Spinal Canal Stenosis

SPINAL CANAL STENOSIS
Spine is composed of 33 vertebrae bones spaced by soft compressible discs and supported by numerous muscles and ligaments. Narrowing of the spaces between the vertebrae bones puts pressure on the nerves that travel through the spine. This condition is referred to as Spinal Canal Stenosis and mainly occurs in the lower back and neck area. The compression of nerves in the lower back and neck spinal area causes pain, tingling, numbness and muscle weakness that can worsens over time if left untreated.

Spinal stenosis is classified according to the location of narrowing of the spine:

• Cervical stenosis:  Spinal space narrowing occurs on the part of the spine near the neck.
• Lumbar stenosis: Lumbar stenosis is the common type of spinal canal stenosis and space narrowing occurs in the lower back part of the spine compressing the nerves that travels through the lower back.

Patients diagnosed with spinal canal stenosis may experience numbness, tingling and weakness in the area of compression with severe pain, loss of balance and neck cramping or cramping on the legs. Narrowing of the spinal spaces and compression of spinal nerves can also be due to the overgrowth of bone, herniated disc, thickened ligaments, and presence of tumors in the spine or spinal injuries. The doctor diagnoses the condition by evaluating the symptoms and tries to investigate the root cause of the condition. This is achieved traditionally by imaging test to showcase the spinal space compression and compression of nerves in the spinal area.

Conventional treatment method includes pain relievers, antidepressants, anti-seizure drugs, Epidural Injections and physical therapy to ease the chronic pain and to build up strength and flexibility of the spinal cord. Severe cases require Spine Surgery.

ALTERNATIVE TREATMENT METHODS AT BETH YEHUWDAH ARTHRITIS CENTRE, PULLAD & DAYSTAR CLINIC, ALAPPUZHA FOR SPINAL CANAL STENOSIS-
In Dr John’s experience many patients with mild to moderate Spinal Canal Stenosis on MRI scan may respond well symptomatically to Caudal Epidural Steroid Injections and those with severe Spinal Canal Stenosis especially with Cauda Equina Syndrome and other neurological deficits usually are best candidates for Spine Surgery.  However, unless the root cause behind Spinal Canal stenosis and that being Spinal Instability (eg.bone overgrowth, herniated disc and inflamed thick ligaments) is addressed; the symptoms tend to recur eventually! Bone growth often occurs in the degenerating spine because the bone is trying to stabilize the spine from excessive movement or laxity. Disc prolapse usually occurs secondary to gradual failure of posterior ligamentous integrity behind the level of facet joints.

The stable spine behaves like a see saw with its fulcrum at the facet joint during movement. The disc in front is partially balanced by ligaments and muscles at the back. If there is damage to the ligaments/muscles behind the facet joint in the form of strain, more weight is transferred to the disc region in the front which may lead to disc prolapse. In Dr John’s experience Platelet Rich Plasma Prolotherapy  and Dextrose Prolotherapy offer the best results by stimulating the body’s immune system to repair and naturally tighten these ligaments and muscles at the back of the facet joint, thereby relieving stress in front of the facet joint namely the disc region. This is the same reason, it can be used to treat most patients with mild to moderate Spinal Canal Stenosis, as well as few cases of severe spinal canal stenosis (MRI) where typical history of claudication distance (progressively decreasing walking distance) is absent and there is no bowel/ bladder involvement, nor any neurological deficits.

Chronic Conditions caused by Spinal Instability: Radiculopathy, Spinal Canal Stenosis, Degenerative disc disease, Herniated disc, Sciatica, Spondylolisthesis, Spondylosis, Bulging disc and facet joint Subluxations.

