Orthopedics-Online

Spinal stenosis

Definition of spinal stenosis

In spinal stenosis (Spinal canal narrowing) it is a degenerative (wear-related) Disease of the spine with narrowing of the spinal canal and a resulting pressure on the spinal cord or the nerve roots running in it.
A distinction is made between a cervical, the cervical spine, a thoracic, the thoracic spine and a lumbar, the lumbar spine.

The spinal canal runs in the spine between the vertebral body and the vertebral arch as a cavity, which is also known as the vertebral canal and is separated from the individual vertebral holes (Vertebral foramen) is formed. The clinical picture of spinal canal stenosis occurs predominantly in old age, beyond the age of 60. The lumbar spine is usually affected by spinal stenosis.

The following illustration therefore mainly describes the spinal stenosis of the lumbar spine.

Cause of spinal stenosis

The development of spinal canal stenosis must be seen in connection with other degenerative diseases of the spine.

The wear of the intervertebral discs as the cause of spinal canal stenosis begins as early as the 1920s. This can lead to a protruding disc or a herniated disc (nucleus pulposus prolaps). The increasing loss of water from the intervertebral discs leads to a decrease in height of the intervertebral body section (osteochondrosis). The consequences are an overload of the small vertebral joints, a malfunction of the spinal ligaments and a creeping instability of the spinal column movement segment, each consisting of two vertebral bodies and the intervertebral disc in between.

The base and cover plates of the vertebral bodies are more stressed by the lowered intervertebral disc. The body reacts to this with bone compression in the area of these structures (sclerotherapy), which can be seen radiologically.

The body tries to counter the creeping instability of the spine by producing bony additions to the vertebral bodies (osteophytes / exophytes) that look for support in the environment.

If the instability is very advanced, the spine can become warped due to wear and tear, which further weakens the statics of the spine (degenerative scoliosis).

The changed spine statics also changes the origin and attachment points of the muscles and the ligamentous apparatus of the spine, whereby some muscles and ligaments come too close and shorten and others are stretched too much. Both of these lead to the weakening of these structures through the loss of function. Painful muscle hardening (muscle tension / myogelosis) can develop.

An incongruent position of the vertebral body joints to one another leads to premature cartilage wear of the joint partners. The same processes then take place that are well known for knee arthrosis or hip arthrosis. There is inflammation of the joints, swelling and thickening of the capsules, and joint deformity even more quickly than in the large joints. The overall picture of a vertebral joint arthrosis (spondylarthrosis) has emerged.

Displacements of the vertebral bodies caused by instability (Pseudospondylolisthesis)
Thickening of the vertebral joint structures
bony vertebral canal attachments
Intervertebral disc bulges
and
Thickening of the vertebral ligaments (Ligamentum flavum)

can ultimately lead to a considerable narrowing of the vertebral canal (spinal canal stenosis) and press the spinal cord itself or the nerve roots that come off. A pressure on the nerve root in the nerve root is called recess stenosis Lateral recess, mostly due to degenerative changes in the upper vertebral joint process (Superior articular process) caused.

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The spine is difficult to treat. On the one hand it is exposed to high mechanical loads, on the other hand it has great mobility.

The treatment of the spine (e.g. herniated disc, facet syndrome, foramen stenosis, etc.) therefore requires a lot of experience.
I focus on a wide variety of diseases of the spine.
The aim of any treatment is treatment without surgery.

Which therapy achieves the best results in the long term can only be determined after looking at all of the information (Examination, X-ray, ultrasound, MRI, etc.) be assessed.

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Symptoms of spinal stenosis

The complaints that can be caused by spinal stenosis are diverse and not very characteristic. Only in a very advanced stage of the spinal stenosis does a disease-specific constellation of symptoms occur (Signs of illness) on.

Common symptoms of spinal stenosis include:

Back pain (lumbago) at rest, when moving, when exercising, depending on the severity of the disease
Back pain radiating to the legs (lumbar sciatica), either according to the area of spread (dermatome) of a nerve root or unspecific.
Sensory disturbances in the legs
Paresthesia (Paresthesia) of the legs, e.g. Burning, pins and needles, feeling cold, cotton wool underfoot
Leg weakness
Restricted movement of the lumbar spine
Muscle tension
Bladder / rectal disorders (Problems with bowel movements and urination)

Back pain with a maximum when walking and radiating through the buttocks into the legs and a feeling of weakness in the legs are typical of spinal stenosis. The symptoms improve by bending the trunk forward (e.g. cycling). Likewise by sitting down and lying down.

