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Melanie Cole (Host): Patients suffering from spinal stenosis often experience pain as the spinal column begins to narrow. Before looking into spinal stenosis treatment, it is beneficial to understand the condition itself. And my guest to explain that today, is Dr. Hector Pacheco. He’s an adult and pediatric spine surgeon and a member of the medical staff at Temecula Valley Hospital. Welcome to the show Dr. Pacheco. So, give us a little working definition. What is spinal stenosis?

Dr. Hector Pacheco, MD (Guest): Well thank you for the invitation and I will be glad to discuss that. Spinal stenosis is the medical term for compression of the nerves, very similar to for example, somebody stepping on a water hose. It causes pressure on the nerves and then it causes the nerves not to work correctly and sometimes people experience pain or weakness.

Melanie: Do we know what the underlying causes are? Can they be contributing by a lack of bone density or someone shrinking or is it because there is a disk problem? Do we know what causes the stenosis?

Dr. Pacheco: Yes, there’s common causes and it is usually divided into age groups. In the younger patient it is usually from a herniated disk related to some activity often in sports or work and they cause some kind of a twisting motion with lifting and it causes the tissue to get injured and then that causes pressure on the nerve. As you get older, you start getting some changes in your joints and in your spine. But sometimes that can cause pressure on the nerves and that can lead to stenosis.

Melanie: What are some signs and symptoms? What might people notice as far as pain and movement limitations?

Dr. Pacheco: Right, so in the younger patient, they normally describe all of the sudden feeling pain mostly and usually in the leg. It is pain that they didn’t have before, kind of a burning sensation, that they have difficulty sitting or walking. If it is in the arm, they have a similar kind of complaint that it goes down below the elbow or in the leg it is down below the knee. In the older patients, that kind of have stenosis from some of the aging, they describe feeling tired, like they get – their legs get heavy and they get tingling in both legs. The notice they can’t walk as far and sometimes they have trouble sleeping at night. They get restless legs, things of that nature.

Melanie: Doctor, is stenosis always or generally is it – does it go along with sciatica because people hear about sciatic pain going down their leg, it can be incredibly debilitating? Do they necessarily go together?

Dr. Pacheco: Yes, so stenosis in the lumbar spine causes pressure on the nerves coming from the lumbar spine. Those nerves are very similar to what happens when somebody braids their hair. They all come together outside of the spine and that’s called the sciatic nerve and then people have sciatica or pain down that nerve and down into the leg. So, it usually is connected. If you have stenosis and it is significant enough, then you can have sciatica or pain along the sciatic nerve in the areas that are covered by that.

Melanie: What are some treatment options? First of all, how do you diagnose it and once you do, what are some treatment options once you have determined what’s going on? What’s the first line of defense?

Dr. Pacheco: Right, so most commonly people will describe the change, there is something going on with them that is unique and different, and they usually describe this kind of tingling or burning sensation in their arm or leg and then just kind of listening to their history, they usually see a physician, they describe these symptoms and usually related it to some kind of activity. Even for those who have arthritis and pinching of the nerves, usually something that kind of pushes them over the edge. And then you kind of examine the patient and you find that they do have signs where the nerve is irritated and then following that, x-rays or MRI studies will confirm that. So, the nice thing about all this is that most of these conditions do not require surgery as an emergent treatment. And so, you can follow, look at a patient and then proceed with medical management with some medication, change in the diet, making it less inflammatory, modifying their activity, physical therapy. If they don’t get better, then the next is to proceed with some kind of injections right along the nerve and then if they still don’t get better, then you always have surgery as a treatment option.

Melanie: So, speak about the epidural injections. Are these ultrasound-guided? How do injections work and how long do they work for?

Dr. Pacheco: So, epidural steroid injections, the best way to do them is do them under x-ray guidance or what they call fluoroscopy and that is usually done by a pain management specialist. So, they can actually see where the needle is going, to put it exactly where the nerve is at and then they inject a combination of a little anesthetic with a steroid. The benefit for that is that it is sort of like putting the medication exactly where you need it to be. Those can be done safely every six months as needed and some people get tremendous relief, some people get a little bit of relief and it’s a good way to look at to see if surgery would be a good option for you if don’t get better.

