Spinal Stenosis

By admin On Oct 27, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Spinal Stenosis

Stephen J. Rohrer

Basics

Description

Stenosis of the spinal canal is defined as narrowing of the available space within the spinal canal causing impingement on the neural and/or vascular elements of the spine.
A general consensus defines spinal stenosis as an anteroposterior diameter of <13 mm from C3 to C7.
Spinal stenosis is also divided into congenital and acquired forms.
It appears to affect men more than women (1).

Epidemiology

Most often occurs in the lumbar spine but can occur in the cervical spine
Rarely occurs in the thoracic spine

Incidence

The absolute incidence of spinal stenosis is unknown, but lumbar spinal stenosis is an increasing cause of disability in older patients.

Risk Factors

Degenerative changes in the intervertebral disks, ligaments, and facet joints, as well as osteophyte formation surrounding the canal
Older age
Spondylitic disease of the spine may contribute to stenosis.

Genetics

Genetics play a role in some cases of spinal stenosis in conditions such as spondyloarthropathies, dwarfism, and spina bifida.

General Prevention

Degenerative changes may not be able to be prevented, but symptom severity may be limited by maintaining a healthy back.
Core strengthening, appropriate flexibility and posture, and maintaining a healthy body weight may slow the progression of symptoms.

Etiology

Spondylosis, or degenerative arthritis affecting the spine, is the most common cause of lumbar spinal stenosis and typically affects individuals over the age of 60 yrs.

Commonly Associated Conditions

Degenerative arthritis
Disk bulging
Facet osteophytes
Ligamentum flavum hypertrophy
Spondylolisthesis

Diagnosis

History

Typically, the earliest complaint is back pain.
Bilateral leg pain often involving the buttocks and thighs and spreading toward the feet
The pain may be described as burning, cramping, or dull fatigue.
Classically, the symptoms of lumbar canal stenosis worsen with ambulation or standing and are relieved by sitting.
In severe late-stage cases where the sacral roots are impinged, visceral disturbance may manifest with urinary incontinence.
The history for cervical spinal stenosis may include transient quadriplegia after a tackle or just bilateral “stingers” (numbness and pain down both arms).

Physical Exam

A broad-based gait is often present.
Abnormal Romberg test
The spine must be examined for abnormal curvature or limitation in range of motion (ROM).
Commonly, flexion relieves symptoms, and extension is painful.
The back should be examined for tenderness, which may suggest a fracture, neoplasm, or infection.
The straight-leg test should be done to rule out disk herniation. Generally, patients with lumbar spinal stenosis do not have a positive straight-leg test.
A femoral stretch test where the knee is flexed in a prone position may elicit pain in patients with spinal stenosis at L3–4.
The physical examination also should include an examination of the skin, nails, and distal pulses of the feet to evaluate for possible vascular claudication. Patients with vascular claudication often will have pallor, nail dystrophy, absence of hair, and distal pulses in their feet. Popliteal and femoral pulses need to be examined.
Cervical spinal stenosis requires a careful active ROM exam of the neck and an upper extremity neurologic exam.

Diagnostic Tests & Interpretation

Imaging

Plain films are not diagnostic but may demonstrate degenerative spine disease or spondylolisthesis.
In the C-spine, a vertebral canal–vertebral body ratio under 0.8 was defined by Torg as spinal stenosis. The Torg ratio, however, is not used exclusively to evaluate cervical spinal stenosis. Even though it carries about a 93% sensitivity, it leads to many false-positive results and has a poor positive predictive value for predicting cervical cord neurapraxia (2)[C].
CT scans ± intrathecal contrast material injection (CT myelogram) may demonstrate encroachment of the canal by osteophytes, hypertrophied lamina, or other degenerative changes.
MRI is currently the preferred method to establish a diagnosis and exclude other conditions. MRI is both noninvasive and visualizes the soft tissue structures that may be obstructing the canal (3)[B].

