Wednesday, December 06, 2006

Treating Spinal Stenosis with Osteopathic Manipulative Treatment

1. Jarski RW, Loniewski EG, William J, Bahu A, Shafinia S, Gibbs K, Muller M. The
Effectiveness of OMT as Complementary Therapy Following Surgery: A
Prospective Match-Controlled Outcome Study. Altern Ther Health Med 2000; 6(5); 77-81.

Ask the Doctor: What is spinal stenosis?
By Dr. Bharat Sangani

Q: What is spinal stenosis?

A: Spinal stenosis occurs when excessive soft tissue or bone narrows the openings in the bones of the back.

This can irritate, squeeze or pinch the nerves that come from the spinal cord. In many people, this can cause pain, numbness or weakness in the legs, feet and buttocks. Although sever disability is uncommon, if it is not treated it can lead to nerve damage or paralysis.

Q: What causes spinal stenosis?

A: As we age, our spine ages also. This can be accelerated with wear and tear. The soft tissues may thicken. The cartilage of the back joints may deteriorate. Bony growths (spurs) develop. The combination of all this narrows the openings for the nerves.

Q: What are symptoms of spinal stenosis?

A: Symptoms vary in different people. They may include: low-back pain, which may radiate from the back to the buttock and down the leg, sometimes to the foot; weakness, numbness, or cramping in legs, usually worse when walking and relieved by sitting. In severe cases, there is loss of bowel or bladder control.

Q: How is spinal stenosis diagnosed?

A: Diagnosis is based heavily on your symptoms and a physical examination at your doctor's office. Imaging studies can include MRI scans, CT Scans, Myelography (dye test) and conventional x-rays.

Q: How is spinal stenosis treated?

A: In most cases, it is best to start with conservative treatment. Heat, ice, topical creams and over-the-counter anti-inflammatories work for many people.

Prescription medications may include a stronger anti-inflammatory medications, steroids, and, for short periods, narcotic pain medications. Many people have good results with physical therapy or chiropractic treatments. Steroid (cortisone) injections performed by pain specialists can help.

If symptoms still persist with conservative measures, surgery can be considered. The most common surgery is a decompressive laminection, which removes the bone and thickened tissues that are squeezing the nerves.

This is usually an overnight hospital stay, with a six-week recuperation. Sometimes this is combined with a fusion, which uses bone graft and often metal instrumentation to stabilize sections of spine. Surgeries tend to be more effective for lower extremity symptoms. Surgery can be safely performed at any age, provided medical problems are controlled.

Q: How can spinal stenosis be prevented?

A: In many cases, there may be no way to prevent the aging changes that cause stenosis. Some of the symptoms, however, may be controlled by maintaining a healthy back. Regular exercise, weight control and good posture are all important.

Don't smoke. There is evidence that links smoking to back pain, disc problems, and decreased bone density (osteoporosis). This can increase your risk of fracture and bone deterioration. Smoking also makes bone healing more difficult after surgery.

Summary: Spinal stenosis, although common, is a very treatable condition. Please see your doctor, who can help guide you through the proper treatment regimen.

More on Spinal Stenosis:

Definition of Spinal Stenosis
Spinal stenosis is a narrowing of the spinal canal, which places pressure on the spinal cord. If the stenosis is located on the lower part of the spinal cord it is called lumbar spinal stenosis. Stenosis in the upper part of the spinal cord is called cervical spinal stenosis. While spinal stenosis can be found in any part of the spine, the lumbar and cervical areas are the most commonly affected.

