I want to begin this article with a case study from our recently published research in the Biomedical Journal of Scientific & Technical Research.
- The patient was a 77 year-old female with a 20-year history of lower back pain, which had progressed with age.
- The patient wore a back brace to attempt to reduce the stiffness and pain when standing or sitting for extended periods of time.
- Radiographic assessment of her lumbar spine showed mild dextroscoliosis (a sideways curve) and
- a mild narrowing of L1-L2, L3-L4 and moderately severe narrowing of L5-S1.
- Her baseline resting and active pain prior to treatment was:
- 1/10 (resting) and 5/10 (active), and a 33/40 functionality score.
After physical assessment of her lower back, we determined her pain was generated from a lumbosacral sprain. Not the narrowing of the L1-L5,S1
She had one Bone marrow derived stem cell treatment and at first follow up two weeks after the injections, the patient experienced no pain or stiffness and reported 90% total improvement. Approximately a year after treatment, she felt even better, and stated that she was able to perform aerobics and line dancing for an hour and a half a day with no pain. She reported infrequent stiffness, but not as severe as it was prior to treatment.
Her resting and active pain were 0/10 and functionality score was 39/40.(1)
This was one document case in the medical literature. Over the years we have helped many people avoid a stenosis surgery they did not want or possibly did not even need.
Doctors question spinal stenosis surgery
Despite the fact that many studies insist that surgical treatment is the best option for lumbar spinal stenosis, a startling study was published in the medical journal Spine. In this study, American, Canadian and Italian researchers published their evidence:
“We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. . . However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment.” (2)
In the above research it should be pointed out the comparison between lumbar surgery and conservative treatments did not include stem cell therapy. They included the traditional conservative treatments including physical therapy, cortisone injections, pain medications and others listed below.
The MRI’s role in confusing and frightening patients
One of the reasons surgery may be no better than conservative care is that the surgery tried to fix a problem that was not there: Pain.
In the medical journal Osteoarthritis and Cartilage,doctors reported that many asymptomatic individuals, those with no pain or other challenges, have radiographic lumbar spinal stenosis. In other words they only have lumbar spinal stenosis on the MRI.
The doctors noted:
- We found that 77.9% of participants had more than moderate central stenosis and 30.4% had severe central stenosis. Only 17.5% of the participants with severe central stenosis were symptomatic.
- They also concluded: Although radiographic lumbar spinal stenosis is common. Symptomatic lumbar spinal stenosis were relatively uncommon in these patients.(3)
Patients with spinal stenosis seek information on alternatives and want to be given choices
A diagnosis of spinal stenosis can be frightening because of the implications that a surgery may be needed to avoid paralysis. It is important to note that in instances where stenosis is so severe that the patient has lost circulation to the legs or bladder control – a surgical consult should be made immediately.
In the December 2017 edition of the medical journal Spine, doctors from the University of Pittsburgh and University Toronto reported these observations in patients seeking non-surgical treatments for lumbar spinal stenosis.
- Three themes related to medical treatment and symptom management arose from analyses –
- (1) an emotional response (depression, anxiety) to lumbar spinal stenosis;
- (2) a desire for education about lumbar spinal stenosis and motivation to pursue education from any available source; and –
- (3) a desire for individualized care based on self-management techniques and lifestyle changes.
- Emotional responses were more evident in individuals receiving medical care, while the other two themes were consistent across all 3 treatment groups.
Individuals with lumbar spinal stenosis may believe misinformation and information from non-medical sources, especially when medical providers do not spend sufficient time explaining the disease process and the reasoning behind treatment strategies. Receiving individualized care focused on self-management led to fewer negative emotions toward care and the disease process. Clinicians should be prepared to address all three of these aspects when providing care to individuals with lumbar spinal stenosis.(4)
Back pain can certainly cause anxiety, depression, and catastrophizing thoughts. The people in this study wanted education and involvement in their choice of treatment. I hope I can provide some for you here in this article.
Understanding the surgical options for stenosis
Lumbar Spinal Stenosis is a narrowing of the space between vertebrae where the spinal cord and the spinal nerves travel. It is a diagnostic term to describe lower back pain with or without weakness and loss of sensation in the legs. It is a very common condition brought on mostly by aging and the accompanying degeneration of the spine.
In the recommended surgical procedures for spinal stenosis, two choices are the most favored.
- A Decompression procedure where the surgeon will shave and cut away the bone narrowing the spinal canals.
- The second, a fusion procedure to limit the movement between two vertebrae and hopefully stop the compression of nerves.
A paper published in October 2017 gives a good outline where conservative medicine is in the treatment of Lumbar stenosis. It is from doctors at the University of South Carolina
- Current literature supporting the inclusion of physical therapy and gabapentin/pregabalin (nerve pain medications) within initial treatments have been positive.