Spine decompression and Fusion surgery is recommended as a means to accelerate that type of stabilization as well as to relieve symptoms due to Spinal Canal Stenosis. Spine Surgery with posterior instrumentation provides Rigid fixation of Spinal components thereby indirectly transferring most of the flexion extension movement to the facet joints above and below the level of fixation, which may increase degenerative stresses on the facet joints above and below the site of rigid spine fixation, which in turn might lead to pain within few years post surgery. Regenerative medicine including PRP Prolotherapy and Dextrose Prolotherapy does not work in the same way. They help stabilize the spine by strengthening and tightening the under-appreciated spinal ligaments and muscle attachments. These techniques help stabilize the spine in a dynamic way, which can prove to be helpful indirectly in treating patients with Spinal Canal Stenosis.

Many times a patient with back pain; despite various treatments still has pain and now has been recommended a spine surgery because “MRI shows something”. But is it in fact the disc prolapse on MRI always the cause of the patient’s pain? Medical researchers are asking, “Maybe we should look at the spinal ligaments?”

Patients who are in severe back pain usually bring an MRI/ X-ray and/or scan that may show an inaccurate picture of what is causing their pain. In a landmark study by Boden et al in the Journal of Bone and Joint Surgery (Am) 1990, which has been quoted by nearly 2700 other articles Dr Boden does MRI scans of the Lower Back for people who have no lower back pain, sciatica or neural claudication in lower limbs. He gets neuro-radiologists to interpret the MRI without them being told the history and examination findings. He found that 57% of apparently “normal” people above the age of 60 years without any backache or nerve symptoms in legs had “abnormal” MRI changes with 36% having Disc prolapse and 21% having Spinal Canal Stenosis. If 57% of apparently normal people have abnormal Spine MRI, how can we be sure that when a patient presents with back pain, that his pain is actually related to the bulging disc, when that disc bulge could certainly be asymptomatic. The MRI cannot show muscle spasms from a simple cervical/ lumbar strain which can cause excruciating pain. Neither can it detect microstructural damage at the ligament bone junctions/ enthesitis nor can it detect nerve sheath CCPs (chronic constricting points) along the course of various nerves. Conversely, a herniated disc may be seen on MRI which may be completely painless. Yet that herniated disc will send the patient to surgery. Dr Tejaz John has observed in his clinical practice that at times patients may bring MRI showing disc prolapse towards one side whereas the symptoms are experienced on the opposite side.

Here is a statement from the medical journal Childs Nerv Syst. 2015: “As important as the vertebral ligaments are in maintaining the integrity of the spinal column and protecting the contents of the spinal canal, a single detailed review of their anatomy and function is missing in the literature.” Unlike muscle tissue, ligaments and tendons have a poor supply of blood to regenerate them. This is why ligaments can remain in a weakened and irritable inflammatory state and may not heal. The chronic back/ neck pain patient may have history of trauma or overuse to the Spine that result in injury to various spinal ligaments that hold the vertebrae and spinal processes in place. Ligaments can bear a normal amount of stress that causes them to stretch up to their natural limit, returning back to their normal length once the stress is removed. If added (traumatic) stress is applied on the ligament, it is stretched beyond its natural range of extension, and subsequently fails to return to its original length but instead remains permanently overstretched resulting in plastic deformation, diminishing its integrity and attachment to the bone. This causes ligament and soft tissue loosening and subsequent Spinal Instability.

PRP Prolotherapy for Spinal Canal Stenosis secondary to Spinal Instability Platelet-Rich Plasma Therapy (PRP) has been found to be effective in treating degenerative disc disease by medical researchers by dealing with the problem of spinal ligament instability. The sooner the spinal ligament instability is treated, the better the results and patient satisfaction. In fact, abnormal stress on the spinal ligaments could be an important cause for most pain in degenerative disc disease. PRP is an effective means of alleviating neck and lower back pain because it eliminates pain by stimulating the local immune response to heal the underlying tissues and may help avoid surgery in cases of spinal ligament instability.

PRP prolotherapy is a combination treatment where PRP is injected into region of the joint and dextrose prolotherapy is given to the ligaments of the joint. This treatment may help a patient who does not want surgery and helps to overcome the disease condition with minimally invasive injection techniques. The treatment method stimulates the natural immune repair mechanisms of the body and delivers the building block essential to build and repair damaged tissues.

