Spinal stenosis

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Spinal stenosis
Classification and external resources

Lumbar trefoil canal
MedlinePlus 000441

Spinal stenosis is an abnormal narrowing (stenosis) of the spinal canal that may occur in any of the regions of the spine. This narrowing causes a restriction to the spinal canal, resulting in a neurological deficit. Symptoms include pain, numbness, paraesthesia, and loss of motor control. The location of the stenosis determines which area of the body is affected.[1] With spinal stenosis, the spinal canal is narrowed at the vertebral canal, which is a foramen between the vertebrae where the spinal cord (in the cervical or thoracic spine) or nerve roots (in the lumbar spine) pass through.[2] There are several types of spinal stenosis: lumbar stenosis and cervical stenosis being the most frequent. While lumbar spinal stenosis is more common, cervical spinal stenosis is more dangerous because it involves compression of the spinal cord whereas the lumbar spinal stenosis involves compression of the cauda equina.

Contents

Types [edit]

The most common forms are cervical spinal stenosis, at the level of the neck, and lumbar spinal stenosis, at the level of the lower back. Thoracic spinal stenosis, at the level of the mid-back, is much less common.[1]

In lumbar stenosis, the spinal nerve roots in the lower back are compressed which can lead to symptoms of sciatica (tingling, weakness, or numbness that radiates from the low back and into the buttocks and legs).

Cervical spinal stenosis can be far more dangerous by compressing the spinal cord. Cervical canal stenosis may lead to serious symptoms such as major body weakness and paralysis. Such severe spinal stenosis symptoms are virtually absent in lumbar stenosis, however, as the spinal cord is not present in the adult lumbar spine.[citation needed] Cervical spinal stenosis is a condition involving narrowing of the spinal canal at the level of the neck. It is frequently due to chronic degeneration,[3] but may also be congenital or traumatic. Treatment frequently is surgical.[3]

Cervical Spinal Stenosis [edit]

Causes [edit]

Definition [edit]

Cervical Spinal Stenosis is a serious diagnosis in which the spinal canal in the neck becomes narrow. The cervical spine is composed of seven vertebrae located in between the head and the chest, as shown in Figure 1. “Cervical Spinal Stenosis occurs at the craniovertebral junction or it appears as a developmental defect with diffuse narrowing of the cervical canal” [4]. The main cause of this injury is changes in shape of the spinal canal due to older age. “Cervical Spinal Stenosis has become more apparent in the older population” [5]. Overtime the discs in between the spinal column can bulge out farther than normal, thickening the tissues or even destroying them as shown in Figure 2.

MRI Cervical Spinal Stenosis

Symptoms [edit]

Symptoms of this diagnosis usually develop over a long period of time and usually do not occur unless the spinal canal is squeezed. “As the disc continues to wear, it begins to collapse….over time this causes wear and tear arthritis of the facet joints” [6]. Symptoms can vary between stiffness, pain, or numbness in the neck, shoulders, arms, hands, or legs. A person can also experience balance and coordination problems or loss of bowel and bladder control.

People Affected [edit]

Cervical Spinal Stenosis is very common throughout the population. “The amount of operations of the cervical spine in the United States was as high as 55 per 100,000 in the year 2000” (ncbi). The pain from Cervical Spinal Stenosis can range from mild to severe but in either case a doctor should be consult.

Prevention [edit]

Range of motion testing [edit]

Physical therapy is a commonly used non-surgical form for treatment. According to the University Of Maryland Medical Center, patients would first have to participate in a series of tests and evaluation to determine the best program prescription. Physical therapists would observe posture, balance, range of motion, and manual examination. These tests determine how much and what type of treatments a patient needs. Patients are advised to ease pain by limiting trigger movements that cause pain. Physical therapists would advise resting as much as possible to relieve stress of the humerus and back. Range of motion would determine what type of exercises would be needed for treatment ([7]). The goals of P.T.’s are to help mobilize and get patients into a better positioning. The most important thing is to utilize exercises that restore the spinal cord into a neutral position ([8]).

Exercises [edit]

Exercises such as the seated back row and band rows help retract and depress the shoulder girdle. Stretches for the pectoralis major and anterior deltoids reduce the protraction of the shoulder girdle, restoring the spine and muscles in the correct anatomical position. These help prevent the early onset of the disease by keeping the spine neutral versus in a compressive flexion.

cervical spine

Other Preventative measures [edit]

The most important thing to do is take preventative measures to ensure the pain does not return. This all begins with posture. Since Cervical Spinal Stenosis is degenerative, the most important preventative measures are to keep the cervical spine in a neutral position in both standing, sitting, and while exercise to ensure that there is no pinching or dysfunction of the neck ([9]). In order to prevent any paralysis down the arms due to the effects of spinal compression, stretches and exercises such as the rows directed under a physical therapist and trainer should be utilized ([10]).

