Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the

spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue that extends from the medulla oblongata in the lower brainstem to the lumbar region of the vertebral column (backbone) of vertebrate animals. The center of the spinal c ...

or nerve roots. Symptoms may include pain,

numbness Hypoesthesia or numbness is a common side effect of various medical conditions that manifests as a reduced sense of touch or sensation, or a partial loss of sensitivity to Sensory receptor, sensory stimuli. In everyday speech this is generally r ...

, or weakness in the arms or legs. Symptoms are typically gradual in onset and improve with leaning forward. Severe symptoms may include loss of bladder control, loss of bowel control, or

sexual dysfunction Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction ...

. Causes may include

osteoarthritis Osteoarthritis is a type of degenerative joint disease that results from breakdown of articular cartilage, joint cartilage and underlying bone. A form of arthritis, it is believed to be the fourth leading cause of disability in the world, affect ...

rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects synovial joint, joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and h ...

, spinal tumors, trauma, Paget's disease of the bone,

scoliosis Scoliosis (: scolioses) is a condition in which a person's Vertebral column, spine has an irregular curve in the coronal plane. The curve is usually S- or C-shaped over three dimensions. In some, the degree of curve is stable, while in others ...

spondylolisthesis Spondylolisthesis is when one spinal vertebra slips out of place compared to another. While some medical dictionaries define spondylolisthesis specifically as the forward or anterior displacement of a vertebra over the vertebra inferior to it (o ...

, and the genetic condition

achondroplasia Achondroplasia is a genetic disorder with an autosomal dominant pattern of inheritance whose primary feature is dwarfism. It is the most common cause of dwarfism and affects about 1 in 27,500 people. In those with the condition, the Rhizomeli ...

. It can be classified by the part of the spine affected into cervical,

thoracic The thorax (: thoraces or thoraxes) or chest is a part of the anatomy of mammals and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main ...

, and lumbar stenosis. Lumbar stenosis is the most common, followed by cervical stenosis. Diagnosis is generally based on symptoms and

medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to revea ...

. Treatment may involve medications, bracing, or surgery. Medications may include NSAIDs, acetaminophen, anticonvulsants ( gabapentinoids) or steroid injections. Stretching and strengthening exercises may also be useful. Limiting certain activities may be recommended. Surgery is typically only done if other treatments are not effective, with the usual procedure being a decompressive laminectomy. Spinal stenosis occurs in as many as 8% of people. It occurs most commonly in people over the age of 50. Males and females are affected equally often. The first modern description of the condition is from 1803 by Antoine Portal, and there is evidence of the condition dating back to

Ancient Egypt Ancient Egypt () was a cradle of civilization concentrated along the lower reaches of the Nile River in Northeast Africa. It emerged from prehistoric Egypt around 3150BC (according to conventional Egyptian chronology), when Upper and Lower E ...

Types

The most common forms are lumbar spinal stenosis, at the level of the lower back, and cervical spinal stenosis, which are at the level of the neck. Thoracic spinal stenosis, at the level of the mid-back, is much less common. In lumbar stenosis, the spinal nerve roots in the lower back are compressed which can lead to symptoms of

sciatica Sciatica is pain going down the leg from the lower back. This pain may go down the back, outside, or front of the leg. Onset is often sudden following activities such as heavy lifting, though gradual onset may also occur. The pain is often desc ...

(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 Myelopathy describes any neurologic deficit related to the spinal cord. When due to trauma, myelopathy is known as (acute) spinal cord injury. When inflammatory, it is known as myelitis. Disease that is vascular in nature is known as vascular ...

, a serious condition causing symptoms including major body weakness and paralysis. 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 The cauda equina () is a bundle of spinal nerves and spinal nerve rootlets, consisting of the second through fifth lumbar nerve pairs, the first through fifth sacral nerve pairs, and the coccygeal nerve, all of which arise from the lumbar enl ...

) continuing further down. Cervical spinal stenosis is a condition involving narrowing of the spinal canal at the level of the

neck The neck is the part of the body in many vertebrates that connects the head to the torso. It supports the weight of the head and protects the nerves that transmit sensory and motor information between the brain and the rest of the body. Addition ...

. It is frequently due to chronic degeneration, but may also be congenital or traumatic. Treatment frequently is surgical.

Signs and symptoms

Common

* Standing discomfort (94%) * Discomfort/pain, in shoulder, arm, and hand (78%) * Bilateral symptoms (68%) * Numbness at or below the level of involvement (63%) * Weakness at or below the level of involvement (43%) * Pain or weakness in buttock / thigh only (8%) * Pain or weakness below the knee (3%)

Neurological disorders

* Cervical (spondylotic) myelopathy, a syndrome caused by compression of the cervical spinal cord which is associated with "numb and clumsy hands", imbalance, loss of bladder and bowel control, and weakness that can progress to paralysis. *

Pinched nerve Radiculopathy (; ), also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly (a neuropathy). Radiculopathy can result in pain ( radicular pain), weakness, altered s ...