Spinal canal stenosis is therefore also referred to as intermittent claudication (claudication), because those affected have to stop after a short walk to experience pain relief, just like when window shopping. Because this is often uncomfortable and embarrassing for the patients, people pretend to be interested in the displays in the shop windows.

Further information on this: Symptoms of spinal stenosis

On the cervical spine

In the vast majority of cases, there is a narrowing of the spinal canal, i.e. the canal through which the nerves of the spinal cord are guided, in the thoracic spine and, to a limited extent, in the lumbar spine. But there are also cases in which such a narrowing occurs in the cervical spine and causes discomfort accordingly. The cervical spine extends from vertebrae C1 to C7.

Due to the pressure that arises on the exiting nerves of the cervical spine in spinal canal stenosis, neck pain, in particular, increases in intensity. The patients also complain of severe numbness in the upper extremities. At the beginning of spinal canal stenosis and thus one of the first symptoms are tingling sensations in the arms, hands or fingers. Sometimes a feeling of cold ora cotton wool sensation reported. In extreme cases, mobility can also be impaired. Sometimes those affected can only move their arms or legs to a limited extent.

Lumbar spine discomfort

The lumbar spine forms the bottom end of the spine and consists of 5 vertebrae. The remaining 2 vertebrae are the sacrum and the coccyx. If a narrowing of the spinal canal occurs in this area, it is also referred to as lumbar spinal canal stenosis.

If there is a narrowing in this area, those affected initially report back pain in the deep lumbar spine and the legs quickly become tired. Most of the time, the narrowing of the spinal canal is not abrupt but rather creeping, and so the first symptoms appear slowly.
Most of the time, the first symptoms of untreated spinal stenosis do not recede, but worsen bit by bit. As the disease progresses, the legs begin to tingle and feel numb. In the vast majority of cases, those affected only go to the doctor then. In any case, these symptoms indicate a severe impairment of the nerves in the lumbar spine area.

In addition to extensive neurological testing (this determines which nerves are affected and at what level). Imaging should then take place as soon as possible. Magnetic resonance tomography is the method of choice here. It may be performed with a contrast medium and shows very clearly where the spinal cord is narrowed. In the further course, with untreated spinal stenosis, the affected person experiences increasing motor failure of the legs. Most of the time, the legs buckle and the patient no longer has adequate control of the movement. If no treatment measures are initiated here, there may be complete symptoms of paralysis in the area of the legs.

In general, symptoms tend to resolve slowly after decompression surgery. Nevertheless, it is particularly important to start appropriate therapeutic treatment as early as possible in order to avert long-term damage. The causes of spinal canal stenosis usually lie in increasing degeneration, i.e. wear and tear, of the vertebral bodies. Calcifications or prolapsed intervertebral discs in this area can also lead to the space in the spinal column becoming increasingly narrow. In addition to the main causes of degeneration in the area of the vertebral bodies, incorrect loads in daily life or inadequately balanced malpositions are possible causes.

Spinal canal stenosis in the lumbar spine can also trigger a so-called cauda equina syndrome, which should be recognized urgently and, if left untreated, can lead to permanent paraplegia. We therefore recommend our website for further information:

Cauda equina syndrome

Diagnosis of spinal stenosis

The patient's medical history (anamnesis) with the indications of spinal stenosis is indicative. Mostly, however, the unspecific symptoms of the disease are described. The clinical picture and the level of the spinal stenosis cannot usually be determined by the examination findings alone.

Imaging methods help diagnose the disease and its extent.

roentgen

In principle, the x-ray of the spine can be described as basic imaging diagnostics. The attending physician receives an insight into the posture of the spine via the X-ray images. In addition, changes in the bony (reduction in calcium salts, curvatures of the spine, a fracture of the vertebral body, arthrosis of the vertebral joints, additions to the vertebral body) and lowered discs can be detected.

The spinal stenosis itself cannot be seen directly in conventional x-rays. For this, cross-sectional imaging methods such as CT (computed tomography) and MRT (magnetic resonance tomography) are necessary, which can show the width of the spinal canal through their transverse incision.

