Spinal Stenosis

Ovid: 5-Minute Sports Medicine Consult, The

Spinal Stenosis
Stephen J. Rohrer
  • 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).
  • Most often occurs in the lumbar spine but can occur in the cervical spine
  • Rarely occurs in the thoracic spine
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 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.
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
  • 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
  • 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


Ongoing Care
  • 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].
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.
  • 723.0 Spinal stenosis in cervical region
  • 724.00 Spinal stenosis of unspecified region
  • 724.01 Spinal stenosis of thoracic region

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