The “Aging” Back
Your body goes through many changes as you get older. You may not see or hear as well as you did when you were younger. We recognize that this is a natural process, and we learn to accept it or make adjustments for it, such as getting glasses or a hearing aid.
As your spine ages, it also goes through some natural changes. In a condition often referred to as the Degenerative (or “Aging”) Spine, the gelatin-like centers of your discs begin to dry out, causing them to become compressed or “flattened” (Fig.5). This, in turn, causes the vertebrae to”settle.” It’s one of the reasons most people actually become shorter as they grow older.
The Slowly Closing Window
As your discs begin to “compress” and your vertebrae begin to “settle”, the window-like openings of the foramen become smaller and smaller (Figs. 5,above & 6,below). Eventually, the opening can become so small that the nerve is “pinched” against a vertebra. It’s similar to laying your hand on a window sill. As long as the window is open, there is no problem. However, if someone slowly closes the window, there will be a point at which your hand begins to feel the pressure. The more the window is closed, the greater the pressure and the greater the pain you will feel.
The Loss of Your Spine’s “Shock Absorbers”
At the same time, your aging discs are drying out and losing their ability to act as effective “shock absorbers.” Your vertebrae begin to bounce against one another and this jarring action actually causes the bone matter of the vertebrae to grow. This results in the formation of bone spurs. The jagged edges of this new growth can cause both the spinal canal and the foramen to become even smaller. When this happens, the result is often the pinching of the cauda equina and/or a spinal nerve root.
When a spinal nerve is pinched by a narrowing of the foramen, the condition is referred to as lateral recess stenosis. Symptoms include intense pain, numbness and/or weakness in one leg. When the cauda equina becomes compressed by a narrowing of the spinal canal, the condition is referred to as lumbar canal stenosis and the pain, numbness and/or weakness appears in both legs.
If the aging of the spine is a natural process and happens to everyone, why does one person end up with lateral recess stenosis or lumbar canal stenosis while his/her neighbor is seemingly unaffected? The answer is that everyone’s spine is unique. Some people are born with discs which are naturally more”plump” than others. Some have wide foraminal or spinal canal openings, while others have narrow ones. These factors as well as your weight, posture and level of physical activity help to determine who will be adversely affected by the aging process.
Because the aging of the spinal discs is a natural and irreversible process, treatment options for lateral recess stenosis or lumbar canal stenosis are limited to the following:
- Taking Medication: For some, medication may help to ease the pain in the affected area and thereby provide relief.
- Using Physical Therapy: For those with only limited pinching of the spinal nerves, measures such as physical therapy or gentle exercise may provide relief
- Having Surgery: For those with severe compression of the cauda equina and/or spinal nerves, a decompressive lumbar laminectomy often is the recommended treatment.
When Surgery is NOT an Option:
The severity of your symptoms (pain, weakness, numbness) and your general health and physical condition will play an important part in determining when surgery is not an option for you. In general, surgery is not an option when:
- you do not have leg symptoms;
- your back and leg symptoms are not caused by a pinched nerve;
- there is a medical reason which prevents you from having surgery;
- medication which reduces swelling or relieves pain would provide you with adequate relief; or
- physical measures would improve your condition.
When Surgery IS an Option:
A decompressive lumbar laminectomy is usually recommended only when specific conditions are met. In general, surgery is recommended when a spinal nerve root(s) is pinched and you have:
- leg pain which limits your normal daily activities; or
- weakness in your leg(s) or feet; or
- numbness in your legs; or
- difficulty in walking or standing.
The Risks of Having Surgery:
Some of the more common risks of having any surgery include excessive bleeding, infection, or a negative reaction to anesthesia. Certain unforeseen circumstances could even lead to death. Clinical experience and scientific calculation indicate that these risks are low, but surgery is still a human effort. You should feel free to ask any questions you have about your specific risk factors.
Since a decompressive lumbar laminectomy involves surgery in and around the spine, further nerve damage is a possibility. In some cases, the nerve is already so damaged that the surgical procedure required to simply take the pressure off the nerve could be the “straw that breaks the camel’s back.” The end result could be numbness, paralysis or a loss of bowel and bladder control.
