Spinal stenosis

Definition

Spinal stenosis is a narrowing of areas in the lumbar (back) or cervical (neck) spine, which causes pressure on the spinal cord or one or more of the spinal nerves.

Alternative Names

Pseudo-claudication; Central spinal stenosis; Foraminal spinal stenosis

Causes, incidence, and risk factors

Spinal stenosis may be caused by:

• Arthritis involving the spine, usually in middle-aged or elderly people
• Herniated or slipped disk
• Injury that causes pressure on the nerve roots or the spinal cord itself
• Defect in the spine that was present from birth (congenital defect)
• Tumors in the spine
• Paget's disease of bone
• Achondroplasia

Symptoms

Often, symptoms will be present and gradually worsen over time. Most often, symptoms will be on one side of the body or the other.

• Numbness, cramping, or pain in the back, buttocks, thighs, or calves, or in the neck, shoulders, or arms
• Weakness of a portion of a leg or arm

Symptoms are more likely to be present or get worse when you stand or walk upright. They will often lessen or disappear when you sit down or lean forward. Most people with spinal stenosis cannot walk for a long period of time.

More serious symptoms include:

• Difficulty or imbalance when walking
• Problems controlling urine or bowel movements
• Problems urinating or having a bowel movement

Signs and tests

During the physical exam, your doctor will try to pinpoint the location of the pain and figure out how it affects your movement. You will be asked to:

• Sit, stand, and walk. While you walk, your doctor may ask you to try walking on your toes and then your heels.
• Bend forward, backward, and sideways.
• Lift your legs straight up while lying down. If the pain is worse when you do this, you may have sciatica, especially if you also feel numbness or tingling in one of your legs.

Your doctor will also move your legs in different positions, including bending and straightening your knees. All the while, the doctor is assessing your strength, as well as your ability to move.

To test nerve function, the doctor will use a rubber hammer to check your reflexes. Touching your legs in many locations with a pin, cotton swab, or feather tests your sensory nervous system (how well you feel). Your doctor will instruct you to speak up if there are areas where the sensation from the pin, cotton, or feather is duller.

A brain/nervous system (neurological) examination can confirm leg weakness and decreased sensation in the legs. The following tests may be done:

• EMG
• Spinal MRI or spinal CT scan
• X-ray of the spine

Treatment

Even when your back pain does not go away completely, or if it gets more painful at times, learning to take care of your back at home and prevent repeat episodes of your back pain can help you avoid surgery. Your doctor and other health professionals are partners with you to manage your pain and keep you as active as possible.

Generally, conservative management is encouraged. This involves the use of medications, physical therapy, and lifestyle changes. Steroid injections may relieve pain for a period of time.

Various other medications may help with chronic pain, including phenytoin, carbamazepine, or tricyclic antidepressants such as amitriptyline.

If the pain is persistent and does not respond to these measures, surgery is considered to relieve the pressure on the nerves or spinal cord. Surgery is performed on the neck or lower back, depending on the site of the nerve compression.

See also:

• Foraminotomy
• Laminectomy
• Spinal fusion

Expectations (prognosis)

Many people with spinal stenosis are able to carry on active lifestyles for many years with the condition. Some change in activities or work may be needed.

Spine surgery will often provide full or partial relief of symptoms. However, future spine problems are still possible after spine surgery. The area of the spinal column above and below a spinal fusion are more likely to be stressed when the spine moves. Also, if you needed more than one kind of back surgery (such as laminectomy and spinal fusion), you may be more likely to have future problems.

Complications

Injury can occur to the legs or feet due to lack of sensation. Infections may get worse because you may not feel the pain related to them. Changes caused by nerve compression may be permanent, even if the pressure is relieved.

Calling your health care provider

Call your health care provider if you have symptoms of spinal stenosis.

More serious symptoms that require immediate attention include:

• Difficulty or imbalance when walking
• Problems controlling urine or bowel movements
• Problems urinating or having a bowel movement

References

Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Blood E, Hanscom B, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med. 2008;358:794-810.

Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med. 2008;358:818-825.

Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr., Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.