- A recent randomized, double-blinded clinical trial of adding calcitonin (prevents bone breakdown) to epidural steroid injections have shown improvement in pain and function up to 1 year.
- The minimally invasive lumbar decompression (mild) procedure is showing ongoing beneficial results in pain and function.
- Spinal cord stimulation (SCS) may have a role for select patients with lumbar spinal stenosis.
- Finally, the benefits of surgical treatment versus nonsurgical treatment is ultimately inconclusive because of the nature of data collection, inconsistencies.(5)
This is indeed a fair assessment of SOME of the treatment options available to patients.However, not all doctors agree. At New York University in June 2017 research, doctors wrote:
The highest levels of evidence do not support minimally invasive surgery over open surgery for cervical or lumbar disc herniation. However, minimally invasive surgery fusion demonstrates advantages along with higher revision and hospital readmission rates. These results should optimize informed decision-making regarding minimally invasive surgery versus open spine surgery, particularly in the current advertising climate greatly favoring minimally invasive surgery.(6)
Should a patient then even seek surgery, minimally invasive or open spine? It is possible that a sham or placebo surgery can deliver the same results
Researchers at the University of Sydney say that the evidence for recommending lumbar spinal surgery as the best option to patients is lacking and it is possible that a sham or placebo surgery can deliver the same results.(7)
In the research I cited at the top of this article, doctors at the Italian Scientific Spine Institute in Milan wrote: We cannot conclude on the basis of this review whether surgical or nonsurgical treatment is better for individuals with lumbar spinal stenosis. We can however report on the high rate of effects reported in three of five surgical groups and that no side effects were reported for any of the conservative treatment options.(8)
“Considering the majority of these procedures are unnecessarily being performed for degenerative disc disease alone, spine surgeons should be increasingly asked why they are offering these operations to their patients”
A team of Japanese researchers found that patients with lumbar spinal stenosis who do not improve after nonsurgical treatments are typically treated surgically using decompressive surgery and spinal fusion surgery. Unfortunately the researchers could not determine if the surgery had any benefit either.(9) Maybe the patient’s problem was not the stenosis?
Now let’s go to another paper that has more of an opinion: From Dr. Nancy Epstein of Winthrop University Hospital:
- “The incidence of nerve root injuries following any of the multiple minimally invasive surgical techniques resulted in more nerve root injuries when compared with open conventional lumbar surgical techniques. Considering the majority of these procedures are unnecessarily being performed for degenerative disc disease alone, spine surgeons should be increasingly asked why they are offering these operations to their patients?”(10)
Surgeons at Leiden University Medical Centre in the Netherlands speculate that doctors go into a diagnosis of lumbar spinal stenosis with the thought that there is osteoarthritis – a bony overgrowth on the spinal nerves. Once determined, the symptoms of patients can be categorized into two groups; regional (low back pain, stiffness, and so on) or radicular (spinal stenosis mainly presenting as neurogenic claudication – nerve inflammation).
In the patients who primarily complain of radiculopathy (radiating leg pain) with an stable spine, a decompression surgery may be recommended to remove bone from around the nerve root to give the nerve root more space. The surgeons warn of the fear that surgery to a stable spine will make it unstable.(11)
A fusion procedure to limit the movement between two vertebrae and hopefully stop the compression of nerves is another option. As mentioned by independent research above – surgery for spinal stenosis should only be considered after conservative therapies have been exhausted. Surgical treatment of lumbar spinal disorders, including fusion, is associated with a substantial risk of intraoperative and perioperative complications,as pointed out in the research by surgeons from Catholic University in Rome.(12)
Treatment with Bone marrow derived stem cells and PRP
Bone growth occurs in the spine because the bone is trying to stabilize the spine from excessive movement or laxity. Fusion surgery is recommended as a means to accelerate that type of stabilization. Regenerative medicine including PRP and Stem Cell Therapy (watch the video) works in a completely different way. They stabilize the spine by strengthening the often forgotten and underappreciated spinal ligaments and tendons. These techniques help stabilize the spine, which is imperative as unstable joints can lead to – or further exacerbate – the arthritis that causes spinal stenosis.
In the medical journal Insights into imaging, researchers wrote of the four factors associated with the degenerative changes of the spine that cause spinal canal stenosis:
- disc herniation.
- hypertrophic facet joint osteoarthritis, (an overgrowth of bone)
- ligamentum flavum hypertrophy (inflammation of the spine’s supporting ligaments – the ligamentum flavum).