Treatments [edit]

Cervical Spine

Non-surgical Treatments [edit]

Surgical and non-surgical treatments are available to treat cervical stenosis. Non-surgical type treatments are more common for most cervical stenosis cases. Most cervical stenosis cases can be treated with analgesics, which are medications that relieve pain [11]. Some anti-inflammatory drugs include NSAIDS or corticosteroids and some pain alleviating drugs include muscle relaxants, which calm spasms, and analgesics. The neck may need to be immobilized with the use of a neck brace or cervical collar. This immobilization is usually only necessary for a short period of time. Physical therapy is a commonly used non-surgical form of treatment. Stretching, massages, and bracing can help strengthen the neck, increase mobility and flexibility and gain endurance [12].

Laminectomies [edit]

If the non-surgical treatments prove to be ineffective after about six to eight weeks, surgical treatment may be needed [13]. The different surgical procedures act to release pressure and decompress or widen the spinal cord either from the front, top or back [14]. During a laminectomy the surgeon will either replace or remove the top of the vertebrae called the laminae. This procedure is beneficial because it releases the pressure being put on the spinal canal, which allows more room for the nerves in the spinal canal [15]. If the back of the spinal cord is being removed, this is called a Posterior Cervical Laminectomy.

Other Surgical Options [edit]

If the surgery includes decompressing the spinal cord through the anterior side, intervertebral discs will be removed sometimes due to them bulging or being herniated. This procedure is known as a discectomy. If the cervical stenosis is more severe, a spinal fusion can be performed. This surgery requires using a piece of bone from another part of the body, more commonly the hip, and combining it with the spine [16].

Signs and symptoms [edit]

Common [edit]

  • Standing discomfort (94%)
  • Numbness (63%)
  • Weakness (43%)
  • Bilateral symptoms (68%)
  • Discomfort above and below knee (78%)
  • Buttock / Thigh only (15%)
  • Below the knee (7%)[17]
  • "Shopping cart sign"- need to grab a shopping cart when going into a store in order to hold onto the cart and bend over relieving the pain in the legs.

Neurological disorders [edit]

  • Pinched nerve,[18] causing numbness.
  • Intermittent neurogenic claudication [17][19][20] characterized by lower limb numbness, weakness, diffuse or radicular leg pain associated with paresthesis (bilaterally),[19] weakness heaviness in buttocks radiating into lower extremities with walking or prolonged standing.[17] Symptoms occur with extension of spine and are relieved with spine flexion. Minimal to zero symptoms when seated or supine.[17]
A healthy human vertebral column
  • Radiculopathy (with or without radicular pain) [19] neurologic condition - nerve root dysfunction causes objective signs such as weakness, loss of sensation and of reflex.
  • Cauda equina syndrome [21] Lower extremity pain, weakness, numbness that may involve perineum and buttocks, associated with bladder and bowel dysfunction.

Other [edit]

  • Fever
  • Nocturnal pain
  • Gait disturbance
  • Structural deformity
  • Unexplained weight loss
  • Previous carcinoma
  • Severe pain upon lying down
  • Recent trauma with suspicious fracture
  • Presence of severe or progressive neurologic deficit [21]
  • Lower back pain [17][20] due to degenerative disc or joint changes [22]
  • Narrowing of spinal canal, nerve root canal or intervertebral Canal Stenosis: Start with nonsurgical therapy. Cleveland ral foramina [20]

Causes [edit]

Aging: All the factors below may cause the spaces in the spine to narrow,

  • Body’s ligaments can thicken (ligamentum flavum)
  • Bone spurs develop on the bone and into the spinal canal
  • Intervertebral discs may bulge or herniate into the canal
  • Facet joints break down
  • Compression fractures of the spine, which are common in osteoporosis
  • Cysts form on the facet joints causing compression of the spinal sack of nerves (thecal sac)

Arthritis: Two types,

Heredity:

  • Spinal canal is too small at birth
  • Structural deformities of the vertebrae may cause narrowing of the spinal canal

Instability of the spine, or spondylolisthesis:

  • A vertebra slips forward on another

Trauma:

  • Accidents and injuries may dislocate the spine and the spinal canal or cause burst fractures that yield fragments of bone that go through the canal [23]

Tumors of the spine:

  • Irregular growths of soft tissue will cause inflammation
  • Growth of tissue into the canal pressing on nerves, the sac of nerves, or the spinal cord.

