Relieve Spinal Stenosis In The Lower Back

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What is spinal stenosis in the lower back?

Spinal Stenosis in the lower back can be associated with a variety of symptoms from sciatic type symptoms of pain down the leg, to hip pain and localized pain in the lower back. It is a diagnosis that deflates those who receive it, not least because it has a shroud of mystery to it. Our task today is to help you better understand what stenosis is, specifically, as well as understand it in the context of your lower back or sciatic pain. Finally what you should know if you have stenosis, with regards to both your short and long term plan for lower back relief & rehabilitation.

Misconceptions around a diagnosis of spinal stenosis

Spinal stenosis in the lumbar spine isn’t really a diagnosis. In so far as in isolation it does not give you significant usable information. Don’t worry, we’ll explain.

For starters, the structure of the spine is a series of vertebrae stacked on top of one another, the vertebrae have a ring-like structure behind the thick block-like body at the front. Through this ring runs the spinal cord. When all of the vertebrae are joined up with their supporting ligament, this chain of vertebral “rings” forms a canal, the spinal canal. This makes up the first “hole”, more on that later. Secondly, between each of the vertebrae there is a little space that is formed by two semi-circular indents coming together. For example, the L5 vertebrae on top of the S1 vertebra, form two rings either side, out of these rings comes the L5 nerve roots either side. These go on to form the sciatic nerve. These two holes are considered the “exit foramina” and the “lateral recess” and form the second “hole”. 

The term stenosis will then be applied to these areas, for example, canal stenosis, lateral recess stenosis or foraminal stenosis. But what does this mean? That a hole is smaller than it should be and is being infringed upon. That’s all, it requires context in order for it to be a useful statement, and for so many patients, this context is not explicitly communicated. 

There are 2 main types of stenosis

From here we can start to provide some clarity to all of this obscure stenosis talk. This part is important, people always want to know, can i fix it, what can i expect for the long term, will it get worse, etc. Understanding which “type” of stenosis is helpful for you, and please bear in mind this classification we’re using here is to help you understand it better. 

Soft tissue spinal stenosis

This is perhaps the best, although often it can be associated with the most pain. This is where a soft tissue, most commonly a spinal disc such as the L5 disc, becomes injured. This might be a bulge, or more severe herniation. This means that some of that disc has moved into a position that it is infringing on the boundaries of one of the “rings” we mentioned earlier. So instead of them being a 1cm squared ring in size, for example that was filled with 0.5cm squared of tissue, nerves connective tissue etc, we now have a 0.75cm squared ring, with 0.5cm squared of tissue running through the hole. 

Hopefully these numbers make sense, but you can see from the example here, that the disc has created a block and reduced the size of the ring by 25%, this has had an effect of reducing the amount of “free space” by 50%. 

These numbers are arbitrary numbers for easy math and visualization of the problem and not to scale.

Hard tissue spinal stenosis

Now the numbers ring the same in this example too, only this time, it might be that you have a spondylolisthesis, where the hole changes shape as the top vertebra slides forwards as the bottom one stays in place. It could also be that there is some significant bony change and osteoarthritis of both the vertebral body and facet joint arthrosis. In this scenario that same infringement on the boundaries is present, only this time it is bony tissue that is infringing instead of soft disc tissue.

When it comes to “hard tissue” stenosis, it is always worth considering that this takes years to develop. Often it has been developing for many years whilst you’ve not had much in the way of pain at all. The first consequences showed some minor stiffness or aching. The degree of degenerative change is not always commensurate with the degree of pain, in fact it more commonly is not.

A final stenosis consideration that’s not spoken about

Fluid, or inflammation, any number of tissues can become injured in the regions right next to these “rings”. Inflammation will then be directed to the area as part of a natural healing process. One of the issues with this, is that excess fluid in a confined space increases the pressure. In our experience, this is why so many people get stuck. 

They get an imaging report back and it says something like, stenosis or disc bulge but no nerve compression. Yet they have symptoms of nerve compression. What this perhaps fails to take into account is that the area has secretion of chemicals that drive inflammation, pooling excessive fluid right next to those rings where the nerves are located – spinal nerves or the spinal cord. Oftentimes, it is this build up that is responsible for the nerve irritation. You’ve no doubt seen how much swelling can occur in a minor sprain of a finger, wrist or ankle. In these cases the stretchy soft tissue allows everything to accommodate the excess fluid, not so when we have bony margins and “rings”!

Appreciating the reality of spinal stenosis

Hopefully by this point it is becoming clear that the focus on spinal stenosis in a myopic manner is not helpful, we should instead focus on the injury at hand, is it soft tissue or hard tissue that is responsible for this stenosis. What’s the narrative and context around this, that is where a better understanding can come from.

The reality with all of these types however, is that the hole is smaller. We have to remember in cases of the lateral recess and exit foramina stenosis, the size of these holes change a lot based on the position of the spine. Rotating left and right, bending forwards and backwards, this all influences the size of the hole. And if we’ve lost 50% of the “give” in the neutral position, like in the example earlier, we have less room or margin for error. 

Knee hugs for spinal stenosis – should you do it?

