Dr. Benjamin Cohen: I’m Dr. Benjamin Cohen, your host. A neurosurgeon who specializes in spinal surgery and I'd like to welcome back one of our former guests, Dr. Barry Fabrikant, or as his patients affectionately call him Dr. Barry, a chiropractor. Today, our topic is going to be lumbar spinal stenosis.
Another common problem that tends to affect patients probably from their 50s into their 70s and 80s. I like to refer to it as age related spinal narrowing because it really is a age related problem. It's arthritic problem and how I would define it is all the elements of the spine tend to get thicker. The spine is surrounded by a disk that may bulge out a little bit more, there's ligament in the back that gets a little thicker, the joints get a little bit thicker, and all sum together they cause this narrowing or stenosis of the spinal canal.
What that basically does is cause patients to have back and leg pain when they stand and walk. They tend to get better when they sit or flex forward. The reason why they get better when they sit or flex forward is because they're opening the space around the spinal canal as they flex, or in a sitting position. When we stand up straight, it's almost like a nutcracker effect where the space gets even more narrow.
Patients would rather go on a stationary bike, or play tennis, and they don't like to walk, or do things standing. Many patients with spinal stenosis will come to me, and they’ll have imaging, and they'll have the diagnosis, but for whatever reason they're not in bad shape, they're pretty functional, it doesn't bother them all the time.
We want to do something conservatively, initially, medically, short of surgery, to see if we can treat them and get them better. One of the things that comes up is physical therapy and/or chiropractic care. Dr. Barry, I'll ask you, I’m sure you see a lot of patients with spinal stenosis, lumber stenosis. What’s your approach? What do you tell them? What types of things can you do to help them get better and keep them away from somebody like me?
Dr. Barry Fabrikant: Fantastic question, important topic. Almost everybody coming in today over 50, upon it, looking at MRI, you're seeing spinal stenosis. Often, patients, clients, are thinking, "Here, I have this disease called stenosis." Yet, it's not something you're born with, it's something that develops over time. Probably, at the forefront of this problem is postural distress, people collapsing their core, people sitting over the computer, taking a hour and a half ride each way in to the city forward and back, and spending this whole host of time sitting and it's breaking down your spine. Your spine is responding by developing more calcium to protect that area, to guard the area.
One day, you wake up, somewhere four or five decades down, and you have spinal stenosis. This disease process actually affects people who are broken down in their posture. It's an important conversation to start dealing with how are you holding yourself. How are you holding yourself when you work, when you play, when you dance, when you commute? Probably, the most important conversation we begin with is how you hold your core, how you stack your head over your shoulders, how your shoulders stack over the pelvis, and your pelvis over your knees and hips.
Dr. Benjamin Cohen: As we talked about last time, posture is at the core of all this. You had a saying, what was that saying?
Dr. Barry Fabrikant: Right. If you Google the term, "sitting is the new smoking", it's just a host of topics of how sitting is related now even to mortality, high rates in mortality.
Dr. Benjamin Cohen: Interesting.
Dr. Barry Fabrikant: It's frightening, sitting is the new smoking. In fact, everybody’s sitting today.
Dr. Benjamin Cohen: What you're saying is the lumbar stenosis that we see in patients in their 60s and 70s may ultimately be the end result of poor postural positioning in their 20s, 30s, 40s and 50s?
Dr. Barry Fabrikant: There's a whole host of thought that it's the way you hold yourself, and the way you move, the way you posture yourself that ultimately will determine how effective, how strong, and how capable you are when you move, bend, dance, play, lift.
When you're out of your center, that your muscles take over, and then you start to have this grinding, stressful pain in the muscles that ultimately will start to be transferred to the desks, and to the spinal bones. The bones and the body will respond by producing more calcium to protect that area and then that calcium starts to grow into the spinal canal, and you find yourself with spinal stenosis.