Diagnosis [edit]

Making the diagnosis of spinal stenosis involves a complete evaluation of the spine. The process always begins with a medical history and physical

MRI exhibiting areas of lumbar stenosis

examination. Imaging studies (x-ray, MRI, etc.) are often used to determine the extent and location of the nerve compression.

Medical history [edit]

The medical history is the most important aspect of the examination as it will tell the physician about subjective symptoms, possible causes for spinal stenosis, and other possible causes of back pain.[24]

Physical examination [edit]

The physical examination of a patient with spinal stenosis will give the physician information about exactly where nerve compression is occurring. Some important factors that should be investigated are any areas of sensory abnormalities, numbness, irregular reflexes, and any muscular weakness. [24]

MRI [edit]

The MRI has become the most frequently used study to diagnose spinal stenosis. The MRI uses magnetic signals (instead of x-rays) to produce images of the spine. MRIs are helpful because they show more structures, including nerves, muscles, and ligaments, than seen on x-rays or CT scans. MRIs are helpful at showing exactly what is causing spinal nerve compression.[24]

CT myelogram [edit]

A spinal tap is performed in the low back with dye injected into the spinal fluid. X-Rays are performed followed by a CT scan of the spine to help see narrowing of the spinal canal. This is a very effective study in cases of lateral recess stenosis. It is also necessary in patients with a pacemaker as they cannot undergo an MRI.

Treatments [edit]

Non-surgical treatment includes:

  • Education about the course of the condition and how to relieve symptoms
  • Exercise, to maintain or achieve overall good health, aerobic exercise, especially riding a stationary bicycle, which allows for a forward lean, can relieve symptoms
  • Weight loss, to relieve symptoms and slow progression of the stenosis
  • Physical therapy, to provide education, instruction, and support for self-care; physical therapy instructs on stretching and strength exercises that may lead to a decrease in pain and other symptoms [25]
  • Lumbar Epidural Steroid Injections- these may provide some temporary relief and sometimes work for a few years. If the stenosis is severe, these are not very beneficial.

Surgical Treatment:

  • Lumbar Decompressive Laminectomy- Removing the roof of bone overlying the spinal canal and thickened ligaments in order to decompress the nerves and sac of nerves. This procedure is well tolerated in the hands of a skilled neurosurgeon or orthopedic spine trained surgeon. 96% of patients undergoing this procedure report "good results".[26]

Epidemiology [edit]

  • Swedish study defined spinal stenosis as a canal of 11mm or less found an incidence of 5 per 100,000 inhabitants.[27]
  • National Low Back Pain Study recorded that out of 2,374 patients with low back pain, 35% had bone related spinal nerve compression.
  • Data from National Ambulatory Medical Care survey suggests 13-14% of patients with low back pain may have spinal stenosis.
  • The NAMCS data shows the incidence in the U.S. population to be 3.9% of 29,964,894 visits for mechanical back problems.[28]
  • The Longitudinal Framingham Heart Study found 1% of men and 1.5% of women had vertebral slippage at mean age of 54. Over the next 25 years, 11% of men and 25% of women developed degenerative vertebral slippage.[29]
  • 250,000-500,000 U.S. residents have symptoms of spinal stenosis.

References [edit]

