Thanks to modern medicine, human lifetime has been extending, which has resulted in higher number of patients with aging-dependent spinal stenosis. Problems in our facet joints, which negatively affect our quality of life, can develop due to various reasons.
The first doctor to highlight spinal stenosis and the possibility in which spinal cord may remain under compression, causing numbness as well as weakness in legs was a Turkish doctor, Prof. Dr. Münir Ahmet Sarpyener, who published his scientific article about the subject in the journal of Bone and Joint Surgery in 1945, which has still been considered a prestigious article.
Dr. Yunus Aydın and his team have closely followed the Turkish surgical information and the experience on the issue and have also contributed to it for years. We have had broad experience in this field through the high number of surgeries which we have performed.
How does spinal stenosis develop?
Comprising of 33 vertebrae stacked up on top of one another, having intervertebral discs in between, making meaningful indents and juts, and held together through the ligaments, our spinal cord provides us the feature to be able to walk on our two legs -with the support of muscles and rib cage, which makes us different from other animals. This capability to stand that humans have is actually against the gravity. Gravity pulls us down as we get older. We can resist it as much as the strength of our vertebral column. The main aim of Pilates, which has recently been popular, is to delay this bending. As the diameter of vertebral canal gets narrower, the protection mechanism in our bodies which we are born with comes into play. It causes us to bend forward and prevents the canal from narrowing down further. If we bend backwards, the ligamentum flavum (yellow ligament), which has become thicker, bends towards the canal and increases the narrowness even further. To avoid this problem, the protection mechanism of our bodies comes into play and put us into fetal position.
What are the symptoms of spinal stenosis?
When patients with spinal stenosis apply to a doctor, they generally comes along having also lumbar disc herniation, however, spinal stenosis causes disturbances even when there is no lumbar disc herniation. Stenosis means that a nerve fails to get sufficient blood when it needs to. Like any tissue in our body, nerves also feed on blood stream. Just like the amount of fuel a car consumes on the road is different from that of the car in the parking lot, the amount of energy a nerve uses when we are running is different from when we are walking. The blood stream brings energy, so blood vessels that bring blood should be able to get wider when required. It requires more size to be able to get larger. Normal vertebral canal differentiates in neck, back and lumbar regions. Also, there are congenital differences amongst people. Those who have a wider canal are in a more advantageous situation in terms of violations by adjacent organs. A nerve has an additional size to tolerate any move into its borders caused by hernias or thickened ligaments. Not everyone suffers -to same extent- from a herniation or a stenosis of the same size.
Due to reasons such as aging, trauma, etc., the ligaments connecting our vertebrae and facet joints get thicker. This is essentially a default reaction of our body against the strain on it. This is something like when a skin forms a callus when irritated. The effects like lifting heavy objects, twisting motions, obesity cause wear and tear of the discs between the vertebrae and of the facet joints, and lead to repairs, thus thickening of ligaments and joints. These non-nervous structures that get thicker occupy the area of nerve which they are supposed to protect. By default, the body takes any precaution it can against this situation; it melts the fat layer over the meninges, develops kyphosis to widen the canal, puts the body in a bending-forward position, narrows down the area of the cerebrospinal fluid. And the nerves that should normally be freely inside the fluid get together back to back with an effort to make room for the nerves. If a suddenly developing herniation does not interrupt this process, the development of these series of event causes a very slight disturbance for us. When we start sensing a slight backache, temporary numbness in legs, it means a particular threshold has been exceeded. Patients at this stage feel a tingling in legs which is then followed by weakness in legs. In early stages, these complaints go away after a few minutes rest. This is also called “the window disease”, which means that patients, when got tired out there in the street, stop to look at shop windows and then continue walking when pain fades away. As disease advances, the distance at which the complaints start gets shorter. As it further advances, it becomes painful for patient to even walk around the house. If it advances even further, nerves can no longer function and it leads to paralysis and numbness in relevant muscles, and patient starts limping. At even more advanced stages, patient is stuck in bed with urinary and fecal incontinence.
What treatment is applied for spinal stenosis?
The solution should start with the least harmful one. By default, the body solves the problem through a bed rest. A long bed rest for 15-20 days removes the complaints, including simple hernia, too. When there is no more pain, losing weight and a gymnastics program would be useful as a protective precaution. Considering our culture, this part would be the most difficult and unproductive part, as it requires participation of patient.
If bed rest alone does not suffice, medication or physiotherapy methods can be used additionally. If those do not suffice, cortisone and anesthetics can be given through injection (I rarely use these). If those do not suffice either, it is surgery’s turn. By the way, the word “surgery” should not immediately imply a standard description in our minds. Every surgeon has their own way, just like everybody cherishes his own way of doing things.