, causing numbness. * Intermittent neurogenic claudication characterized by lower limb numbness, weakness, diffuse or radicular leg pain associated with

paresthesia Paresthesia is a sensation of the skin that may feel like numbness (''hypoesthesia''), tingling, pricking, chilling, or burning. It can be temporary or Chronic condition, chronic and has many possible underlying causes. Paresthesia is usually p ...

(bilaterally), weakness and/or heaviness in buttocks radiating into lower extremities with walking or prolonged standing. Symptoms occur with extension of spine and are relieved with spine

flexion Motion, the process of movement, is described using specific anatomical terminology, anatomical terms. Motion includes movement of Organ (anatomy), organs, joints, Limb (anatomy), limbs, and specific sections of the body. The terminology used de ...

. Minimal to zero symptoms when seated or

supine In grammar, a supine is a form of verbal noun used in some languages. The term is most often used for Latin, where it is one of the four principal parts of a verb. The word refers to a position of lying on one's back (as opposed to ' prone', l ...

. *

Radiculopathy Radiculopathy (; ), also commonly referred to as pinched nerve, refers to a set of conditions in which one or more nerves are affected and do not work properly (a neuropathy). Radiculopathy can result in pain (radicular pain), weakness, altered se ...

(with or without radicular pain), a neurologic condition in which nerve root dysfunction causes objective signs such as weakness, loss of sensation, and loss of reflex. *

Cauda equina syndrome Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. Signs and symptoms include low back pain, sciatica, pain that radiates down the leg, numbness ...

: lower extremity pain, weakness, numbness that may involve

perineum The perineum (: perineums or perinea) in placentalia, placental mammals is the space between the anus and the genitals. The human perineum is between the anus and scrotum in the male or between the anus and vulva in the female. The perineum is ...

and buttocks, associated with bladder and bowel dysfunction. * Lower back pain due to degenerative disc or joint changes.

Causes

Congenital

* Spinal canal is too small at birth * Structural deformities of the vertebrae may cause narrowing of the spinal canal.

Aging

Any of the factors below may cause the spaces in the spine to narrow. * Spinal

ligaments A ligament is a type of fibrous connective tissue in the body that connects bones to other bones. It also connects flight feathers to bones, in dinosaurs and birds. All 30,000 species of amniotes (land animals with internal bones) have ligam ...

can thicken ('' ligamenta flava'') * Bone spurs develop on the bone and into the spinal canal or foraminal openings *

Intervertebral discs An intervertebral disc (British English), also spelled intervertebral disk (American English), lies between adjacent vertebrae in the vertebral column. Each disc forms a fibrocartilaginous joint (a symphysis), to allow slight movement of the ver ...

may bulge or herniate into the canal or foraminal openings *

Degenerative disc disease Degenerative disc disease (DDD) is a medical condition typically brought on by the aging process in which there are anatomic changes and possibly a loss of function of one or more intervertebral discs of the vertebral column, spine. DDD can take ...

causes narrowing of the spaces. *

Facet joint The facet joints (also zygapophysial joints, zygapophyseal, apophyseal, or Z-joints) are a set of synovial joint, synovial, plane joints between the articular processes of two adjacent vertebrae. There are two facet joints in each functional s ...

s break down *

s may

hypertrophy Hypertrophy is the increase in the volume of an organ or tissue due to the enlargement of its component cells. It is distinguished from hyperplasia, in which the cells remain approximately the same size but increase in number. Although hypertro ...

* Compression fractures of the spine, which are common in

osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to more porous bone, and consequent increase in Bone fracture, fracture risk. It is the most common reason f ...

* Synovial cysts form on the facet joints causing compression of the spinal sac of nerves (thecal sac)

Arthritis

Osteoarthritis Osteoarthritis is a type of degenerative joint disease that results from breakdown of articular cartilage, joint cartilage and underlying bone. A form of arthritis, it is believed to be the fourth leading cause of disability in the world, affect ...

Rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects synovial joint, joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and h ...

—much less common cause of spinal problems

Instability of the spine

* A vertebra slips forward on another (

)

Trauma

* Accidents and injuries may dislocate the spine and the spinal canal or cause

burst fracture A burst fracture is a type of traumatic spinal injury in which a vertebra breaks from a high-energy axial load (e.g., traffic collisions or falls from a great height or high speed, and some kinds of seizures), with shards of vertebra penetrating s ...

s that yield fragments of bone that go through the canal. * Patients with cervical myelopathy caused by narrowing of the spinal canal are at higher risk of acute spinal cord injury if involved in accidents.

Tumors

* Irregular growths of soft tissue will cause inflammation. * Growth of tissue into the canal pressing on nerves, the sac of nerves, or the spinal cord.

Diagnosis

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 Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and rad ...

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 of spinal stenosis, and other possible causes of back pain.

