Irene Kulesh was walking her dog one day when she suddenly felt numbness in her legs. "I couldn't walk half a block without sitting down," she recalls. Mrs. Kulesh was diagnosed with lumbar spinal stenosis, a condition where the spinal canal narrows and places pressure on the spinal cord and nerve roots.

After two rounds of water exercise therapy, the retired operating room nurse wasn't getting better, and she was referred to Dr. Robert Heary, an associate professor of neurosurgery at New Jersey Medical School and director of The Spine Center at University Hospital. He agreed with the diagnosis, but, because Mrs. Kulesh wasn't getting relief from conservative measures, suggested that she have a decompressive laminectomy. Part of the affected vertebrae, the lamina, was removed during the procedure, opening up more space within the spinal canal and taking pressure off the nerves.

"The surgery went smoothly, and I had little pain. I was moving about without a walker after a week or so," says the 75-year-old Mrs. Kulesh, who had the procedure in August 2002. "I love to walk and can drive again; I raked leaves in the fall. I feel wonderful. For me, the operation was a miracle."

Part of the Aging Process

Lumbar spinal stenosis is a common back problem among older people. "Aging takes a toll on the back," says Dr. Michael Vives, an assistant professor of orthopaedic surgery at New Jersey Medical School and an orthopaedic surgeon at University Hospital "As we get older, the hinge-like facet joints that connect the vertebrae can deteriorate, while such problems as bulging or collapsed discs are occurring in the anterior, or front, portion of the spine. Ligaments thicken and bone spurs can develop. These degenerative changes can all contribute to a narrowing of the spinal canal, or lumbar spinal stenosis." Although most cases of lumbar spinal stenosis are age related, it can also be caused by a tumor, trauma, or conditions such as Paget's disease, a metabolic bone disorder.

With less room in the spinal canal, the nerves become compressed and cause lower back and leg pains as well as numbness or heaviness in the legs. The symptoms of lumbar spinal stenosis can be similar or related to other conditions.

"While lumbar spinal stenosis can lead to sciatica, the two conditions are quite different," says Dr. Mitchell Reiter, assistant professor of orthopaedic surgery at New Jersey Medical School and an orthopaedic surgeon at University Hospital. "Sciatica refers to a shooting or radiating pain down the legs, rather than the leg numbness and weakness more typically associated with stenosis. Sciatica-type pain is frequently caused by a herniated disc, but patients with stenosis can also experience shooting pains in the legs." The more common leg pain, or claudication, that patients with lumbar stenosis experience could also be caused by insufficient blood flow to the legs, so doctors must be careful to fully evaluate the patient.

In rare cases of stenosis, the nerves that control bladder and bowel function are affected, a condition known as cauda equina syndrome. Without prompt treatment, the damage can become permanent, affecting a person's voluntary control of the bowels and bladder.

Usually, however, lumbar spinal stenosis is not a medical emergency, and there's time to explore conservative treatment. The first step involves diagnosing the condition through medical history, physical exam, and imaging studies. It's typically the history that provides the doctor with valuable information. "During the physical exam, the patient often is sitting. The spine is flexed, and there is usually no pain. It's when the patient stands or walks and the spine is extended that there is pain or numbness," explains Dr. Heary, who recently authored a chapter on lumbar spinal stenosis for a medical textbook. "The patient's description of the pain and when it comes and goes can be quite revealing."

Sitting and squatting help relieve the pain for many people with lumbar spinal stenosis; so does leaning forward while pushing a shopping cart. A person with lumbar spinal stenosis may not be able to walk more than a half block at a time without needing to sit or rest, but finds much relief and a better ability to ambulate when he or she is leaning on a shopping cart. The slight forward position people take when pushing a cart flexes the spine and relieves the pain or numbness.

The doctor next orders some imaging studies, most often X-rays and MRI's. "The X-rays can show degeneration of the facet joints and whether a bone has slipped forward," says Dr. Vives. "MRI is used to view soft tissue, such as the discs and nerve roots. For patients with pacemakers, a non-magnetic type of imaging, such as CT scan or a myelogram, an X-ray procedure using a contrast dye, is performed."

