The study entitled, Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis (also called  Carotid Revascularization Endarterectomy vs. Stenting Trial or CREST) encompassed nearly 2500 patients from 116 medical centers across the United States and Canada.

Dr. Solomon says, “The Crest trial is, in my opinion, the largest and best study comparing endarterectomy and stenting for carotid artery disease.”

Stenting is a minimally invasive technique  where surgeons access the Carotid artery in the neck through an artery in the groin, then a stent, or piece of tubing, is placed inside the artery to ensure that it stays open.  Endarterectomy is a more traditional surgical procedure where the artery is opened and the plaque is removed.

Solomon continues, “The results [of CREST] are very consistent with previous trials. Most importantly, when compared to carotid endarterectomy, carotid stenting is associated with a higher periprocedural risk of stroke or death, a difference that was still significant at 4 years. The increased risk of stroke with stenting was offset by an increased risk of myocardial infarction in the endarterectomy patients, but stroke has much greater longterm health consequences than heart attack.”

The authors of this newly published research overall found little difference between these two procedures in terms of major outcome including, incidences of stroke, heart attack, and death. There were a couple of minor differences worth noting, however.

According to the authors, “The incidence of periprocedural stroke was slightly lower in the endarterectomy group than in the stenting group, whereas the incidence of myocardial infarction (heart attack) was lower in the stenting group.”

Also, they said that younger patients had, “a slightly better outcome with carotid-artery stenting and older patients having a better outcome with carotid endarterectomy.”

Dr. Solomon said, “My interpretation of the Crest Trial is that it supports the way we practice here at Columbia University Medical Center. Carotid endarterectomy is the preferred treatment for most patients with carotid stenosis, especially older patients with symptoms of carotid blockage. There are many instances where surgery is not ideal, such as patients with radiation induced stenosis, recurrent stenosis after previous endarterectomy, stenosis that is near the skull base, and certain medical conditions that contraindicate open surgery. In these patients we are gratified that stenting has been shown to be a reasonable alternative to open surgical treatment.”

What is Spinal Stenosis?
Spinal stenosis is a general term for narrowing of the spinal canal or where the spinal nerves come out of the spine. Our spines are made up of bones (vertebrae) that stack up on top of each other from our tailbone to our neck. There is a canal that runs through all these bones and inside is the spinal cord. The spinal cord sends branches or nerve roots out through exit holes in the spine. These nerve roots further branch out to become the nerves in our arms legs and the rest of our body. Spinal stenosis is when the canal or the exit holes get blocked and put pressure on the spinal cord or nerve roots. The blockage can happen for lots of reasons but the most common one is changes in the spine that happen with old age. In fact, most spinal stenosis patients are over 65 years old (Cheney is 68). The symptoms of spinal stenosis in the low back can include, pain in the back or legs, numbness and tingling in the legs, or loss of motor control of the legs. Usually these symptoms are made worse with standing up straight or walking.

What surgery can be done?
First of all, surgery is typically not the first line of treatment. Patients are usually given physical therapy, anti-inflammatory drugs, and pain management. If these more conservative treatments fail then surgery is considered. The most likely surgical procedure is called a decompressive laminectomy. What that means is that pressure is taken off the spinal cord and or nerve roots. This involves removing part of the bone called the lamina ( + ectomy means to remove -hence the name) behind the spinal cord and or cleaning out the exit holes we mentioned. The procedure is done under general anesthesia, and usually requires a brief hospital stay. Patients are encouraged to walk the day after surgery.

To learn more about spinal stenosis and its treatment options at the Spine Center check out these links: Spinal stenosis and laminectomy and physical therapy.

For people with spinal stenosis it is more comfortable to sit. Standing or walking usually makes their symptoms worse.

Photo from HuffingtonPost.com

Dr. Solomon’s special interests include aneurysms, arteriovenous malformations, and carotid artery stenosis.

Learn more here: They Walk in the Shoes of Giants and Even Sit in Their Chairs

Surgery is not recommended for all spinal conditions; it is only recommended when noninvasive measures have been tried and have failed. For example, surgery may be recommended for persistent back or neck pain. Surgery may also address conditions in which a nerve or the spinal cord is compressed and neurological function is compromised, or if the spine has become unstable due to disease.

Our surgical team offers the highest level of expertise in an array of sophisticated spinal procedures for the treatment of disk problems, stenosis, tumors, fractures, deformity, and instability. For example, our surgeons are highly trained in minimally invasive techniques including microsurgical and endovascular options, such as decompression lumbar laminectomy; microdiscectomy; embolization of spinal arteriovenous malformations or hypervascular tumors; vertebroplasty; and kyphoplasty.

Research has consistently shown that experienced surgeons and practitioners at centers of excellence achieve the best possible patient outcomes.