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Spinal Stenosis

  • Compression of neural elements secondary to osteoarthritic changes (bone spurs, hypertrophied ligamentum flavum, disc space narrowing) at intervertebral levels and facet joints
  • Characterized by back and/or lower extremity pain, numbness, weakness, and possible bladder/bowel dysfunction.
General Prevention
No known preventive measures
  • Symptoms develop during the 5th and 6th decades.
  • No gender predominance
  • Degenerative spondylolisthesis with spinal stenosis is 4 times more common in females .
Risk Factors
Increasing age and spinal arthritis
No definitive genetic links
  • Disc dehydration leads to loss of height with bulging of the annulus and ligamentum flavum into the spinal canal, thus increasing joint loading of the facets.
  • Increased joint loading leads to reactive sclerosis and osteophytic bone growth, which in turn leads to additional compression of the neural elements.
  • Congenital:
    • Chondrodystrophy
    • Idiopathic
  • Acquired:
    • Degenerative
    • Spondylolytic
    • Iatrogenic
    • Posttraumatic
    • Paget disease
  • Long-standing back pain that progresses to buttock and lower extremity pain
  • Neurogenic claudication (pain, tightness, numbness, and subjective weakness of lower extremities)
  • Symptoms worsen with standing, walking, and back extension.
  • Symptoms improve with sitting or leaning forward.
Signs and Symptoms
  • Insidious onset
  • Progresses slowly
  • Symptoms worse when walking uphill and improve with leaning forward (e.g., while pushing a cart in a grocery store)
Physical Exam
  • Few physical findings may be present even in affected patients.
    • Gait alteration (Rule out cervical myelopathy or intracranial pathology.)
    • Loss of lumbar lordosis
    • Decreased ROM of the lumbar spine
    • Straight-leg-raise test may be positive if nerve root entrapment is present.
    • Muscle weakness, most commonly in the L5 distribution.
    • Consider rectal examination to rule out cauda equina syndrome in selected patients.
Spinal stenosis usually is diagnosed with a combination of history, physical examination, and imaging studies.
Complete blood cell count, C-reactive protein, and ESR usually are used if infection or cancer is in the differential diagnosis.
  • AP and lateral spine radiographs:
    • Show degenerative changes or spondylolisthesis
    • Rule out fractures, infection, or tumor
    • Flexion/extension views help evaluate instability.
  • MRI shows compression of neural elements.
  • CT-myelography:
    • Comparable to MRI in showing neural compression, but an invasive procedure (contrast injection associated with subsequent headache)
    • Often obtained in patients who have had previous spinal instrumentation or cannot tolerate an MRI examination (e.g., those with claustrophobia, pacemaker)
Diagnostic Procedures/Surgery
Selective injections can be used to localize the source of pain in patients with multiple sites of neural compression and unclear findings.
Pathological Findings
  • Decreased disc height
  • Facet hypertrophy
  • Spinal canal and/or foraminal narrowing
  • Disc herniation of bulging
  • Possible intervertebral instability
Differential Diagnosis
  • Vascular claudication (symptoms do not improve with leaning forward)
  • Cervical myelopathy
  • Spinal stenosis in the thoracic spine
General Measures
  • Brace or corset may help for a short time, but it is not recommended for long term because it leads to paraspinal muscle weakness.
  • Weight loss
As tolerated, as long as no other pathology (e.g., fractures, gross instability, etc.) is present

Special Therapy
Physical Therapy
  • General conditioning (Patients can ride an exercise bicycle without many problems because they can lean forward and relieve symptoms.)
  • Aquatic therapy
  • Back extensor muscle strengthening
  • Abdominal muscle strengthening
  • Gait training
No role for maintenance opiates
First Line
  • Anti-inflammatory medications (in absence of gastrointestinal side effects)
  • Enteric-coated aspirin (fewer gastrointestinal side effects)
  • Acetaminophen
Second Line
  • COX-2 inhibitors (Be aware of a changing side-effect profile.)
  • Lumbar epidural steroids
  • Indicated when nonoperative treatment fails, and the patient cannot attain a tolerable quality of life.
    • Preoperative clearance by an internist, cardiologist, and/or anesthesiologist is necessary.
  • Decompression of neural elements is a mainstay of treatment.
    • Generally includes a laminectomy, but foraminotomies and discectomy also should be performed if they are involved in neural compression
  • Fusion is necessary in the presence of instability or if extensive decompression results in instability (with disruption of the pars interarticularis and/or >50% of articular facets)
  • Instrumentation with pedicle screws commonly is used to achieve fusion.
Routine follow-up is at 6 weeks, 3 months, 6 months, 1 year, 2 years, and then every 2 years.
  • Spinal stenosis generally worsens with time.
  • Surgery is successful in improving pain and symptoms in patients for whom nonoperative treatment fails.
  • Severe spinal stenosis can lead to bowel and/or bladder dysfunction.
  • Surgical complications include infection, neurologic injury, pseudarthrosis, chronic pain, and disability.
Patient Monitoring
Patients are monitored for resolution of symptoms, fusion (if arthrodesis was performed), and development of any complications.
  • 723.0 Cervical spinal stenosis
  • 724.00 Spinal stenosis
  • 724.02 Lumbar spinal stenosis
Patient Teaching
Patients should be educated about the natural history of the condition and about awareness of progressive motor weakness and bladder/bowel dysfunction.

Q: What is the most common symptom of spinal stenosis?
A: Positional pain (worse with lumbar spine in extension and better with lumbar spine in flexion).
Q: What is the best imaging modality to diagnose spinal stenosis?

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