Differential Diagnosis

Vascular claudication
Space-occupying lesion such as a neoplasm
Herniated disk
Trauma, eg, compression fracture
Degenerative subluxation of the vertebrae (spondylolisthesis)
Infectious process, eg, diskitis or epidural abscess
Spear tackler's spine:
- Developmental narrowing of the cervical spinal canal
- Straightening or reversal of the normal cervical lordotic curve
- Preexisting minor posttraumatic x-ray evidence of bony or ligamentous injury
- Documentation of using spear-tackling techniques

P.545

Treatment

Nonsurgical management of lumbar stenosis may be attempted initially in patients who do not have severe pain or significant weakness. Patients on warfarin sodium or those who have severe risks for complications with decompressive surgery may not be candidates for invasive procedures.
NSAIDs and exercises may provide some relief for patients with lumbar spinal stenosis. Flexion exercises that reduce lumbar lordosis are especially useful.
Morbidly obese patients should be encouraged to lose weight.
Research is limited to suggest support for or against specific nonsurgical approaches, but studies are currently ongoing.

Pre-Hospital

Management of acute symptomatic cervical spinal stenosis after trauma includes stabilization of the spine with a cervical collar and transport to an emergency setting.

Medication

There is little evidence that pharmacologic therapy provides long-term relief in spinal stenosis (3)[B].

Additional Treatment

Epidural steroid injections may provide short-term relief (2–3 wks), but long-term efficacy results are conflicting (3)[B].

Additional Therapies

Though a systematic review of the literature failed to support physical therapy or exercises as a stand-alone treatment for lumbar spinal stenosis, experts believe it to be beneficial for certain patients (3)[V].

Complementary and Alternative Medicine

In a Cochrane review, spinal manipulation associated with exercise has been shown to be beneficial for mechanical neck pain (1)[B].
Lumbosacral corset bracing may provide symptomatic relief while walking, but the symptoms return once the brace is removed (3)[C].

Surgery/Other Procedures

Most patients benefit from decompression of the lumbar canal.
Typically, multilevel decompressive laminectomies are needed because the canal stenosis often occurs at multiple levels.
Multilevel laminotomies, foraminotomies, and even decompression of the lateral recesses may be alternative methods of treatment.
Most patients with radiographic and clinical evidence of spinal stenosis get significant long-term relief from decompressive surgery.

Ongoing Care

Prognosis

According to the North American Spine Society, patients followed for 2–10 yrs with mild to moderate stenosis have a 20–40% chance of requiring surgical intervention.
Of those who do not have surgery, 50–70% will have improvement in their pain (3)[C].

References

1. Gross AR, Hoving JL, Haines TA, et al. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine. 2004;29:1541–1548.

2. Torg JS, Guille JT, Jaffe S. Injuries to the cervical spine in American football players. J Bone Joint Surg Am. 2002;84-A:112–122.

3. Snyder, D, et al. Treatment of degenerative lumbar spinal stenosis. Am Fam Physician, August 1, 2004.

Additional Reading

Alvarez JA, Hardy RH. Lumbar spine stenosis: a common cause of back and leg pain. Am Fam Physician. 1998;57:1825–1834, 1839–1840.

Atlas SJ, Delitto A. Spinal stenosis: surgical versus nonsurgical treatment. Clin Orthop Relat Res. 2006;443:198.

Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database Syst Rev. 2004;CD001878

Cantu RC. The cervical spinal stenosis controversy. Clin Sports Med. 1998;17:121–126.

Garfin SR, et al. Spinal stenosis. J Bone Joint Surg [Am]. 1999;81:573–583.

Martinelli TA, Wiesel SW. Epidemiology of spinal stenosis. Instr Course Lect. 1992;41:179–181.

Waters, W, et al. Clinical guidelines for multidisciplinary spine care, diagnosis and treatment of degenerative lumbar spinal stenosis. Nor Am Spine Society, 2007.

Codes

ICD9

723.0 Spinal stenosis in cervical region
724.00 Spinal stenosis of unspecified region
724.01 Spinal stenosis of thoracic region