Spinal Stenosis


Article Author:
Stanley Hoang


Article Editor:
Fassil Mesfin


Editors In Chief:
Wanda Wright
Cynthia Oster


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
4/11/2019 10:39:11 PM

Introduction

Spinal stenosis is a condition in which the spinal cord and the nerve roots are compressed by a number of pathologic factors, leading to symptoms such as pain, numbness, and weakness. The upper neck (cervical) and lower back (lumbar) areas most frequently are affected, although the thoracic spine also can be compressed most frequently by a disk herniation. Three different anatomic sites in the spine can be affected by spinal stenosis. First, the central canal, which houses the spinal cord, can be narrowed in an anterior-posterior dimension, leading to compression of neural elements and reduction of blood supply to the spinal cord in the cervical area and the cauda equina in the lumbar area. Secondly, the neural foramen, which are openings through which the nerve roots exit the spinal cord, can be compressed as a result of disk herniation, hypertrophy of the facet joints and ligaments, or unstable slippage of one vertebral body relative to the level below. Lastly, the lateral recess, which is seen in the lumbar spine only and is defined as the area long the pedicle that a nerve root enters just before its exit through the neural foramen, can be compressed from a facet joint hypertrophy. [1][2][3] Depending on the level of the spine affected, each type of compression can lead to different symptoms that warrant a particular treatment modality.

Etiology

In the cervical spine, stenosis can be caused by a combination of factors. Some individuals can have a congenitally narrowed spinal canal that is exacerbated by pathologic factors. Disk herniation together with the formation of osteophytic spurs, hypertrophy of the articular facets and ligamentum flavum, and ossification of posterior longitudinal ligaments can lead to central and foraminal stenosis. Structural factors such as subluxation from disk and facet joint degeneration and changes in the normal lordotic curvatures of the spine can lead to spinal compression. In the thoracic spine, disk herniation either from degenerative causes or trauma can lead to stenosis at specific levels. In the lumbar spine, hypertrophy of the facet joints and ligamentum flavum in the setting of disk herniation or spondylolisthesis can lead to worsening stenosis. Spondylolisthesis in the lumbar spine, defined as anterior subluxation of one vertebral body on top of another, is seen most commonly at L5 on S1 and L4 on L5. This can lead to compression of the nerve that exits below the pedicle of the anteriorly subluxed vertebra and results in neurogenic claudication.[4][5][6]

Epidemiology

Risk factors that lead to the development of spinal stenosis are multifactorial. There is a genetic influence as demonstrated in the study of twins. Cumulative trauma can lead to the progression of the disease. Osteoporosis can be a contributing factor. Cigarette smoking in several epidemiological studies has been shown to lead to back pain and degenerative spinal diseases. In the lumbar spine, obesity and loss of muscle tone can lead to stresses and dependence on the bony and ligamentous structures of the spine for structural support.

Pathophysiology

Many theories regarding the pathophysiology of spinal stenosis suggest a number of confluent mechanisms. The spinal cord can be directly compressed by osteophytic bones and ligamentous hypertrophy. Compression of local vascular structures can lead to ischemia of the spinal cord from arterial insufficiency and venous stasis. A herniated disk can exert repeated local trauma to the spinal cord or nerve root during repetitive flexion and extension movements, especially in the unstable spine with multiple levels of subluxations.

History and Physical

Initial evaluation of a patient with spinal stenosis often begins with a detailed history of symptoms and physical exam, with a focus on sensation, motor strength, reflexes, and gait. Stenosis in the cervical spinal can lead to radicular symptoms due to nerve root compression and myelopathy due to spinal cord compression. Radicular symptoms are dependent on the level affected, with the nerve root affected being the one that exists at that level. For example, a C5-6 disk herniation leads to a C6 radiculopathy. C6-7 disk herniation is the most common, leading to a wrist drop and paresthesia in the 2 and three fingers. C5-6 disk herniation is the next common, resulting in weakness in forearm flexion and paresthesia in the thumb and radial forearm. C7-T1 disk herniation can lead to weakness in the hand intrinsics muscles and numbness in the 4 and five digits. Lastly, a C4-5 disk herniation can lead to deltoid weakness and shoulder paresthesia. Patients also can experience pain and paresthesia in the head, neck, and shoulder.  Cervical spondylotic myelopathy can be seen in patients with greater than 30% spinal narrowing, leading to gait disturbance, lower extremity weakness, and ataxia. Stenosis in the lumbar spine can lead to neurogenic claudication, myeloradiculopathic symptoms, sensory disturbances, motor weakness, and pathologic reflexes. Disk herniation is most common at the L4-5 and L5-S1 levels. A herniated disk at L5-S1 can lead to plantarflexion weakness, decrease sensation in the lateral foot, and cause pain in the posterior leg. A disk herniation at L4-5 can lead to a foot drop and numbness in the large toe web and dorsal aspect of the foot. Lastly, an L3-4 disk herniation can lead to knee extension weakness, numbness in the medial foot, and pain in the anterior thigh.