The Risks of Not Having Surgery:
Without surgery, simple everyday activities also could lead to further nerve damage. The consequences could be much the same as those associated with surgery, including numbness, paralysis or a loss of bowel and bladder control.
The Benefits of Having Surgery
You can think of surgery as the first step in the healing and recovery process. It can help relieve pressure on your spinal nerve(s) and, thereby, help relieve your leg symptoms. It also may help you begin the process of regaining more normal function in your legs.
Your Chances for Success
Your level of healing will be determined by your age, your general health and the severity of the damage to your spinal nerve(s). Your attitude and your willingness to work at recovery also will play an important part in your recovery process.
Making Your Decision
When you consider your options, keep in mind the impact your condition has on your way of life and carefully weigh the risks and benefits of having surgery against the risks and benefits of not having surgery. The decision is yours!
If You Decide to Have Surgery
Approach your surgery with a positive mental attitude and with full confidence that you have made the right decision. While the surgeon concentrates on finding and removing the cause of your pinched nerve, you must concentrate on the recovery process. Cooperate fully with your surgeon and focus on the improvements you will make in the future – not on the problems of the past.
The Surgeon’s Role
Your surgeon will:
- review your neurological history and examination;
- review your diagnostic tests;
- plan a surgical approach; and
- review the procedure with you.
You must have a thorough understanding of the diagnosis (what is causing your back or leg symptoms) and the risks and benefits of the proposed surgery. Once you are confident that surgery is the correct option for you, turn your thoughts to the future and the recovery process.
Beginning the Operation
In the operating room, a decompressive lumbar laminectomy begins with an incision in your lower back (Fig. 6). Through this opening, your surgeon will reach the area where your cauda equina and/or spinal nerve(s) are being pinched.
After the incision is made, the surgeon will use a retractor to pull aside fat and muscle until the vertebra is exposed. A fine drill is then used to remove a section of the vertebra (dotted lines in Figs. 7,above & 8). Next, an opening is cut in the ligamentum flavum through which the spinal canal can be reached.
Removing the Cause of Pressure
Once the spinal nerve root(s) and cauda equina have been exposed, the surgeon will use a fine drill to remove bone spurs or rough edges of the intervertebral disc (Fig.9). This will make the openings of the foramen and the spinal canal larger and help to relieve pressure on your spinal nerves (Fig.10,next page).
Fusion And Instrumentation
On some occasions it may be necessary to stop the movement between two adjacent vertebrae. This is called a fusion. Your surgeon will place bone graft chips between the vertebrae to create a solid section of bone which prevents the motion. The surgeon may also elect to use metal implants (Fig.11) to prevent any motion while the bone graft hardens.
Closing the Incision
The operation is completed when each layer of the incision is closed with suture material (stitches) or surgical staples. If the outer incision is closed with staples or non-absorbable sutures, they will have to be removed after the incision has healed.
What to Expect After Surgery
The Healing and Recovery Process
The healing process can begin as soon as the foramen or spinal canal openings have been enlarged and the spinal nerves are no longer being pinched (Fig10). Healing is the body’s natural process of restoring its damaged tissues to a normal, or nearly normal, condition. Healing occurs on its own, but is influenced by such factors as general good health, physical fitness, nutrition and rest. Recovery is the process during which you work at becoming well. You must commit yourself to staying in good health (which means exercising), maintaining a positive mental attitude and following your physician’s instructions.
Have Realistic Expectations
Recognize that healing and recovery will not happen overnight. It is a process. You may find that much of your progress will be like taking two steps forward and one step “back. “Accept it! And then do all that you can to make sure your steps”forward” are large ones and your steps “backward” are small ones.
Be Patient and Persistent
During the recovery period in the hospital and at home, try to rebuild your strength gradually. Rest when you feel fatigued but be persistent in your efforts.
It is important for you to recognize that we all heal at a different rate. The speed at which you will recover depends in part on your age, your general level of health, your overall physical fitness and your mental attitude. Generally, you will heal more slowly if you are overweight, out of shape or smoke, or if you are a diabetic or have other pre-existing medical problems.
