Conquer Back and Neck Pain - Walk It Off! (20 page)

A patient once consulted me because of back pain, aching in her legs while walking, a limp, groin pain, and loss of motion in one hip. She had an MRI scan of her spine that showed spinal stenosis and an x-ray of her hip that showed osteoarthritis. She was exercising for an hour a day on an exercise bicycle and had lost 50 pounds on a diet over the previous year. Her quality of life was moderately impaired because she could no longer play tennis. She did not want to have her hip replaced or have spinal surgery for stenosis. Her reason for the consultation was to get my reassurance that she was not harming herself by delaying surgery on her spine. I reassured her that, on the contrary, she was helping herself by exercising and waiting for surgery until either condition significantly impaired her quality of life. If she had been unable to keep up her exercise routine and was getting out of shape, I would have recommended surgery for her hip as well as her spine. The order in which I would have recommended the surgery, hip versus spine, would have depended on which symptoms were bothering her most — those coming from the hip or those coming from the spine.

In this pain drawing, the patient shows pain in the right groin from arthritis of the right hip and pain down the backs of the legs and sides of the thighs from spinal stenosis in the low back. The patient describes the pain from both conditions as aching in nature.

Twenty percent of people with symptomatic spinal stenosis in the lumbar spine (low back) can have stenosis in the cervical spine (neck). The normal diameter of the spinal canal in the neck is the size of a nickel. The spinal cord in the neck is the diameter of a dime. The combination of disc narrowing and bulging, facet enlargement, and ligament thickening can narrow the spinal canal in the neck to less than the diameter of the spinal cord. When this occurs, the blood supply to the spinal cord in the neck can be shut off and parts of the spinal cord will stop functioning (myelopathy). This is exactly what happened to my aunt (read her story in
Chapter 1
).

Loss of balance, stumbling, tripping, falling, and lack of coordination may be symptoms of spinal stenosis in the neck. Although some patients will experience pain in the arms with exercise that is relieved by rest (neurogenic claudication), it is not as common as leg pain from spinal stenosis in the low back. This presents a real problem for patients who have severe symptomatic spinal stenosis in the neck and low back at the same time. Occasionally I will see a patient with severe spinal stenosis in the low back and neck who cannot walk more than a few hundred feet because of leg pain. They are so preoccupied with their leg pain that they do not realize that they are tripping and falling because of severe spinal stenosis in their neck. I try to explain to them that they should have an operation on their neck to relieve the pressure on their spinal cord to prevent paralysis (remember the story of my aunt whose surgery was too late to save her?) before having an operation on their low back to relieve their leg pain. This is always difficult for the individual to understand because they want their pain relieved first. Fortunately, for some people who are in good general health, we can perform surgery on the neck and the low back under the same anesthesia.

Arm pain from a spinal stenosis or a disc herniation in the neck can be confused with shoulder pain from rotator-cuff problems and with hand pain from carpal tunnel syndrome. All three conditions may be present at the same time, with pain from one site compounding the pain from another site and confusing the patient as well as the doctor as to where the pain is coming from. This situation is called shoulder-hand syndrome. In these cases I will consult a neurologist (medical specialist in diseases of the brain, spinal cord, and peripheral nerves; see
Chapter 4
) to try to determine which site is the primary source of the arm pain. Neurologists often perform an electomyogram and nerve conduction velocity (EMG/NCV) to sort out this syndrome. This test is performed by placing needles in your muscles and stimulating the nerves to the muscles and measuring the way the muscle contracts as well as the speed of the impulse along the stimulated nerve. An EMG/NCV can determine if the pain is coming from the nerve being stimulated in the neck area or at the wrist (carpel tunnel syndrome). It is an uncomfortable test, but it is not harmful or dangerous. This test is also used to differentiate leg pain from peripheral neuropathy, a condition seen in diabetics, versus pain from spinal stenosis.

Another source of pain in the upper extremities that can be confused with spinal stenosis is thoracic outlet syndrome, which is a constriction of nerves from your neck to your arm that occurs between your collarbone and your first rib at the base of your neck. This is a rare syndrome and can be diagnosed by your doctor by feeling the arterial pulses in your wrists at the same time your arm is moved passively throughout a range of motion.

Spinal stenosis can also occur in the thoracic spine, but it is rare. If it does occur, it is usually localized to the lower thoracic spine where it joins the lumbar spine. And it is almost always associated with spinal stenosis in the lumbar spine. The symptoms of spinal stenosis in the thoracic spine can be pain and weakness in the legs with walking. Anyone with a congenitally small spinal canal is susceptible to developing symptomatic spinal stenosis in the thoracic spine. Therefore we usually perform an MRI scan of the entire spine, neck, chest, and low back in people who are born with a small spinal canal.