CT and MRI

The cross-sectional diagnosis (CT and MRI of the lumbar or cervical spine, either with or without contrast agent) enables the pain to be assigned to a specific nerve or a specific section of the spine.

With the help of a CT (computed tomography) examination, in particular further questions regarding the bony structure can be answered (e.g. spinal canal stenosis, vertebral body fracture).

MRI of the lumbar spine or cervical spine (magnetic resonance tomography), on the other hand, is even more valuable in spinal column diagnostics, which, in addition to the bony structures, is significantly better than CT, also the soft tissue structures (Discs, nerve roots, ligaments) represents. All of the above Diseases can be detected with the MRI of the lumbar or cervical spine and assigned to a specific section of the spine.
You can find further information on this under our topics:

MRI cervical spine
MRI lumbar spine

Myelography

Myelography describes an examination in which the patient is injected with contrast medium into the dural sac.
The dural sac surrounds the spinal cord and is the area in the lower lumbar spine that surrounds the beginning of a nerve before it leaves the spinal canal.
By mixing nerve water and contrast agent, specific issues relating to the spinal cord can be clarified. Functional images of the spine are usually taken after the contrast agent has been injected (in flexion and extension) in order to detect nerve / spinal cord obstruction in a functional position.

However, myelography has been replaced in its priority position by MRI, which is due, among other things, to the fact that the administration of contrast media carries a certain - albeit low - risk of complications. However, it has the advantage that images of the spine can be obtained under load (i.e. with the patient standing) and in certain body positions. The MRI has not yet been able to do this.

At the same time, a CT examination is often connected with spinal canal stenosis, which is more informative for certain questions due to the contrast agent applied (myelo-CT) and is even superior to MRI in terms of spinal cord assessment.

To rule out nerve damage or to be able to determine the degree of possible nerve damage, extended examinations must be carried out. This can be done through a specialist neurological examination and collection of neurophysiological parameters (e.g. nerve conduction velocity).

You can find further information under our topic:

Myelography

Spinal stenosis of the lumbar spine

Symptoms

Patients often complain of severe back pain, which can often also radiate, for example in one or both legs (lumbar sciatica). These radiating pains are mostly described as shooting and stabbing. Another feature is the often restricted walking distance. Depending on the severity of the constriction, patients indicate after (a few) 100 meters that their legs start to hurt and they feel an uncomfortable tingling sensation or numbness that prevents them from walking. This phenomenon is called Spinal claudication designated. A characteristic of claudication in spinal stenosis is that the pain improves when the patient bends forward (Reclination). (Whereas an improvement in the symptoms caused by reclination in the Claudicatio intermittens - colloquially also described as "intermittent claudication" - is not observed. This is caused by insufficient arterial blood flow in the lower extremities with peripheral arterial occlusive disease, so it has completely different causes, but similar symptoms.) The improvement through prevention can be explained by the fact that the spinal canal widens a little and thus a slight relief of the spinal cord is reached. Affected patients usually prefer a sitting position bent forward over lying, which in pronounced cases can lead to them trying to sleep while sitting.

therapy

Basically, a spinal canal stenosis is first approached conservatively (i.e. non-operatively). The aim here is not to remove the underlying cause, but to treat the resulting consequences. The measures include relieving the spinal cord, for example through step bed positioning or - if the patient is still mobile - exercise such as cycling. Painkillers are used as medication, especially those from the group of non-steroidal anti-inflammatory drugs (NSAIDs), including substances such as ibuprofen, diclofenac, piroxicam and celecoxib (Celebrex®). In addition, starting physiotherapy early plays an important role in treating muscular tension and learning back-friendly behavior. Syringes that contain local anesthetics for temporary anesthesia and are injected directly into the affected area can also provide temporary relief.

Surgical intervention should be considered if the patient continues to have significant symptoms even after conservative treatment, i.e. the disease is therapy-resistant. But also - or especially - if there are neurological failures such as paralysis or major sensitivity disorders, an operation should urgently be reconsidered. The aim of the operation is to relieve the spinal cord by removing or splitting bony or ligamentous parts of the spine (belonging to the ligamentous apparatus). This procedure is known as microsurgical decompression. Microsurgery because it works with a surgical microscope, which makes it possible that only very small skin incisions have to be made. If the tightness extends over several vertebrae, the operation must be carried out openly (i.e. with a larger skin incision).