- and spondylolisthesis (stress fractures causing the vertebrae to slip out of place)
The same research suggests that these conditions can prevent the formation of new tissue (collagen) which can initiate repair.(13)
Collagen is of course the elastic material of skin and ligaments. Here the association between collagen interruption and spinal stenosis can be made to show spinal instability can be THE problem of symptomatic stenosis.
A fascinating study on what damaged spinal ligaments can do
A fascinating study in the Asian Spine Journal investigated the relationship between ligamentum flavum thickening and lumbar segmental instability, disc degeneration, and facet joint osteoarthritis. Ligament thickening is the result of chronic inflammation. Chronic ligament inflammation is the result of a ligament injury that is not healing.
What these researchers found was a significant correlation between ligamentum flavum thickness, spinal instability and disc degeneration. More so, the worse the degenerative disc disease, the worse the ligamentum flavum thickness.(14)
PRP and stem cells address the problem of ligament damage and inflammation. Addressing these problems address the problems of spinal instability. Addressing the problems of spinal instability can address the problems of spinal and cervical stenosis.
Ask Dr. Darrow about spinal stenosis
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1 Darrow M, Shaw BS. Treatment of Lower Back Pain with Bone Marrow Concentrate. Biomed J Sci&Tech Res 7(2)-2018. BJSTR. MS.ID.001461. DOI: 10.26717/ BJSTR.2018.07.001461.
2 Zaina F, Tomkins‐Lane C, Carragee E, Negrini S. Surgical versus non‐surgical treatment for lumbar spinal stenosis. The Cochrane Library. 2016 Jul 1.
3 Lynch AD, Bove AM, Ammendolia C, Schneider M. Individuals with lumbar spinal stenosis seek education and care focused on self-management–results of focus groups among participants enrolled in a randomized controlled trial. The Spine Journal. 2017 Dec 12
4 Ishimoto Y, Yoshimura N, Muraki S, Yamada H, Nagata K, Hashizume H, Takiguchi N, Minamide A, Oka H, Kawaguchi H, Nakamura K. Associations between radiographic lumbar spinal stenosis and clinical symptoms in the general population: the Wakayama Spine Study. Osteoarthritis and cartilage. 2013 Jun 1;21(6):783-8.
5 Patel J, Osburn I, Wanaselja A, Nobles R. Optimal treatment for lumbar spinal stenosis: an update. Current Opinion in Anesthesiology. 2017 Oct 1;30(5):598-603.
6 Vazan M, Gempt J, Meyer B, Buchmann N, Ryang YM. Minimally invasive transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion: a technical description and review of the literature. Acta Neurochir (Wien). 2017 Jun;159(6):1137-1146
7 Machado GC, Ferreira PH, Yoo RI, et al. Surgical options for lumbar spinal stenosis. Cochrane Database Syst Rev. 2016 Nov 1;11:CD012421.
8 Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical Versus Nonsurgical Treatment for Lumbar Spinal Stenosis. Spine (Phila Pa 1976). 2016 Jul 15;41(14):E857-68.
9 Inoue G, Miyagi M, Takaso M. Surgical and nonsurgical treatments for lumbar spinal stenosis. Eur J Orthop Surg Traumatol. 2016 Oct;26(7):695-704. doi: 10.1007/s00590-016-1818-3. Epub 2016 Jul 25.
10 Epstein NE. More nerve root injuries occur with minimally invasive lumbar surgery: Let’s tell someone. Surg Neurol Int. 2016 Jan 25;7(Suppl 3):S96-S101. doi: 10.4103/2152-7806.174896. eCollection 2016.
11 Overdevest GM, Moojen WA, Arts MP, Vleggeert-Lankamp CL, Jacobs WC, Peul WC. Management of lumbar spinal stenosis: a survey among Dutch spine surgeons. Acta Neurochir (Wien). 2014 Aug 7. [Epub ahead of print]
12. Proietti L, Scaramuzzo L, Schiro’ GR, Sessa S, Logroscino CA. Complications in lumbar spine surgery: A retrospective analysis. Indian J Orthop. 2013 Jul;47(4):340-5. doi: 10.4103/0019-5413.114909.
13 Kushchayev SV, Glushko T, Jarraya M, et al. ABCs of the degenerative spine. Insights into Imaging. 2018;9(2):253-274. doi:10.1007/s13244-017-0584-z.
14 Yoshiiwa T, Miyazaki M, Notani N, Ishihara T, Kawano M, Tsumura H. Analysis of the Relationship between Ligamentum Flavum Thickening and Lumbar Segmental Instability, Disc Degeneration, and Facet Joint Osteoarthritis in Lumbar Spinal Stenosis. Asian Spine Journal. 2016;10(6):1132-1140. doi:10.4184/asj.2016.10.6.1132. 2373