Spinal stenosis is used to define “patients with symptoms related to anatomical reduction of the lumbar spinal size,” asymptomatically or with symptoms (Genevay & Atlas, 2011). One sign and symptom of spinal stenosis is neurogenic claudication, which is the most common symptom of spinal stenosis, sometimes called pseudoclaudication (Genevay & Atlas, 2011). Neurogenic claudication is a reference to leg symptoms (pain) in the buttocks, groin, and anterior thigh, with radiation travelling down the backside of the leg to the feet. Neurogenic claudication is also sometimes accompanied by “fatigue, heaviness, weakness and/or paresthesia” (Genevay & Atlas, 2011). The second sign is that symptoms worsen when standing or walking and it is relieved by sitting” and there is relief in siting and laying flat (Genevay & Atlas, 2010). Thirdly, there is a “simian stance.” Patients with spinal stenosis will sometimes adopt the “simian stance,” which is a position that includes having the “hip and knee slightly flexed” due to difficulty standing straight up (Genevay & Atlas, 2010). Fourthly, spinal stenosis patients will report having nocturnal leg cramps. In a study by Matsumo et al, “patients had significantly more frequent attacks of nocturnal leg cramps than the control population, and leg cramps disturbed the quality of the patients’ life” and “leg cramps should be recognized as one of the symptoms of LCS,” which disrupts the patients’ life (2009). Lastly, with spinal stenosis, there may be bowel and bladder problems. It is known that “people with more severe stenosis may have problems with bowel and bladder function” (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2013). The National Institute of Arthritis and Musculoskeletal and Skin Diseases also report the occurrence of “cauda equina,” which is a severe form of spinal stenosis, which “may include loss of control of the bowel, bladder, or sexual function and/or pain, weakness, or loss of feeling in one or both legs” (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2013).
The first risk factor associated with spinal stenosis is genetics. Genetics involves the inherited traits to make one more vulnerable to spinal stenosis (Perry, 2016). People that genetically inherit a “small spinal canal” or have a “curvature of the spine” which applies pressure to nerves and surrounding soft tissues are at greater risk for developing spinal stenosis (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2013). Additionally, those that inherit a condition called achondroplasia , which is ”defective bone formation” resulting in shorter, thicker pedicles that reduce the diameter of the spinal canal, are at higher risk for developing spinal stenosis (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2013).
The second risk factor associated with spinal stenosis is age. As people age, the risk for spinal stenosis increases. Murphy cites that if “you are 50 years old or older,” that is a risk factor for developing spinal stenosis (2015). According to Mayo Clinic Staff, most people that have spinal stenosis are over the age of fifty (2015).
The third risk factor complements the second, which is the existence of degenerative conditions. Spinal stenosis usually results from age-related changes associated with gradual degeneration, with inflammatory or structural roots. It is known that as people age, spinal ligaments may harden from calcification, bones and joints may enlarge, and bone spurs can surface. The National Institute of Arthritis and Musculoskeletal and Skin Diseases contend that “when the health of one part of the spine fails, it usually places increased stress on other parts of the spine… this decreases the space (neural foramen) available for nerve roots leaving the spinal cord” (2013). Examples of degenerative conditions include a herniated or bulging disk and bone spurs. In turn, there is a greater risk for developing spinal stenosis. One further degenerative condition that contributes to spinal stenosis is osteoarthritis. Aging with secondary changes is the most common cause of spinal stenosis. Osteoarthritic conditions involve an overgrowth of bone with gradual wearing away, forming bone spurs. The condition is known often as spondylosis. In relation to spinal stenosis, “this condition may be accompanied by disk degeneration, and an enlargement or overgrowth of bone that narrows the central and nerve root canals” (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2013).
The fourth risk factor is the existence of various medical conditions, separate from degenerative and genetic conditions. According to Murphy, “some medical conditions can cause spinal stenosis. These include: Osteoarthritis and bony spurs that form as we age, Inflammatory spondyloarthritis (e.g., ankylosing spondylitis), Spinal tumors, Paget’s disease,” and trauma (2015). Osteoarthritis and sponyloarthritis were mentioned previously. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, “tumors of the spine are abnormal growths of soft tissue that may affect the spinal canal directly by inflammation or by growth of tissue into the canal” (2013). This results in bone resorption and bone displacement, contributing to the narrowing of the spinal canal (spinal stenosis). Additionally, accidents, or trauma, can cause mechanical dislocation of the spine and fragments of bone can penetrate the canal, resulting in a narrowed spinal canal (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2013). Lastly, Paget’s disease of the bone is a medical condition that puts one at risk for spinal stenosis. Paget’s disease will result in enlarged and abnormal bone losses, with thick and fragile bone production. This condition will mainly affect the spine, though it can affect almost any bone. Physiologically, the “blood supply that feeds healthy nerve tissue may be diverted to the area of involved bone,” acting as a contributor to spinal stenosis (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2013).
