Spinal Stenosis

The word stenosis refers to abnormal condition characterized by the constriction or narrowing of an opening or passageway in a body structure. The term stenosis is widely used in medicine for different parts of the body, including blood vessels, the GI tract and the spinal column. Typically, the term spinal stenosis refers to the central canal of the spinal column, although stenosis (narrowing) may affect other parts of the spine as well (foramenal stenosis, lateral recess stenosis).

Video: About Spinal Stenosis
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Lumbar Stenosis

Lumbar spinal stenosis
Fig. 1: Lumbar spinal stenosis

Lumbar stenosis is a narrowing of the spinal canal in the lower part of the spine. This narrowing places pressure on the spinal nerves and/or spinal cord. While some patients are born with this narrowing, most cases of lumbar stenosis occur in patients over the age of 50 and are the result of aging and "wear and tear" on the spine.

Many patients with lumbar stenosis remain symptom-free until other conditions further compress the spinal canal. Other conditions that can cause compression include:

  • Calcification (the ligaments of the spine thicken and harden)
  • The formation of osteophytes (bony growths on bones and joints)
  • Bulging or herniated discs
  • The slipping of one vertebra onto another (called spondylolisthesis)
  • Trauma (such as from an accident)

Symptoms

The symptoms of lumbar spinal stenosis include:

  • Low back pain that eases when bending forward or sitting.
  • Pain, weakness, or numbness in the legs, calves or buttocks.
  • Burning sensations, tingling, and pins and needles in the involved extremity, such as a leg.
  • Bladder and bowel problems (in severe cases).
  • Although rare, very severe cases can also cause significant loss of function or even paraplegia.

Diagnosis

As with all spinal conditions, good treatment is always based on an accurate diagnosis. The comprehensive diagnostic process includes:

  • Medical history. Your doctor will talk to you about your symptoms, how severe they are, and what treatments you have already tried.
  • Physical examination. You will be carefully examined for limitations of movement, problems with balance, abnormal posture, and pain. During this exam, the doctor will also look for loss of reflexes in the extremities, muscle weakness, or loss of sensation.
  • Diagnostic tests. MRIs and CT scans give three-dimensional views of the lumbar spine and can help detect osteophytes (bony growths) and herniated discs. MRI is superior in demonstrating the details of the spinal canal. Occasionally doctors use a myelogram. This is a test that involves injecting liquid contrast dye into the spinal column to show where the spinal cord pressure is occurring.


Fig. 1 Sagittal MRI demonstrates moderate central spinal stenosis at L3-4 (white arrow) and narrowing at L4-5 (yellow arrow)
Fig. 2 Axial MRI slice at the L3-4 level confirms moderately severe central spinal stenosis
Fig. 3 Axial MRI slice at L1-2 demonstrates a normal central canal. Notice the large amount of spinal fluid (white) surrounding the spinal nerves (black dots)

Non-operative Treatment

Most cases of lumbar stenosis are successfully treated with non-surgical techniques. A combination of the following treatments will be used with most patients suffering from lumbar central spinal stenosis:

  • Medications
    • Anti-inflammatory medications help reduce swelling and pain
    • Narcotic painkillers are prescribed to alleviate acute pain (only if absolutely necessary)
  • Physical therapy. An exercise prescription tailored to your condition is provided to your physical therapist. A typical prescription involves:
    • Stretching exercises
    • Strengthening exercises
      • This involves specific exercise program designed to strengthen your posture in positions that will reduce the narrowing around the nerves in your spinal canal.
    • Balance training
      • Most patients with spinal stenosis experience difficulty with balance. Training is necessary to restore their full function.
  • A therapeutic transforaminal epidural steroid injection (TFESI) series:
    • Selected patients will benefit from a focused epidural injection series, under live x-ray guidance, using a strong anti-inflammatory medication (corticosteroid).
    • Maximum benefit typically occurs following 2 to 4 injections

If these non-surgical measures do not work, you may be recommended for surgery. There are a number of surgical techniques that can be used to treat this condition. The goal of each of these surgical treatments is to widen the spinal canal and relieve the pressure by removing the cause of compression. The consulted neurosurgeon, of course, will discuss all of your options with you before deciding which procedure is best for you.

Surgical Treatment

The most common surgery for lumbar stenosis is called a decompressive laminectomy in which the laminae (roof) of the vertebrae are removed to create more space with the spinal nerves. If only a portion of the laminae need to be removed, it is called a partial laminectomy or laminotomy. If there are herniated or bulging discs, these may also be removed (this is called a discectomy) to increase canal space. Sometimes the foramen (the area where the nerve roots exit the spinal canal) may also need to be enlarged. This procedure is called a foraminotomy.

