Ep 346 - Spinal Stenosis Surgery:"I Have a Client Who . . ."Pathology Conversations with Ruth Werner

0:00:01.4 Ruth Werner: Hello, I Have A Client Who listeners, Ruth Werner here, and I'm so excited to let you know that my library of online self-paced continuing education courses has just expanded. I now have a two-hour ethics course called A Doctor's Note is Not Good Enough, and what is better? This NCBTMB-approved course goes into why a doctor's permission or approval or even a prescription doesn't provide the legal or safety protection you might think it does. Then we look at how to start useful conversations with healthcare providers that will actually get us to safe and effective massage for our clients with complex conditions. Visit my website at ruthwerner.com for more information and to register for A Doctor's Note is Not Good Enough, and What is Better?  

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0:01:00.1 RW: Hi, and welcome to I Have A Client Who Pathology conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I'm Ruth Werner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer, even with our most challenged clients, but we need to figure out a way to do that safely, effectively and within our scope of practice, and sometimes, as we have all learned, that is harder than it looks. Today's I have a client who story might leave listeners a little frustrated, but that's just because some questions don't have clear answers, and sometimes the stakes connected to those answers aren't clear and those stakes can be really high. And I'm sorry about that, but pretending this isn't true because clear answers are more comfortable than fussy ones doesn't really solve the problem. 

0:02:12.9 RW: A lot of what I'm talking about today is out of our metaphorical reach in terms of diagnosis and treatment and scope of practice, but because people trust us to give them good advice, we can sometimes be in a position to get in a bit of trouble here, and I thought I would use this, I have a client who, story to shine a light on the very, very complicated topic of spinal stenosis and decompression surgery. Here's an edited version of today's story, which did not come to me from a massage therapist, but from someone whose friend is headed for surgery and he wants to know if massage therapy might be helpful in the meantime. And the story goes like this. 

0:02:55.3 RW: A friend of mine's father is 88 and has spinal stenosis. He's planning on having a third surgery in the fall. Doctors have deemed that he's healthy enough for this surgery. Would massage therapy work for him between now and the surgery or maybe instead of the surgery? No rush on this of course and don't feel obligated to answer. Just thought I'd reach out. But this is one of those topics that sort of gets under my skin, so of course I answered. And here's what I said. I said, he must be a hale and hearty 88-year-old to be approved for a third spinal surgery and or his stenosis must be causing him a lot of pain and limitation. Either way, massage won't be a substitute for surgery because if his doctors are correct, the problem is in the shape of his vertebra and massage can't change that. However, massage both before and after may help with his pain and sleep and general well-being. 

0:03:52.9 RW: And I continued not to pop anyone's balloon, but it's worth pointing out that imaging tests like X-Rays and MRIs and CT scans can show tissue anomalies, but these anomalies don't always have a cause and effect relationship to the level of pain that someone experiences. So while his tests show that he has stenosis and that might indeed be the source of his pain, sometimes pain can develop and persist independently of these anomalies. Lots of people have x-rays that indicate they need surgery, but they don't actually have any pain, urgh, urgh, arc. So, in this story and in my response, we have a couple of things going on. One is this person has spinal stenosis, and I'll say more about that in a minute, and the other is about the relationship between symptoms, especially pain and expectations and medical imaging, because the connection from these things to the others is not always clear. One of the reasons this I have a client who prompt caught my attention for this episode is that I am one of the co-hosts of an ongoing event called The Back Jam. 

0:05:09.9 RW: This is a production of The Massage Mentor Institute. And by the way, ABMP is a sponsor of The Back Jam. Thank you very much. But my point is, I am spending every Monday in May with some of our fields very top educators who are sharing their knowledge about manual therapies in the context of back pain, and I will share a link to The Back Jam in the show notes, of course. Last week, one of the presenters who's my friend and esteemed colleague, Whitney Lo, who introduced a new term to me, VOMIT. VOMIT stands for Victim of Medical Imaging Technologies. And it speaks to a different set of research projects than the ones I mentioned in my note to our contributor. I was referring to a series of tests in which random x-rays of volunteers spines were given to surgeons with a request that they identify who is in pain and what kind of surgery was needed. There was just one problem, while lots of suggestions were made about surgical interventions, none of the subjects had any pain or symptoms. This demonstrates that what an X-ray looks like and what a person experiences may not always be completely connected. 

