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Spinal Stenosis

Spinal Stenoses

Spinal stenosis is a common condition characterized by a narrowing of the spinal canal. 


Presentation

The severity of the presentation differs from person to person depending on the body type. Size of the spinal canal does not affect the symptoms. Patients with spinal stenosis present with a chronic back pain. The symptoms vary with the location of the stenosis. However, pain, motor weakness, paresthesia and numbness of the lower limbs are the associated common symptoms.

Stenosis in the lumbar spine results in lumbago with radiculopathy. Urinary incontinence and loss over rectal control is seen in severe cases of spinal stenosis. Classical symptoms of lumbar stenosis include bilateral neurologic claudication.
Patients experience diffuse pain in the lower extremity which is intermittent and accompanied with paresthesiae. In a study conducted on 75 patients, it was observed that numbness, radiculopathy and neurologic claudication were present throughout in equal intensity. Neurologic claudication is aggravated with prolonged standing and descending and is relieved with elevation of extremity or by lying in a supine position [2].

The compensatory changes that develop eventually in patients of lumbar stenosis are leaning on to objects, posture changes like forward bending and slowing of gait.

Stenosis in the cervical spine results in a syndrome called cervical spondylotic myelopathy. Symptomatically there is proximal upper extremity weakness with loss of upper arm power. Later it may progress to ataxia due to compression of the spinocerebellar tracts.

Patients may also develop paresthesiae, weakness, upper arm radiculopathy and depressed reflexes depending on the level of nerve root impingement. In cases where there is inflammation of the ligamentum flavum or at the facetal joint capsule, the presentation may be asymptomatic as there is no nerve root compression. Such cases only show radiologic changes. In cases of metastasis of spine, the regional pain is present due to nerve root compression along with canal stenosis.

