Dr Gelb Q & A
UM Spine Program
Below are University of Maryland Spine Program surgeon Dan Gelb's answers to commonly asked questions about spine-related disorders and surgical treatments.
This information is not intended to be a substitute for individual medical advice in diagnosing or treating a health problem. Please consult with your physician about your specific health care concerns.
Click on a question below for an answer to a specific question, or scroll down to view the complete list of questions.
Spinal Stenosis Pain
Question: I've have had 2 chiropractors tell me that I have spinal stenosis but the last neurologist told me nothing was wrong. In the meantime I'm in extreme pain. Can you help?
Answer: The diagnosis of spinal stenosis is generally fairly straightforward. Either an MRI scan or myelogram will show the narrowing of the spinal canal. Many people have radiographic stenosis, which is asymptomatic. Only in cases where there is symptomatic leg pain that is related to standing and walking with a sense of leg heaviness or fatigue deserve treatment. Back pain alone is generally related to arthritis in the back and not the stenosis per se.
Spinal Stenosis Symptoms
Question: I was initially diagnosed with spinal stenosis after having an MRI. My main symptoms are low back pain and an inability to stand up straight and walk (I am now walking somewhat bent over with a cane). I went to another doctor, who said the stenosis wasn't bad enough to cause my problems -- he said it was muscle weakness combined with scoliosis. I've had physical therapy for about three weeks and, while I feel stronger, I'm not walking any better. It seems to me my symptoms are characteristic of spinal stenosis. Any thoughts?
Answer: Certainly it may take 3 to 6 months of consistent exercise to see much effect. But if there is structural spinal deformity (scoliosis), no amount of exercise will correct that. Spinal stenosis generally gives leg pain and a feeling of leg heaviness, not just backache and hunched posture.
Standard Laminectomy vs. Endoscopic Surgery
Question: What are the pros and cons of a standard laminectomy versus endoscopic surgery for severe lumbar spinal stenosis with arthritis?
Answer: I think standard laminectomy or laminectomy using a microscope is easier and more likely to be complete than endoscopic techniques. I think standard laminectomy has a proven track record that endoscopic surgery does not.
Question: I've been diagnosed with lumbar spinal stenosis and a degenerative disc. I'm a 56-year old male with an active lifestyle. My doctor says a laminectomy is a possibility but fusion is more probable. I'm exploring all options, so if you could comment on the following I'd appreciate it:
What has your institution found to be the best non-surgical treatments?
What are the long-term effects of using NSAIDs such as Ibuprofen?
What is your opinion of the 'port hole' decompression surgery developed by The New Hampshire Spine Institute?
The use of genetically engineered protein your institution has developed seems to be quite an alternative to bone grafting. This is of great interest to me if fusion is my last resort. How widely is it used?
If surgery is not done, what are the long-term effects to neural deficits, integrity, damage etc. if one tries to live with the discomfort and follows a conservative care plan with exercise & NSAIDs?
Our best results come from a combination of NSAIDS medications, weight loss and occasional epidural steroid injections, although for persistent severe symptoms, surgery is probably the most definitive solution.
Long-term NSAID use is generally well tolerated although there can be long-term effects on kidney and liver function. Most of these effects are reversible, I believe. Check with your primary care provider. He or she may want to run some routine blood screening tests to be sure the medications are not having any ill effects.
In correctly selected patients, many types of minimal decompression techniques can give good relief and maintain the stability of the spine to avoid the need for fusion. I do not know if one particular technique is any better than any other. Even standard laminectomy/medial facetectomy should not require fusion if there is no pre-existing deformity (spondylolisthesis or scoliosis), or instability. Ninety percent of patients report good relief of leg pain and about 75% report substantial relief of back pain with decompression alone without fusion as long as the above criteria aremet.
The genetically engineered recombinant bone graft substitute is commercially available but quite expensive. Therefore, we do not recommend it except in extreme circumstances. Other surgeons may have different opinions about this.
The long-term outlook for spinal stenosis is fairly benign. Most individuals develop a level of symptoms which remains fairly stable over time. It is unusual to see people develop progressive neurological deficits; surgery can reverse many mild deficits even if they are relatively longstanding.
Question: I am a 46-year-old female who has had 3 previous back surgeries. I am still in pain. Do you know of any doctors who are experienced in removing BAK cages and doing revision surgery?
Also, how would you know if indeed the BAK cages are causing the pain? Shortly after surgery over 5 years ago, I developed pain in one particular area, right where the left cage is. It has always remained, even after each subsequent surgery to 1) add rods and screws posteriorly and then a few years later to remove the rod and screw on that same side only. Thus, I feel the left cage has something to do with the pain. Have you removed them in a person who has had them over 5 years? What else could be causing the pain? Who's to say something wasn't pushed behind it when it was installed?
Answer: My partner, Dr. [Steven] Ludwig, and I certainly have experience with revision of BAK cages. The cages rarely need to be removed but both he and I have done it before when necessary. Successful revision surgery is generally a complex analysis of the causes of continued pain. There is not always an easy solution such as simple instrumentation removal. Revision anterior surgery can be complex and dangerous.
Regarding your second question, I think there are three basic issues here:
Are the cages appropriately placed or are they causing some type of extrinsic neurologic compression?
Is their some type of nerve being pinched separate from anything being caused by the cage itself?
Is the fusion that was performed solid? Usually this can be determined by a careful study of the imaging studies, more specifically a CT myelogram with one-millimeter cuts and sagittal and coronal reconstructions.
I think this is the only way to determine with any certainty what the problem is and I would not recommend any further surgery until the cause of the pain was specifically determined. Another thing that might be useful would be a selective nerve root block of the exiting nerve root at the level of the cages on that side to see how much pain relief it affords.
This is how I would approach this problem if such a patient were to see me in the office.
Question: I underwent a discectomy in 1988 and a discectomy with fusion in 1991. About four years ago I started experiencing back pain in my lower right side, upper buttock, and hip. The pain was only occasional and something I could control, but the pain has become constant and significantly worse. An orthopedic surgeon I visited wasn't interested because I didn't have pain down my leg symptomatic of a spinal problem. He suggested I might be experiencing arthritis as a result of the surgeries, and that I should learn to live with it. At 47 years old I am discouraged at the prospect of facing a long life of pain and degeneration. What source of diagnosis and treatment can you recommend pursuing?
Answer: Advanced degeneration of the segments next to a previous fusion certainly is a well-recognized phenomenon that can cause pain many years following a spinal fusion, especially with instrumentation. Often symptoms from this type of arthritis can be controlled non-surgically with medication and exercise. Occasionally, the pain becomes so severe that extension of the fusion is necessary in order to control pain. This is especially true when spinal stenosis with nerve root compression develops.
The diagnosis is relatively straightforward with plain X-rays and either an MRI scan or a myelogram. If you have already gone through a conservative management program consisting of nonsteroidal anti-inflammatory pain medications and physical therapy, then I think you need to see another spine surgeon for a second opinion.
If you are a patient of a referring physician and would like to schedule an appointment with one of our doctors, please call 410-448-6400.