Lumbar Spinal Stenosis | Central Stenosis

Lumbar Spinal Stenosis (Central Stenosis) Overview

There are five vertebral bodies that make up the lumbar spine better known as the lower back. Nerves exiting off of the spinal cord (at the lower thoracic spine as the spinal cord ends at the upper lumbar spine) travel through the central canal. The central canal is made up of individual rings from each vertebra stacked one on top of the other. The nerves exit one at a time through the sides of these vertebral bodies. Over time, as wear and tear and other degenerative conditions, such as disc degeneration and facet arthritis, take their toll on the lower spine, these rings that make up the central canal will begin to narrow. If the narrowing is substantial, it causes nerve compression of the spine of the sac of nerves (cauda equina) which will lead to lumbar central stenosis or lumbar spinal stenosis.

Stenosis of the lumbar spine (and central stenosis), next to the herniated disc, is one of the most common conditions of the spine that is experienced over time—especially by those who are over 50 years of age with females having the majority of problems. The most common cause of lumbar stenosis is degenerative changes of the spine. The most common problem associated with stenosis is degenerative spondylolysthesis (please see section on that subject in this web site).

Lumbar spinal stenosis can also be linked to other conditions such as tumors, infections of the spine, metabolic bone disorders and other known diseases but these are exceedingly rare.

Symptoms of Lumbar Spinal Stenosis

The narrowing of the spinal canal can occasionally cause lower back pain but that is the exception rather than the rule. When someone complains of lower back pain, one might hear them refer to sciatica or their sciatic nerve (pain that radiates from the lower back and buttocks). Lower back pain from the sciatic nerve (pain in the buttocks) oftentimes is actually stenosis. The most common complaints of lumbar spinal stenosis (central stenosis) are a dull ache or “numbness” in the sacroiliac region of the spine and buttocks with prolonged standing or walking that increases with the amount of time doing that activity. Sciatica and sacroiliac syndrome symptoms will start to extend down the back of the legs with prolonged standing or walking. A general weakness or fatigue of the legs and loss of sensation can also occur (also side effects of sciatic nerve pain).

In most cases, standing and bending backwards worsens the symptoms whereas sitting or leaning forward helps to relieve them. As the individual bends forward or crouches, the space within the spinal canal increases and relieves the pressure on the sac of nerves. Generally, symptoms associated with lumbar central stenosis and stenosis of the spinal canal typically worsen over time but many times, they don’t advance at all. Occasionally, they can improve over time even without physical therapy exercises for the spine.

(Click to Enlarge Image) This is a top down picture of the effects of aging on the spine. The top picture is a normal spinal canal. The bottom picture shows hypertrophy (enlargement) of the facets in the rear of the canal and bulging of the disc in the front which conspire to narrow the spinal canal.

(Click to Enlarge Image) This diagram shows how aging starts to narrow the spinal canal. The arrow in front points to a bulging disc that presses into the canal from front to back. The arrow behind points to ligamentum flavum that has enlarged with aging which pushes into the canal from the rear.

(Click to Enlarge Image) This illustration demonstrates the change in the diameter in the canal in a patient with spinal stenosis. The picture on the right shows the canal wide open with flexion (bending forward). The picture on the left shows significant compression of the nerve sac in the canal (arrow) with backwards bending. Standing and walking require backwards bending, so the symptoms of central stenosis occur with walking and standing.

(Click to Enlarge ) Stenosis of L3-4. This flexion film (arrow) shows the dye in the spinal canal filling the defect that was there in flexion.

(Click to Enlarge) Stenosis of L3-4 staning upright. Note at arrow that the dye in the canal does not fill at the narrowed segment.

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(Please keep reading below for more information on this condition.)

Treatment of Central Stenosis

Non-Surgical

Anti-inflammatory medications, pain relievers, muscle relaxers and cold/heat therapies can help to relieve lower extremity pain associated with lumbar spinal stenosis. Physical therapy and alternative therapies such as acupuncture are also options for lower back pain and pain in the buttocks and legs. Injections are very helpful to control the symptoms. If all measures have been exhausted without using surgery and pain and symptoms are still occurring, surgery will be the next step to treating the condition.

Surgical

There are surgical procedures that can help relieve the pressure on the nerves and therefore the symptoms of lumbar central stenosis. It’s important to understand all of the reasons why spinal surgery for stenosis might be necessary.

A decompressive laminotomy or laminectomy for stenosis can be performed to create more space in the spinal canal for the nerves. This is done by removing a portion of the roof of the canal and any spurs that have grown into the canal from the degenerative facets. This is essentially a roto-rooter surgery to make more room for the nerves. Please see section on surgical options for this procedure.
If instability has occurred along with spinal stenosis (example is unstable degenerative spondylolysthesis) spinal fusion stabilization procedure may be required in addition to the decompression surgery. There is a nice video which explains this surgery for degenerative disc disease with spinal stenosis.

For more information on lumbar spinal stenosis, or to determine the appropriate treatment option for your case of central stenosis, please contact Dr. Donald Corenman, spine specialist and back doctor in the Vail, Aspen, Denver and Grand Junction, Colorado area.

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Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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Lumbar Spinal Stenosis (Central Stenosis)