How does PRP work? Blood components are of four major types - plasma, platelets, white blood cells and red blood cells. Platelets assist in clotting and are also the “first-responders” of the body post injury; helping repair an injured region and in building up of new tissue and thereby promoting the healing process. Once platelets contact collagen in damaged tissues, the platelets release various biological growth factors (Table 1 as given below) to promote healing in soft tissues locally. Activated platelets commonly release the following growth factors:

Table 1: Various biological growth factors released by PRP when activated

PRP injection delivers a high concentration of autologous (patient’s own) platelets to the joints and soft tissues in the lower back. Platelets present in the blood are the first responders to an injured area and helps build up new soft tissues. Introducing high concentration of platelets directly into the joint using PRP injection stimulates the healing process and faster recovery from the joint condition.

Dextrose Prolotherapy for Spinal Canal Stenosis
Lower Back pain with Spinal Canal Stenosis is one of the leading causes of disability, yet most of the people suffering from it do not know that Spinal instability is most likely the real cause of the problem! Once we know that spinal ligamentous instability is at the root of the problem of Spinal Canal Stenosis in most patients Dextrose Prolotherapy may offer great results by stimulating the body’s immune system to repair and naturally tighten these ligaments and muscles at the back of the facet joint, thereby relieving stress in front of the facet joint namely the disc region.  We see, most patients take pain tablets and muscle relaxers to cover the pain, which only masks further degeneration and leads to an endless “pain management” cycle. This is like treating the symptoms versus correcting underlying spinal instability. Comprehensive Dextrose Prolotherapy can break this cycle by assisting the regeneration of weakened and stretched-out soft tissue structures of the lumbar spine, alleviating pain and instability. Using Prolotherapy, these conditions can be treated properly and safely to give a more desirable symptomatic outcome.

Prolotherapy is an almost painless injection technique under local anesthesia where very thin needles are used to inject high concentrations of dextrose solution (sugar similar to glucose) in to loose and damaged ligaments, tendon and muscle attachments around the osteoarthritic joint/ entheses. Prolotherapy works by increasing the glucose concentration in the fluid outside the cells. This results in movement of fluid from inside the cells to the outside of the cells thereby shrinking the cells and causing temporary cell damage (hyperosmolar damage). As the cells are temporarily damaged, they release many biosignals to the body which results in stimulation of the immune system of the body to accelerate the inflammatory process locally resulting in increased local blood circulation, fibroblast (fibrous cell) proliferation, ligament regeneration, tightening and repair. In Dr Tejaz John’s experience, Prolotherapy is an effective non surgical treatment method used successfully in Spinal instability. This treatment method has the ability to strengthen the existing intact, but weakened, ligamentous and tendinous attachments in the Spine. Along with the treatment technique, it is important to perform series of movement and muscle strengthening exercises to strengthen the already weakened muscles in the chronic degenerated Spine. We treat patients who have been diagnosed with bulging discs, spinal stenosis, degenerative disc disease, spondylolisthesis, failed back surgery syndrome, sciatica, and more for which Prolotherapy can give a more desirable pain-relief outcome.

Patient Benefits of PRP Prolotherapy and Prolotherapy:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• For those who wish to avoid if not delay repeated Surgery
• May significantly reduce the symptoms associated with Backache associated with Failed Surgery.
• Reduced risk of adverse events
• Repairs and tightens ligaments improving spine stability and ease of standing, sitting & walking
• Safe and effective treatment method
• Faster healing and recovery
• PRP Prolotherapy results in safe, significant, effective, progressive improvement of back pain, function and reduction of stiffness.