0:06:23.9 RW: Whitney was referring to a different study in which people were shown pictures of images, X-rays and MRI scans that showed severe bony distortions of the spine, and they were told that those pictures were of them, and afterwards, they reported more pain than before having seen the pictures. You get it? Pain, pictures, expectations, it's a complicated set of relationships. Alright, let's put all that aside for the moment, and let's talk about stenosis. This is a term that refers to the narrowing of a tunnel, we can have stenosis in our arteries or our intestines, or as in this case, bony foramina. In the spine, stenosis can develop in a couple of different locations in the spinal canal where a loss of space might put pressure directly on the spinal cord, which is very bad news, or in the intervertebral foramina where the spinal nerve roots emerge also bad news. And these openings get occluded usually because of osteophytes, bone spurs or other sub-optimal bony growth that intrudes on what should be a generous amount of space. 

0:07:36.4 RW: It could also be related to a trauma or a tumor, but slow-growing osteophytes are usually the cause and these are completely silent unless they begin to put pressure on nerve tissue. They can show up on an x-ray or a CT scan or MRI, but if they don't compress the nerve root or the spinal cord, they don't cause symptoms and they are essentially meaningless. The only other way in which osteophytes in the spine can cause symptoms is if they interfere with movement. I've heard about this happening in the neck more often and in the lumbar spine, a person might discover as they age that their range of motion in their neck is progressively more and more limited, although this might not be accompanied by pain. If they do press on nerve tissue, then they can cause a lot of symptoms, including things like pain, when the person walks or bends over, numbness or tingling near the legs or the groin or the low back, bladder or bowel problems, which is less common, but it can be serious. 

0:08:42.8 RW: This, especially along with a pattern of numbness in the groin and medial thighs can be a sign of Cauda Equina syndrome, pressure on the Cauda Equina that needs to be relieved quickly or the damage may become permanent. If this bony growth is happening in the neck, we may have some similar signs or symptoms happening in the arms as well. Why do these osteophytes grow and the bones change their shape? Well, that's often related to age-related changes, including things like osteoarthritis or spondylosis, which is a kind of osteoarthritis analog at the spine, or possibly something weird happening with the posterior longitudinal ligament. That's a vertical structure and it runs down the anterior aspect of the vertebral canal. There are a few situations like ankylosing spondylitis and some others that can cause the posterior longitudinal ligament to thicken and ossify. This has even been seen after injections to help dissolve a protruding disc. 

0:09:45.5 RW: Another possible factor in nerve pressure and spinal stenosis is disc injury. They don't often use the term herniated disc because that implies something that probably isn't happening in the spines of older people. We don't really have enough of that soft gooey nucleus pulposus left to bulge, that's the herniation in a way that might cause nerve compression. However, older discs can crack and protrude and get much thinner than they were in our youth, and all of that together can make what was once plenty of room for nerve tissue to pass through the intervertebral foramina much more crowded. Joint inflammation or disc damage usually happens in the neck or the lumbar spine, where the spine is most mobile and therefore most vulnerable to damage. The damage itself is problematic, plus it could put pressure on nerve tissue, which is never good, but another issue that sometimes doesn't get enough attention is that tissue damage along the spine leads to the release of some pro-inflammatory chemicals that are actively neurotoxic. They make nerves scream, if you will. This causes a level of pain response that we might not see with similar kinds of damage elsewhere. 

0:11:00.5 RW: So we have all kinds of things going on here, chemical secretions that initiate a big pain response, maybe some disc damage, maybe some bony overgrowth, but what is going to show on the X-ray or a CT scan or MRI, it's the bones, and it's easy to blame any anomalies in bone shape or alignment for whatever pain a person is experiencing, and the obvious answer is to reshape the bones to clear out any occlusions to take pressure off. This is decompression surgery. If the vertebrae are fused together as part of this treatment, then we have decompression plus a spinal fusion, and there's actually an I Have A Client Who episode on that and a massage and body work article on that and yes, of course, they will be in our show notes. The statistics on surgical success for lumbar spinal stenosis are overall pretty good, about 80% of patients have a successful outcome. I applaud the surgeons and the post-op physical therapists, and most of all the patients, all of whom work hard to get these good results, and these procedures can add years of pain-free or at least pain-reduced, high quality time to a person's life. 