Wheelchair Bound
  • Five patients had significant improvement in myelopathy and were ambulating normally, 1 had modest improvement in ambulation, and 1 remained wheelchair-bound. All patients achieved solid radiographic fusions.[ncbi.nlm.nih.gov]
Fecal Incontinence
  • A 74-year-old woman appeared with urinary retention and fecal incontinence for the previous 24 hours. Computed tomography scan showed spinal stenosis from L2 to L4.[ncbi.nlm.nih.gov]
  • Signs and symptoms of cervical stenosis include a spastic gait, upper extremity numbness, upper extremity and lower extremity weakness, radicular pain in the upper limbs, urinary incontinence, fecal incontinence, muscle wasting, sensory deficits, and[neurosurgery.ufl.edu]
  • Failure to receive quick treatment to relieve this pressure can result in: Permanent paralysis Urinary and/or fecal incontinence Loss of sexual sensation Weakness Pain or loss of feeling in one or both legs Downtown (AMC) Northern Suburbs Western Suburbs[nm.org]
Back Pain
  • To assess the cost utility of lumbar interlaminar epidural injections in managing chronic low back and/or lower extremity pain secondary to lumbar disc herniation, spinal stenosis, and axial or discogenic low back pain.[ncbi.nlm.nih.gov]
  • NO MORE BACK PAIN![amazon.com]
  • She remained neurologically intact and was fully ambulatory, but had severe back pain in the area of the deformity. Because of the severity and progression of her deformity, a combined anterior and posterior fusion and stabilization was required.[ncbi.nlm.nih.gov]
  • We report progression of neurologic symptoms after spinal anesthesia in 2 patients with preexisting spinal stenosis, characterized preoperatively solely by nonradicular back pain.[ncbi.nlm.nih.gov]
  • At just over 2 years after decompression, patients with CS may not need to be treated by a fusion in the setting of lower back pain; however, longer-term follow up is necessary to further assess these outcomes.[ncbi.nlm.nih.gov]
Leg Pain
  • Spinal stenosis is in some patients the unidentified cause of failure of treatment of foot and leg pain.[ncbi.nlm.nih.gov]
  • Visual analog scale (VAS) of back and leg pain and the Oswestry Disability Index (ODI) were measured preoperatively and at follow-up. The mean SD value of preoperative VAS leg pain score was 7.6 1.17.[ncbi.nlm.nih.gov]
  • Primary outcomes were the Roland-Morris Disability Questionnaire (RDQ) (range, 0-24, where higher scores indicate greater disability) and leg pain intensity (range, 0 [no pain] to 10 [pain as bad as you can imagine]).[ncbi.nlm.nih.gov]
  • Lumbar spinal stenosis is typically a degenerative condition that leads to compression of the spinal canal and lateral recess, resulting in leg pain and walking disability.[ncbi.nlm.nih.gov]
  • There was no association between the different muscle parameters and stenosis severity or back or leg pain duration or severity.[ncbi.nlm.nih.gov]
Neurogenic Claudication
  • claudication Lumbar spinal stenosis w neurogenic claudication Myelopathy due to spinal stenosis of lumbar region Neurogenic claudication co-occurrent and due to spinal stenosis of lumbar region Neurogenic claudication due to spinal stenosis of lumbar[icd10data.com]
  • We report a case of a skeletally immature achondroplastic adolescent with significant thoracolumbar lordosis who presented with neurogenic claudication and urinary incontinence progressing over a 1-year period.[ncbi.nlm.nih.gov]
  • A classic symptom is that of neurogenic claudication, involving leg pain and weakness brought on by walking. The pain is relieved by sitting or lying down, not by standing and resting as would be seen in arterial insufficiency-induced claudication.[ncbi.nlm.nih.gov]
  • NEUROGENIC CLAUDICATION Neurogenic claudication is a common symptom from lumbar spinal stenosis. Neurogenic claudication literally means cramping or painful legs from a nerve problem.[spinemd.com]
  • Patients present with symptoms of neurogenic claudication or radiculopathy.[bestpractice.bmj.com]
Low Back Pain
  • To assess the cost utility of lumbar interlaminar epidural injections in managing chronic low back and/or lower extremity pain secondary to lumbar disc herniation, spinal stenosis, and axial or discogenic low back pain.[ncbi.nlm.nih.gov]
  • Estimated costs to those who are severely disabled from low back pain range from 30-70 billion annually.[clinicaltrials.gov]
  • The program in Treat Your Own Spinal Stenosis can effectively treat not only spinal stenosis, but also chronic low back pain, lumbar disc herniations, bulging discs, spondylolisthesis, sciatica - as well as PREVENT further low back pain episodes - SO[amazon.com]
  • The American Pain Society and the American College of Physicians recommend spinal manipulation as primary care for low back pain (1) of which spinal stenosis is a common cause.[coxtechnic.com]
Spine Pain
  • The patient had an uneventful spinal decompression with resolution of radicular symptoms and axial spine pain. Dural ectasia poses a significant risk when operating on the lumbosacral spine.[ncbi.nlm.nih.gov]
  • In previous large, randomized studies, such as SPORT (Spine Pain Outcomes Research Trial), non-operative care was at the discretion of the surgeon and patient, Skolasky said. "Surgical management is well-honed," he added.[medpagetoday.com]
  • Spinal Stenosis Spine Pain in neck or back Difficulty walking Numbness, weakness or pain in extremities Foot disorders Pain or a heavy feeling in the legs Reduced sensation to touch, heat or cold Born with a narrow spinal canal Traumatic injury Aging[nm.org]
  • Symptoms of Spinal Stenosis in the Thoracic Spine Pain in the rib cage or internal organs Pain that radiates down the back of the legs Aching in the legs that leads to difficulty walking Problems with balance and coordination Problems with bowel or bladder[bonati.com]
Sciatica
  • Transcript of Exercises for sciatica: spinal stenosis EXERCISES FOR SCIATICA SPINAL STENOSIS My name is Sammy Margo.I'm a chartered physiotherapist. Today we're going to look at exercisesfor spinal stenosis.[nhs.uk]
  • Learn how what can happen to the sciatic nerve during the course of lumbar spinal stenosis to cause sciatica.[spine-health.com]
  • The program in Treat Your Own Spinal Stenosis can effectively treat not only spinal stenosis, but also chronic low back pain, lumbar disc herniations, bulging discs, spondylolisthesis, sciatica - as well as PREVENT further low back pain episodes - SO[amazon.com]
  • (radiating pain) Shrinking spaces between vertebrae, which can also affect nerves going to other body parts — may cause numbness, weakness, and sciatica Stenosis usually occurs in the cervical region of the spine near the head and neck, or in the lumbar[everydayhealth.com]
Paresthesia
  • To describe the chiropractic management of a patient with paresthesia on the entire left side of her body and magnetic resonance imaging (MRI)-documented cervical spinal cord deformation secondary to cervical spinal stenosis.[ncbi.nlm.nih.gov]
  • Both patients complained of paresthesias and weakness in their lower extremities on postoperative day 1. Neurologic examination in each case was consistent with a polyradiculopathy.[ncbi.nlm.nih.gov]
  • Other symptoms of spinal stenosis can involve paresthesia, weakness or cramping in one or both extremities, rest pain, or burning pain, and are commonly misdiagnosed as peripheral neuropathy, especially in patients with diabetes.[ncbi.nlm.nih.gov]
  • Patients experience diffuse pain in the lower extremity which is intermittent and accompanied with paresthesiae.[symptoma.com]
  • Burning, stabbing, a cold feeling, aching, numbness, paresthesia, or a weak or tired feeling of the feet (during some part of the disease process) depend on spinal position and may occur during standing, walking, or even lying in bed.[ncbi.nlm.nih.gov]
Numbness in the Buttocks
  • Lumbar Spinal Stenosis • Pain, sciatica, tingling sensations, feelings of pins and needles, weakness or numbness in the buttocks, legs, calves. • Symptoms may increase when walking and decrease when sitting, bending forward, or lying down. • Rare: Bladder[ortho-spine.com]
  • […] to the buttock, thigh, or leg particularly during walking or standing for a long time.[physio-pedia.com]
Extrapyramidal Symptoms
  • The decision to drain the subdural hematoma in our case resulted in full recovery of the patient's gait and other extrapyramidal symptoms. This paper reviews the literature on reversible P-L symptoms caused by bilateral chronic subdural hematomas.[ncbi.nlm.nih.gov]
Urinary Incontinence
  • We report a case of a skeletally immature achondroplastic adolescent with significant thoracolumbar lordosis who presented with neurogenic claudication and urinary incontinence progressing over a 1-year period.[ncbi.nlm.nih.gov]
  • Because the affected nerves have many functions, the condition may cause diverse problems in the lower body, including back pain, pain or numbness in the legs as well as constipation or urinary incontinence.[arthritis.org]
  • Signs and symptoms of cervical stenosis include a spastic gait, upper extremity numbness, upper extremity and lower extremity weakness, radicular pain in the upper limbs, urinary incontinence, fecal incontinence, muscle wasting, sensory deficits, and[neurosurgery.ufl.edu]
  • Urinary incontinence and loss over rectal control is seen in severe cases of spinal stenosis. Classical symptoms of lumbar stenosis include bilateral neurologic claudication.[symptoma.com]

