Spinal stenosis

Spinal stenosis
Lumbar trefoil canal
Classification and external resources
Specialty Orthopedics, neurosurgery
ICD-10 M48.0
DiseasesDB 31116
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, with 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.

Signs and symptoms

Illustration depicting spinal stenosis and spinal cord compression

Common

Neurological disorders

Causes

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

Arthritis: Two types,

Heredity:

Instability of the spine, or spondylolisthesis:

Trauma:

Tumors of the spine:

Types

The most common forms are cervical spinal stenosis, which are 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 myelopathy, a serious conditions causing symptoms including major body weakness and paralysis.[12] Such severe spinal stenosis symptoms are virtually absent in lumbar stenosis, however, as the spinal cord terminates at the top end of the adult lumbar spine, with only nerve roots (cauda equina) continuing further down.[13] 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,[14] but may also be congenital or traumatic. Treatment frequently is surgical.[14]

Diagnosis

Moderate to severe spinal stenosis at the levels of L3/4 and L4/5
MRI exhibiting areas of lumbar stenosis

The diagnosis of spinal stenosis involves a complete evaluation of the spine. The process usually begins with a medical history and physical examination. X-ray and MRI scans are typically used to determine the extent and location of the nerve compression.

Medical history

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.[15]

Physical examination

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.[15]

MRI

The MRI has become the most frequently used study to diagnose spinal stenosis. The MRI uses electromagnetic signals 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.[15]

CT myelogram

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 for patients in which MRI is contraindicated, such as those with implanted pacemakers.

Red flags

Treatments

Treatment options are either or surgical or non-surgical. Overall evidence is inconclusive whether non-surgical or surgical treatment is the better for lumbar spinal stenosis.[16]

Non-surgical treatments

The effectiveness of non surgical treatments is unclear as they have not been well studied.[17]

Surgery

Lumbar decompressive laminectomy: This involves removing the roof of bone overlying the spinal canal and thickened ligaments in order to decompress the nerves and sac of nerves. 70-90% of people have good results.[21]

Epidemiology

References

  1. 1 2 Vokshoor A (February 14, 2010). "Spinal Stenosis". eMedicine. Retrieved December 30, 2010.
  2. "Fast Facts About Spinal Stenosis". National Institute of Arthritis and Musculoskeletal and Skin Diseases. Retrieved 2015-04-17.
  3. 1 2 3 4 5 Mazanec D. J.; Podichetty V. K.; Hsia A. (2002). "Lumbar Canal Stenosis: Start with nonsurgical therapy". Cleveland Clinic Journal of Medicine. 69 (11).
  4. "What is CSM?". Myelopathy.org. Retrieved 2015-11-23.
  5. "Cervical Radiculopathy (Pinched Nerve)". AAOS. Retrieved 13 December 2011.
  6. 1 2 3 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.
  7. 1 2 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.
  8. 1 2 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
  9. Mazanec, D. J., Podichetty, V. K., Hsia, A. (2002) Lumbar Clinic Journal of Medicine 69 (11).
  10. "Spinal stenosis Causes". Mayo Clinic. 2012-06-28. Retrieved 2015-04-17.
  11. Wu, Jau-Ching; Ko, Chin-Chu; Yen, Yu-Shu; Huang, Wen-Cheng; Chen, Yu-Chun; Liu, Laura; Tu, Tsung-Hsi; Lo, Su-Shun; Cheng, Henrich (2013-07-01). "Epidemiology of cervical spondylotic myelopathy and its risk of causing spinal cord injury: a national cohort study". Neurosurgical Focus. 35 (1): E10. doi:10.3171/2013.4.FOCUS13122.
  12. "CSM Symptoms". Myelopathy.org. Retrieved 2015-11-23.
  13. Waxman, SG (2000). Correlative Neuroanatomy (24th ed.).
  14. 1 2 Meyer F, Börm W, Thomé C; Börm; Thomé (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 2696878Freely accessible. PMID 19626174.
  15. 1 2 3 Cluett, Jonathan, M.D. (2010) Spinal Stenosis - How is Spinal Stenosis Diagnosed?
  16. Zaina, F; Tomkins-Lane, C; Carragee, E; Negrini, S (29 January 2016). "Surgical versus non-surgical treatment for lumbar spinal stenosis.". The Cochrane database of systematic reviews. 1: CD010264. doi:10.1002/14651858.CD010264.pub2. PMID 26824399. Retrieved 5 February 2016.
  17. 1 2 Ammendolia, C; Stuber, KJ; Rok, E; Rampersaud, R; Kennedy, CA; Pennick, V; Steenstra, IA; de Bruin, LK; Furlan, AD (30 August 2013). "Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication". The Cochrane database of systematic reviews. 8: CD010712. doi:10.1002/14651858.CD010712. PMID 23996271.
  18. "Lumbar Spinal Stenosis-Treatment Overview". WebMD. Retrieved 2015-04-17.
  19. Manchikanti, L; Kaye, AD; Manchikanti, K; Boswell, M; Pampati, V; Hirsch, J (February 2015). "Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review.". Anesthesiology and pain medicine. 5 (1): e23139. doi:10.5812/aapm.23139. PMID 25789241.
  20. Chou, R; Hashimoto, R; Friedly, J; Fu, R; Bougatsos, C; Dana, T; Sullivan, SD; Jarvik, J (25 August 2015). "Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis.". Annals of Internal Medicine. 163: 373–81. doi:10.7326/M15-0934. PMID 26302454.
  21. Malamut, edited by Joseph I. Sirven, Barbara L. (2008). Clinical neurology of the older adult (2nd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 220. ISBN 9780781769471.
  22. "coflex Interlaminar Technology - P110008". FDA. 2014-01-17. Retrieved 2015-04-17.
  23. "Spinal Stenosis Details". Spinalstenosis.org. Retrieved 2015-04-17.
  24. Treatment of Degenerative Lumbar Spinal Stenosis, Evidence Report/Technology Assessment, No. 32]. (2001). In AHRQ Archive. Retrieved 2/29/2012.
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