Expect Some Pain After Surgery
It is normal to have some pain after any operation. After a decompressive lumbar laminectomy, there may be some leg “aching” which occurs as the nerve(s) attempts to heal. You also may feel some muscle spasms across your back and down your legs. And if there was inflammation in the nerve root, you may continue to feel some pain until this inflammation diminishes. You will be given appropriate medication to control your pain, relieve back spasms and reduce inflammation.
Be Prepared for Some Emotional Changes
It is not unusual to feel tired and discouraged for several days following surgery. These feelings may be your body’s natural reaction to the cutback of extra hormones it generated during surgery. Although some emotional letdown can be expected, you must not let it get in the way of your recovery. Don’t look back at past problems. It is important for you to look at even the smallest positive steps you make as progress towards your recovery goal.
Develop a Positive Mental Attitude
You should begin to work on a positive mental attitude even before the surgery is performed. Direct your energies toward the solution of your problem, rather than worrying about what caused your problem. Don’t be discouraged by minor setbacks during the recovery process. Concentrate on the progress you make and will continue to make in the future.
The Recovery Process
Commit to a Healthy Lifestyle
Now is the time to commit yourself to a healthier lifestyle. You can begin by taking these important steps:
Watch your weight: If you are overweight, you must gradually return to your proper weight. Crash diets rarely work. Commit yourself to better eating habits and stay with them for the rest of your life.
Become more active: Your physician will tell you when you when you can resume normal physical activities after surgery. Make up your mind now that you will develop a regular aerobic exercise routine, such as walking, swimming or riding a bike. However, always check with your physician before starting any exercise program.
Going Home from the Hospital
In general, hospital stays are becoming shorter, and even though you may feel somewhat uncomfortable at the time you are released, your physician usually will allow you to go home when:
- your vital signs are stable;
- you can walk on your own;
- you can eat without having nausea;
- you have resumed normal bladder activity; and
- your wound is healing.
Recovering at Home
Once you are at home and you begin to resume your normal activities, follow the guidelines listed below (and contact your physician’s office if you have any questions):
- Exercise: try to do as much as you can. Daily walking is the best exercise. Set reasonable goals, but gradually increase the distance you walk each day. Check with your physician before starting any exercise program.
- Sitting and standing: do not sit or stand for long periods of time. If you have muscle spasms in your back or pain in your leg(s), changing positions frequently should help.
- Sleeping: rest when you feel fatigued, but do not spend all of your time in bed. Please note that waking up with a “stiff” back is not uncommon. For relief, try taking a short walk or a warm shower. If you do not have a firm mattress, invest in one – it is important for proper back support.
- Caring for your incision: wash your incision gently and pat it dry. If you see any increased redness, swelling or drainage, notify your physician.
You should gradually reduce the amount of pain medication you take. Begin by increasing the amount of time between pills, and then reduce the number of pills taken each time. A certain amount of discomfort can be expected until the swelling goes down and the nerve sensitivity decreases. Substitute moist heat, gentle exercise and short rest periods for pain medication whenever possible.
The best way to minimize future problems with your spine is to maintain a healthy lifestyle. It is important that you:
- eat a well-balanced diet in order to aid proper healing (avoid foods high in calories and fat content);
- continue to eat a healthy diet in the future to reach and maintain your proper body weight;
- get the proper amount of sleep;
- participate in some form of regular aerobic exercise (such as walking, swimming, or riding a bike.)
- Take extra care when lifting, bending or twisting; and
- Take care of other health problems (such as heart disease or diabetes.)
The Decision-Making Process
A Patient-Centered Approach
This book is provided to help you make an informed decision about your health care. It is an essential part of a patient-centered approach to medicine, called collaboration, in which the health care team (physicians, nurses and technicians), the health care institutions (hospitals, insurance companies, etc.) and the patient’s family all work towards achieving the best possible recovery for the patient.
Why the Patient is at the Center
Experience has shown that patients who are given the opportunity to make decisions about their own health care have less anxiety before their surgery and recover more quickly after their surgery. Recognize that you have a right and a responsibility to participate in the decisions involving your health care.