Spinal Stenosis

Contents

What is Spinal Stenosis?

Spinal stenosis is a condition in which the spinal canal narrows and the nerve roots and spinal cord become compressed. Because not all patients with spinal narrowing develop symptoms, the term "spinal stenosis" actually refers to the symptoms of pain and not to the narrowing itself. [1][2][3]

Etiology

  • Congenital stenosis = present at birth
  • Acquired stenosis = onset at another point in life

Acquired spinal canal stenosis is more often and several possible causes are known:

[1][2][3]

Epidemiology

Spinal stenosis is most common in people older than 50 years.[3][4] Because of the aging of the population, incidence rates have been increasing. [5]

There are several types of spinal stenosis. Lumbar spinal stenosis and cervical spinal stenosis occur most often. The lumbar spinal stenosis is more common than cervical spinal stenosis but the latter is more dangerous because it involves compression of the spinal cord. The lumbar spinal stenosis involves compression of the cauda equina

Pathological process

Symptoms of spinal stenosis often start slowly and get worse over time. Pain in the legs may become so severe that walking even short distances is unbearable. Frequently, patients must sit or lean forward to temporarily ease pain. [1]

Characteristics / Clinical presentation

Depending on where the narrowing takes place, patients may feel pain, cramping, weakness or numbness in the lower back and legs, neck, shoulder or arms.[1][2][3] Patients commonly present with an insidious history of back pain with gradual onset of radiating pain into the buttocks and extremities. Neurogenic claudication (or pseudoclaudication) is the most common presenting symptom. It is characterized by bilateral pain or weakness in the buttocks, thighs and calves, is initiated by prolonged standing and walking and relieved by sitting or bending forward. Pain may vary from dull and aching to dysesthetic or sharp and truly radicular. Less commonly, symptoms present unilateral. [6][7][8]

Differential Diagnosis

During the differential diagnosis, red-flag symptoms must be assessed. If such symptoms are present, further diagnostic workup is immediately warranted.

Types of Spinal Stenosis

Lumbar spinal stenosis (LSS) is a narrowing of the spinal canal in the lower back. LSS can be divided in etiology ( primary and secondary stenosis) and anatomy (central, lateral and foraminal stenosis).

Primary stenosis is a congenital condition. Secondary stenosis can have several possible causes. In most of the cases it is a chronic degeneration or other causes can be rheumatoid arthritis , spine trauma, bone tumors, calcification of the Ligamentum Flavum[9]. Anatomic classification can be applied differentiating between  centrally (central stenosis), the nerve root canal (far lateral recess stenosis), or narrowing of the intervertebral (IV) foramen (foraminal stenosis). One single or combination of anatomic variation(s) can occur. [10]

Central stenosis can be caused by degeneration of the vertebral disc. This can lead to  narrowing of spinal canal around the cauda equina.;Lateral stenosis;can be related to the lateral recess ( entrance zone and midzone ) [11] [12]or the foramina ( exit zone ). Foraminal stenosis is related to a narrowing of the spinal foramina [12]. It can be the result of a reduced height of the intervertebral space. Foraminal stenosis is also related with age-related degenerative disease of the lumbar discs and/or lumbar facet joints; this increases bone deposition (i.e. osteophytes) due to abnormal redistribution of load bearing in the lumbar spine.  Thickening of the joint capsule, osteoarthritis of the facet joints, and cyst formation can also narrow the spinal canal or IV foramen[13]

Entrance zone is located medial to the processus articulatio superior. The causes of stenosis in this area can be osteophytes, herniated nucleus pulposus, short pedicle and facet joint morphology. The mid zone is located from the medial to lateral pedicle. The causes of stenosis in this area can be osteophytes. Exit zone is located around the foramina. The causes of stenosis in this area van be hypertrophy, luxation of the facet joint, osteophytes[12] 

Lateral and Foraminal Stenosis can lead to compression of the nerve roots leaving the spinal canal.[14] The L4-L5 are the most frequent affect with LSS, followed by L3-L4 , L5-S1 and L1-L2[9]. Spinal stenosis can cause compression of the nerve roots of blood vessels, which can be related to the painful symptoms of lumbar spinal stenosis [15]