Spinal stenosis of the cervical spine

Symptoms

In the area of the cervical medulla, among other things, there are nerves that supply the arms. In addition to neck pain, a possible symptom of cervical tightness is pain in the arms (Brutality) and hands, which can spread to tingling and numbness. A weakness in arms and hands and fine motor clumsiness can also be indicative. But not only the nerves supplying the upper half of the body run in the cervical spine, but also the nerves supplying the lower part of the body. In the case of pronounced compression of the spinal cord, it can also lead to pain in the legs and unsteady gait, even a loss of control over stool and urine leakage is conceivable. The immediate consultation of a doctor is urgently required here.

therapy

Here, too, a conservative therapeutic approach with painkillers and physiotherapy should always be tried. In the case of damage to the spinal cord, which is noticeable through neurological deficits such as paralysis, however, an operative approach should urgently be reconsidered.
There are two possible approaches to surgery. One from the front (ventral) and one from behind (dorsal). When approaching from the front, intervertebral discs or bony parts can be removed. When intervening from the dorsal side, vertebral arches can be sawn open or parts of the ligamentous apparatus removed or split, which also relieves the spinal cord.

Read about this: Exercises for spinal canal tenosis of the cervical spine

Surgery for spinal stenosis

The operation of a spinal canal stenosis, also known as decompression treatment, is carried out after the risk has been properly weighed against the benefit by the neurosurgeon. It cannot be carried out without risks, but it is often indispensable because severe, untreated spinal stenosis threatens paraplegia.
The aim of decompression treatment is to give the constricted spinal cord enough space so that enough nerve stimuli can be passed on unhindered in this area. The operation is carried out using a surgical microscope with the patient lying on his back. Overall, an approx. 3-4 cm long incision allows access to the spinal area of the cervical spine. The disc of the affected vertebra is removed using a surgical microscope. The structures that led to the narrowing of the spinal canal are then separated out. As soon as these structures have been removed, the area where the disc of the cervical spine was is filled with a plastic construction.
The hospital stay is about three days. The neck must be immobilized for 2 days after the operation. Thereafter, the physiotherapeutic follow-up treatment begins, which can take several weeks to months. In general, the area where the spinal canal stenosis occurred is no longer narrowed. Such a bottleneck can occur elsewhere.

Read more under our topic: Surgery for spinal stenosis

Surgery of a spinal stenosis of the lumbar spine

If conservative treatment, i.e. physiotherapeutic or medicinal treatment, does not produce the necessary success, then it must be considered whether an operative procedure makes sense. Here it is necessary to weigh the risks against the benefits of an operation. Especially if the symptoms persist for months, worsen and also lead to neurological complaints and failures, an operation must be seriously considered.

The procedure takes place under general anesthesia. It is carried out in special centers and usually takes place in a minimally invasive manner, i.e. with an operative keyhole technique. Usually a surgical microscope is used for this, which guarantees the surgeon a good view and access to the spine. The operation is also known as a decompression laminectomy. After disinfection and incision, the surgeon removes parts of the vertebral body. These parts are vertebral arches, spinous processes, and facet joints.
Sometimes it can also be necessary to completely remove a disc. The surgeon can then see through his microscope which structure leads to the corresponding narrowing of the spinal canal. Most often these are calcifications or bony protrusions and degenerative changes that lead to such a narrowing. These protrusions or calcifications are then removed. Sometimes parts of the intervertebral disc are reinserted, sometimes they are replaced with a plastic preparation.
In some cases it can also happen that the area in the spine area needs to be stiffened. In this case, two vertebral bodies opposite one another are connected by a screw or a nail and thus immovably bound to one another. Since this usually only affects 2 joint bodies, this stiffening has no effect on the entire mobility of the spine.
After an operation, the patient usually has to stay in the clinic for 3-5 days. Then the rehabilitation phase begins, which also consists of extensive physiotherapeutic treatment. A physiotherapist should be consulted 2-3 times a week and appropriate exercises performed. These exercises usually cause the muscles to build up, which should ensure that the spine is relieved. In addition, those affected are shown exercises that they can use in everyday life and that are intended to ensure that such bad postures no longer occur. This is the only way to prevent another herniated disc of the lumbar spine or spinal canal stenosis in the following years.

Treating stenosis without surgery

The focus of the treatment of spinal stenosis is the relief of the spine. In principle, particular care should be taken to ensure that the spine is not bent too much into the hollow back during everyday activities.

