Spinal stenosis

Last updated: August 2, 2022

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Spinal stenosis is characterized by the narrowing of the central spinal canal, intervertebral foramen, and/or lateral recess within the cervical spine, thoracic spine, or lumbar spine, resulting in progressive nerve root compression. It is commonly caused by degenerative joint disease and most often occurs in middle-aged and elderly individuals. Lumbar spinal stenosis is the most common form and causes load-dependent lower back pain that radiates to the buttocks and legs. Lumbar extension (standing or walking downhill) exacerbates the pain (pseudoclaudication or neurogenic claudication), while lumbar flexion (sitting or walking uphill) improves symptoms. Imaging, preferably MRI without IV contrast, and the presence of clinical features are required to confirm the diagnosis. Treatment of lumbar spinal stenosis initially involves conservative therapy (analgesia and physiotherapy); patients with refractory or severe spinal stenosis often require surgical decompression of the spinal cord (laminectomy). Cervical and thoracic spinal stenosis are less common and patients typically present with symptoms of myelopathy; management involves surgical decompression in most cases, with conservative therapy reserved only for mild cases.

  • Incidence [1][2]
    • Lumbar stenosis is the most common form of spinal stenosis (affects ∼ 5 individuals per 100,000 population).
    • Cervical stenosis affects 1–2 individuals per 100,000 population.
    • Thoracic stenosis is rare.
  • Age range: middle-aged and elderly population

Epidemiological data refers to the US, unless otherwise specified.

Progressive narrowing of the central spinal canal, intervertebral neural foramen, and/or lateral recess (cervical C2 or lumbar spine L1) caused by any of the following: [1][3][4]

All levels

  • Pain is most often gradual onset, chronic, or subacute, depending on the etiology.
  • Acute pain can occur due to an exacerbation of a chronic underlying process or complication (see “Acute back pain” for details).
  • Radiculopathy (at various affected vertebral levels) often occurs alongside spinal stenosis features, typically due to comorbid etiology, e.g., degenerative disk disease.

Lumbar spinal stenosis [3][5]

  • Load-dependent lower back pain that worsens with walking
  • Neuropathic claudication: a group of neuropathic symptoms affected by postural changes [6]
  • Unsteady wide-based gait
  • Reduced lower extremity reflexes
  • Mild motor weakness and sensory changes may be present.
  • Abnormal Romberg test

Leaning on a shopping cart to alleviate pain (so-called “shopping cart sign”) is a common clinical feature in patients with lumbar stenosis. [7]

Cervical spinal stenosis [8]

Clinical features are those of myelopathy and vary depending on the level of cord compression. Pain is less common compared with lumbar spinal stenosis.

Lhermitte sign should prompt evaluation for cervical stenosis, especially in elderly patients. [8]

Thoracic spinal stenosis [9]

As with cervical spinal stenosis, clinical features are those of myelopathy and vary depending on the severity and level of cord compression. They include:

Approach [3]

  • Characteristic clinical features present: Confirm diagnosis with imaging.
  • Mild to moderate symptoms PLUS signs of stenosis on imaging: Consider adding EMG.
  • Acute exacerbation and/or new associated symptom of concern: Follow approach for “Acute back pain”.

A diagnosis of spinal stenosis requires the presence of both findings on imaging and clinical features of spinal stenosis.

Neuroimaging [3][10]

Obtain an urgent MRI spine (with and without IV contrast) and neurosurgery consult for patients with rapidly progressive neurological deficits suspicious for spinal cord compression, cauda equina and/or conus medullaris syndrome

X-ray spine

Neuropathic claudication vs. vascular claudication
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, running, or cycling; 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.

Lumbar spinal stenosis [3]

Conservative management [15][16]

Surgery

  • Indications [3]
    • Severe lumbar stenosis
    • Moderate lumbar stenosis with insufficient response to conservative therapy
    • Patients who elect to undergo surgery
  • Surgical options to relieve spinal cord compression [3][18][19]
    • Laminectomy (decompression surgery)
      • Removal of the dorsal part of the involved vertebra (lamina), thereby relieving the spinal compression
      • Can be combined with vertebral fusion (e.g., in patients with dynamic instability)
    • Laminotomy: minimally invasive removal of part of the lamina
    • Interspinous process spacer devices: Small implants are placed between the spinous processes in a minimally invasive procedure.
  • Outcome: high recurrence rate with all forms of surgical management [20]

Cervical and thoracic spinal stenosis [9][21][22]

There is a paucity of evidence on the optimal management of cervical and thoracic stenosis.