Cervical spinal stenosis is a narrowing of the spinal canal in the cervical region ( C1-C7). It compresses the nerve roots where they leave the spinal cord.[14] The symptoms of cervical stenosis are head-neck-shoulder pain caused by the degeneration of the disc and instability[16]. This form of spinal stenosis is more dangerous than lumbar spinal stenosis. [14]

Clinical Presentation

• Patients usually >65 years old
• Symptoms in back and leg
• Pain with standing
• Pain with walking
• Neurogenic claudication (pain and/or parethesias, and/or cramping to one or both legs)

• Observable decreased lumbar lordosis

• Lengthened hip extensor muscles (gluteus maximus and hamstrings)
• No pain when sitting
• Pain worsens with lumbar extension

• Pain improves with lumbar flexion[13]


Diagnostic procedure

Diagnosis is made by a doctor based on patient history and physical examination. In addition, medical imaging can be performed to confirm the diagnosis:

  • X-ray,
  • MRI (Magnetic Resonance Imaging) is used most frequently and gives the best results, [5]
  • CAT-scan (Computerized Axial Tomography),
  • Myelogram (which requires an injection of liquid dye into the spinal canal),
  • Bone scan (shows where bone isbreaking down or being formed) [17][18]

Physical Diagnostic Procedures

Bicycle Stress Test
• Patient pedals in an upright position preserving lumbar lordosis on an upright cycle ergometer. Distance pedaled is recorded.
• Patient than pedals in a slumped position (i.e. flexed position). Distance pedaled is recorded.
• Positive Test: If patient pedals further in slumped position compared to upright position, LSS is indicated.

Upright posture with lumbar lordosis
Upright posture with lumbar lordosis
Slumped posture with decreased lumbar lordosis
Slumped posture with decreased lumbar lordosis



Two-Stage Treadmill Test
• Patient walks on treadmill with 0% grade (i.e. extended position). Distance walked is recorded.
• Patient then walks on treadmill with an uphill slope (i.e. flexed position). Distance walked is recorded.
• Positive Test: If patient walks further on an uphill slope, LSS is indicated[19].

Upright posture with no incline
Upright posture with no incline
Flexed posture with incline
Flexed posture with incline

Management / Interventions

Many therapeutic modalities could be used in the management of spinal stenosis. Treatment plans must be individualizes based on each specific patient's presentation.

Lumbar Stenosis

Conservative treatment includes a combination of different interventions:

  • Bed rest [20]
  • Medications (Paracetemol, NSAIDs if paracetemol doesn't decrease pain)
  • Epidural steroid injection may relieve leg pain for weeks to months but does not influence functional status or the need for surgery at 1 year [20][21]
  • Acupuncture
  • Physical agents
  • Flexion-based exercise programs[20]
    o Lumbar flexion exercises are done to reduce the lumbar lordosis. This is the most comfortable position for the patient because the symptoms reduce in combination with a decrease of the epidural pressure in the lumbar spinal canal.[22]
    oSingle knee to chest
    (Patient supine. Flex one knee to chest. Hold position for 30 seconds. Alternate legs. Progress to double knee to chest.)
    o Double knee to chest
    (Patient supine. Flex both knees to chest. Hold position for 30 seconds.)
  • Manual stretching of the back and hip musculature
  • Manipulation of the spine
  • Manipulation of the pelvis and hip
  • Strengthening of gluteus medius (hip abduction exercises), gluteus maximus (functional squats, leg press, step-ups)
  • Stabilization of abdominal and back muscles to avoid excessive lumbar extension [23]
  • Body weight-supported treadmill ambulation
  • Postural and ergonomic advice [20]
  • Address impairments in mobility, coordination and strength
  • Corsets may help to maintain a posture of slight lumbar flexion to avoid atrophy of paraspinal muscles but it should be worn only for a limited number of hours per day [20][24]

Whitman et al. found that the combination of the interventions listed above had superior outcomes compared to a combination of flexion exercises, non-thermal ultrasound to the lumbar area, and regular treadmill walking in treating patients with spinal stenosis. There were improvements in disability, patient satisfaction, and in the Two-Stage Treadmill Test[19].

