Spinal stenosis is an abnormal narrowing of the

spinal canal The spinal canal (or vertebral canal or spinal cavity) is the canal that contains the spinal cord within the vertebral column. The spinal canal is formed by the vertebrae through which the spinal cord passes. It is a process of the dorsal body ca ...

neural foramen The intervertebral foramen (also called neural foramen, and often abbreviated as IV foramen or IVF) is a foramen between two spinal vertebrae. Cervical, thoracic, and lumbar vertebrae all have intervertebral foramina. The foramina, or opening ...

that results in pressure on the

spinal cord The spinal cord is a long, thin, tubular structure made up of nervous tissue, which extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column (backbone). The backbone encloses the central canal of the spi ...

nerve roots A nerve root (Latin: ''radix nervi'') is the initial segment of a nerve leaving the central nervous system. Nerve roots can be classified as: *Cranial nerve roots: the initial or proximal segment of one of the twelve pairs of cranial nerves leaving ...

. 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 stimuli. In everyday speech this is generally referred to as num ...

, 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 as ...

. Causes may include

osteoarthritis Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone which affects 1 in 7 adults in the United States. It is believed to be the fourth leading cause of disability in the w ...

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

spinal tumor Spinal tumors are neoplasms located in either the vertebral column or the spinal cord. There are three main types of spinal tumors classified based on their location: extradural and intradural (intradural-intramedullary and intradural-extramedullar ...

s, trauma,

Paget's disease of the bone Paget's disease of bone (commonly known as Paget's disease or, historically, osteitis deformans) is a condition involving cellular remodeling and deformity of one or more bones. The affected bones show signs of dysregulated bone remodeling at the ...

scoliosis Scoliosis is a condition in which a person's spine has a sideways curve. The curve is usually "S"- or "C"-shaped over three dimensions. In some, the degree of curve is stable, while in others, it increases over time. Mild scoliosis does not t ...

spondylolisthesis Spondylolisthesis is the displacement of one spinal vertebra 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 (or t ...

, and the genetic condition

achondroplasia Achondroplasia is a genetic disorder with an autosomal dominant pattern of inheritance whose primary feature is dwarfism. In those with the condition, the arms and legs are short, while the torso is typically of normal length. Those affected ha ...

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

cervical In anatomy, cervical is an adjective that has two meanings: # of or pertaining to any neck. # of or pertaining to the female cervix: i.e., the ''neck'' of the uterus. *Commonly used medical phrases involving the neck are **cervical collar **cerv ...

thoracic The thorax or chest is a part of the anatomy of humans, 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 divisions of the crea ...

, and

lumbar stenosis Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case ...

. 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 rev ...

. Treatment may involve medications, bracing, or surgery. Medications may include NSAIDs, acetaminophen, or

steroid injections A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and ...

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

. 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.

Types

The most common forms are

lumbar spinal stenosis Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case ...

, at the level of the lower back, and

cervical spinal stenosis Cervical spinal stenosis is a bone disease involving the narrowing of the spinal canal at the level of the neck. It is frequently due to chronic degeneration, but may also be congenital. Treatment is frequently surgical. 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

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 like heavy lifting, though gradual onset may also occur. The pain is often described ...

(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. The most common form of myelopathy in humans, ''Spinal cord compression, cervical spondylotic myelopathy (CSM)'', also called ''degenerative cervical myelopathy'', results fro ...

, a serious condition causing symptoms including major body weakness and paralysis. Such severe spinal stenosis symptoms are virtually absent in

, however, as the spinal cord terminates at the top end of the adult lumbar spine, with only nerve roots (cauda equina) continuing further down. Cervical spinal stenosis is a condition involving narrowing of the

at the level of the

neck The neck is the part of the body on many vertebrates that connects the head with the torso. The neck supports the weight of the head and protects the nerves that carry sensory and motor information from the brain down to the rest of the body. In ...

. 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, 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 sensati ...

, causing numbness. * Intermittent neurogenic

claudication Claudication is a medical term usually referring to impairment in walking, or pain, discomfort, numbness, or tiredness in the legs that occurs during walking or standing and is relieved by rest. The perceived level of pain from claudication can be ...

characterized by lower limb numbness, weakness, diffuse or

radicular Radicular pain, or radiculitis, is pain "radiated" along the dermatome (sensory distribution) of a nerve due to inflammation or other irritation of the nerve root (radiculopathy) at its connection to the spinal column. A common form of radicul ...

leg pain associated with

paresthesia Paresthesia is an abnormal sensation of the skin (tingling, pricking, chilling, burning, numbness) with no apparent physical cause. Paresthesia may be transient or chronic, and may have any of dozens of possible underlying causes. Paresthesias ar ...

