Spinal Stenosis

Spinal stenosis is the progressive narrowing of the central spinal canal, intervertebral foramen, and lateral recess, leading to compression of the nerve root. Spinal stenosis can occur in the cervical, thoracic, and lumbar spine and is commonly caused by degenerative bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones disease (mostly affecting the elderly). Patients present with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, weakness, numbness, and tingling in the neck or lower back, which may radiate to the legs and buttocks. Clinical examination shows symptom improvement with spinal flexion and symptom deterioration with spinal extension. The diagnosis is confirmed with MRI. Conservative management includes analgesic/antiinflammatory medications and physiotherapy. Decompression surgery (laminectomy) is considered in advanced cases, or if conservative management fails.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

  • Spinal stenosis is characterized by the progressive narrowing of the spinal canal, intervertebral foramen, and lateral recess. 
  • Spinal stenosis causes compression of the nerve root in the cervical, thoracic, and lumbar regions of the spine. 

Epidemiology

  • Incidence: 5 per 1,000 individuals > 50 years of age
  • Most common age groups: middle and elderly
  • More common in women
  • Risk factors:
    • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
    • Family history
    • Trauma

Etiology

  • Acquired causes: 
    • Degenerative changes (e.g., spondylosis, degenerative arthritis)
    • Trauma
    • Iatrogenic (postoperative)
    • Lipoma Lipoma A lipoma is a benign neoplasm of fat cells (adipocytes) and the most common soft tissue tumor in adults. The etiology is unknown, but obesity is a predisposing factor; genetics also play a role, with multiple lipomas occurring in various inherited disorders. Lipoma, synovial cysts, neural cysts, and neoplasms
    • Systemic disorders (e.g., Paget disease, ankylosing spondylitis Ankylosing spondylitis Ankylosing spondylitis (also known as Bechterew's disease or Marie-Strümpell disease) is a seronegative spondyloarthropathy characterized by chronic and indolent inflammation of the axial skeleton. Severe disease can lead to fusion and rigidity of the spine. Ankylosing Spondylitis)
  • Congenital causes:
    • Approximately 9% of spinal stenosis cases
    • Spinal dysraphism
    • Segmentation failure
    • Achondroplasia
    • Osteopetrosis

Pathophysiology

  • Narrowing of the spinal canal and lateral recess causes nerve compression. 
  • Due to the narrowing of the canal, compression of the nerve root can arise from direct mechanical compression or increased intrathecal pressure.

Clinical Presentation

  • Bilateral pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain (most commonly in the lower back)
  • Radiation to the buttocks and/or legs
  • Associated symptoms:
    • Cramping
    • Numbness
    • Weakness
    • Paresthesia
  • Symptoms ↓ with spinal flexion:
    • Widens the spinal canal
    • Examples:
      • Sitting
      • Cycling
      • Walking uphill
      • Bending forward
  • Symptoms ↑ with spinal extension:
    • Narrows the spinal canal
    • Examples:
      • Standing
      • Walking downhill

Diagnosis and Management

Diagnosis

  • Detailed history and physical examination is necessary to localize the level of spine affected. 
  • Imaging:
    • MRI: the diagnostic gold standard (CT alternatively)
    • X-ray: to assess for degenerative bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones changes 
  • Nerve conduction studies: to differentiate lumbar stenosis from lumbosacral plexopathy Plexopathy Neuropathy is a nerve pathology presenting with sensory, motor, or autonomic impairment secondary to dysfunction of the affected nerve. The peripheral nerves are derived from several plexuses, with the brachial and lumbosacral plexuses supplying the major innervation to the extremities. Mononeuropathy (affecting a single nerve) and plexopathy (affecting the plexus) can occur from trauma, compression, and systemic diseases. Mononeuropathy and Plexopathy and generalized peripheral neuropathy
Spinal stenosis on mri

Magnetic resonance imaging (MRI) showing extensive spinal stenosis:
(A): L1–L2
(B): L2–L3
(C): L3–L4
(D): L4–L5
(E): L5–S1
(F): Sagittal T2-weighted image reveals stenosis from L1–L2 through L5–S1 (arrowheads).

Image: “Preoperative magnetic resonance images” by Saito K, Miyakoshi N, Hongo M, Kasukawa Y, Ishikawa Y, Shimada Y. License: CC BY 2.0

Management

The goal of spinal stenosis management is to reduce symptoms and increase the individual’s functional status. 