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 In biology, a reflex, or reflex action, is an involuntary, unplanned sequence or action and nearly instantaneous response to a Stimulus (physiology), stimulus. Reflexes are found with varying levels of complexity in organisms with a nervous s ...

, and any muscular weakness.

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-ray An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...

s or

CT scans A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

. MRIs are helpful in showing exactly what is causing spinal nerve compression.

Myelography

In CT myelography, 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

* Fever * Nocturnal pain *

Gait Gait is the pattern of Motion (physics), movement of the limb (anatomy), limbs of animals, including Gait (human), humans, during Animal locomotion, locomotion over a solid substrate. Most animals use a variety of gaits, selecting gait based on s ...

disturbance * Structural deformity * Unexplained weight loss * Previous

carcinoma Carcinoma is a malignancy that develops from epithelial cells. Specifically, a carcinoma is a cancer that begins in a tissue that lines the inner or outer surfaces of the body, and that arises from cells originating in the endodermal, mesoder ...

* Severe pain upon lying down * Recent trauma with suspicious fracture * Presence of severe or progressive neurologic deficit

Treatments

Treatment options are either surgical or non-surgical. The overall evidence is inconclusive whether non-surgical or surgical treatment is better for lumbar spinal stenosis.

Non-surgical treatments

The effectiveness of non-surgical treatments is unclear as they have not been well studied. * Education about the course of the condition and how to relieve symptoms * Medicines to relieve pain and inflammation, such as acetaminophen,

nonsteroidal anti-inflammatory drug Non-steroidal anti-inflammatory drugs (NSAID) are members of a Indication (medicine), therapeutic drug class which Analgesic, reduces pain, Anti-inflammatory, decreases inflammation, Antipyretic, decreases fever, and Antithrombotic, prevents bl ...

s (NSAIDs) * Exercise, to maintain or achieve overall good health,

aerobic exercise Aerobic exercise, also known as cardio, is physical exercise of low to high intensity that depends primarily on the aerobic energy-generating process. "Aerobic" is defined as "relating to, involving, or requiring oxygen", and refers to the use of ...

, such as riding a stationary bicycle, which allows for a forward lean, walking, or swimming can relieve symptoms * Weight loss, to relieve symptoms and slow the progression of the stenosis *

Physical therapy Physical therapy (PT), also known as physiotherapy, is a healthcare profession, as well as the care provided by physical therapists who promote, maintain, or restore health through patient education, physical intervention, disease preventio ...

to support self-care. Also may give instructions on stretching and strength exercises that may lead to a decrease in pain and other symptoms. * Lumbar epidural steroid or anesthetic injections have low quality evidence to support their use.

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 sacs of nerves. 70–90% of people have good results. * Interlaminar implant: This is a non-fusion U-shaped device that is placed between two bones in the lower back that maintains motion in the spine and keeps the spine stable after a lumbar decompressive surgery. The U-shaped device maintains height between the bones in the spine so nerves can exit freely and extend to lower extremities. * Surgery for cervical myelopathy is either conducted from the front or from the back, depending on several factors such as where the compression occurs and how the cervical spine is aligned. **

Anterior cervical discectomy and fusion Anterior cervical discectomy and fusion (ACDF) is a surgical procedure to treat nerve root or spinal cord compression by decompressing the spinal cord and nerve roots of the cervical spine with a discectomy, followed by inter-vertebral fusion to ...

: A surgical treatment of nerve root or spinal cord compression by decompressing the spinal cord and nerve roots of the cervical spine with a discectomy in order to stabilize the corresponding vertebrae. ** Posterior approaches seek to generate space around the spinal cord by removing parts of the posterior elements of the spine. Techniques include

laminectomy A laminectomy is a surgical procedure that removes a portion of a vertebra called the Lamina of the vertebral arch, lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postla ...

, laminectomy and fusion, and laminoplasty. Decompression plus fusion appears no better than decompression alone, while spinal spacers appear better than decompression plus fusion but not better than decompression alone. No differences were found in the type of decompression.

Epidemiology

* The NAMCS data shows the incidence in the U.S. population to be 3.9% of 29,964,894 visits for mechanical back problems. * It occurs more frequently in women.

Prognosis

In a study of 146 patients with lumbar spinal stenosis (mean age, 68 years, 42% women) who did not undergo surgery, followed up for 3 years, the study reported that approximately one-third of participants indicated improvement; approximately 50% reported no change in symptoms; and approximately 10% to 20% of patients condition worsened.

Research

A RCT is being conducted in

Sweden Sweden, formally the Kingdom of Sweden, is a Nordic countries, Nordic country located on the Scandinavian Peninsula in Northern Europe. It borders Norway to the west and north, and Finland to the east. At , Sweden is the largest Nordic count ...

, to compare surgery versus non-surgical treatment for lumbar spinal stenosis.

References

External links

* * * {{Dorsopathies Geriatrics Spinal cord disorders Vertebral column disorders Wikipedia medicine articles ready to translate