Physiotherapy, massages or simple heat treatment can effectively help to relieve the heavily stressed spinal column. Also, a doctor may prescribe medication to help relieve pain. In some cases, muscle relaxants can improve the symptoms. Cortisone therapy can also be helpful in a few cases, as it causes the inflamed sections of the spinal canal to decongest. However, the medication is often not a permanent solution, as it can lead to severe side effects.

If the spinal canal is so narrowed that a nerve root has become infected, additional injections using syringes can be considered. Local anesthetics are injected into the area around the nerve root to relieve the pain.In addition, a cortisone preparation can also be injected here to alleviate the possible inflammation of the nerve root.

Which therapy is suitable is decided in consultation with the doctor. Only when none of these measures show any effect will surgery be considered.

Can a stenosis be cured without surgery?

Spinal canal stenosis is a disease that increases with age. The spinal canal is narrowed by bony outgrowths or worn intervertebral discs. Inside the spinal canal (also called the vertebral canal) run the spinal cord and nerves that run into all areas of the body. These can get under pressure due to the narrowing of the spinal canal and become inflamed. This ultimately leads to pain and discomfort in those affected.
Whether a spinal stenosis can be cured without surgery depends on the cause. In most cases, however, conservative treatment with painkillers, physiotherapy or physical treatment can effectively improve the symptoms. If the cause lies in the wear and tear of the intervertebral discs, which ultimately exert pressure on the nerves in the spinal canal, the pain that is triggered can be treated with conservative treatment (medication, etc.) and the pain can be alleviated, but this does not treat the actual trigger. Therefore, when you stop taking the pain reliever, pain occurs over and over again.

However, if the cause of the narrowing of the spinal canal is an inflammatory process, an effective, long-term pain-relieving and curative treatment can be achieved through cortisone therapy. The cortisol, which can be taken orally as well as by injections (syringes), causes the inflammation to decongest and thereby "widened" the spinal canal again, so that no more pressure is exerted on the spinal cord and the exiting nerves.

You may also be interested in this topic:

disc prolapse
Symptoms of a herniated disc

What is the difference between an absolute and a relative stenosis?

The difference between an absolute and a relative spinal canal stenosis lies in the diameter of the narrowed spinal canal. In the case of relative spinal stenosis, the mean diameter is between 10-14mm. In the case of absolute spinal stenosis, the diameter is even more narrowed. Here it is already below 10mm.

However, the criterion of the mean diameter is usually not sufficient for a final assessment of the severity of a spinal canal stenosis, since the spinal canal can still be sufficiently wide in the middle, while it is severely narrowed in the outer area. Since the nerves that pull into defined areas of the body are located in the outer area of the spinal canal, a narrowing there can on the one hand lead to enormous pain and on the other hand it can be deduced from the localization of the stenosis. For example, when pain is drawn in from the lower leg to the tip of the foot, a narrowing of the spinal canal in the lower lumbar area can be concluded, since the corresponding nerve emerges from the spinal canal in the area of the fifth lumbar vertebra.

In principle, however, it can be said that absolute spinal canal stenosis is a more advanced stage than relative spinal canal stenosis. Therefore, the absolute stenosis is usually associated with relatively stronger pain and should be treated by a doctor as soon as possible in order to avoid possible permanent damage.

Anatomy of the lumbar spine

The lumbar spine (lumbar spine) is made up of the five lumbar vertebrae of the spine. Since they are located in the lower part of the spine, they have to carry the highest percentage of weight. For this reason they are also much thicker than the other vertebrae. However, this does not avoid the signs of wear and tear that occur very frequently, particularly in this area.
For example, joint wear and herniated discs in the lumbar spine are the most common.

The lumbar spine also differs in structure from the other areas of the spine.
For example, from the second lumbar vertebra onwards, there is no longer a spinal cord, but only individual nerve roots that pull further down and emerge from the nerve root holes (neuroforamen) that are designated for them.
This area, in which the spinal cord ends and the spinal canal is filled with nerves, is known as the "horse's tail" or, medically, as the cauda equina.

Synonyms in a broader sense for spinal canal stenosis

Synomies or similar diseases: spinal canal narrowing, spinal canal wear, degenerative spinal column disease, lumbar syndrome, lumbar spine syndrome, spinal claudication, neuroforamen stenosis