What helps spinal stenosis besides surgery?

In reply at @jenniferhunter….thank you so much for this wonderful list of questions…..as far as the Mayo doctor, I saw a physiatrist (a couple times), who did not give me this diagnosis over a year ago and through portal messaging sees no reason to have me seen again unless I cannot reach the 6,000 steps a day marker even if I have daily issues with my back and all conservative measures that have been being utilized are helpful but not offering much pain relief.
Perhaps now, I can pursue the next step there for another opinion. I have original Medicare/supplement and am seen at Rochester Mayo for other specialists but it is getting very difficult to be seen there. Also, no matter what I do, any future will include all those questions for a surgeon if I decide to proceed. I have agreed to try an injection. Thx again and Happy Thanksgiving!

I actually did try the NeuroMD and didn’t find it very helpful. I had several “technical” problems with it. Sold it online to someone but of course lost $$ on it.

I had surgery in 2011 which helped but then developed more stenosis problems at another level. Didn’t want another fusion which was offered to me. I am now 70.

I tried injections etc but it got worse to point I was limping and occ used a cane. I then tried a spinal cord stimulator trial which helped and so had a permanent one put in this January. It has definitely helped me and I am glad I did it. Not everyone seems helped by them. It was an “easy” surgery, went home within hours. The hardest part was all the movement restrictions afterwards for several months. I did it in winter so I could be outside in my yard and garden this summer. I live alone and it made me plan ahead and get creative, but I managed!

Always get at least two opinions! Why does your doctor say surgery won’t help?

@rita9876 So your choice with the orthopedic spine surgeon is they would add 2 extra levels of fusion at the upper end and is that going down to the sacrum at L5 / S1? Either way it sounds like a big surgery with a lot of levels to be fused. Are they using rods to stabilize the spine? Did this doctor give you a reason why they wanted to do the 2 extra levels? Did they show you the MRI and explain why? This is what surgeons should do. Often the discs next to fused levels can become affected because of extra stress put on them because movement isn't normal anymore. It is possible those extra 2 upper levels have an intermediate issue that is expected to get worse, but that is a question you need to ask the surgeon.

The neurosurgeon has the more conservative approach. If you have never had spine surgery, this will be a big change. What are the symptoms that you have right now that concerns your surgeons? Did either of them expect that you may need more spine surgery in the future? Do you have a spine deformity such as scoliosis that needs a curve correction? My spine surgeon at Mayo Rochester was neurosurgeon, Jeremy Fogelson. I mention that just in case you have seen him, as I think he is an excellent surgeon and kind person. Dr. Fogelson is a deformity expert and has a long track record of educational excellence. I would highly recommend Dr. Fogelson. I do think the surgeon's area of interest should match what you need to have done. I have no say here, but let me know what you think.

@jenniferhunter
Thank you very much for taking the time to converse with me on this.
Sorry, for the late reply due to a lot of holiday activities and visiting families.

Re. "So your choice with the orthopedic spine surgeon is they would add 2 extra levels of fusion at the upper end and is that going down to the sacrum at L5 / S1?"
-> Yes, pretty much, at least that is my understanding. Below is the exact wording from the doctors, I would like to know if my understanding is incorrect, therefore the direct quote. Thanks!
Ortho's plan: "3-stage surgery over 3 days. Stage 1 would be a posterior lumbar decompression at L2-3, 3-4 and 4-5 with screw placement from low thoracic T11 down to the sacrum and a TLIF at L2-3 and L3-4. Stage 2 would be an anterior lumbar decompression instrumented fusion at L4-5 and L5-S1 with the assistance of our vascular surgery colleagues. He would use NuVasive base cages as instrumentation for the anterior surgery. Then, stage 3 would be the remainder of the procedure with any additional decompression that was needed and then instrumentation from T11 down to the pelvis. We would request BMP and allograft for all 3 stages."
Neuro's plan: 2 stages. "Based on the numbering of L6 as the transitional segment I think she would require at least an L5-6 and possibly L6-S1 ALIF if we are able to mobilize that segment and break up the autofusion followed by multilevel posterior column osteotomies and fixation from L2 down to the sacrum and pelvis."

Re. "What are the symptoms that you have right now that concerns your surgeons?" Currently, I am unable to walk or stand without pain. I have had a lot of conservative treatments, PTs, Chiro, injections and so on. I came to Mayo June of 2021 looking for help. After initial assessments, I saw an Ortho surgeon in Aug. of 2021, then a neurosurgeon Oct. of 2022. Both surgeons said my deformity could only be corrected by surgeries. The Ortho surgeon mentioned, scoliosis is in the future, developing. The Neurosurgeon, said I have a lot of curvatures which are off.

Re. Dr. Fogelson, I did not get to see him even though I requested him after reading people's comments about him. I was told that his schedule was full and was unable to see me.

In terms of doctor, I like both of my doctors. The ortho surgeon seemed very good. He spent quite a bit of time with me during our consultation. His office has also been very responsive to all my questions since last fall. I am currently on the 8th dose of the bone density building medicine, Evenity. The neurosurgeon also was personable and also spent a lot of time with me during consultation. The ortho surgeon is listed as working in the spine area about 20 years and the neurosurgeon is listed as in the spine area about 5 years.

Thank you so much for your assistance. I know I am the one that need to make the decision eventually, but conversing with someone who has been through similar surgery really helps. I appreciate all of your inquires, as they help me to think through my issues.

@rita9876 There are some differences between the 2 surgical plans other than the number of levels involved. The ortho surgeon describes fusions from both an anterior and posterior approach. He isn't real specific about exactly what his stage 3 plan is or how many more levels could be involved.