  1. ^ a b Vokshoor A (February 14, 2010). "Spinal Stenosis". eMedicine. Retrieved December 30, 2010. 
  2. ^ http://www.niams.nih.gov/Health_Info/Spinal_Stenosis/spinal_stenosis_ff.asp
  3. ^ a b Meyer F, Börm W, Thomé C (May 2008). "Degenerative cervical spinal stenosis: current strategies in diagnosis and treatment". Dtsch Arztebl Int 105 (20): 366–72. doi:10.3238/arztebl.2008.0366. PMC 2696878. PMID 19626174. 
  4. ^ Epstein, B. S. "Result Filters." National Center for Biotechnology Information. U.S. National Library of Medicine, n.d. Web. 17 Apr. 2013.
  5. ^ Meyer, Frerk, Wolfgang Borm, and Claudius Thome. "Degenerative Cervical Spinal Stenosis - Current Strategies in Diagnosis and Treatment." N.p., n.d. Web. 13 May 2013.
  6. ^ "University of Maryland Spine Program." University of Maryland Medical Center. N.p., n.d. Web. 13 May 2013.
  7. ^ Wu XD., Yuan W., Chen HJ., Chen Y., Wang., JX., Cao P., Zhang Y., Wang XW., Yang LL., Chen YY., Tsai N. Neck Motion following multilevel anterior cervical fusion: comparison of short-term and midterm results. J Neurosurg Spine. 2013 Apr; 18(4): 362-6.
  8. ^ University of Maryland Medical Center. (2012, June 7). Retrieved April 6, 2013, from umm.edu: http://www.umm.edu/spinecenter/education/rehabilitation_of_the_cervical_spine.htm
  9. ^ Meyer, F., Borm, W., Thome, C. Degenerative Cervical Spinal Stenosis Current Strategies in Diagnosis and Treatment. Dtsch Arztebl Int. 2008 May. 105920): 366-372.
  10. ^ Pingel, A., Kandzior, F. Anterior decompression and fusion for cervical spinal canal stenosis. Eur Spine J. (2013) 22: 673-674.
  11. ^ Princeton Brain and Spine Care: Cervical Stenosis Causes and Treatments. (2013). Retrieved April 6, 2013, from princetonbrainandspine.com: http://www.princetonbrainandspine.com/subject.php?pn=cervical-stenosis-008
  12. ^ Rao, R. (2009, May 19). Cervical stenosis, myelopathy and radiculopathy . Retrieved from http://www.knowyourback.org/Pages/SpinalConditions/DegenerativeConditions/CStenosis_Myelopathy_Radiculopathy.aspx
  13. ^ Frerk, M., Borm, W., & Thomé, C. (2008). Degenerative Cervical Spinal Stenosis: Current Strategies in Diagnosis and Treatment. Deutsches Arzteblatt, 105(20), 366-372. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696878/
  14. ^ University of Virginia School of Medicine: Cervical Stenosis. (2011, May 16). Retrieved April 6, 2013, from medicine.virgina.edu: http://www.medicine.virginia.edu/clinical/departments/neurosurgery/cervical-stenosis
  15. ^ Ma, C. B. (2012, Nov 15). Laminectomy. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/007389.htm
  16. ^ Princeton Brain and Spine Care: Cervical Stenosis Causes and Treatments. (2013). Retrieved April 6, 2013, from princetonbrainandspine.com: http://www.princetonbrainandspine.com/subject.php?pn=cervical-stenosis-008
  17. ^ a b c d e Mazanec, D.J., Podichetty, V.K., Hsia, A. (2002) Lumbar Canal Stenosis: Start with nonsurgical therapy. Cleveland Clinic Journal of Medicine 69(11).
  18. ^ "Cervical Radiculopathy (Pinched Nerve)". AAOS. Retrieved 13 December 2011. 
  19. ^ a b c Costantini, A., Buchser, E., Van Buyten, J.P. (2009). Spinal Cord Stimulation for the Treatment of Chronic Pain in Patients with Lumbar Spinal Stenosis. Neuromodulation, 13(4), 275-380. doi:10.1111/j.1525-1403.2010.00289.x
  20. ^ a b c Goren, A., Yildiz, N., Topuz, O., Findikoglu, G., & Ardic, F. (2010). Efficacy of exercise and ultrasound in patients with lumbar spinal stenosis: A prospective randomized controlled trial. Clinical Rehabilitation, 24(7), 623-631. doi:10.1177/0269215510367539
  21. ^ a b Doorly, T.P., Lambing, C.L., Malanga, G.A., Maurer, P.M., Ralph R., R. (2010). Algorithmic approach to the management of the patient with lumbar spinal stenosis. Journal of Family Practice, 59 S1-S8
  22. ^ Mazanec, D.J., Podichetty, V.K., Hsia, A. (2002) LumbarClinic Journal of Medicine 69(11).
  23. ^ http://www.mayoclinic.com/health/spinal-stenosis/DS00515/DSECTION=causes
  24. ^ a b c Cluett, Jonathan, M.D. (2010) How is spinal stenosis diagnosed, spinal stenosis, http://orthopedics.about.com/cs/spinalstenosis/a/spinalstenosis_2.htm
  25. ^ http://www.webmd.com/back-pain/tc/lumbar-spinal-stenosis-treatment-overview
  26. ^ Greenburg, Mark (2010). Handbook of Neurosurgery 7th edition. New York: Thieme Publishing. p. 484. ISBN 978-1-60406-326-4. 
  27. ^ http://www.vancouverspinecarecentre.com/con_spinalstenosis
  28. ^ Spinal Stenosis. (2011) In SpinalStenosis.org. Retrieved 2/29/12, from http://www.spinalstenosis.org/.
  29. ^ Treatment of Degenerative Lumbar Spinal Stenosis: Summary of Evidence Report/Technology Assessment, No. 32. (2001). In AHRQ Archive--Home Page. Retrieved 2/29/2012, fromhttp://archive.ahrq.gov/clinic/epcsums/stenosum.htm.

External links [edit]

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