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Overview of Spinal Stenosis

Spinal stenosis is a narrowing of the tunnel within your spine where the spinal cord and nerves travel. This narrowing is typically due to arthritic changes (degenerative wear and tear) in the joints of the spine that surround the cord and nerves. Because stenosis causes pressure to be applied on nerves, these nerves may not function properly. The result can be pain, numbness, tingling, or weakness in the arms or legs. In severe cases, there can be loss balance or bladder control.

Most cases of spinal stenosis can be treated without surgery.

Symptoms

Since arthritis is usually the cause of spinal stenosis, symptoms present gradually and then worsen over time. Spinal stenosis is seen at the neck (cervical spine) and low back (lumbar spine). Symptoms may include:

  • Neck (cervical) Stenosis:
    • Neck pain with pain radiating into one or both arms.
    • Numbness and tingling into the arm, hands, and fingers.
    • Weakness in the arms, hands, and fingers with loss of dexterity and grip strength at the hand. Symptoms may be in one or both arms.
    • Loss of balance, coordination, or bowel/bladder function. These symptoms are worrisome for severe spinal cord compression, and should be evaluated by a doctor immediately.
  • Lower back (lumbar) Stenosis:
    • Lower back and buttock pain with pain radiating into one or both legs.
    • Numbness and tingling into the legs and feet.
    • Weakness in the legs. Symptoms can occur in one or both legs.
    • Symptoms are often exacerbated by prolonged standing and walking, and relieved with sitting or bending forward. During standing and walking, the lumbar spinal canal becomes narrower, increasing stenosis symptoms. In the seated or forward bent position, the spinal canal opens, relieving pressure on the nerve roots, diminishing symptoms. This is why stenosis patients find relief by sitting, or by bending forward while walking (for example leaning on a shopping cart).

Spinal stenosis symptoms should not be ignored. If you start to develop neck or low back pain with pain, numbness, tingling, or weakness radiating into your arms and legs, you should contact your doctor for evaluation.

Causes

The spinal cord and nerves travel through a tunnel within the bony spinal column. The joints of the spine surround this tunnel. As these joints become degenerated, arthritic, and deformed, they crowd into the tunnel, narrowing it (stenosis). This places pressure on the spinal cord or nerves.

Patients over the age of 50 are at the greatest risk for developing spinal stenosis secondary to degenerative changes at the spine. Spinal stenosis can also be caused by degenerative disc disease or a herniated disc, thickening of spinal ligaments, trauma, tumors, genetic disease, and lastly, congenital deformities such as advanced scoliosis.

Diagnosis

A diagnosis of spinal stenosis is often made after a thorough history and exam are performed by your medical doctor. The location of symptoms (arms or legs), exacerbating factors (upright stance and walking), relieving factors (sitting or bending forward) will suggest the diagnosis.

The exam typically includes:

  • Range of motion testing – an assessment of spinal movement of your spine (multiple directions) relative to any pain elicited.
  • Neurological assessment – a group of tests of motor, sensory, and reflex tests that may aide in pinpointing the area of the spine where your symptoms emanating. This assessment includes testing:
    • Strength of the limbs
    • Sensation to light touch and pin prick
    • Reflexes
    • Walking and balance assessments
  • Palpation – Palpation of muscles and other structures of the spine to determine the source of pain.

Depending on the exam findings, your doctor may make a diagnosis of spinal stenosis and advise you to begin conservative treatment, usually physical therapy for strengthening and postural training. If indicated, the doctor may order further testing. The two commonly ordered imagining studies are:

  • X-ray: examines the bones in your spine. An x-ray can locate arthritic changes in the vertebrae, including the location and severity of bone spurs. They can also be used to determine the extent of loss or increase in certain curvatures of the spine, which may also be contributing to your spinal stenosis symptoms.
  • MRI (magnetic resonance imaging): An MRI will be ordered to locate the exact level of pressure on the spinal cord or nerves. It can also locate tumors and damage to discs and ligaments in the spine that may also be a cause of your pain.

Treatment of Spinal Stenosis

Conservative Treatment

Conservative treatment includes OTC and prescription medication, physical therapy, or epidural steroid injections. One or all may be used to treat your spinal stenosis symptoms.

  • Commonly used medications:
    • Over the counter medications such as Advil or Tylenol may be used to treat mild or moderate symptoms.
    • Anti-depressants are effective for chronic pain symptoms, including chronic pain caused by spinal stenosis.
    • Anti-seizure medications can be used to treat nerve pain caused by a pinched nerve(s) from spinal stenosis.
    • Opioids are carefully used when pain symptoms are severe. Often, they are prescribed for short term use and are only used as a last resort if nothing else is helping with the pain.
  • Physical Therapy:
    • Physical Therapy is usually the first treatment prescribed to manage your symptoms. Physical therapists can perform manual therapy and provide you with a program of stretching and exercises to help alleviate your symptoms more quickly than with medication or injections alone. You may also receive Physical Therapy post-surgery. (discussed below).
  • Epidural Injections:
    • A physician performs an image guided injection to the nerve root identified as the source of the pain. Corticosteroids help to manage the pain by decreasing inflammation of surrounding the nerve. The steroid acts like “a bucket of water thrown on the fire” decreasing the patient’s severe pain caused by inflammation.

Surgery Treatment

For about 95% of patients, conservative treatments allow return to normal functioning. For the unfortunate few who do not get better enough, or develop worsening symptoms, surgery is an effective option. Surgical Intervention includes:

  • Laminectomy – By removing excess joint and ligament overgrowth, the surgeon creates room for the crowded spinal cord and nerves within the bony tunnel. The nerves now have more room to breathe, and symptoms quickly improve as the nerves heal.
  • Fusion – Sometimes so much joint and ligament needs to be removed that the spine is made unstable by laminectomy. When this happens, the surgeon must then restabilize the spine using metal screws and rods to create a fusion.

Summary

Most spinal stenosis symptoms are due to degenerative changes in the spine that occur over time and are managed with conservative treatments such as medication, epidural injections, and physical therapy. When symptoms cannot be managed conservatively or are causing worsening disability and quality of life, surgical procedures such as decompressive laminectomy and / or a spinal fusion may be indicated. If you notice increasing neck or low back pain, numbness, tingling, or weakness radiating into the arms and legs you should come in for an evaluation. You do not have to live in pain.

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