The spinal cord is a structure located in the canal behind the vertebral bodies. It starts from the bottom of the head and goes along to below. There are 5 separate groups of vertebrae in the spine: neck (cervical), chest (thoracic), waist (lumbar), sacral and coccygeal region. Spinal canal narrowing is mostly seen in the waist and neck area. There are 5 vertebrae in the lumbar region. This region is the spine region where the body weight is most concentrated. Other formations here are; It is the disc between the vertebrae (herniated disc occurs from this structure), the facet joints where the vertebrae articulate with each other, the strong connective tissue passing behind the body of the vertebrae, and the yellow ligament behind the spinal sac.
Spinal canal narrowing occurs right behind the vertebrae. It refers to the narrowing of the spinal canal all around, compressing the spinal cord passing through it from top to bottom at various levels, and the resulting pressure on the nerve roots. Lumbar spinal canal narrowing is a degenerative process. Degenerative changes in all the structures listed above contribute to this process, and the patient may face the problem of stenosis after a while. The main factors in the narrowing of the lumbar spinal canal are the decrease in the water content of the intervertebral discs as we age, the inward growth of the facet joints, the calcification of the ligament behind the vertebrae, which creates pressure on the spinal cord from the front, and the yellow ligament behind the spinal cord, which thickens and creates pressure from the back.
What are the symptoms of spinal canal stenosis?
Spinal canal stenosis in the waist is a slowly developing process. For this reason, it may not cause complaints and symptoms at first. However, as the disease progresses, patients' quality of life deteriorates and their daily activities are significantly restricted. When this clinical picture occurs in patients, the spinal canal diameter is usually narrowed above a certain degree, and the spinal cord and the nerve roots coming out of it are compressed.
Patients may experience back and waist pain, loss of strength and numbness in the feet. The most obvious symptom in patients is cramps and contractions in the legs after walking a certain distance. Over time, the walking distance at which these findings appear decreases, and in later periods, patients experience leg pain even during indoor walking periods. They face cramp and contraction problems. If walking patients rest when cramps and spasms occur, their complaints will decrease. Then, when they start walking again, they face the same problem again. Patients may have pain that starts from the waist and hip and spreads to the leg and foot.
Patients with lumbar spinal canal narrowing may have difficulty lying on their back. In later stages, these patients tend to walk leaning forward. Because the patient wants to voluntarily make the spinal canal a little wider by leaning forward.
In case of narrowing of the spinal canal in the neck; Weakness, tingling, numbness in the arms and/or hands, and in more serious cases, weakness in the legs, loss of function, and gait disturbance may be observed.
If spinal cord compression is severe, patients may have difficulty or be unable to perform fine tasks (such as not being able to button up their shirt, tie their shoelaces). symptoms (such as not being able to connect) may occur. In advanced cases where the disease also affects the legs, patients may become unable to walk without assistance. Again, in advanced cases, the patient may become unable to hold urine and stool.
In the examination of patients, increased reflexes in the arms and legs, loss of strength and sensation in the hands and legs may be found. Additionally, a group of abnormal findings, which we call pathological reflexes, may be detected in the hands and feet. Some or all of the above-mentioned findings may be present in a patient.
Deterioration in attacks of spinal canal narrowing in the neck is more common. The patient is comfortable or has few symptoms in the intermediate periods of these attacks. Very slow progression is observed in 25% of patients, and sudden deterioration is observed in 2% of patients.
What are the treatment options for lumbar spinal canal stenosis?
In non-advanced cases, non-surgical methods are used for patients; Bed rest, medication, physical therapy, and spinal injections may be applied. Many medications can be used in drug treatment, from simple painkillers to very severe narcotic painkillers. However, the necessity of these and the dosage of which one to use is a matter for the physician to decide. Epidural injection is also one of the non-surgical treatment methods. In this application, the epidural empty area other than the membrane layer surrounding the nerves is removed. Corticosteroid (cortisone) is applied to the skin. If success is achieved, it may need to be repeated later. In physical therapy applications to be carried out after the decision of the physical therapist, the aim is to eliminate the pain or reduce it to tolerable levels, strengthen the muscles and provide freedom of movement.
However, the patient's walking distance, which we call neurogenic claudication, decreases over time and accompanied by cramps and contractions in the legs. Surgical treatment should be applied in cases where there is loss of strength in the legs, bladder and bowel problems have developed, and the patient's quality of life has decreased. The name of the surgery in the medical literature is lumbar decompression surgery. The spinal cord sac is relieved by removing the bones on both sides and the yellow connective tissue that form the back roof of the spine. In appropriate cases, an approach is made from one side in order not to further damage the strength of the spine, that is, bone tissue is removed from one side behind the spine, but expansion surgery is performed under a microscope on both sides. Since lumbar spinal canal narrowing is an advanced degenerative process, the vertebrae may slide over each other in some patients. Sometimes, the stenosis is severe and unilateral or bilateral limited relief is not sufficient and the entire posterior bone roof and facet joints may need to be removed. In these cases, in addition to spinal cord release surgery, screws and cages may be required to fix the patient's vertebrae. However, this does not mean that screw-cage application should be applied to all patients. Patients should pay attention to their waist health in the postoperative period and avoid activities that may cause back pain. Two other important factors affecting future waist health are to continue the recommended exercise programs and be careful not to gain weight.
Treatment for cervical spinal canal narrowing. What are the options?
Damage caused by pressure due to canal stenosis in the spinal cord, which we call myelopathy, is one of the most important factors in deciding on surgery. If there is no myelopathy, and if weakness and loss of sensation in the arms, hands, and legs are not severe, non-surgical methods (such as physical therapy, drug therapy) may help to partially solve the patient's problem.
Surgery t. edematous disc that puts pressure on the spinal cord, osteophyte (calcification) formation, calcification (calcification) of the strong ligament structure passing behind the vertebrae, the yellow ligament at the back of the spinal cord growing and becoming more prominent, inward degenerative growth of the facet joints where the vertebrae articulate with each other, and rarely the vertebrae overlapping each other. The aim is to eliminate the factors that cause slipping and narrowing of the spinal canal. In short, this is called decompression surgery, that is, surgery to remove the pressure.
Removal of this pressure is possible with front or back surgery. However, the decision as to which one is more appropriate is made by the brain and neurosurgeon after the examinations. If only the disc causes the pressure in frontal surgeries, surgery can be performed only on the disc without any intervention on the two vertebrae adjacent to that disc. Sometimes the structure that creates frontal compression may be calcification of a very strong ligament that extends behind the vertebrae. In this case, the spinal body(s) and disc tissue along the affected level are removed. A bone graft or a cage-like prosthetic material that replaces the spine is placed in its place. Then, fixation (fusion) is performed from the front with plates and screws. However, this does not mean that screw-cage application is required for all patients.
In surgeries performed from the back, the yellow ligament that creates pressure and the roof (lamina) that forms the back of the spine may need to be completely removed. In this case, it would be appropriate to perform fixation (fusion) surgery by placing screws and rods holding them in the spine in order to strengthen the spine. It is also possible to widen the spinal canal with laminoplasty surgery, which is performed with the help of a prosthetic material placed after a part of the lamina is removed and cut away.
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