Melanie: If surgery becomes a consideration, explain when that would happen and how do you use spinal navigation for more accurate and precise surgical experience?

Dr. Pacheco: Right, so there’s a different kind of surgery. People talk about having laser surgery and sometimes they actually have a lot of arthritis and they are going to need a much bigger surgery. So, it really depends on a patient not getting better, they just cannot function, and they have signs of nerve being pinched that’s causing the problem in the leg or the arm, then you can mechanically remove that portion and that’s called surgery. If it is just a small problem, you can do something like a discectomy. If it is something where they have a lot of arthritis, if the patient has scoliosis or deformity; sometimes you have to remove bone or quite a bit of it or realign the spine and if you do that; then you have to combine that with some screws and rods and things of that nature to free up the nerve adequately.

Melanie: What’s life like for someone that’s had spinal surgery?

Dr. Pacheco: Most of the patients that I have seen have gone through the whole treatment protocol and they have gotten to the point where they are not functioning well and what they find is that first of all, they have less pain and then it gives them a road to recovery. So, little by little, people get better and most patients I would say a good 80% definitely have an improvement. Some take a little longer depending on their age or how bad their condition was before they had surgery but by and large, most patients who come to have surgery are those who have tried everything and just not getting better and afterwards, they improve, and they are happy or satisfied with having surgery.

Melanie: Does stenosis come back? Is it necessarily age related?

Dr. Pacheco: You can have stenosis and it can happen at pretty much any time. Those that occur from degenerative changes and arthritis and stuff, they take a long time to develop. So, the same thing is true if you do surgery and free all that up; it can come back but it will take a long time. So, it is not something that comes back right away.

Melanie: In summary, Dr. Pacheco, what would you like to tell people who suffer from pain due to spinal stenosis? What do you really want them to know?

Dr. Pacheco: Well I want to give them a sense of hope that there is treatment options and in the medical field advances and what we could offer people today is something we couldn’t offer them 50 years ago, maybe even ten years ago. The main thing is to go look at your – go see your doctor. People are living longer. Find out exactly what you have. Find out what treatment options you have and then develop a plan that either is aligned with what their goals are and being realistic about that and then if they come to have a surgery, they always do best when they can emotionally embrace surgery. And that means that they kind of go in with an honest assessment of what they have, what the treatment options are and then decide what it is that they are trying to achieve. What I have seen is most patients want to have more function and that’s what really gives them the courage to have surgery and in my opinion, I really – I’m really motivated to see patients wanting to get better and making the commitment to that both before and after surgery.

Melanie: And why should they come to Temecula Valley Hospital for their care? Tell us about your team.

Dr. Pacheco: Right, so what we have here is Temecula Valley Hospital is a new hospital. They definitely have a commitment to serving the community and one of the things that we can offer here is the ability to do simple to complex spine surgery. So, in my experience, I do simple procedures like discectomies to major revisions and one of the things that I do is I have an open-door policy. I will see any patient whether they have had no surgeries or ten or more and sit down and look and see what they have and really give them a treatment option to see what options are available to them. Sometimes patients decide not to do anything and that’s fine. Other times, they weren’t aware that we could offer them something. So, I think that the first is have themselves evaluated. They can then have a discussion with family and friends and the important part is to have a patient informed and make an informed decision about whether they want to proceed with surgery or not. I would also like to add that what we can offer at Temecula Valley Hospital is part of my surgical treatment plan and that is that every patient that has surgery, I carefully preoperatively template putting in the pedicle screws, looking at the diameter, the length and the trajectory and that’s a big part of being able to do a decompression, realignment, restoring the anatomy and be able to give patients consistent results.

Melanie: Thank you so much Dr. Pacheco for being with us today. It’s really great information. You’re listening to TVH Health Chat with Temecula Valley Hospital. For more information, please visit www.temeculavalleyhospital.com. That’s www.temeculavalleyhospital.com . Physicians are independent practitioners who are not employees or agents of Temecula Valley Hospital. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if spine surgery is right for you. This is Melanie Cole. Thanks so much for listening.