The most important thing to understand, is the fact that when stenosis occurs alongside the presence of inflammatory build up mentioned earlier, we get symptoms. Because of this forward bending, knee hugs, rounding the back, child’s pose, will be common exercises that are recommended, and all feel nice when you do them! 

This is because they make the hole bigger, they temporarily increase the size of the hole! 

But is this really a good thing? We must understand that all things are connected, if we have degradation of the tissues and injuries to the tissues that limit flexion. I.e. we have some degree of damage to the disc, perhaps it’s a minor bulge. The back of the disc as well as many of the spinal ligaments that help with the same sort of role will be damaged. These tissues have invariably been stretched beyond what they’re comfortable with. As they are trying to heal, they’re working on knitting themselves back together again. 

Remember that these tissues are also in close proximity to those rings! So if we are continually pulling them apart with knee hugs and other flexion based activities, we are continually disrupting the healing process, creating irritation, fostering an inflammatory reaction. This drives those chemicals again that cause inflammation to build up. 

This inflammation builds up again after your fresh bout of knee hugs, fills the ring that already had less space, and you’re back to trying to do the knee hugs again to make the hole bigger. 

What you often find in these cases is that these exercises have allowed the patient to fall down a slippery slope for so long that it is difficult for them to begin to return their spine to a normal position. Difficult, not impossible. It is a case of the segment has been flexed so much it struggles to move back to a normal position, and the ligaments are so lax and loose they do not do a good job of providing support to the region. 

It takes time to undo this but it highlights the importance of having an understanding about what is going on in the back, especially with spinal stenosis, as if you are operating on the assumption that you have a reduced “ring” size, you will naturally do things like knee hugs to make the ring bigger, unaware of the “cause” of the stenosis in the first place!

Health of the tissues in hard spinal stenosis

You might be wondering at this point, what about the hard tissues, forming stenosis. It is correct, that unlike the soft discs, hard tissue bony change offers a somewhat permanent degree of stenosis. It is important to recognise here however, that where we see such degraded hard tissues, we are sure to find the quality of the surrounding soft tissues to be weakened and of lesser quality too. 

Moving forwards in this scenario, our objective would be to make sure that we are strengthening the tissues that surround these degenerative and arthritic joints so they are as healthy as they can be. Working to restore, or maybe build for the first time in decades, the appropriate strength and stability in the core muscles and lower body muscles is your primary focus! It’s not easy, it takes time, but it is the most fruitful pursuit!

Given the more permanent nature of this form of spinal stenosis, we must also recognise that unlike the soft tissue stenosis, we will always have a degree of sensitivity here. To quote the example earlier, the ring will always be 25% smaller with 50% less free space. So even if we have a minor strain of some soft tissues, it is more likely to quickly result in pressure building up to the point at which symptoms appear. 

Many of you reading this will have an older family member who perhaps has more frail skin in certain areas of their body, they know that if they have a minor scratch, it bleeds more, it’s less efficient at healing up. It will, but it’s a real nuisance. But mentally when it happens they’re aware of why they have the more severe reaction and are calm and collected in the event. They take steps on a daily basis to reduce the likelihood that they will scratch that area. Your task if you have “hard” stenosis is somewhat similar: take steps (strengthening) to protect the area from unnecessary aggravations. You will also hopefully now have a better understanding and therefore be able to more accurately appraise the circumstances that led to the flare up too.

Ultimately you’ll do much better!

In closing, stenosis of the spine is one of those somewhat useless diagnoses, it doesn’t tell us too much without the context around what is causing the stenosis. To the degree we have permanent change, we must make the commitment to work harder to build more strength and support so that our body’s slight vulnerabilities are not as easily exploited. Taking steps to increase the strength of the core, back and hips is vital, alongside improving hip flexibility so the lower back is protected further from being in compromised positions. This takes time, and is an ongoing activity for the long term. 

You can do it! 

And if you do need any help, then you can always take a look at our Back In Shape Program, which will support you every step of the way in building your back and body for the long term, with Phased, progressive back friendly workouts.

Comment of the Week – Janet

“I am convinced the collagen along with the exercises that I have done for the past 3 years have eliminated my pain, I no longer have any stiffness and only occasionally feel discomfort from tight glutes which can be relived when I do do glute stretching and use the gun”

3 Steps to Fix Your Symptoms If You Have Spinal Stenosis

  • Learn to control your neutral spine

When you have smaller spaces for the nerves to come out, uncontrolled rotations and extensions in particular can catch you out and give sharp local or radiating pain. Developing spinal control is vitally important in the first instance.

  • Strengthen the back and the hips

By providing strong musculature you can more easily control the spine and control movement of the body in general. It takes time to build real strength improvements. Much of your early symptom relief comes from step one and an improved control. It is the strength changes that make you more resilient and these take time and consistency with your training and workouts!

  • Improve the mobility of your hips as they get stronger

Your hips can be very mobile and to the degree they are strong enough to manage through the larger ranges of movement, they will be able to decrease the work that your lower back needs to do. This decreases the degree to which the lower back is required to move, not that it won’t move. Especially in cases of more permanent change, we have to recognise that the back simply cannot partake in the same amount of motion, therefore the hips being strong first, and then improving their flexibility is essential for the long term!

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