Dr. Schechter's Blog Spinal Stenosis, Imaging, Pain

Originally posted: March 25, 2015

A colleague shared an interesting article by Kuittinen, et al out of Finland. The authors looked at visually measured spinal stenosis on MRI and correlated it with patient symptoms. It wasn't what you might have expected.

Spinal stenosis is narrowing of the spinal canal. It's more common as we get older and can cause characteristic symptoms including pain in the legs with walking and




improvement with leaning over or sitting down. Treatment options are limited-- PT and medication don't help much. Epidurals are temporary and surgery is often ineffective.

The authors found that patients' leg pain was higher and walking distance less with moderate stenosis than severe. They found that degree of stenosis did not correlate well with functional capacity or patient symptoms.

While this study does not address psychological factors or issues, it does point out again that imaging results are not determinative for pain. In this study, patients with severe stenosis did better than moderate. There was not a 1 to 1 correlation between pain and degree of narrowing.

So I remind people of one of the basic principles of spinal/orthopedic medicine. Treat the patient, not the imaging!

Look beyond the obvious and individualize care. Consider the psychological.

 

I would like to know what Dr. Schechter thinks this statement from this study's conclusion means?

"Our findings indicate that advanced degenerative hypertrophy may potentially be a protective mechanism that causes relief of patient symptoms."

Is it saying that the severe narrowing is actually keeping the person from pain? And that the more severe the narrowing (worse the images look) the less pain the person should be in? In other words, the imaging doesn't mean much beyond looking for danger?

Could the statement be made that the "abnormalities" and "degenerative" changes seen on most images that are currently being blamed for pain are actually preventing pain? Instead of hurting, they're helping?

 

I'm not exactly sure Steve. It's clear the imaging is not determinative of symptoms in and of itself. That's the most important fact htere. As for why patients with severe findings have milder symptoms than moderate, that's one of the more curious results here. It reminds me of "degenerative discs". The end stage of a disc wearing out is two bones (vertebrae) fusing together. Well that's a biological spinal fusion and you haven't even paid $60,000 for it or been through surgery and recovery. So sometimes the body is going through a healing process and we interpret it as a "wearing out" thing. I know that's not a definitive answer to your question, but I hope it clarifies just a bit.

 

Thanks for the reply. It was a good answer, from a question that may never be answerable. But we're getting closer to the truth. Every event cuts two ways. With high tech imaging many lives were helped with greater detection, but within that deeper look we began to find things that didn't exist, and blame things that are not problems. Dr. Sarno truly is a pioneer.

The most devastating diagnosis that people are reporting to me is this thing called "bone on bone." When they get that diagnosis they seem to be locked into pain for life. But does it even exist? Would it cause chronic pain?

I understand the guided image of bone against bone, it's devastating. Even the thought of it makes me cringe. But most of those people didn't have bone on bone, it was a poor diagnosis. I was told that I had bone on bone in my ankle, which looks like a ball of arthritis, fused together. But that pain ended when my back pain did. The diagnosis crippled me, not my ankle.

So I wonder, if as you said here, that a spine that has fused itself would even cause pain, or would it solve its own problem by nature's great design?

 

Bone impacting on bone scares the s--t out of me. I wish I had never heard of it, long before
reading this exchange of posts. It's funny how an image of pain can take over and create fear,
even turning nothing structural into a reality.

I tell myself that arthritis or any bone pain is not from bone rubbing on bone.
It is from God telling my subconscious to send me pain so I deal with my TMS repressed emotions
and/or perfectionist and goodist personality.

Thank you both, Steve and Doc Dave. It convinces me that bone on bone is only a
bone of contention. It isn't real.

 

I'm replying here to an older blog but I just am so fed up with health practitioners seeming like they almost delight in telling patients that this or that is "bone on bone". What's up with that.? I think they must offer classes in med school: Bone on Bone 101, 102 etc. Interestingly I have a friend who plays raquetball with our group who had a spinal lumbar fusion (as well as cervical disc surgery) when she was in her 20s. She's in her mid 50s now and is actually playing very well. Since I have back pain standing I asked her if she did. She told me her docs told her she was now "bone on bone" but that she was doing pretty well and only got some pain if standing for over TWO hours! She seems fine playing rball too!
Doesn't add up. Very interesting observation of Dr. Schecter's comparing the 60K fusion with a "biological" fusion.

 

I'm with you Walt. All it does is scare people. I wonder if anatomically it's possible for the end plates of vertebrae to actually transmit pain signals? Or do they think nerve roots are impinged in that situation? How about the knee joint? Read the book The Biology of Belief and the experiment with " sham" knee surgery.