Fifth, there are certain health habits that put one at risk for spinal stenosis, mainly smoking and obesity. Perry writes, “ingredients in cigarettes can constrict blood vessels and other passageways in the body” (2016). Additionally, Perry discusses how obesity “places more stress on the spine, which can lead to instability” and spinal problems that can influence the development of spinal stenosis (2016).
The first treatment available for spinal stenosis is laminectomy/laminotomy. This procedure involves the complete removal of the lamina (laminectomy) or the partial removal of the lamina (laminotomy) of the affected vertebra of the spine. After removal of the lamina or part, some cases will call for the linkage of “adjoining vertebrae with metal hardware and a bone graft (spinal fusion) to maintain the spine’s strength” (Mayo Clinic Staff, 2015). With bony overgrowths in the spine the space in the spinal canal narrows, increasing pressure in the canal, resulting in “pain, weakness or numbness that can radiate down your arms or legs” (Mayo Clinic Staff, 2015). The Mayo Clinic Staff recommend that a “laminectomy is usually better at relieving these types of radiating symptoms than it is at relieving actual back pain (2015). Potential complications of laminectomy/laminotomy include “bleeding, infection, blood clots, nerve injury, [and] spinal fluid leak” (Mayo Clinic Staff, 2015). The procedure will involve a small incision in the back over the affected vertebrae and the removal of certain lamina. Postoperatively, there will be limitations on some activities- bending, stooping, amount of lifting, walking, and sitting. (Mayo Clinic Staff, 2015).
The second treatment option is the foraminotomy. The foraminotomy is a “surgery that widens the opening in your back where nerve roots leave your spinal canal” (Benjamin, 2014). The procedure involves an incision made in the mid-back, over the spine. Using instruments, the skin, muscles, and ligaments are moved to obtain a view. Bone is cut or shaved to expose the nerve root opening, or the foramen. After, a spinal fusion may be used to stabilize the area (Benjamin, 2014). Risks of a foraminotomy include “bleeding, infection in wound or vertebral bones, damage to a spinal nerve, causing weakness, pain, or loss of feeling, partial or no relief of pain after surgery, return of back pain in the future, [and] thrombophlebitis” (Benjamin, 2014). After the surgery, a soft collar is usually worn around the neck and within about a week or two, driving is permitted, with about four weeks being the time for the resumption of “light work” (Benjamin, 2014).
Thirdly, another treatment for spinal stenosis is laminoplasty. A laminoplasty procedure “opens up the space within the spinal canal by creating a hinge on the lamina [and] metal hardware bridges the gap in the opened section of the spine,” usually performed on the vertebrae in the neck (Mayo Clinic Staff, 2015). The Mayo Clinic Staff outlines the procedure:
“Instead of removing the bone and other compressive structures, the bone overlying the spinal cord (the “lamina”) is partially cut on both the right and left sides. This creates a hinge on one side of the lamina and a small opening on the other side. The lamina is then moved into the “open” position by elevating the lamina on the open side” (2015).
After, a spacer made out of bone, metal, or plastic, is used to hold the spinal canal open. The Mayo Clinic Staff writes, “the final position resembles an open door being help open with a door stop, and many surgeons refer to this technique as an “open-door” laminoplasty” (2015). A variant of this procedure is the “French-door” which is the creation of hinges on both sides of the lamina accompanied by an opening in the lamina’s center (Bhatia, 2009). Bhatia writes that “the main complaint after this kind of surgery is pain in the back of the neck” and nerve palsy, which will usually resolve (2009). Additionally, following a laminoplasty, nerve functions improve in about six to eighteen months, with many patients having a “complete resolution of the pre-operative symptoms” (Bhatia, 2009).