In most cases of lumbar spinal stenosis, doctors will recommend non-surgical measures such as physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) such aspirin or ibuprofen. Bracing or steroid injections are sometimes tried, but Dr. Heary says their effectiveness is not well proven. "Still, for an elderly patient who wants to avoid surgery, attempts at conservative measures are worthwhile, and it is not unreasonable to try a series of steroid injections or wear a brace for a few months," he says.

Conservative treatments do help some people, agrees Dr. Vives, noting that about one-third of patients being followed for lumbar spinal stenosis come to the point where surgery is considered. "It comes down to quality of life issues," he says. "Can the patient manage well without surgery, or is he unable to do those things that are key functions for an independent lifestyle?"

Decompressive laminectomy, the procedure that Mrs. Kulesh had, is typically the least stressful for patients, with about an hour and a half in the operating room and a two-day hospital stay. But in some cases, there's evidence of instability in the spine or a condition called spondylolisthesis, where there is slippage of one vertebrae over another. That's when the surgeon has options to help stabilize the spine: a laminectomy and spinal fusion, sometimes using instrumentation such as screws and rods.

During spinal fusion, bone is taken from another part of the body (usually the pelvis) and grafted between the affected vertebrae; as the graft heals, the two bones join together. Screws and rods are sometimes used to secure the area during the healing process. These are more involved operations that require a longer hospital stay.

One of Dr. Reiter's patients, John Shephard, had a decompressive laminectomy and two vertebrae fused last year. Before then, he experienced periodic back pain for about 20 years. While in his mid-50s, Mr. Shephard saw one doctor who told him "not much could be done" for his lumbar spinal stenosis. And so he managed as best he could by taking an occasional aspirin. But in September 2001, upon returning from a vacation, the pain came on as never before. "It was like throwing a switch," says Mr. Shephard, now 60, an installation and repair supervisor for a phone company. "It was impossible for me to stand for very long, and each night my wife helped me get my legs up on the bed. One time when I was walking my dogs, I tripped and fell but couldn't get up. My wife came outside and found me laying on the sidewalk."

Mr. Shephard found Dr. Reiter by searching on the World Wide Web. One of the qualities he was looking for, in addition to an experienced back surgeon, was a physician and a hospital that would respect his beliefs about blood. As one of Jehovah's Witnesses, this was an important matter.

"I was extremely reassured when Dr. Reiter told me he believed in treating the whole patient, not just the patient's back, and would respect my beliefs. That meant a great deal to me," says Mr. Shephard. "Michelle Thomas, coordinator of University Hospital's bloodless program, helped me along the way."

One blood-conserving technique used during Mr. Shephard's back surgery was hemodilution. This technique involves the collecion of several units of blood from the patient immediately before surgery and the replacement of that blood volume with an IV solution. The patient's existing blood supply is thus diluted; consequently any blood that is lost in surgery contains very little whole blood but a highly diluted mixture of blood and solution. The withdrawn blood is returned slowly without being stored or having the circuit disconnected.

On both counts - relieving his spinal stenosis and the blood issue - Mr. Shephard considers his surgery a success. "My confidence in Dr. Reiter was well placed, and the nurses were generous with their time. My physical therapist at University Hospital was wonderful. She was always by my side as I practiced walking and climbing stairs in those first days after surgery," he says. "While I was apprehensive about surgery, I knew I needed it, and today I'm a new man."

Like Mr. Shephard and Mrs. Kulesh, most people who have surgery for lumbar spinal stenosis experience good results. When there is dissatisfaction, it's often because the surgeon wasn't thorough enough and didn't free up the nerves completely, or stenosis develops in new areas of the spine above or below where the laminectomy procedure was performed. "Done properly, lumbar spinal stenosis surgery has an excellent success rate for relieving patients' pain and improving their function," says Dr. Reiter.

To arrange for a consultation with Dr. Heary, call (973) 972-2334. To arrange for a consultation with Drs. Reiter or Vives, call (973) 972-0679.

Interested in learning more about the Bloodless Program at University Hospital? Just click on our website for complete information. http://www.theuniversityhospital.com/bloodless/index.htm