Spinal stenosis is a progressive narrowing of the opening in the spinal canal. The spine is a long series of bones called vertebrae. Between each pair of vertebra is a fibrous intervertebral disk. Collectively, the vertebrae and disks are called the backbone. Each vertebra has a hole through it. These holes line up to form the spinal canal. A large bundle of nerves called the spinal cord runs through the spinal canal. This bundle of 31 nerves carries messages between the brain and the various parts of the body. At each vertebra, some smaller nerves branch out from these nerve roots to serve the muscles and tissue in the immediate area. When the spinal canal narrows, nerve roots in the spinal cord are squeezed. Pressure on the nerve roots causes chronic pain and loss of control over some functions because communication with the brain is interrupted. The lower back and legs are most affected by spinal stenosis. The nerve roots that supply the legs are near the bottom of the spinal cord. The pain gets worse after standing for a long time and after some forms of exercise. The posture required by these physical activities increases the stress on the nerve roots. Spinal stenosis usually affects people over 50 years of age. Women have the condition more frequently than men do.

Cervical spinal stenosis is a narrowing of the vertebrae of the neck (cervical vertebrae). The disease and its effects are similar to stenosis in the lower spine. A narrower opening in the cervical vertebrae can also put pressure on arteries entering the spinal column, cutting off the blood supply to the remainder of the spinal cord.

Some patients are born with this narrowing, but most often spinal stenosis is seen in patients over the age of 50. In these patients, stenosis is the gradual result of aging and “wear and tear” on the spine during everyday activities. There most likely is a genetic predisposition to this since only a minority of individuals develops advanced symptomatic changes. As people age, the ligaments of the spine can thicken and harden (called calcification). Bones and joints may also enlarge, and bone spurs (called osteophytes) may form. Bulging or herniated discs are also common. Spondylolisthesis (the slipping of one vertebra onto another) also occurs and leads to compression. When these conditions occur in the spinal area, they can cause the spinal canal to narrow, creating pressure on the spinal nerve.

Spinal stenosis causes pain in the buttocks, thigh, and calf and increasing weakness in the legs. The patient may also have difficulty controlling bladder and bowel functions. The pain of spinal stenosis seems more severe when the patient walks downhill. Spinal stenosis can be congenital, acquired, or a combination. Congenital spinal stenosis is a birth defect. Acquired spinal stenosis develops after birth. It is usually a consequence of tissue destruction (degeneration) caused by an infectious disease or a disease in which the immune system attacks the body's own cells (autoimmune disease). The two most common causes of spinal stenosis are birth defect and progressive degeneration of the tissue of the joints (osteoarthritis). Other causes include improper alignment of the vertebrae as in spondylolisthesis, destruction of bone tissue as in Paget's disease, or an overgrowth of bone tissue as in diffuse idiopathic skeletal hyperostosis. The spinal canal is usually more than 0.5 in (12 mm) in diameter. A smaller diameter indicates stenosis. The diameter of the cervical spine ranges is 0.6-1 in (15-12 mm). Any opening under 0.5 in (13 mm)in diameter is considered evidence of stenosis. Acquired spinal stenosis usually begins with degeneration of the intervertebral disks or the surfaces of the vertebrae or both. In trying to heal this degeneration, the body builds up the spinal column. In the process, the spinal canal can become narrower.

The narrowing of the spinal canal itself does not usually cause any symptoms. It is when inflammation of the nerves occurs at the level of increased pressure that patients begin to experience problems. Patients with lumbar spinal stenosis may feel pain, weakness, or numbness in the legs, calves or buttocks. In the lumbar spine, symptoms often increase when walking short distances and decrease when the patient sits, bends forward or lies down. Cervical spinal stenosis may cause similar symptoms in the shoulders, arms, and legs; hand clumsiness and gait and balance disturbances can also occur. In some patients the pain starts in the legs and moves upward to the buttocks; in other patients the pain begins higher in the body and moves downward. This is referred to as a “sensory march”. The pain may radiate like sciatica or may be a cramping pain. In severe cases, the pain can be constant. Severe cases of stenosis can also cause bladder and bowel problems, but this rarely occurs. Also paraplegia or significant loss of function also rarely, if ever, occurs.