Workup

MRI and CT scans remain the standard scanning procedures in order to study the site and extent of the spinal stenosis. MRI scans helps in viewing the spinal structure, bones, vessels and muscular ligaments, while CT scans provide information about the central canal, lateral recess, and the vertebral foraminae [5] [6].

Angiography is rarely indicated and is done only in suspected cases of vascular malformations. Neuronal studies include needle electromyography which detects lumbosacral radiculopathy along with axonal loss. Nerve conduction studies are done to helps to rule out neuropathies like peripheral neuropathy, tarsal tunnel syndrome etc. [7].

Treatment

The aim to treatment of spinal stenosis is pain management and limiting the further disability. Non-surgical treatment includes analgesics, anti inflammatory agents and anti spasmodic, along with this physical therapy such as traction, exercises to strengthen muscles helps to reduce pressure and improves mobility.

Surgical intervention is indicated in cases of severe pain not responding to oral medications, neuropathy and radiculopathies [8].

Surgery includes lumbar decompressive laminectomy in which the nerves are decompressed by removing the roof of the vertebrae overlying the thickened ligaments. After this an interlaminal implant is placed between the two bones to in order to stabilize the joints [9] [10].

For neuropathic pain, tricyclic antidepressants are given but are not highly recommended due to their adverse effects especially in elderly age group. The radicular pain from the lateral recess stenosis is relieved by membrane–stabilizing anticonvulsants such as gabapentin and caramazepine. In patients not responding to medications and other physical therapies, epidural steroid injection provides relief. 

Prognosis

Patients undergoing surgery get good relief from the pressure symptoms as the compression of the affected nerve root gets released. Spinal stenosis results in morbidity more than mortality. This condition often causes disability and chronic pain rather than death. In individuals with spinal canal stenosis, the anterior cord compression causes a central spinal cord syndrome, likewise, a posterior cord compression causes partial dorsal column syndrome.

The spinal stenosis at the cervical or the thoracic region leads to compression symptoms leading to myelopathy and weakness in the lower extremity along with difficulty in maintain gait. In individuals with lumbar spinal stenosis, a study showed that about 90% of 169 patients showed symptomatic relief over the period of two years without undertaking any treatment. In another study of 32 patients suffering from moderate stenosis, no symptomatic change was observed in 70% of them despite taking conservative treatment for 4 years, while 15% showed improvement [4].

Etiology

Spinal stenosis occurring congenitally is due to segmentation failure, achondroplasia or due to incomplete closure of the vertebral arch. Developmental anomalies include early vertebral arch ossification, vertebral wedging, osseous exostosis and thoracolumbar kyphosis.

Acquired causes include trauma, degeneration changes due to disc prolapsed, ligamentum flavum hypertrophy and spodylolisthesis.

Other causes include diseases such as Paget disease, fluorosis, acromegaly and malignancy. Cervical spinal stenosis results also from rheumatic arthritis and ankylosing spondylosis.

Epidemiology

It is estimated that about 250,000 to 500,000 US residents have been suffering from the symptoms of spinal stenosis. This represents that spinal stenosis accounts to be a major health issue in the United States. About 1 in 1000 of the population in the age group older to 65 years suffers from this condition. It is more prevalent in the older age group. Of these, there are about 35% patients who are asymptomatic.