Dr. Benjamin Cohen: Got it. Now, let's assume we have a patient who's 72 years old and in fairly good health, who finds himself now with the diagnosis of spinal stenosis. Maybe they complained to their primary care doctor that they have this back and leg pain, they get an MRI, they have it. Well, they see you first or me first, it's determined that we're going to initiate a trial of conservative or medical management, if we're considering surgery. What is your approach? What types of treatments specifically would you do with them to try to help get their symptoms treated?
Dr. Barry Fabrikant: It's a multi-fold approach. First thing we'll do is look at the postural alignment of the spine. Spine covers your central nervous system, covers the spinal cord. If that spine is motioning and moving properly, it's centered properly, you’re probably going to have the best performance. Sometimes we find that the spinal bones are out of their center, they're stuck out of alignment and they're not motioning properly.
We'll address that problem as we see it. This is soft tissue element. There's the muscles, the tendons, the ligaments, that need to be addressed. Are the muscles lengthened properly? Are they conditioned properly? Then, there's a concept of how to move. We’ll initiate a series of treatment to correct those spinal imbalances. If they get to the end of this program and they're better, of course, they’re better, but if they're not, then we have to consider higher diagnostics, MRI, CAT scan.
If the stenosis, the narrowing in the spinal canal, is pathologic, to the point where it needs surgical correction, well, one of the ways we’ll know that is that it's unrelenting pain. It’s pain that does not go away, it's pain that does not recede back, they're not getting any benefit from the conservative care. That's one element that says this may need a surgical intervention. If there is motor loss, meaning the muscles start to go weak and they're losing the ability to lift a foot, what we call foot drop.
Dr. Benjamin Cohen: Foot drop.
Dr. Barry Fabrikant: Correct. Then, we know that that's another step up, that the patient is moving into that danger zone of motor muscle loss. The most advanced is when you get organs that fail to do what they're doing because the nerve flow to them is so altered that maybe they're losing function of urinary control, or bladder control, or bowel control.
Dr. Benjamin Cohen: Yes. A lot of people don't realize that the nerves that travel to their bladder run through the same space that goes to the legs. It's certainly more of an urgent situation, and more of a severe situation, but I've had patients who have basically presented with urinary dysfunction to the point where they're not able to do urinate properly. That becomes more of an emergency and it can be caused from spinal stenosis.
Dr. Barry Fabrikant: I think that's one of the first questions on intake. Are you experiencing any changes in your urinary patterns, any bowel functions? That's one of my red flags that say this is no longer a chiropractic issue. Now, we're looking at something that may be of surgical concern and need to get on that.
Dr. Benjamin Cohen: I also find that lumbar stenosis sometimes can be misdiagnosed, or under diagnosed, in the sense that not everybody with leg pain and problems walking has a problem in their low back. It may be in the neck. Sometimes you'll find that patients that have spinal stenosis in the low back also have spinal stenosis in the neck. In the neck, it's sometimes more concerning because that actually compresses the spinal cord, which ends somewhere in the mid back, and not a lot of people realize the low back actually is not the spinal cord, it's just the nerve roots. A lot of times in our practice, we will image both the neck and the low back as well because the problems can sometimes overlap.
Dr. Barry Fabrikant: We're also looking at people visually and seeing problems. Sometimes patients come in and, even at a young age, they're already beginning to develop Dowager's Hump, which is that hump that starts to occur between the neck and the upper back, and nursing home posture, as I call it, where the head is so far flexed at the shoulders they have problems turning to the right, turning to the left. We're already starting to see the effects of a spine that's fusing and developing stenosis. They may have pins, needles, tingling down in arm, or hand, or wrist.
Dr. Benjamin Cohen: Well, that's why it's just so important to get a full history and a full examination because so many of these issues can overlap. Getting the diagnosis right is so important to selecting the proper treatment.
Dr. Barry Fabrikant: Absolutely.
Dr. Benjamin Cohen: I'm getting the cue that we're starting to run out of time. But, once again, thank you for joining us, Dr. Barry. Thank you.
Dr. Barry Fabrikant: You're welcome
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