Is surgery the only answer for spinal stenosis? Let’s answer that question for the low back first. Spinal stenosis develops slowly over a period of years and usually does not cause nerve damage. Symptoms of pain, weakness, or poor balance may come on intermittently and slowly or all at once near the end stage of the disease, when the spinal canal is severely narrowed. From my experience in advising thousands of patients who suffer from the symptoms of spinal stenosis, surgery is appropriate when the quality of life of the individual has significantly deteriorated. Most patients do not want to undergo surgery until their walking is impaired to the point that they cannot walk more than two city blocks. This degree of impairment usually corresponds to a significant deterioration in the person’s quality of life. Patients who cannot sit comfortably, walk short distances, stand for any period of time, and whose sleep is impaired because of pain usually request surgery, and that is when it is indicated.

Spinal stenosis is corrected surgically by performing laminectomies and foraminotomies at each constricted level. This means that the roof of the spinal canal (lamina) and part of the enlarged facet joints are removed along with the thickened ligaments to decompress the spinal canal and nerve channels (foramen). To adequately decompress the constricted spinal canal requires open surgery in my experience. I have had to re-operate on many patients who previously had micro-or arthroscopic surgery for spinal stenosis. The corrective surgery following these minimal procedures is much more difficult and the results are not as good as they could have been had the person had effective surgery from the beginning.

The necessity for emergency surgery for spinal stenosis is rare in my experience. Over the past 35 years of taking care of patients with this condition, I have had to perform emergency surgery on very few patients with spinal stenosis. One patient fell in the bathtub and ruptured a disc in a very constricted spinal canal, causing cauda equina syndrome. Another patient with a severe spinal stenosis had acute onset of paralysis following an epidural steroid injection. I do not prescribe epidurals for patients with severe spinal stenosis for this reason. And I have also performed surgery on several patients with spinal stenosis that was made acutely worse as the result of a vertebral fracture where bone was displaced into an already constricted spinal canal.

Top drawing shows spinal stenosis with pinched nerve. Bottom drawing shows the nerves decompressed, and the crosshatches show the location of a spinal fusion.

As I stated in the previous chapter, the size of a disc herniation on the MRI scan should not be an indication for surgical disc excision. On the contrary, the appearance of spinal stenosis on an MRI is one indication for surgery for this disorder. Research shows that when there is more than 75 percent constriction of the spinal canal in a person whose activity is limited by pain, surgery is the best way to obtain relief. This is particularly true when the spinal canal is highly constricted at more than one disc level, which is usually the situation. Spinal stenosis usually is most common between the fourth and fifth and the third and fourth vertebrae on the low back, and between the fifth and sixth and the sixth and seventh vertebrae in the neck. It is common for spinal stenosis to occur at more than one disc level in both the neck and low back.

I have managed many more patients with symptomatic spinal stenosis without surgery than I have operated upon. The best long-term treatment is any aerobic exercise that you can perform for at least 30 minutes daily within the limits of your pain and stamina. Walking, either outside or on a treadmill, riding a stationary bicycle, and aquatic exercises are the best aerobic exercises. You should do whichever one you can tolerate the best. I do not recommend stretching, massage, traction, or manipulation for patients with spinal stenosis. These maneuvers can aggravate the pain coming from the low back and increase the pressure on the spinal cord in the neck.

Maintaining a nutritious and healthy diet is as important for your back as it is for your blood pressure, brain, and heart. If you are overweight, you should lose weight to take the pressure off of your back. And if you are underweight, try to eat the correct foods to maintain your bone strength. Much more will be said about these issues in
Chapter 11
. Eating nutritiously and maintaining a healthy weight will help you to live with spinal stenosis and avoid surgery. Even if you eventually require surgery for this condition, maintaining normal weight, strength, and stamina will increase your chances of excellent results.

Spinal stenosis may be aggravated or caused by deformities of the spine such as curvature (scoliosis) or slippage of the spine (spondylolisthesis) — more about these conditions in the next chapter.

The most common deformity of the spine that can cause back pain or contribute to the severity of painful spinal stenosis is spondylolisthesis. You have conquered half of this book when you can say spondy-lo-lis-thesis rapidly! Spondylolisthesis literally means spine (spondy) and slippage (listhesis). Literally, one vertebra slips forward on the one below. Just as with spinal stenosis, there are two forms of spondylolisthesis: the first one, isthmic spondylolisthesis, is inherited; and the other is secondary to disc degeneration, degenerative spondylolisthesis (occurs as a result of disc degeneration, see illustration on page 78).