Lumbar Spinal Stenosis (elderly mom)

[RiderJen]

A few days before Christmas my mom was taken to the hospital with severe radiculopathy pain in her right hip and front of right leg. This is the 2nd acute flare-up (1st was summer 2009). MRI (then and now) reveals lumbar Spinal Stenosis with bulging L2-L3 disk. Bulge last year was 2mm, now it is 5mm. She also has "severe osteoporosis" in the lumbar spine.

My mom is 80 but very active and otherwise very healthy. She exercises and is completely independent. She already knew she has osteoporosis.

She received 1 epidural injection last Thursday morning, and will receive the 2nd one tomorrow (thursday). She improves every day, but it's hard to know if that is due to the last week's epidural, or if she might have improved without it.

Anyway, last Thursday (1 week after admission) she was transferred to a health care rehab facility for PT. She is receiving excellent nursing care and is very happy also with the PT. Every day, she walks further and more often, and needs less and less pain med. When the pain does flare up, it still is severe but less so. She is not a complainer so I know the pain must be excruciating if she mentions it or refuses to take more steps.

She is hoping to return home next week after receiving more daily PT at this facility. I am overseeing her care, and will assist her when she returns home until she can be independent again. We're beginning to discuss out-patient PT and other options to help her return to as much independence as possible.

She's is open to surgery if the other measures don't provide enough relief. We've been told that the surgery to scrape the disk is very successful and "not a big deal", even in the elderly. However, an orthopedic surgeon told me he is reluctant to do that with her "because of her age". (Would a neurosurgeon be the best for this type of surgery?)

I want to support her in all she wants to do (within reason), and not push her into anything that might hurt or hinder her recovery or set her back.

Can anyone share any information with respect to this surgery to remove the bulge, and also the best PT to prevent this from occurring again? Her arms and legs are very strong because of the exercise she has done on her own for years.

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[piyush.jaiswal6]

hi rider, i m physical therapist running my clinic in india, i think in your case, lumbar traction with foot in 90 degrees, with 1/3 of body weight, intermittent, for 6,7 days for a period of 20 min. daily would help, see traction helps in bringing back the prolapsed disk to its original form, or you can also look for distraction therapy, along with that spinal anterior posterior glides forthe affected disk wud help her, all this corticosteroids injection are not the treatment for this, they are just the temporary thing, its good not to go for surgery at this point

[RiderJen]

Thank you very much. My mom is still in the rehab facility where she is getting daily PT, which includes walking increasing distances every day, now starting to climb stairs (she lives independently in a 2-story home), and other exercises to improve her function before she goes home (hopefully, the end of next week). Every day, she shows a lot of improvement which I believe is because she has exercised (including strength training and aerobic walking) for years; the OT says she can see a big difference between her and others who don't exercise at all.

Anyway, I will keep your suggestions handy to consider when looking for PT after her discharge.

QUESTION: Why do you recommend against surgery at this point? I have been told that the surgery to remove the disk bulge is "no big deal" and very successful even on elderly patients.

Also --- what about "spinal decompression"? I am seeing this mentioned more and more and wondering if it may be a good option for her.

The number of options is overwhelming, and it's difficult for a layperson to sort what's best from the rest.

[piyush.jaiswal6]

hi rider, my point regarding surgery was that, as the bones gets osteoporotic by this age, and doing such surgeries has some sort of risk of sensation loss, but always natural things are always the best, you don't get that thing after surgery what you have it before, i recommend you to get PT service who are good at relieving disc compression, see such buldges are can be easily tackled with proper traction, and yeah i told you about decompression therapy, you can know about it by searching in youtube, you will find the video there, its also like the traction only, but its just the advanced form of it, see spinal surgeries can now be easily avoided. and we ppl are doing that job, don't worry, and yeah see we prescribe the spinal flexors and spinal extensors exercise after the patient gets rid of pain, in order to built up the strength in surrounding muscles to prevent its reoccurance
fell free to ask any question, bye

[Dr Damien]

Dear Rider Jen

I have just read your thread and Im glad your mom is making functional recovery. I appreciate Piyush's suggestion and I agree with the advice that corticosteroids injections are only temporary relief treatments however i would be careful with a decision to manage her with lumbar traction using a traction force 1/3 her body weight since you say she is "severely" osteoporotic. I presume she is on bone strengthening medication.

the functional exercises the physiotherapist is given her is good because nothing beats back issue better than mobility. Also weight bearing and walking help to natuarlly improve bone strength.

Disc bulges in the elderly are not very common to be honest, stenosis yes. This is because generally with the aging process the discs shrink with regards fluid content. If your mother is as fit as you say, genetically her discs may still be fairly in good shape. However because of general degeneration, the housing tissues for the discs in the middleaged and the elderly( like your fit mother) can make then susceptible to rupture hence a bulge.

If I were the physiotherapist seeing you mother, I would be aiming to get her to achieve spinal extension without pain, either by gradually progressing the positions i would put her in in bed. for example...getting her to be able to lie prone if her posture will let her be able to do this and she doesnt have any other health issue..

I would focus on core stability, aimed at strengthening the spine and improving its ability to equate forces experienced during bending movements...I would advise her against any excessive bending or twisting motions for at least eight to 12 weeks...

It is possible that perhaps one of the vertebrae either above or below the problem site is stiff and causing excess movement at the problem site putting too much shear on housing of the bulging disc...