The physician must determine that the symptoms are caused by spinal stenosis. Conditions that can cause similar symptoms include a slipped (herniated) intervertebral disk, spinal tumors, and disorders of the blood flow (circulatory disorders). Spinal stenosis causes back and leg pain. The leg pain is usually worse when the patient is standing or walking. Some forms of spinal stenosis are less painful when the patient is riding an exercise bike because the forward tilt of the body changes the pressure in the spinal column. Doppler scanning can trace the flow of blood to determine whether the pain is caused by circulatory problems. X-ray images, computed tomography scans (CT scans), and magnetic resonance imaging (MRI) scans can reveal any narrowing of the spinal canal. Electromyography, nerve conduction velocity, or evoked potential studies can locate problems in the muscles indicating areas of spinal cord compression.

How Stenosis is Diagnosed
Before making a diagnosis of stenosis, it is important for the doctor to rule out other conditions that may have similar symptoms. In order to do this, most doctors use a combination of tools, including:

History: The doctor will begin by asking the patient to describe any symptoms he or she is having and how the symptoms have changed over time. The doctor will also need to know how the patient has been treating these symptoms including what medications the patient has tried.

Physical Examination: The doctor will then examine the patient by checking for any limitations of movement in the spine, problems with balance and signs of pain. The doctor will also look for any loss of extremity reflexes, muscle weakness, sensory loss, or abnormal reflexes which may suggest spinal cord involvement.

After examining the patient, the doctor can use a variety of tests to look at the inside of the body. Examples of these tests include:

X-rays - these tests can show the structure of the vertebrae and the outlines of joints and can detect calcification.

MRI (magnetic resonance imaging) - this test gives a three-dimensional view of parts of the back and can show the spinal cord, nerve roots, and surrounding spaces, as well as enlargement, degeneration, tumors or infection.

Computerized axial tomography (CAT scan) - this test shows the shape and size of the spinal canal, its contents and structures surrounding it. It shows bone better than nerve tissue.

Myelogram - a liquid dye is injected into the spinal column and appears white against bone on an x-ray film. A myelogram can show pressure on the spinal cord or nerves from herniated discs, bone spurs or tumors.

Bone scan - This test uses injected radioactive material that attaches itself to bone. A bone scan can detect fractures, tumors, infections, and arthritis, but may not tell one disorder from another. Therefore, a bone scan is usually performed along with other tests.

Mild cases of spinal stenosis may be treated with rest, nonsteroidal anti-inflammatory drugs (such as aspirin), and muscle relaxants. Spinal stenosis can be a progressive disease, however, and the source of pressure may have to be surgically removed..

Surgical Treatment
In many cases, non-surgical treatments do not treat the conditions that cause spinal stenosis, however they might temporarily relieve pain. Severe cases of stenosis often require surgery. The goal of the surgery is to relieve pressure on the spinal cord or spinal nerve by widening the spinal canal. This is done by removing, trimming, or realigning involved parts that are contributing to the pressure.

The most common surgery in the lumbar spine is called decompressive laminectomy in which the laminae (roof) of the vertebrae are removed to create more space for the nerves. A surgeon may perform a laminectomy with or without fusing vertebrae or removing part of a disc. Various devices (like screws or rods) may be used to enhance fusion and support unstable areas of the spine.

Other types of surgery to treat stenosis include the following:

Laminotomy - when only a small portion of the lamina is removed to relieve pressure on the nerve roots;

Foraminotomy - when the foramin (the area where the nerve roots exit the spinal canal) is removed to increase space over a nerve canal. This surgery can be done alone or along with a laminotomy;

Medial Facetectomy - when part of the facet (a bony structure in the spinal canal) is removed to increase the space;

Anterior Cervical Discectomy - the cervical spine is reached through a small incision in the front of the neck.

What is Causing the Pain
Your spine must be stable to support upright posture, and also flexible, allowing you to bend and twist. This is mechanically very challenging and makes your spine vulnerable to injury.

The spine is made up of a chain of bones, called vertebrae, which are connected together by ligaments and muscles. The vertebrae cover and protect the spinal cord, which carries sensory messages to and from the brain, controlling all your body functions.