One pharmacological agent used in the treatment of spinal stenosis is gabapentin. Gabapentin has been used for the treatment of “neuropathic pain, [and] may be effective in the treatment of symptoms associated…” with spinal stenosis (Yaksi, Ozgonenel, & Ozgonenel, 2007). The action by which gabapentin “exerts its analgesic and anticonvulsant effects is unknown” but what is known is that gabapentin’s action is related to GABA, a neurotransmitter (Truven Health Analytics, 2016). Adverse reactions include peripheral edema, nausea and vomiting, viral disease, ataxia, nystagmus, fatigue and fever (Truven Health Analytics, 2016). More serious adverse effects include Stevens-Johnson syndrome, anaphylaxis, dizziness, somnolence, psychiatric effects (disorder of form of thought, disturbed thinking, hostility, hyperactivity, mood swings, suicidal thoughts) and angioedema (Truven Heath Analytics, 2016). As with any pharmacologic agents, gabapentin has certain nursing implications. The nurse must “instruct patient to report new or worsening depression, suicidal ideation, or unusual changes in mood or behavior,” teach the patient to avoid activities that involve mental alertness due to somnolence and dizziness, and teach to report “symptoms of anaphylaxis or angioedema” including difficulty breathing and itching (Truven Health Analytics, 2016). In addition, the nurse must warn the patient about “DRESS” which is an acronym for “drug reaction with eosinophilia and systemic symptoms,” indicative of multi-organ hypersensitivity (Truven Health Analytics, 2016). Further, the patient should be counseled not to suddenly stop taking gabapentin due to a potential for increased seizures (Truven Health Analytics, 2016).
The second pharmacological agent used in spinal stenosis is Methocarbamol, or Robaxin. It is a muscle-relaxer and as Genevay and Atlas write, in addition to analgesics and non-steroidal anti-inflammatory drugs, “muscle relaxants… are commonly used in patients with LSS (lumbar spinal stenosis)” (2010). The action of methocarbamol is a central nervous system depressant with “sedative and musculoskeletal relaxant activities… [and] the mechanism of action remains unknown and presumed to be due to general CNS depression” (Truven Health Analytics, 2016). Hsiang writes that methocarbamol “reduces nerve impulse transmission from spinal cord to skeletal muscle, providing pain relief for musculoskeletal conditions,” including spinal stenosis (2015). Common adverse effects, as written by Truven Health Analytics include: “dizziness, headache, lightheadedness, [and] somnolence” (2016). Serious adverse effects include leukopenia, anaphylaxis, and seizures (Truven Heath Analytics, 2016). Nursing implications include limiting activities that require coordination and alertness due to dizziness and somnolence. Additionally, the patient must be informed that the color of their urine may become brown, black, or green. The nurse will also teach the patient to report excess sedation. If a dose is missed, the nurse will “instruct patient to take a missed oral dose if it is remembered within 1 h of dose time, but if it is more than 1 h late, patient should skip the missed dose” (Truven Health Analytics, 2016). The patient should also be taught to disclose if they are currently taking any other medications especially medications that can cause sleepiness (such as sleep-aids, sedatives, antidepressants, allergy and cold medicines, or pain medications) to minimize the risk of interaction. (Truven Heath Analytics, 2016).
Two nontraditional (complementary) modalities available to treat spinal stenosis include chiropractic treatment and acupuncture.
The National Institute of Arthritis and Musculoskeletal and Skin Disease recognizes chiropractic treatment as a complementary option for spinal stenosis (2013). Chiropractic treatment is based on he tenet that “restricted movement in the spine reduces proper function and may cause pain” (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2013). Chiropractors may adjust or manipulate the spine mechanically to restore the structure and normal spinal movement. By using traction and pulling force, chiropractic treatments “help increase space between the vertebrae and reduce pressure on affected nerves” (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2013). Research shows that chiropractic treatment is as effective as other non-operative treatments for the acute back pain associated with spinal stenosis. (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2013).
The second nontraditional modality is acupuncture. The National Institute of Arthritis and Musculoskeletal and Skin Diseases writes:
“This treatment [acupuncture] involves stimulating certain places on the skin by a variety of techniques, in most cases by manipulating thin, solid, metallic needles that penetrate the skin. Research has shown that low back pain is one area in which acupuncture has benefited some people” (2013).
Acupuncture has roots in traditional Chinese medicine, grounded in beliefs of energy (Qi). There are different explanations for how acupuncture might work. According to Chon and Lee, “acupuncture points have been reported to correspond to cutaneous areas of high electrical conductivity and distinct histologic differences compared with adjacent tissue” (2013). Theories include the gate control theory of pain, endorphin model, and neurotransmitter models to explain how acupuncture works (Chon & Lee, 2013). Acupuncture is cited to relieve pains. Since symptoms of spinal stenosis typically involve pain, acupuncture is used as a complementary treatment modality to alleviate the pains. (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2013).
There are five different actions younger and middle-age adults can take to prevent or lessen spinal stenosis from advancing as one ages.
Firstly, a younger adult can exercise regularly. Exercises to promote back and spine health include “aerobic exercises like walking, swimming, cycling, and weight training” (The John Hopkins University, n.d.). Regular exercise and being involved in a fitness plan has structural benefits in the prevention of spinal stenosis.