We list the most important complications. The selection is not exhaustive.

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  7. Nadeau M, Rosas-Arellano MP, Gurr KR, et al. The reliability of differentiating neurogenic claudication from vascular claudication based on symptomatic presentation. Can J Surg. 2013; 56 (6): p.372-377. doi: 10.1503/cjs.016512 . | Open in Read by QxMD
  8. Firestein GS. Kelley and Firestein's Textbook of Rheumatology. Elsevier ; 2017
  9. Sirven JI, Malamut BL. Clinical Neurology of the Older Adult. Lippincott Williams & Wilkins ; 2008
  10. Chen Z, Sun C. Clinical Guideline for Treatment of Symptomatic Thoracic Spinal Stenosis. Orthop Surg. 2015; 7 (3): p.208-212. doi: 10.1111/os.12190 . | Open in Read by QxMD
  11. Hartman J, Granville M, Jacobson RE. Radiologic Evaluation Of Lumbar Spinal Stenosis: The Integration Of Sagittal And Axial Views In Decision Making For Minimally Invasive Surgical Procedures. Cureus. 2019 . doi: 10.7759/cureus.4268 . | Open in Read by QxMD
  12. Rao D, Scuderi G, Scuderi C, Grewal R, Sandhu SJ. The Use of Imaging in Management of Patients with Low Back Pain. J Clin Imaging Sci. 2018; 8 : p.30. doi: 10.4103/jcis.jcis_16_18 . | Open in Read by QxMD
  13. Hiwatashi A, Danielson B, Moritani T, et al. Axial loading during MR imaging can influence treatment decision for symptomatic spinal stenosis. AJNR Am J Neuroradiol. 2004; 25 (2): p.170-4.
  14. Abbas J, Peled N, Hershkovitz I, Hamoud K. Is Lumbosacral Transitional Vertebra Associated with Degenerative Lumbar Spinal Stenosis?. BioMed Res Int. 2019; 2019 : p.1-7. doi: 10.1155/2019/3871819 . | Open in Read by QxMD
  15. Bagley C, MacAllister M, Dosselman L, Moreno J, Aoun SG, El Ahmadieh TY. Current concepts and recent advances in understanding and managing lumbar spine stenosis. F1000Res. 2019; 8 : p.137. doi: 10.12688/f1000research.16082.1 . | Open in Read by QxMD
  16. Atlas SJ, Delitto A. Spinal Stenosis Surgical versus Nonsurgical Treatment. Clinical Orthopaedics & Related Research. 2006; 443 : p.198-207. doi: 10.1097/01.blo.0000198722.70138.96 . | Open in Read by QxMD
  17. Dworkin RH, O’Connor AB, Kent J, et al. Interventional management of neuropathic pain: NeuPSIG recommendations. Pain. 2013; 154 (11): p.2249-2261. doi: 10.1016/j.pain.2013.06.004 . | Open in Read by QxMD
  18. Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database of Systematic Reviews. 2020 . doi: 10.1002/14651858.cd013577 . | Open in Read by QxMD
  19. Williams MG, Wafai AM, Podmore MD. Functional outcomes of laminectomy and laminotomy for the surgical management lumbar spine stenosis. J Spine Surg. 2017; 3 (4): p.580-586. doi: 10.21037/jss.2017.10.08 . | Open in Read by QxMD
  20. Machado GC, Ferreira PH, Yoo RI, et al. Surgical options for lumbar spinal stenosis. Cochrane Database Syst Rev. 2016 . doi: 10.1002/14651858.cd012421 . | Open in Read by QxMD
  21. Gerling MC, Leven D, Passias PG, et al. Risk Factors for Reoperation in Patients Treated Surgically for Lumbar Stenosis: A Subanalysis of the 8-year Data From the SPORT Trial.. Spine. 2016; 41 (10): p.901-9. doi: 10.1097/BRS.0000000000001361 . | Open in Read by QxMD
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  23. Fehlings MG, Tetreault LA, Riew KD, Middleton JW, Wang JC. A Clinical Practice Guideline for the Management of Degenerative Cervical Myelopathy: Introduction, Rationale, and Scope. Global Spine J. 2017; 7 (3_suppl): p.21S-27S. doi: 10.1177/2192568217703088 . | Open in Read by QxMD

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