The neuro surgeon recommends ALIF which is anterior approach, and he would achieve deformity correction using osteotomies. This is an over simplification, but basically, they figure out all the geometric angles to correct the curve by taking pie shaped slices of bone from the spine and fusing the spine without those pieces. That can make the foraminae closer together which can compromise the nerve roots unless the surgeon takes that into consideration and may enlarge the foramin if necessary. That would be a question to ask if the nerve roots will have sufficient space and is that likely to change in the years after your spine surgery.

The ortho proposes more hardware and more screws into the spine with rods to support the spine. Both would use rods and screws as instrumentation. The screws needs to be paced at very specific angles so they don't pull out because there is a lot of pressure with body weight at the lower end of the spine. With your osteoporosis and Evenity injections, does that significantly improve your bone density of the spine? Severe osteoporosis can cause a spontaneous compression fracture of the spine and that happened to my elderly mom. It may be worth asking which approach would be a better choice for someone with osteoporosis. Would the extras screws from the orthos procedure be better or worse or cause pressure that could lead to fractures?

The surgeon needs to address what they call sagital balance. Essentially that means that if you drew a center line from your head down your body, your spine should be symmetrical in that sagital plane and not tilted to either side. They also address if the spine is tipped forward or backward in places where it should not be. It is supposed to have a nice S curve. All of this requires correct angles between vertebrae. When you have uneven pressure on the vertebrae, it causes bone growth and remodeling. The neuro mentioned that there is an "autofusion" that needs to be mobilized before it can be fused properly. That is a spontaneous fusion and it might not be lined up in a good way.

The ortho mentions using BMP which is Bone Morphogenic Protein. The neuro may use it too, but doesn't mention it.

Bone Morphogenetic Protein‐2 (rhBMP‐2) has been FDA approved as a bone graft substance in order to increase fusion rates and avoid autograft (taking bone from patient's hip during surgery) harvest. There is some literature that BMP may increase the rate of swelling complications.

Allograft is donor bone that has been cleaned of all the cells, so you have the mineral matrix left that is milled into a shape like a disc for a spine fusion. That is what I have for my fusion at C5/C6.

Both surgeons would include an ALIF (Anterior lumbar Interbody Fusion) which requires a vascular surgeon to be able to move the major blood vessels in front of the spine out of the way, and then move them back after the spine surgeon has finished his work.

The comparison of 20 years experience vs 5 years isn't indicative of the surgeons' capabilities. The question to ask is how many of this particular surgery have they done and what is their personal success rate with it. This is a big surgery that needs a spine deformity expert. Is a surgery with osteotomies preferable to surgery with more hardware with pedicle screws with a history of osteoporosis? Which surgery carries greater risks between the 2 choices? Do you want to get a third opinion? I also look at the surgeons credentials of where they trained, their publications, their areas of interest which needs to match what you need, and if they have won awards or are recognized in their field. Do they also teach their surgical procedures at spine conferences? Does this raise more questions for you?

I just saw an orthopedic spine surgeon who is recommending surgery if injections are unsuccessful. It is directly related to the collapse of my L4-5 disc. The last doctor is saw over a year ago only advocated conservative measures which I do religiously, but have had no success in relieving pain symptoms. This includes PT (over a year); daily HEP program; daily walks; myofacsial release therapy weekly; and ice/heat daily. The conservative doctor continues to not advocate for any further interventions even though pain increases; and numbness in legs has begun. I am going to move ahead with an injection and research his idea about surgery. He states the procedure would only involve this disc area. If anyone has had this procedure or ideas, I would greatly appreciate your input. Have as good an evening as you can.

@jenniferhunter
Thanks again for your reply! Ha, ha, you did raise more questions...
The neurosurgeon at the consultation appointment did draw a vertical line from the head down, then he drew various angels from the vertical line. He spent quite a bit of time talking about my spine deformities using the diagrams.

I will compile a list of questions generated from our discussions and pose them perhaps to the neurosurgeon first.

Hi, first, I’m sorry for the pain that your experiencing. Before proceeding with surgery on the lumbar spine; L4-L5; make sure to see a neurologist, and get a EMG
( electromyogram ).. if you’re experiencing numbness, you can have compression on the nerve, which if severe, can cause paralysis . See Mayo’s page on Peripheral neuropathy.
I had my done, and the neurologist said, “ok, we need to operate… Tomorrow, or you may never walk again” now that was a long time ago, and the best thing I could offer is to do your due diligence. Take care of yourself and stay active!! 🙏🙏🙏

@rita9876 I'm glad your neurosurgeon drew diagrams for you so you can visualize what he proposes. With any hardware that is screwed into the spine, bone quality to hold it in place is very important. Every screw exerts some pressure in a particular direction and there is a risk that screws can loosen, pull out or break. Pedicle screws need precise placement to minimize that risk. I'm not saying that to scare you, but I've watched video presentations by surgeons at conferences taking about this and explaining revision surgeries. With an osteotomy, the bone fusion there has strength. It is worth asking if the osteotomy fusion strength is a better choice, essentially is the fused bone stronger than bone in general? Is that something that should be considered for deformity correction with osteoporosis?

When do you finish your Evenity treatment and then are able to schedule surgery? What would you need to do going forward after deformity surgery to maintain good bone quality and preserve the surgical correction?

You may also want to look at this post earlier in this discussion for a list of questions to ask a spine surgeon. Those came from a list I compiled of possible questions before my surgery.
https://connect.mayoclinic.org/comment/775287/