For those patients who need surgical repair on more than one level, or who have significant spinal instability, spinal fusion may be required in addition to the decompression surgery. This traditionally involves taking a small piece of bone (usually from the hip) and grafting it onto the spine. More recently, for some cases, bone substitutes such as bone morphogenetic proteins (BMPs) are used to facilitate spine fusion. Spinal implants (called instrumentation) such as screws and rods are used to support the spine and provide additional stability while the fusion is healing. In most cases, the surgeon can determine ahead of time if fusion surgery is necessary. Nowadays, surgeons perform many fusions using minimally invasive surgical techniques, thus reducing trauma to soft tissues, reducing blood loss, and ultimately leading to a more rapid recovery. If a fusion is necessary, your surgeon will discuss this with you in advance.

Cervical Stenosis

A common cause of neck pain, especially in older patients, is cervical stenosis. Cervical stenosis is a narrowing of the spinal canal in the neck area or upper part of the spine. This narrowing places pressure on the spinal cord. While some patients are born with this narrowing, most cases of cervical stenosis occur to patients over the age of 50 and are the result of aging and "wear and tear" on the spine.

Many patients with cervical stenosis have a history of some kind of injury or trauma to the neck, however this trauma may have occurred many months or even years before the onset of stenosis symptoms.

Symptoms

The symptoms of cervical spinal stenosis may include the following:

  • Neck pain; not always severe.
  • Pain, weakness, or numbness in the shoulders, arms, and legs.
  • Hand clumsiness.
  • Gait and balance disturbances.
  • Burning sensations, tingling, and pins and needles in the involved extremity, such as the arm or leg.
  • In severe cases, bladder and bowel problems.
  • Although rare, severe cases can also cause significant loss of function or even paraplegia.

Diagnosis

Good treatment is always based on an accurate diagnosis. The comprehensive diagnostic process includes:

  • Medical history. Your doctor will talk to you about your symptoms, how severe they are, and what treatments you have already tried.
  • Physical examination. You will be carefully examined for limitations of movement, problems with balance, and pain. During this exam, the doctor will also look for loss of reflexes in the extremities, muscle weakness, loss of sensation or other signs of spinal cord damage.
  • Diagnostic tests. MRIs and CT scans give three-dimensional views of the lumbar spine and can help detect osteophytes (bony growths) and herniated discs. MRI is superior in demonstrating the details of the spinal canal. Occasionally doctors use a myelogram. This is a test that involves injecting liquid contrast dye into the spinal column to show where the spinal cord pressure is occurring.

Non-operative Treatment

Most cases of cervical spinal stenosis are successfully treated with non-surgical techniques. A combination of the following treatments will be used with most patients suffering from cervical central spinal stenosis:

  • Medications
    • Anti-inflammatory medications help reduce swelling and pain
    • Narcotic painkillers are prescribed to alleviate acute pain (only if absolutely necessary)
  • Physical therapy. An exercise prescription tailored to your condition ia provided to your physical therapist. A typical prescription involves:
    • Stretching exercises
    • Strengthening exercises
      • This involves specific exercise program designed to strengthen your posture in positions that will reduce the narrowing around the nerves in your spinal canal.
    • Balance training
      • Most patients with spinal stenosis experience difficulty with balance. Training is necessary to restore function.
  • A therapeutic transforaminal epidural steroid injection (TFESI) series:
    • Selected patients will benefit from a focused epidural injection series, under live x-ray guidance, using a strong anti-inflammatory medication (corticosteroid).
    • Maximum benefit typically occurs following 2 to 4 injections

Surgical Treatment

If non-surgical measures do not work, your doctor may recommend surgery to treat your stenosis. There are a number of surgical techniques that can be used to treat this condition. The goal of each of these surgical decompression treatments is to widen the spinal canal and relieve the pressure on the spinal cord by removing or trimming whatever is causing the compression. However, since all surgical procedures carry a certain amount of risk, your doctor will discuss all of your options with you before deciding which procedure is best for you.

The most common surgery for cervical stenosis is called a decompressive laminectomy in which the laminae (roof) of the vertebrae are removed to create more space for spinal nerves. If only a portion of the laminae need to be removed, it is called a partial laminectomy or laminotomy.

Your surgeon may also consider performing a posterior laminoplasty. This technique helps to retain spinal stability while also expanding the spinal canal.

If there are any herniated or bulging discs, these may also be removed (this is called a discectomy) to increase canal space. Sometimes the foramen (the area where the nerve roots exit the spinal canal) also need to be enlarged. This procedure is called a foraminotomy.

For those patients who need surgical repair on more than one level or who have significant spinal instability, spinal fusion may be done in addition to the decompression surgery. This involves taking a small piece of bone (usually from the hip) and grafting it onto the spine. Spinal hardware (called instrumentation) such as plates and screws are used to support the spine and provide additional stability. In most cases, it can be determined ahead of time if fusion surgery is necessary.



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