0:12:17.8 RW: However, that statistic means that 20% of the 600,000 people who get surgery each year in the United States to deal with a lumbar stenosis are unchanged or worse after surgery, and that doesn't address however many surgeries are done for cervical stenosis. So we're talking about one out of every five patients. Why are they not getting good results? Well, maybe it's because the shape of the bones wasn't the whole problem. Maybe the pain is related to ligament damage or muscle spasm, or maybe it has become ingrained and self-sustaining a central sensitization, maybe there was a bone and/or disc problem that has resolved, but the soft tissues and sensory neurons haven't given up on those patterns. And this is why back surgery makes me nervous. Is this me saying, don't ever have decompression surgery? Definitely not. 

0:13:17.1 RW: I am blessed that I have never had to deal with this kind of challenge or decision for myself. I have many friends and loved ones who feel that decompression surgery was the best decision they could make, but here's what I am saying. This is a high risk surgery, possible complications include the usual things, blood clots and pulmonary embolism, infection, reactions to anesthesia and so on. Then there's a problem called transitional syndrome, that's where the healthy spinal joints above and below the surgery have to accommodate for extra strain and then they may become damaged. Plus the possibility that hardware can fracture or move or fail, the spinal cord could be injured, damaged nerves may never heal correctly. There's a long-term commitment to some serious medication. 

0:14:06.5 RW: So in my mind, it's important to pursue every option to make sure that spinal surgery is the right choice. Remember, the client in this story is 88 and this will be his third procedure. I don't know if it's a different place than the previous ones or if it's a third try at the same problem. So I did a little digging about long-term risks and benefits of spinal surgery, and I found an enormous study that compared the costs and mortality rate of people with diagnosed stenosis who had surgery to those who didn't. This huge project collected Medicare data from about 125,000 cases of people with diagnosed spinal stenosis or with spinal stenosis plus Spondylolisthesis, that's a situation that involves instability in the lumbar vertebrae with anterior slippage and low back pain. 

0:15:04.6 RW: Some of those 125,000 cases of people with stenosis had surgery, and some chose to avoid it. Now, given what I have told you about my skepticism regarding spinal surgery, what do you think happened in terms of long-term medical costs and mortality? If you said costs and death risk are lower for the people who avoided surgery, which is what I expected would happen, you, like me, would be wrong. In fact, for decompression surgeries, at least those that did not involve fusions, costs were very substantially lower and mortality rates were marginally lower for the people who got surgery. Why? You might ask. Good question. Ultimately, the theory was that the people who did not have surgery used other medical interventions like PT and drugs and other kinds of care much more than the surgical group did. 

0:16:06.4 RW: So here I am, I have talked myself around in a circle. We started with a person contemplating his third spinal surgery for stenosis. I suggested the context in which massage might be helpful, those haven't changed. Remember I said either way, massage won't be a substitute for surgery because if his doctors are correct, the problem is in the shape of his vertebrae. However, massage both before and after may help with his pain and sleep and general well-being, and I will stand by that. I also expressed some concern that spinal surgery is a high-risk procedure with a substantial number that is 20% of 600,000 patients per year, that's 12,000 people who find that the surgery doesn't help or might even make things worse. 

0:16:52.3 RW: And then I looked at the data on long-term outcomes regarding mortality and medical expenses, and I found that patients diagnosed with stenosis who undergo de-compressive surgery probably live longer and need less medical care in the long run than those who choose not to pursue surgery. Does this change my mind? Maybe, a little bit. I still recommend being extremely conservative and to explore all possible alternatives, and a good spinal surgeon would probably suggest the same. But I'll tell you what, I kind of love being proved, if not wrong, at least not entirely right about things like this. Gosh, I wonder what fundamental belief I will have to adjust next. 

0:17:40.6 S2: Hey everybody, thanks for listening to I Have A Client Who Pathology conversations with Ruth Werner. Remember, you can send me your I have a client who Stories to ihaveaclientwho@abmp.com. That's I have a client who, all one word, all lower case, @abmp.com, I can't wait to see what you send me and I'll see you next time. 

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