Neural & Soft Tissue Infilteration Therapy (NESTIT)

Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT):  Steroid tablets and injections of the group Corticosteroids, (which are very different from Anabolic steroids misused by some athletes) have been repeatedly proven medically for the last 70 years in the successful treatment of inflammatory conditions due to its potent anti-inflammatory effect. Though corticosteroids are very effective in reducing inflammation, they carry numerous potential side effects, which are undesirable. To circumvent this problem, and in order to utilize the potent anti-inflammatory effects of steroid injections, at the same time taking appropriate measures to considerably lower its side-effects, Dr Tejaz Koshy John in 2010 while working as an Orthopaedician in his private clinic in Guyana, South America developed NESTIT. NESTIT stands for (Juxta) Neural and Soft Tissue Infilteration Therapy. It consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb. It is preferably given for those patients who have Rheumatoid Arthritis, Inflammatory Arthritis, Synovitis, Inflammatory Low Back Pain, Spondyloarthropathy & Nerve and Nerve root irritation. It is not a substitute for DMARDS (Disease modifying anti rheumatoid drugs), however when given with low dose DMARDS, in Dr Tejaz John’s clinical experience it may result in significant reduction of local inflammation, pain and improvement of joint function in most cases, also indirectly reducing side effects of high dose DMARDS.

NESTIT involves 

1. Administeration of low dose local steroid via infilterative type of injection technique rather than giving oral steroids (as cumulative daily dosage of oral steroids over a 6 week period could exceed the dose of local steroid injection by almost 5 to 10 times) or conventional single injection into joints directly.
2. Reduce the dosage of Steroid given via injection and the use of a sliding scale according to patient’s body weight and height to regulate dosage. A 40 kg woman of 4 feet 9 inches should not receive the same dosage as a 100 kg male of 6 feet height.
3. Dilute the low dose steroid injection upto 80% with sterile water and local anesthetic.
4. Administer relatively insoluble low dose steroid via multiple infilterations locally in inflamed tissues in very small amounts indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions as per requirement, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb.
5. Identification of high risk patients and risk stratification to reduce possibility of side effects, for eg. Patients suffering from serious heart & liver conditions tuberculosis, infections, significant osteoporosis, immuno-compromised patients, menstrual irregularities, already having Cushing’s syndrome, ongoing significant hair loss etc.
6. Regular monitoring of body weight and physical appearance for early detection of Cushingoid features, if it occurs (rarely), to delay/ avoid further injections.
7. Control of High Blood Pressure and Diabetes prior to giving injections.
8. Doing skin sensitivity tests to rule out allergic reactions to the drugs.
9. Explaining possibilities of common & rare side effects to the patient and taking precautions regarding other common side effects wherever possible.
10. Opting for/ Shifting to regenerative treatments like Platelet Rich Plasma and Dextrose Prolotherapy wherever there is secondary degenerative disease / soft tissue damage, once the severe inflammation subsides.

In Dr Tejaz John’s clinical experience, the patient benefits of Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT) treatment are:

• Minimally invasive treatment method.
• Almost painless injection technique using very thin needles under local anesthesia.
• Avoid if not delay Surgery.
• Significantly reduces the symptoms associated with Inflammation in cases of Sciatica due to Sacroilitis, Myofascial syndrome, Fibronodular fasciitis, Enthesitis, Bursitis, Radiculitis and Neuritis, (sometimes wrongly attributed to spinal canal stenosis).
• Reduced risk of adverse events compared to oral steroid tablets which are usually taken daily, due lower dosage (very low steroid dosage compared to cumulative oral steroids over 6 week period).
• Reduced risk of side effects/ adverse effects due to prior risk stratification and identification of high risk patients vs. low risk patients by doing precautionary steps and tests prior to giving injection.
• Reduced incidence of post-injection pain due to highly diluted steroid solution.
• Reduces pain and discomfort in most patients.
• More effective treatment method in Sciatica due to inflammatory conditions.
• Faster recovery.
• NESTIT treatment results in significant, effective, progressive improvement of pain, function and reduction of stiffness if given in series.

At Beth Yehuwdah Arthritis Centre, Pullad and Daystar Clinic, Alappuzha we provide a variety of options for patients suffering from Spinal Canal Stenosis conditions. To know more Spinal Canal Stenosis treatment plans and cost, book an appointment now.