Dr. Yunus Aydın’s spinal stenosis surgery technique:
The first preference is the surgery with microsurgery technique which causes the least harm. If patient’s history is properly examined, one should see that the complaints that require surgery are no older than a few weeks or months, and only a particular part of the aberrations -appearing on film and mentioned in a few lines by radiologists- has exceeded the self-healing mechanism of the body and has actually been disturbing the patient.
Here, we should make a self-criticism; an experienced surgeon heals a patient, in other words, solves the problem in a simple way; whereas a less experienced surgeon includes into the process any and all abnormalities which appear on the film, that is, he/she unnecessarily makes an issue of it. As surgery gets bigger, the risks of patient increase. A surgeon can not be courageous at the expense of patient. By the way, feeling frightened by surgery is also bad, just like feeling too courageous about it is. One should remember that no benefit can be gained without taking any risk at all. Surgical technique and the surgeon who uses that technique should lower the risk down to acceptable levels.
It is not right to perform scoliosis surgeries on old age people by employing the techniques which are actually applied to younger people. If patient has lived without any problems up to that time with those existing curves for 30-40 years, it would suffice – and pose less risk- to solve the latest happening that has disturbed that balance, and put the patient back into the previous state prior to the pain. What patient really needs is to widen the area of nerve.
While solving the spinal stenosis problem of aged people, which is our main subject, we should be well aware that we may encounter particular risks and we should try to reduce such risks. All in all, spinal stenosis does not kill one, however a complication of anesthesia or surgery can. Fortunately, anesthesia today has improved to great extents. It has now become a daily pre-op routine for anesthetists to put patients aged 90+ into sleep.
Surgical technique is the most important issue that increases anesthesia risk. We can generally list the issues that anesthetists do not like as the following: there should not be too much blood, no blood transfusion should be made if possible, surgery should not take a long time, there should not be any lung or heart problem that will require intensive care, etc. So, the technique a surgeon chooses may increase or reduce these risks. If the surgery technique recommended by the surgeon is accepted by the patient, it naturally makes surgeon happy, which is why I have, since my assistantship, preferred the microsurgery technique that is easy to be accepted by patients, and I have made efforts for over 20 years in order to reach the techniques I have applied for the last 12 years. By the way, the high speed drills which have commonly been used today, the bone cutters which run on air pressure and certainly the developed surgical microscopes have all made it possible.
How does healing after microsurgery develop in spinal stenosis?
How does the bilateral vertebral canal opening technique with unilateral approach through a small scar offer the advantages that reduce the above mentioned risks?
- Since vertebral column is accessed through one side, lumbar muscles are stripped off the bones on one side, which means fewer scars.
- Since the carrying strength of the vertebral column is not damaged, there is no need for screw and rods which are placed for added strength in other techniques (these screws and rods are presented to people with fancy name “platinum” but is actually not true). This means less blood and less time.
- In case of any type of hernia, multiple issues related to cases at distant locations can be accessed through two small scars, and it means to avoid a second operation and acting more economically.
- This surgery does not hinder any screw surgery in the future. There has never been any such need in any of the over 1000 cases I have performed so far. This means preserving the natural movement of the vertebral column.
- Patients can start walking 3 hours after the surgery and can make any movement. This means to reduce the post-op emboli risk that might emerge – and is feared of- in old age people.
- The patient can leave hospital the same day and can return to normal life in 15 days, which refers to both economy and a quality life.
Does the press on nerve lead to an immediate paralysis?
This is one of the frequently asked questions. By default, the press on the nerve can not lead to a paralysis immediately. A press on the nerve firstly causes numbness, then ache, then pain, and if the press still persists, partial paralysis and complete paralysis, respectively. The paralysis here should not be confused with the paralysis of the brain. The nerve under compression at the spinal level causes loss of strength limited to hands. If we speak in football terms, our body first warns us with numbness, and then shows us a yellow card, and if the problem still persists, the body shows us a red card in the form of loss of strength. In other words, the press on nerve will not lead to an immediate paralysis; however we should take it into account and take precautions.
How to diagnose spinal stenosis?
An experienced doctor can easily diagnose it with traditional medical knowledge. Patients with spinal stenosis walk in a bending-forward position can not sleep lying on his back and prefers the fetus position, as it alleviates pain. Surgeon will see the severity of the disease through a neurologic examination. The golden standard examination method is the MR scanning, which provides required information to surgeon. Also, it shows other situations – if any – like concomitant hernias, cysts, calcifications.
Do all patients require surgery?
Spinal stenosis in early and middle stages does not require surgery immediately. These patients are recommended preventive and conservative methods. If these methods do not work, patients undergo a surgery. The decision of surgery should be made by the patient himself. If pain severely ruins quality of life, and if the findings in MR match patient’s complaints, patient’s request of surgery is accepted.