According to Whitman, patients treated with nonsurgical physical therapy programs in combination with manipulative therapy may achieve more clinically important improvements at 6 weeks and 1 year than a control group without manipulative therapy. This improvement was accomplished by using manual physical therapy to the thoracic and lumbar spine, pelvis and lower extremities.[25]

Cervical Stenosis

  • Immobilization with a cervical collar
  • Medication (Non-steroidal anti-inflammatories(NSAIDs, Muscle relaxants)
  • Intermittent bed rest
  • Avoidance of activities which stress the cervical spine [26]
  • Traction treatment (longitudinal extension of the cervical spine)
  • Measures to stabilize the cervico-thoracic spine:
    o Strengthening of the nuchal musculature
    o Strengthening of the musculature of the upper quadrant [26]
    o Optimizing scapular movement

Regular exercises can help build and maintain muscle strength and control pain. Guidelines suggest exercise therapy at a frequency of 3 times a week during 30 minutes. [1]


Outcome Measures

  • Oswestry Disability Index
  • The Modified Oswestry Disability Index (MOSW).[27]
  • Fear-Avoidance Belief Questionnaire [15]
  • The Swiss Spinal Stenosis Questionnaire [15]
  • The Oxford spinal Stenosis Score [15]
  • Zurich Claudication Questionnaire [28]
  • The Satisfaction Subscale of the Spinal Stenosis Scale (SSS).[29]
  • The Maine-Seattle Back Questionnaire [28]
  • The Patient Global Rating of Change Scale (GRC) is based on perceived recovery. Scores of +3 (“somewhat better”) or higher define improvement.
  • The 15-point Likert Scale. Patients rate their own perceived amount of improvement. The scale ranges from -7 (“a very great deal worse”) to zero (“about the same”) to +7 (“a very great deal better”).[30]
  • A Numerical Pain Rating Scale (NRPS) for average thigh/leg pain.[31]
  • A walking tolerance test. Patients walk at a self-selected pace for up to 15 minutes on a flat surface, rest for 10 minutes in a seated position, then walk again for up to 15 minutes at a 15% grade incline. The combined distance walked can be used as a marker of walking tolerance.[31]

Resources

Recent Related Research (from Pubmed)