To be thorough, i would request a scan before and after physio to see whether this has had any effect, to be honest the prognosis for a disc bulge is good so, Piyush's advice against surgery is good since conservative management can be productive, if your mothers problem was due to a facet joint bony spur or stenosis then there would be no other way besides surgery

Spinal decompression may be the way to go for the stenosis (not disc bulge) you described...unfortunately there isnt any other way for this problem..

cheers

[RiderJen]

Dr. Damien, thank you for your last reply.

Update on her condition:
She is recovering very well in the rehab facility. She gets PT every day (except on the weekend), and she shows a lot of improvement every day. She is now able to climb stairs and walk on her own (bent at the waist feels better) without a walker, give herself a sponge bath, and dress herself. She can walk further every day before onset of pain, and her pain level has diminished to about 7 (from 10 when she was admitted). Her pain meds have diminished from Dilaudid to Vicodin/Tylenol (as needed) and last night, for the first time, she got through the whole night without any pain meds! She plans to go home at the end of the week (Friday or Saturday) after another full week of in-patient PT, and plans to continue with out-patient PT after she returns home. On Tuesday morning, she'll get her 2nd of three epidural injections.

She's open to someone (nurse, PT) going to her home for a few weeks to give her some assistance until she is completely independent again. She still drives, attends her group functions, serves as a hospital volunteer, takes line-dancing lessons.... you get the idea ... and wants to continue those as much as possible.

The PTs are amazed at how fast she is regaining her strength, but they agree that is due to her prior active lifestyle which includes exercising daily (and living in a 2-story house means climbing stairs throughout the day). Although 80 years old, she can rise from a chair as quickly as any 20-year-old. The PT has told her she needs to "slow down" when she walks, LOL. The problem is in her spine which is very fragile and must be treated with special TLC.

You said:

"..... to be honest the prognosis for a disc bulge is good so, Piyush's advice against surgery is good since conservative management can be productive, if your mothers problem was due to a facet joint bony spur or stenosis then there would be no other way besides surgery

Spinal decompression may be the way to go for the stenosis (not disc bulge) you described...unfortunately there isnt any other way for this problem..".

The MRI revealed lumbar Spinal Stenosis and also severe lumbar osteoporosis. L3 disk bulge is 5mm (last year, it was 2 mm). Doctor said there are other bulging disks, but none as much as this one. Radiculopathy pain is in her right hip and front of right leg, and she is walking further every day before pain re-emerges.

So, while she is still in the hospital and recovering well with PT, I am researching other options to give her the best possible outcome and let her live as independently as possible, including:

• Traction
• Other form(s) of PT
• Spinal decompression
• Surgery to scrape the disk

Surgery being the riskiest, she is open to that but would prefer more conservative treatments if they work and give her a good long-term prognosis.

In researching these options, what should I look for in particular to sort the wheat from the chaff?

Thanks,
Jen

[Dr Damien]

Dear Jen

I think the surgeons and your mom are the ones to really talk to about surgeries.
I personally would advocate for conservative managemnt first...the reality is even without any form of managemnt...the problem will go away on its own after several months...sometimes the bulge, sequesters and resorbs.

the problem is waiting for that to happen may mean that there is a risk to other problems developing before that...here goes my reasoning in deciding...

Traction: maybe is your mom was younger, did not have severe osteoporosis and can endure the positions required...so if you want to consider traction, they bone densities need to be re-checked as a precaution...if this is safe...physiotherapy will go hand in hand...

other forms of PT:??????????...I personally will try my hands on physiotherapy first...with long term benefits...that is difficult to say...u mention mutiple disc bulges...so mmmmmm.....I think its worth having a go....physiotherapy is unlikely to help with the stenosis though...

Spinal decompression: prognosis often very good in the younger patients...
scraping the disk...same as above....

Nowadays, surgeries to the spine do not have to involve excessively invasive procedures...this may be the likely intervention to give the most long term benefit...

the risks, infection, neurological problems, problems with anaesthesia...

My choice...i would recommend a combination of conservative management...
osteoporotic management...meds and functional exercise
corticosteroid injection treatment for major pain relief
physiotherapy...a consideration of traction only if bone density is safe and patients general health means she can sustain the positions required

Surgery...if neither of all this is working...my guess is they should since, functionally your mom is showing signs of reduced pain anyway...

cheers

[RiderJen]

Thank you for your reply and suggestions. I want to help her make informed decisions, and not try any therapy that could cause new injuries (due to her osteoporosis).

She won't take osteoporotic medications because she is very conservative about taking medications and afraid of serious side effects (she's a retired RN). Just recently, she heard about one of those meds causing serious deadly side effects and felt vindicated for refusing to take it. She does exercise almost every day (taking walks, and going to Curves) and does a lot of stretching (the ladies at Curves call her "The Human Pretzel"); she wonders if that much stretching might not be good for her back, even if her back doesn't hurt while doing it. She also eats a healthy diet.

I am hoping the epidural injections will give her long-term relief while she applies other treatments. I'm sure she has heard they may work only temporarily, but I am reluctant to remind her while she is enjoying the relief she is now feeling and don't want to cause her to lose hope or become discouraged. However, my dad had the same injections when he was about 80, and later had some surgery (which gave him complete relief) since the injections didn't work, so I suppose she realizes they work for some and not others, or not for long.