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Spinal Stenosis

Spinal stenosis occurs due to the abnormal narrowing of the space in the spinal canal (vertebral foramen), which can be caused by either bony or soft tissue encroachment. This stenosis may occur in the central spinal canal, in the area under the facet joints (subarticular stenosis), or laterally in the intervertebral foramen.

Although the cause of spinal canal narrowing may be multi-factorial, there are two types of spinal stenosis, 'congenital' meaning from birth or 'acquired', found later on in life.

One type of congenital spinal stenosis is 'pedicogenic stenosis', where the pedicles of the spine are abnormally short, decreasing the space in the spinal canal. Patients tend to become more symptomatic in their thirties to fifties, where mild degenerative changes that would otherwise be tolerated result in further narrowing and cause symptoms.

More commonly seen is 'acquired' stenosis, which typically affects people over 50 years old. This is caused by age-related degenerative changes of the lumbar facet joints and discs, leading to reduced disc height and possible bulging of the disc. Facet joint osteoarthritis can lead to osteophytic (bony) outgrowths from the joints, laminae or pedicles of the spine, and thickening of the joint capsule. These osteophytes can protrude into the spinal canal, further impinging on the space available for the neural structures.

Stenosis may also arise due to a degenerative spondylolisthesis. This is the forward or backward displacement of one vertebrae, in relation to the one below, which can further compromise the diameter of the spinal canal.

What are the symptoms?

Spinal stenosis patients commonly present with diffuse, radicular leg pain, or neurogenic claudication (reduced blood supply to the lumbosacral nerve roots due to compression from surrounding structures). Symptoms can include pain, a feeling of weakness or heaviness in the buttocks radiating into the lower extremities, with walking or prolonged standing (extension based movements). This usually reduces with sitting down, lumbar flexion (leaning forwards), or lying down, helping to reduce compressional forces within the spine. Some patients can develop neurological deficits such as numbness, pins and needles or weakness in the lower or upper limbs. In more serious cases, with severe nerve compression this may lead to poor balance and problems controlling the bladder and/or bowel function.

How is it diagnosed?

If spinal stenosis is suspected, individuals will usually be referred for further investigations including diagnostic imaging (e.g. X-ray, MRI scan) to confirm the diagnosis and to advise on appropriate treatment. Physical examination sometimes demonstrates neurologicical deficits or exacerbation of symptoms with spinal positioning. There is no direct cure for spinal stenosis, but treatments to relieve the symptoms are effective and can improve the outlook.

What treatments are available?

Treatment varies depending on the severity and progression of the condition. Conservative methods are usually recommended first, aiming to reduce compression of the neural structures of the spine. This may include:

  • Pain management- such as analgesics or anti-inflammatory medication to reduce pain
  • Manual therapy – Physiotherapy, Osteopathy or Chiropractic
  • Lumbosacral orthoses
  • Education about your condition and how you can take an active role in managing the symptoms
  • Support and lifestyle advice for self-care and pacing strategies, activity modificationWeight loss, to relieve symptoms and slow progression of the spinal stenosis

Manual therapies can help to reduce down pain and other symptoms experienced. These may include addressing postural and compensatory movement patterns such as the "simian stance" where the hips and knees are often flexed, with the trunk stooped forwards. This position is often adopted to relieve pain and allow patients to continue standing or walking for longer. Treatment can also help reduce lumbar paraspinal and gluteal muscle tightness, often associated with underlying degenerative changes, muscle spasms and poor posture. Other problems that can be addressed are hamstring tightness and decreased mobility of the lower back. Acupuncture may be effective in reducing pain and muscle spasm.

The results of a recent randomised clinical trial by Goren et al (2010) suggest that "stretching and strengthening exercises for lumbar, abdominal, leg muscles as well as low-intensity cycling exercises" are beneficial in reducing pain intensity. Aerobic exercise, especially using a stationary bike, which allows for a forward lean, can relieve symptoms.

Active exercise may help increase muscular stabilisation of the lumbopelvic area, ensuring maintanence of a posterior pelvic tilt to reduce compression through the low back. According to Mazanec et al (2002): "Exercises that encourage lumbar flexion and flattening of the lumbar lordotic curve can be of a clinical benefit to patients suffering from lumbar spinal stenosis." Therefore a gradual return to low impact activity, improving cardiovascular conditioning, is ideal to ensuring that you maintain strength, overall flexibility of the spine and surrounding structure.

Steroid injections, either caudal, interlaminal or transforaminal epidurals, performed under fluoroscopic guidance can help with severe radicular (leg) pain. Surgery to fuse the slipped disc may be needed if severe pain is present that does not get better with conservative treatment, a severe slip of the vertebra, or neurological changes.

Prolotherapy injections are also used in the treatment of stenosis and the instability that is often associated with it. These dextrose injections strengthen the supporting ligaments to stabilise the intervertebral segment.

Decompression surgery may be an option if symptoms are severe and debilitating.

Keeping active with regular exercise is the most important thing to maintain joint strength, joint function and reduce pain.

 

References

"Spinal Stenosis" PubMed Health. Accessed 22 Feb 2012. [Online]http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001477/

Chou R, Atlas S.J, Stanos S.P, Rosenquist R.W (2009) Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine, 34:1078-1093

Doorly, T.P., Lambing, C.L., Malanga, G.A., Maurer, P.M., Ralph R., R. (2010). Algorithmic approach to the management of the patient with lumbar spinal stenosis. Journal of Family Practice, 59 S1-S8

Goren, A., Yildiz, N., Topuz, O., Findikoglu, G., & Ardic, F. (2010). Efficacy of exercise and ultrasound in patients with lumbar spinal stenosis: A prospective randomized controlled trial. Clinical Rehabilitation, 24(7), 623-631.

Katz J.N, Harris M.B (2008) Clinical practice. Lumbar spinal stenosis. N Engl J Med, 358: 818-825

Mazanec, D.J., Podichetty, V.K., Hsia, A. (2002) Lumbar Canal Stenosis: Start with nonsurgical therapy. Cleveland Clinic Journal of Medicine 69(11).

Weinstein J.N, Tosteson T.D, Lurie J.D, et al (2010) Surgical versus nonoperative treatment for lumbar spinal stenosis. Four-year results of the Spine Patient Outcomes Research Trial. Spine, 35:1329-1338

 

The information within this article is in no way intended to replace the professional medical care, advice, diagnosis or treatment of a doctor. Answers to specific problems may not apply to everyone. If you notice medical symptoms or feel ill, you should consult your doctor. If your symptoms do not seem to be improving seek medical/professional help immediately.