight column may have portions that shift and encroach into the canal.

So, I often use the analogy of a pipe where the water represents the nerves and the pipe becoming clogged leading to this condition of pain.

Host:  So, then tell us a little bit first before we get into some of these minimally invasive treatments. Can it be prevented or delayed at all?

Dr. Mehta:  Well, it certainly can be helped with conservative measures. But at times it will reach a point of no return and then further treatments may be. So what are those easy things to try first? Well physical fitness as with any other health condition is so important. Maintaining your weight in an ideal weight setting. Also being able to be flexible and build your core muscles can take pressure off of the back that leads to further development of extra tissue and bone. Using simple over the counter anti-inflammatories such as ibuprofen or also the use of acetaminophen can help with mitigating the pain. Physical therapy is something I offer all the patients that suffer from spinal stenosis to again, build on treatments and try to improve core strength and flexibility.

But eventually, many patients do progress to the point where stenosis becomes more symptomatic and they need help with treatment. So, medications can be prescribed that try to reduce the pain whether those are things like gabapentin or Lyrica or some milder pain relievers like tramadol. In rare occasions, when needed, we will consider the use of opioids but we all know the trouble that opioids can cause for patients, so we want to use those wisely and sparingly.

Host:  That’s so important and thank you for that. So, now let’s talk about first line treatment options for spinal stenosis. What are some initial treatments that you try? Now you mentioned some things to help prevent or delay, physical activity and maintaining core strength but tell us a little bit about what else you might try before you look into some of the surgical options.

Dr. Mehta:  So, another treatment option for patients is the use of epidural steroid injections. And this is the use of steroid in a concentrated and targeted fashion to the area of narrowing that is causing pressure on the nerves. And we believe the pressure on the nerves leads to development of inflammation and the inflammation causes pain. So, injecting steroid with the use of x-ray guidance to be precise allows us to calm or suppress that inflammation and hopefully reduce pain. And it’s a good use of treatment that’s minimally risky and can be done in an office setting without a lot of the steps that need to be taken but over time, if stenosis develops to a point where it continuously puts pressure on the nerves and the inflammation develops quickly; it may not be effective to keep using epidural steroids. And we will need something further beyond that.

Host:  Well then let’s talk about some of these exciting treatments that are the subject today. Tell us a little bit about Vertiflex Superion treatment for spinal stenosis. What is it, how does it treat this? Tell us a little bit about what it’s like.

Dr. Mehta:  Sure. Well it’s important to say that the gold standard for spinal stenosis beyond epidural injections was surgery. And that would involve a laminectomy where under general anesthesia, a patient would have an incision made by a surgeon to cut the bone and tissue that has encroached into the spinal canal freeing up space for these nerves. And for many patients, that may still be the right decision. However, there are patients that are sort of in between the benefit of epidural steroids meaning they’ve tried them and haven’t had sustained benefit but may not want to have surgery or may not be able to have surgery, something medically prevents them from having general anesthesia or the recovery needed for a full laminectomy.

So, fortunately, there have been developments in treating spinal stenosis that are more minimally invasive. One of them being, the Vertiflex Superion device. So, many spinal stenosis patients describe pain when they are standing or walking but when they sit, the pain is relieved very quickly. And often, in New York City, we judge walking ability based on city blocks. And my patients will report that they can walk many blocks as long as there are opportunities to sit along the way for a few moments. But another thing that they notice is that when they walk slightly bent at the waist, such as using a walker or walking in a grocery store leaning over a shopping cart; they find that their pain is relieved, and they can walk much further. And we’ve coined that term the shopping cart sign. That they improve with flexion or bending at the waist.

So, the spacer takes advantage of that to bend at the waist and to create a little bit more room in the spinal canal, it takes almost twenty plus degrees of bending at the waist to translate into a few degrees of movement in between the bones of the spinal canal to free up space around the nerves. But we could put a bracket or what I like to call it, a door stop in between those two bones so that we create the space without the patient having to bend forward. So, this procedure is done in a minimally invasive way. We make a very small incision only in the soft tissue, no bone is cut. It is done under sedation anesthesia or even potentially under local anesthesia depending on the patient’s condition. It takes about half an hour and the recovery is one day. The procedure is essentially a bracket being inserted in between the bones and then closing the skin with two small sutures and the patient going home shortly afterwards.

Host:  Isn’t that amazing? Absolutely fascinating. So, tell us who is a good candidate for this type of procedure and while you’re doing that, briefly tell us about some of the other minimally invasive options out there.

Dr. Mehta:  Well as we talked about, the ideal candidate is a patient that is beyond the conservative measures of physical therapy, medication and epidural steroid injection but still gets relief when they are in flexion or when they sit or when they bend forward slightly. If they experience pain 100% of the time, the spacer may not be successful for them. In terms of the patients that have done the best, they are patients that have had one or two levels of significant stenosis that were open to the idea that this is an interim step between conservative measures and surgery and that they may not get 100% relief but the recovery and pain and so forth is so minimal compared to a surgery.

In terms of other options, there is another procedure called the Mild procedure, M-I-L-D that uses a different approach to treating stenosis. So, rather than inserting a spacer or a bracket in between the bones to change the position; this one attempts to in a minimally invasive way scrape some of the bone or tissue that’s encroaching into the spinal canal with a very small port that’s inserted through the skin and muscle about the thickness of a pencil. Again, done under sedation anesthesia. Recovery time is minimal. Patient goes home the same day. And there are nuances between the two procedures that may make one a better choice than the other. Although I tend to use the spacer more these days.

Host:  Dr. Mehta, as we wrap up, summarize this for us about spinal stenosis and what you’d like listeners to know when they are looking for someone to help with their back pain; what lifestyle, home behaviors they can try, really what you’d like them to know.

Dr. Mehta:  Well first of all, nothing can beat physical fitness. So, controlling your weight, improving your strength, especially around the core muscles, continuing to walk; those things will help mitigate and prevent the development of significant spinal stenosis. But for those that despite their best efforts, do end up with moderate to severe spinal stenosis; they may need further treatment beyond things like epidurals and so forth. So, it’s important to ask your doctor about these treatments. Number one, are you a good candidate given the type of pain that you are experiencing. These are patients that typically experience pain in their legs and not just back pain. Number two, if you’ve had prior back surgery, can you still have these procedures done or will there be a limitation there. And also, it’s important to know if these treatments are not an option, what other treatments are potentially available besides surgery, such as the use of spinal cord stimulation and intrathecal pumps and I know I’ve introduced two terms that could be a podcast in themselves. But hopefully the viewers and listeners are able to use this information to have a meaningful discussion with their doctors.

I also want to add, that consultations for this can be done through video visits and reviews of imaging such as MRI and x-ray but it’s important to have one visit in office to do a thorough examination before undergoing this procedure. At Weill Cornell, we are taking all precautions to prevent the spread of COVID-19 including checking temperatures of patients that are coming. Also limiting visits and visitors during the times. And thorough cleaning in between patient visits.

Host:  Thank you so much Dr. Mehta for joining us today and sharing your incredible expertise. This is something that so many people suffer from with back pain so thank you for coming on and giving us great information. And Weill Cornell Medicine will continue to offer video visits for consultations and discussion to minimize travel and you can be confident of the safety of in-person appointments if needed. Thank you for joining us today and that concludes today’s episode of Back to Health. We’d like to thank our listeners and invite our audience to download, subscribe, rate and review Back to Health on Apple Podcasts, Spotify, Google Play Music. For more health tips, go to www.weillcornell.org and search podcasts. And parents, don’t forget to check out our Kids Health Cast. I’m Melanie Cole.