Evaluation

Diagnosis can be made through imaging with extended release x-ray, CT, and MRI. With the availability of MRI, a plain radiograph is of limited value although dynamic views in flexion and extension modes can demonstrate dynamic instability or spondylolisthesis. CT can help differentiate calcified disks or bone osteophytes from “soft disks,” differentiate ossification of the posterior longitudinal ligament from a thickened posterior longitudinal ligament and detect bone fractures or lytic lesions. MRI is the gold standard; it is able to show intrinsic cord abnormalities, the degree of spinal stenosis, and differentiate other conditions such as tumors, hematoma, or infection. If a patient has a pacemaker and cannot obtain an MRI, a CT myelogram can be performed to identify the level and degree of stenosis.[7][8][9]

Treatment / Management

In patients who suffer from cervical stenosis without myelopathy, conservative management with bracing, rest, or anti-inflammatory medications initially can be employed. For those with myelopathy, surgical decompression can provide some relief from pain and sensory loss and can prevent the exacerbation of myelopathy. Depending on the levels involved and the pathology, an anterior or posterior decompression and fusion can be employed to relieve the compression and stabilize the spine. In the lumbar spine, initial management of back pain can be done with NSAIDs and physical therapy followed by interventional pain management strategies for persistent back pain. When conservative management is inadequate, or the patient develops progressive myelopathy, neurologic deficits, or spinal instability, surgical decompression and fusion are recommended. Depending on the nature of the pathology, a variety of approaches, including anterior, lateral, or posterior can be employed to restore lumbar lordosis, decompress the stenosis, and promote fusion.[10][11][12][11]

Enhancing Healthcare Team Outcomes

Patients with spinal stenosis are often first encountered by the nurse practitioner, primary care physician, emergency department physician and internist. If the patients are asymptomatic, there is usually no treatment necessary. Patients with pain should be encouraged to participate in an exercise program, discontinue smoking and maintain a healthy weight. The few patients with nerve compression should be referred to an orthopedic or neurosurgeon. However, the primary care providers should educate the patient on potential complications of surgery, which can be disabling. For those who maintain a sedentary lifestyle, the quality of life is poor. [13](Level V)


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    Contributed by S. Dulebohn, M.D.
Attributed To: Contributed by S. Dulebohn, M.D.

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Spinal Stenosis - Questions

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A 60-year-old man presents with pain in the upper legs that is exacerbated with walking. Symptoms are relieved with sitting. Peripheral pulses are intact. What is the most likely diagnosis?



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At what diameter of the spinal canal would one say that there is significant stenosis in the lumbar region?



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A 72-year-old man presents with back pain that is relieved with sitting or bending forward. The pain worsens when walking or lying on his back. What is the most likely diagnosis?



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In an adult with mild myelopathy, what is the best treatment?



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A 73-year-old male presents with history of hypertension and GERD on atenolol and omeprazole complaining of pain in his low back and buttocks for the past 7 months that is improved by bending forward, denying trauma and weight loss. The patient is found on exam to have pain with lumbar extension and decreased vibratory sensation but no other abnormalities. What is the most likely diagnosis in this case?



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A 73-year-old female with a history of hypertension and gastroesophageal reflux disease on hydrochlorothiazide and omeprazole presents complaining of pain in her low back and buttocks for the past 7 months that is improved by bending forward. She denies trauma and weight loss. On examination, she has pain with lumbar extension and decreased vibratory sensation but no other abnormalities. What is the most likely diagnosis?



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Lumbar spinal stenosis may present with which of the following?



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Select the spinal ligament most often responsible for spinal stenosis.



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Spinal Stenosis - References

References

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Glassman DM,Magnusson E,Agel J,Bellabarba C,Bransford RJ, The impact of stenosis and translation on spinal cord injuries in traumatic cervical facet dislocations. The spine journal : official journal of the North American Spine Society. 2019 Apr;     [PubMed]
Bindal S,Bindal SK,Bindal M,Bindal AK, Non-instrumented Lumbar Fusion with BMP for Spinal Stenosis with Spondylolisthesis in the Elderly. World neurosurgery. 2019 Mar 20;     [PubMed]
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Koenders N,Rushton A,Verra ML,Willems PC,Hoogeboom TJ,Staal JB, Pain and disability after first-time spinal fusion for lumbar degenerative disorders: a systematic review and meta-analysis. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2019 Apr;     [PubMed]

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