A disc separates each vertebrae and acts like a cushion, absorbing shock along the spine. The disc is made up of jelly like substance known as the nucleus, covered with many strong outer layers called the annulus. The discs do not have a supply of blood vessels to nourish and replenish them, rather, they depend on a transfer of fluids, nutrients and oxygen from the bones (vertebrae) above and below them. This transfer of fluid depends on the difference in pressure between the inside of the discs and the surrounding vertebrae and blood vessels. This is why most disc nutrition and regeneration takes place when we lie down and the pressure inside the discs is reduced. This process is not very efficient, and as we age, the disc is exposed to wear and tear greater than its ability to heal and regenerate.

The discs are prone to injury and degeneration as we use our backs each day, as they are compressed and torqued through sitting, bending and lifting. In the two lower levels of the lumbar spine, stress forces can equal 2,000 to 3,000 pounds of pressure per square inch. Repeated injury weakens the annulus, while the earliest changes that occur in the discs are tears in the annulus. With increased pressure inside the disc, the tears in the annulus may allow the disc to bulge like an old tire with a broken casing. Any internal damage to the disc may cause severe pain in the back. If all of the layers of the annulus break, the jelly-like nucleus will ooze out of the disc, causing a disc herniation. A bulging or herniated disc may press on spinal nerves, causing sciatica, which can be felt as weakness in your muscles, loss of sensation in the skin or a tingling or burning sensation along the nerves in your buttock and legs.

Repeated episodes of injury results in the degeneration of the disc, which becomes stiff and dry, causing it to lose its shock absorbing properties. This process may continue until the disc is collapsed, which increases the mechanical pressure on the bones and joints lending to arthritis (facet syndrome).

Treatment by Osteopathic Manipulative Medicine.

Osteopathic manipulation is used as an adjunct to other medical therapies that are used to manage acute and chronic pain. Recent studies have advocated the use of manipulation in algorithms for back pain and other musculoskeletal conditions. Osteopathy is a philosophy of medical care that combines the needs of patients with the current practices of medicine and its specialties with emphasis on the interrelationships between structure and function and appreciating the body’s ability to heal itself.1 In particular, most osteopathic medicine’s manipulative techniques are aimed at reducing or eliminating the restrictions to proper structure and function so the person’s self-healing mechanism can assume its role in restoring the person’s musculoskeletal health.

What is Manipulation?
Osteopathic manipulative treatment (OMT) is the manual application of forces to the body to restore maximal pain-free movement of the musculoskeletal system3 (Greenman). As a complimentary therapy and unique system of practice, OMT uses vocabulary and methods for approaching patients that are different from those of traditional medicine.1
Pain is the most common reason patients seek manipulation. Other reasons may include psychological issues, wellness, athletic performance, and medical problems without clear musculoskeletal etiology such as asthma, or malignancy. The reason for treatment is also important in that misdiagnosis and delay of appropriate treatment is an important complication.

The Value of Therapeutic Touch
Previous studies have reported decreased blood pressure and anxiety following “hands-on” type of treatment. OMT is holistic approach involving patient-practitioner interaction and purposeful physical contact.

How Popular Is Osteopathy?
Osteopathy has changed the lives of such well-known figures as John D. Rockefeller, Henry Kissinger former presidents Franklin Delano Roosevelt, Dwight Eisenhower and John Fitzgerald Kennedy. The growing demand for Osteopathic services among our population reflects an increasing desire by patients to resolve health problems without drugs or surgery. Osteopathic Medicine continues to gain national attention and remains the fastest growing health profession in the nation.

1. Jarski RW, Loniewski EG, William J, Bahu A, Shafinia S, Gibbs K, Muller M. The
Effectiveness of OMT as Complementary Therapy Following Surgery: A
Prospective Match-Controlled Outcome Study. Altern Ther Health Med 2000;
6(5); 77-81.


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