References

  1. 1.0 1.1 1.2 1.3 1.4 Wise C., Spinal stenosis, American College of Rheumatology, 2013.
  2. 2.0 2.1 2.2 Ogiela D., Spinal stenosis, National Library of Medecin, 2012.
  3. 3.0 3.1 3.2 3.3 Cluett J., M.D, Spinal stenosis, Orthopedics, 2010.
  4. http://www.nlm.nih.gov/medlineplus/spineinjuriesanddisorders.html; http://www.nlm.nih.gov/medlineplus/spinalstenosis.html;
  5. 5.0 5.1 Frek Meyer, et al. ; Degenerative Cervical Spinal Stenosis; Dtsch Arztebl int. 2008 mey; 105(20): 366-372
  6. Hall S, Bartleson JD, Onofrio BM, et al. Lumbar spinal stenosis. Clinical features, diagnostic procedures, and results of surgical treatment in 68 patients. Ann Intern Med 1985;103(2):271–5.
  7. Blau JN, Logue V. Intermittent claudication of the cauda equina. Lancet 1961;1:1081–6.
  8. Katz JN, Dalgas M, Stucki G, et al. Degenerative lumbar spinal stenosis: diagnostic value of the history and physical examination. Arthritis Rheum 1995;38(9):1236–41.
  9. 9.0 9.1 Eberhard S, Harald P, Randolf K, Vieri F, Karl M. Einhäupl et al. Lumbar spinal stenosis: syndrome, diagnostics and treatment. Neurology 2009; 5:392-403.
  10. De Graaf I, Prak A, Bierma-Zeinstra S, Thoma S., Peul W., Koes B. Diagnosis of Lumbar Spinal Stenosis : A Systematic Review of the Accuracy of Diagnostic Tests. SPINE 2006; 31 (10) : 1168–1176.
  11. Sirvanci M., Bhatia M., Ganiyusufoglu K.A., Duran C., Tezer M., Ozturk C., et al. Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR Imaging. Eur Spine 2008; 1: 679–685.
  12. 12.0 12.1 12.2 Karantanas A.H., Zibis A.H., Papaliaga M., Georgiou E., Rousogiannis S. Dimensions of the lumbar spinal canal: variations and correlations with somatometric parameters using CT. Eur Radiol. 1998; 8 : 1581-1585.
  13. 13.0 13.1 Katz JN and Harris MB. Clinical Practice. Lumbar spinal stenosis. New England Journal of Medicine. 2008; 358(8): 818-825.
  14. 14.0 14.1 14.2 http://familydoctor.org/online/famdocen/home/common/brain/disorders/256.html
  15. 15.0 15.1 15.2 15.3 Pratt R. K., Fairbank J. C. T., Virr A. The Reliability of the Shuttle Walking Test, the Swiss Spinal Stenosis Questionnaire, the Oxford Spinal Stenosis Score, and the Oswestry Disability Index in the Assessment of Patients With Lumbar Spinal Stenosis. SPINE 2002; 27(1): 84–91.
  16. University of Maryland – Medical Center http://www.umm.edu/spinecenter/education/cervical_spinal_stenosis.htm
  17. U.S. Department of Health and Human Services, Public Health Service
  18. Goldman L, et al. Questions and answers about spinal stenosis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Cecil Medicine. 24th ed. Philadelphia, Pa.: Saunders Elsevier; 2012
  19. 19.0 19.1 Whitman JM, Flynn TW, Childs JD et al. A Comparison Between Two Physical Therapy Treatment Programs for Patients With Lumbar Spinal Stenosis. SPINE. 2006; 31(22): 2541-49.
  20. 20.0 20.1 20.2 20.3 20.4 J. M. Whitman, ‘Nonsurgical management of patients with lumbar spinal stenosis: a literature review and a case series of three patients managed with physical therapy’, 2003, physical medicine and rehabilitation clinics of north america, number 14, pg 77-101.
  21. Armon C, Argoff CE, Samuels J, Backonja MM. ‘Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology’, Neurology 2007;68:723- 9
  22. J.N. Katz, ‘Lumbar Spinal Stenosis’, The new england journal of medicine, 2008; number 358, pg 818-325
  23. C. Thomé, W. Börm, F. Meyer, ‘Degenerative Lumbar Spinal Stenosis’, Deutsches Ärzteblatt International, 2008, 105(20), pg 373–9
  24. J. M. Whitman, ‘Nonsurgical management of patients with lumbar spinal stenosis: a literature review and a case series of three patients managed with physical therapy’, 2003, physical medicine and rehabilitation clinics of north america, number 14, pg 77-101.
  25. J. M. Whitman, ‘A Comparison Between Two Physical Therapy Treatment Programs for Patients With Lumbar Spinal Stenosis’, 2006, Spine, volume 31, number 22
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  28. 28.0 28.1 Watters W.C., Baisden J., Gilbert T., Kreiner D. S., Resnick D., Bono C. et al.Clinical Guidelines. Degenerative Lumbar Spinal Stenosis. Burr Ridge (IL):NASS; 2007.
  29. Stucki G, Daltroy L, Liang M, et al. Measurement properties of a selfadministered outcome measure in lumbar spinal stenosis. Spine 1996;21:796–803
  30. Jaeschke R, Singer J, Guyatt G. Measurement of health status: ascertaining the minimally clinically important difference. Control Clin Trials 1989;10:407–15
  31. 31.0 31.1 Childs J, Piva S, Fritz J. Responsiveness of the numeric pain rating scale in patients with low back pain. Spine 2005;30:1331–4
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