• Clinical science

Spinal stenosis

Abstract

Spinal stenosis is characterized by the narrowing of the central spinal canal, intervertebral foramen, and/or lateral recess causing progressive nerve root compression in the cervical, thoracic, or lumbar spine. It is commonly caused by degenerative joint disease in middle-aged or elderly individuals. The main symptoms are neck pain or load-dependent lower back pain with radiation to the buttocks and legs. Spinal extension (standing or walking downhill) exacerbates pseudo- or neurogenic claudication, while back flexion (sitting or walking uphill) improves symptoms. An MRI provides the diagnosis. Treatment involves conservative therapy (analgesia, physiotherapy), while refractory cases require surgical decompression of the spinal cord (laminectomy).

Epidemiology

  • Prevalence: 5:1000 in persons > 50 years of age
  • Age range: middle-aged and elderly population
  • Sex: > when associated with degenerative disease

References:[1][2]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Progressive narrowing of the central spinal canal, intervertebral neural foramen and/or lateral recess (cervical C2 or lumbar spine L1) caused by:

References:[1][2][3]

Clinical features

  • Lumbar stenosis
    • Load-dependent lower back pain
    • Unsteady wide-based gait, reduced lower extremity reflexes
    • Neuropathic claudication: a group of typical symptoms (see table below) of spinal stenosis; (may also occur in spinal cord infarction) affected by postural changes
  • Cervical or thoracic (rare) stenosis
    • Neck pain
    • Radiculopathies: depending on the height of the nerve lesion and the affected dermatome (e.g., tingling, paresthesia, or pain in upper extremities in cervical stenosis)

References:[4][5][1][2]

Diagnostics

  • X-ray: degenerative joint changes
  • MRI (confirmatory test): evidence of spinal stenosis (compression of spinal nerves, nerve roots or spinal cord)
    • Possible alternative: CT

Differential diagnoses

Differential diagnosis of neuropathic and vascular claudification
Neuropathic claudication Vascular claudication
Clinical features
  • Bilateral radiation of pain to buttocks and/or legs
  • Associated cramping, numbness, weakness, or tingling in the legs
  • Typically unilateral pain below the knee
Exacerbating factors
  • Spinal extension : standing, walking downhill, or even at rest
  • Walking, reproducible after a certain distance
Relieving factors
  • Spinal flexion : sitting, cycling, walking uphill, bending forward
  • Completely resolved with rest/standing (unless advanced, then pain at rest may occur)
Ankle-brachial index
  • Normal
  • Abnormal

The differential diagnoses listed here are not exhaustive.

Treatment

  • Symptomatic treatment
    • NSAIDS
    • Physiotherapy, which focuses on exercises that promote stability and abdominal muscle strengthening
    • Epidural steroid injections if symptoms persist despite above treatment (may improve ∼ 50% of cases)
  • Surgery: if conservative therapy fails
    • Removal of any bony attachments
    • Laminectomy (decompression surgery): removal of the dorsal part of the vertebra (lamina) which covers the spinal cord
    • Recurrence is common

References:[4][5][1]