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

extension Extension, extend or extended may refer to: Mathematics Logic or set theory * Axiom of extensionality * Extensible cardinal * Extension (model theory) * Extension (predicate logic), the set of tuples of values that satisfy the predicate * E ...

of spine and are relieved with spine

flexion Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relative ...

. 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', lyi ...

. * Radiculopathy (with or without

radicular pain Radicular pain, or radiculitis, is pain "radiated" along the dermatome (sensory distribution) of a nerve due to inflammation or other irritation of the nerve root (radiculopathy) at its connection to the spinal column. A common form of radiculit ...

) neurologic condition—nerve root dysfunction causes objective signs such as weakness, loss of sensation and 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, pain that radiates down the leg, numbness around ...

- Lower extremity pain, weakness, numbness that may involve

perineum The perineum in humans is the space between the anus and scrotum in the male, or between the anus and the vulva in the female. The perineum is the region of the body between the pubic symphysis (pubic arch) and the coccyx (tail bone), includi ...

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

Causes

Aging

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

ligaments A ligament is the fibrous connective tissue that connects bones to other bones. It is also known as ''articular ligament'', ''articular larua'', ''fibrous ligament'', or ''true ligament''. Other ligaments in the body include the: * Peritoneal li ...

can thicken (''

ligamenta flava The ligamenta flava (singular, ''ligamentum flavum'', Latin for ''yellow ligament'') are a series of ligaments that connect the ventral parts of the laminae of adjacent vertebrae. They help to preserve upright posture, preventing hyperflexion, a ...

'') *

Bone spurs An exostosis, also known as bone spur, is the formation of new bone on the surface of a bone. Exostoses can cause chronic pain ranging from mild to debilitatingly severe, depending on the shape, size, and location of the lesion. It is most commonl ...

develop on the bone and into the spinal canal or foraminal openings *

Intervertebral discs An intervertebral disc (or intervertebral fibrocartilage) lies between adjacent vertebrae in the vertebral column. Each disc forms a fibrocartilaginous joint (a symphysis), to allow slight movement of the vertebrae, to act as a ligament to hold t ...

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 normal aging process in which there are anatomic changes and possibly a loss of function of one or more intervertebral discs of the spine. DDD can take place with ...

causes narrowing of the spaces. *

Facet joint The facet joints (or zygapophysial joints, zygapophyseal, apophyseal, or Z-joints) are a set of synovial, plane joints between the articular processes of two adjacent vertebrae. There are two facet joints in each spinal motion segment and e ...

s break down *

s may hypertrophy * 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 bone fragility, and consequent increase in fracture risk. It is the most common reason for a broken bone ...

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

Arthritis

Osteoarthritis Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone which affects 1 in 7 adults in the United States. It is believed to be the fourth leading cause of disability in the w ...

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

—much less common cause of spinal problems

Congenital

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

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 risks 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 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.

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

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

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, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...

s or CT scans. MRIs are helpful at 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 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, mesodermal ...

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

neurologic Neurology (from el, νεῦρον (neûron), "string, nerve" and the suffix -logia, "study of") is the branch of medicine dealing with the diagnosis and treatment of all categories of conditions and disease involving the brain, the spinal c ...

deficit

Treatments

Treatment options are either surgical or non-surgical. Overall evidence is inconclusive whether non-surgical or surgical treatment is the 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 therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...

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

aerobic exercise Aerobic exercise (also known as endurance activities, cardio or cardio-respiratory exercise) is physical exercise of low to high intensity that depends primarily on the aerobic energy-generating process. "Aerobic" is defined as "relating to, inv ...

, 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 progression of the stenosis * Physical therapy to support self-care. Also may give instructs 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 sac 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, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postlaminectomy syndrome. Depending ...

, laminectomy and fusion, and

laminoplasty Laminoplasty is an orthopaedic/neurosurgical surgical procedure for treating spinal stenosis by relieving pressure on the spinal cord. The main purpose of this procedure is to provide relief to patients who may have symptoms of numbness, pain, or ...

. Decompression plus fusion appears no better than decompression alone, while spinal spacers appears 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. * The Longitudinal Framingham Heart Study found 1% of men and 1.5% of women had vertebral slippage at a mean age of 54. Over the next 25 years, 11% of men and 25% of women developed degenerative vertebral slippage.

Research

A RCT is being conducted in

Sweden Sweden, formally the Kingdom of Sweden,The United Nations Group of Experts on Geographical Names states that the country's formal name is the Kingdom of SwedenUNGEGN World Geographical Names, Sweden./ref> is a Nordic country located on ...

, 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