Secondly, to shy away from the development of spinal stenosis, the younger adult can maintain a healthy weight. According to the Laser Spine Institute, “one of the main reasons why components of the spine deteriorate is that the spine supports the weight of the body” (2016). By exercising, a healthy weight is maintained so that the spine is not subject to additional stress. Spinal stress is a contributor to spinal stenosis and by exercising; one can lessen the onset of the condition. (Laser Spine Institute, 2016). Perry also recommends to maintain a healthy weight since “additional weight causes a compression of the vertebrae and discs in your spine… [increasing] your chance of developing spinal stenosis” (2016).
Thirdly, the Laser Spine Institute recommends to “practice good body mechanics” (2016). Being conscious of how one is lifting and using their body to move allows for the practice of moving properly to prevent spinal damage. Proper lifting techniques are emphasized especially when picking up heavy objects. It is also recommended to “practice good posture when sitting, standing, and sleeping to prevent improper compression of the discs or ligaments in your spine” (Laser Spine Institute, 2016).
Fourthly, daily stretching can lessen the development of spinal stenosis. The Laser Spine Institute states that stretching increases flexibility and strength between vertebrae and “strong ligaments have a lower chance of developing a degenerative disease and contributing to spinal stenosis” 2016). Further, by improving flexibility, the “ligaments in your spine [become stronger] and decrease your chance of disc and ligament degeneration” and spinal stenosis (Perry, 2016).
Fifth and lastly, Perry recommends avoidance of smoking. There has been literature and research that links smoking to back pains, in addition to the degenerative effects on the discs that leads to narrowing (or stenosing) of the spinal canals (Perry, 2016). Further, Perry states that smoking decreases bone density, putting the smoker at risk for fractures and deterioration. These factors mediated by smoking will “increase your risk of developing spinal stenosis” (2016).
References
Benjamin, M. (2014). Foraminotomy. Medline Plus. Retrieved from https://www.nlm.nih.gov/medlineplus/ency/article/007390.htm
Bhatia, N. (2009). Cervical Laminoplasty. Retrieved from http://www.knowyourback.org/Pages/Treatments/SurgicalOptions/CervicalLaminoplasty.aspx
Genevay, S. & Atlas, S. (2011). Lumbar Spinal Stenosis. Best Practice Residence Clinical Rheumatology, 24 (2). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841052/#R30
Chon, T. & Lee, M. (2013). Acupuncture. Retrieved from http://go.galegroup.com/ps/retrieve.do?sort=RELEVANCE&docType=Report&tabID=T002&prodId=PPNU&searchId=R3&resultListType=RESULT_LIST&searchType=AdvancedSearchForm&contentSegment=¤tPosition=1&searchResultsType=SingleTab&inPS=true&userGroupName=cuny_nytc&docId=GALE%7CA347407526&contentSet=GALE%7CA347407526&authCount=1&u=cuny_nytc
Laser Spine Institute. (2016). Spinal stenosis — simple lifestyle changes to help prevent spinal stenosis. Retrieved from https://www.laserspineinstitute.com/back_problems/spinal_stenosis/spinal_stenosis_articles/can_spinal_stenosis_be_prevented/
Matsumo, M. (2009). Nocturnal leg cramps: a common complaint in patients with lumbar spinal canal stenosis. Spine, 34 (5). Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19247159
Mayo Clinic Staff. (2015). Laminectomy. Retrieved from http://www.mayoclinic.org/tests-procedures/laminectomy/basics/definition/PRC-
Murphy, J. (2015). Spinal Stenosis. American College of Rheumatology Retrieved from http://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Spinal-Stenosis
Hsiang, J. (2015). Spinal Stenosis Medication. Medscape. Retrieved from http://emedicine.medscape.com/article/1913265-medication#4
National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2013). Questions and Answers about Spinal Stenosis. Retrieved from http://www.niams.nih.gov/health_info/spinal_stenosis/#spine_d
Perry, M. (2016). Spinal Stenosis Risk Factors. Laser Spine Institute. Retrieved from https://www.laserspineinstitute.com/back_problems/spinal_stenosis/risk/John Hopkins Medicine. (n.d.). Lumbar Spinal Stenosis. Health Library. Retrieved from http://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/lumbar_spinal_stenosis_134,18/
Truven Health Analytics. (2016). Gabapentin. Micromedex Solutions. Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/CS/A75BC8/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/009593/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=Gabapentin&UserSearchTerm=Gabapentin&SearchFilter=filterNone&navitem=searchALL#
Truven Health Analytics. (2016). Methocarbamol. Micromedex Solutions. Retrieved from http://www.micromedexsolutions.com/micromedex2/librarian/PFDefaultActionId/evidencexpert.DoIntegratedSearch#
Yaksi, A., Ozgonenel, L., & Ozgonenel, B. (2007). The efficiency of gabapentin therapy in patients with lumbar spinal stenosis. Spine. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17450066/