Conservative management: 

  • Physiotherapy:
    • Aimed at strengthening muscles
    • Techniques to increase lumbar flexion and reduce lumbar lordosis
  • Medication: 
    • NSAIDs
    • Epidural injection of corticosteroids
  • Bracing
  • Rest

Surgery:

  • Failure of conservative therapy
  • Presence of significant myelopathy, radiculopathy, and/or neurogenic claudication
  • Laminectomy is the most frequently employed surgery.

Differential Diagnosis

  • Spinal disc herniation Spinal disc herniation Spinal disk herniation (also known as herniated nucleus pulposus) describes the expulsion of the nucleus pulposus through a perforation in the annulus fibrosus of the intervertebral disk. Spinal disk herniation is an important pain syndrome with the potential for neurologic impairment. Spinal Disk Herniation: the expulsion of the nucleus pulposus through a perforation in the anulus fibrosus of the intervertebral disc. Spinal disc herniation Spinal disc herniation Spinal disk herniation (also known as herniated nucleus pulposus) describes the expulsion of the nucleus pulposus through a perforation in the annulus fibrosus of the intervertebral disk. Spinal disk herniation is an important pain syndrome with the potential for neurologic impairment. Spinal Disk Herniation is most commonly caused by degenerative disc disease. Clinical presentation includes pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, paresthesia, and, in severe cases, muscle weakness and bladder/bowel dysfunction. Diagnosis is clinical and can be confirmed with diagnostic imaging (i.e., MRI). Depending on the severity of the symptoms, management‌ ‌can be conservative or surgical. 
  • Radiculitis: the compression of a nerve root exiting the spinal column. Radiculitis is caused by either a bacterial/viral infection (mainly borreliosis or herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox) or autoimmune/cryptogenic inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation. Individuals present with pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain radiating from the affected nerve to the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord without any muscle weakness. Diagnostic studies and management depend on the suspected etiology.
  • Lumbar compression fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures: may occur as a result of trauma or pathological weakening of the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones. Midline back pain Back pain Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. Back Pain is the hallmark of lumbar compression fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures. X-ray, CT, or MRI is used for diagnosis. Decompression surgery is often performed along with physiotherapy to provide long-term care. 
  • Rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis: both a symmetric, inflammatory polyarthritis and a chronic, progressive autoimmune disorder. Rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis occurs most commonly in middle-aged women with joint swelling, pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, and morning stiffness. Prolonged and severe disease can lead to irreversible joint deformities. Diagnosis is based on strong clinical suspicion and confirmed by blood tests (e.g., rheumatoid factor, anti-cyclic citrullinated peptide antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins) and imaging. Management involves long-term disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs are antiinflammatory medications used to manage rheumatoid arthritis. The medications slow, but do not cure, the progression of the disease. The medications are classified as either synthetic or biologic agents and each has unique mechanisms of action and side effects. Disease-modifying Antirheumatic Drugs, biologic agents, and physical therapy. 
  • Osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis: degenerative joint disease occurring most frequently in the hands, hips, and knees. Individuals present with joint pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, stiffness lasting < 30 minutes, and decreased range of motion. Physical exam may reveal crepitus with joint motion and Heberden/Bouchard nodes. The diagnosis is confirmed by radiographic joint findings. Management includes conservative measures, analgesic medications, glucocorticoid intra-articular injections, and surgery for advanced disease.

References

  1. Levin, K. (2019). Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis. UpToDate. Retrieved August 16, 2021, from https://www.uptodate.com/contents/lumbar-spinal-stenosis-pathophysiology-clinical-features-and-diagnosis
  2. Raja, A., Hoang, S., Patel, P., Mesfin, F. B. (2021). Spinal Stenosis. https://www.ncbi.nlm.nih.gov/books/NBK441989/
  3. Lee, B. H., Moon, S. H., Suk, K. S., Kim, H. S., Yang, J. H. (2020). Lumbar Spinal Stenosis: Pathophysiology and Treatment Principle: A Narrative Review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7595829/
  4. Wu, L., Cruz, R. (2020). Lumbar Spinal Stenosis. https://www.ncbi.nlm.nih.gov/books/NBK531493/
  5. Katz, J. N., & Harris, M. B. (2008). Clinical practice. Lumbar spinal stenosis. The New England journal of medicine. 358(8), 818–825. https://doi.org/10.1056/NEJMcp0708097

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