Lower lumbar spine is more prone to foraminal stenosis as the diameter of the dorsal root ganglion is larger than that of the foramen.

Among the Asians, cervical stenosis is more common. This is due to the ossification of the posterior longitudinal ligament. The longitudinal Framingham heart study recorded degenerative slip disc syndrome in about 1% of men and 1.5% female above the age group of 54. A Swedish study revealed 5 of 100,000 residents developed spinal stenosis with the canal diameter 11mm or less [2].

Sex distribution
Age distribution

Pathophysiology

The spinal canal comprises of the spinal cord, cerebrospinal fluid and the dural membranes which capsules the cerebrospinal fluid. The prolapse of the intervertebral discs due to degeneration or due to trauma and other mechanical factors results in narrowing of the spinal canal and the lateral recesses. Along with the narrowing of the spinal canal, the other changes observed are, thickening of the posterior longitudinal ligament, and hypertrophy of the facet joints, epidural fat deposition and inflammation of the ligamentum flavum.

The degeneration leads to further subluxation of the vertebral bodies thus resulting in the spur formation. The common site for this is mainly the fifth, sixth and the seventh cervical vertebraes [3].

Prevention

Simple measures like exercising regularly , going for daily walks, maintaining ideal body weight , maintaining a good posture and understanding one’s own body mechanics are ways to prevent back pathology. Doing regular exercises strengthens the muscles of the back and helps in shock absorbing in case sudden change of posture or trauma.

Summary

Spinal stenosis is a condition in which there is narrowing of the spinal canal. This is commonly seen in the lumbar and cervical spine. Lumbar spinal stenosis is often accompanied by nerve impingement. It includes central as well as lateral recess stenosis.

In lateral canal stenosis, as there is involvement of the nerve it results in severe radiculopathy, with muscle weakness, pain and immobility. This occurs due to a series of changes in the components of the central and lateral canal such as ligamentum flavum inflammation, bony spurs, epidural fat deposition and facetal hypertrophy [1].

Management of spinal stenosis includes conservative or surgical treatment. Conservative approach comprises of rest, analgesics, anti inflammatory medications, physical exercises, and weight loss. Surgery is done in patients who have severe pain, disability, neuropathy or malignancy.

Patient Information

Spinal stenosis occurs due to narrowing of the spinal canal. This leads to pressure to the surrounding nerves. Disc degeneration is the common cause of spinal stenosis. This leads to collapse of the disc space and compression of the facetal joints thus irritating the spinal nerves and giving rise to pain and numbness.

Treatment includes anti inflammatory drugs, pain killers, injections to relieve the numbness. Physical therapy such as traction and strengthening exercises are an important part of the overall regimen to be followed. Patients are instructed to avoid factors which can cause aggravation such as excessive lumbar extension or doing descending walks, or factors that can produce stress on the affected bone, and ligaments such lifting heavy weights they are encouraged to do more of exercises such as pilates, flexion training , gluteal strengthening, etc. [10].

References

Article

  1. Arnoldi CC, Brodsky AE, Cauchoix J, Crock HV et al. Lumbar spinal stenosis and nerve root entrapment syndromes. Definition and classification. Clin Orthop Relat Res. 1976 Mar-Apr; (115):4–5.
  2. Kalichman L, Cole R, Kim DH, Li L, et al. Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine J. 2009 Jul;9(7):545-50.
  3. Truumees E. Spinal stenosis: pathophysiology, clinical and radiologic classification. Instr Course Lect. 2005;54:287-302.
  4. Macnab I. Negative disc exploration: an analysis of the causes of nerve root involvement in sixty-eight patients. J Bone Joint Surg Am. 1971 Jul;53(5):891–903.
  5. Herkowitz HN. Spinal stenosis: radiologic and electrodiagnostic evaluation. In:Rothman RH, Simone FA, (Eds) The spine. 3rd edition. Philadelphia: W.B. Saunders;1992. p. 830–57.
  6. McAfee PC, Yaun H. Computed tomography in spondylolisthesis. Clin Orthop Relat Res. 1982 Jun;(166):62–71.
  7. Johnson DW, Farnum GN, Latchaw RE, Erba SM. MR imaging of the pars interarticularis. Am J Roentgenol 1989 Feb;152(2):327-32.
  8. Brown, LL. A double-blind, randomized, prospective study of epidural steroid injection vs. the mild (R) procedure in patients with symptomatic lumbar spinal stenosis. Pain Pract. 2012 Jun;12(5):333-41.
  9. Eisenstein S. Lumbar vertebral canal morphometry for computerized tomography in spinal stenosis. Spine 1983 Mar;8(2):187–91.
  10. Bridwell KH. Lumbar spinal stenosis. Diagnosis, management, antreatment. Clin Geriatr Med. 1994 Nov; 10(4):677–701.

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Last updated: 2018-06-22 10:00