Spinal stenosis
Spinal stenosis
SpecialtyOrthopedics, neurosurgery
SymptomsPain, numbness, or weakness in the arms or legs[1]
ComplicationsLoss of bladder control, loss of bowel control, sexual dysfunction[1]
Usual onsetGradual[1]
TypesCervical, thoracic, lumbar[2]
CausesOsteoarthritis, rheumatoid arthritis, spinal tumors, trauma, Paget's disease of the bone, scoliosis, spondylolisthesis, achondroplasia[3]
Diagnostic methodBased on symptoms and medical imaging[4]
Differential diagnosisCauda equina syndrome, osteomylitis, peripheral vascular disease, fibromyalgia[5]
TreatmentMedications, exercises, bracing, surgery.[6]
MedicationNSAIDs, acetaminophen, steroid injections[7]
FrequencyUp to 8% of people[4]

Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots.[6] Symptoms may include pain, numbness, or weakness in the arms or legs.[1] Symptoms are typically gradual in onset and improve with leaning forward.[1] Severe symptoms may include loss of bladder control, loss of bowel control, or sexual dysfunction.[1]

Causes may include osteoarthritis, rheumatoid arthritis, spinal tumors, trauma, Paget's disease of the bone, scoliosis, spondylolisthesis, and the genetic condition achondroplasia.[3] It can be classified by the part of the spine affected into cervical, thoracic, and lumbar stenosis.[2] Lumbar stenosis is the most common, followed by cervical stenosis.[2] Diagnosis is generally based on symptoms and medical imaging.[4]

Treatment may involve medications, bracing, or surgery.[6] Medications may include NSAIDs, acetaminophen, anticonvulsants (gabapentinoids) or steroid injections.[8][7] Stretching and strengthening exercises may also be useful.[1] Limiting certain activities may be recommended.[6] Surgery is typically only done if other treatments are not effective, with the usual procedure being a decompressive laminectomy.[7]

Spinal stenosis occurs in as many as 8% of people.[4] It occurs most commonly in people over the age of 50.[9] Males and females are affected equally often.[10] The first modern description of the condition is from 1803 by Antoine Portal, and there is evidence of the condition dating back to Ancient Egypt.[11]

Types

The most common forms are lumbar spinal stenosis, at the level of the lower back, and cervical spinal stenosis, which are at the level of the neck.[12] Thoracic spinal stenosis, at the level of the mid-back, is much less common.[13]

In lumbar stenosis, the spinal nerve roots in the lower back are compressed which can lead to symptoms of sciatica (tingling, weakness, or numbness that radiates from the low back and into the buttocks and legs).[citation needed]

Cervical spinal stenosis can be far more dangerous by compressing the spinal cord. Cervical canal stenosis may lead to myelopathy, a serious condition causing symptoms including major body weakness and paralysis.[14] Such severe spinal stenosis symptoms are virtually absent in lumbar stenosis, however, as the spinal cord terminates at the top end of the adult lumbar spine, with only nerve roots (cauda equina) continuing further down.[15] Cervical spinal stenosis is a condition involving narrowing of the spinal canal at the level of the neck. It is frequently due to chronic degeneration,[16] but may also be congenital or traumatic. Treatment frequently is surgical.[16]

Signs and symptoms

Drawing showing spinal stenosis with spinal cord compression

Common

Neurological disorders

A human vertebral column

Causes

Congenital

Aging

Any of the factors below may cause the spaces in the spine to narrow.

Arthritis

Instability of the spine

Trauma

Tumors

Diagnosis

Moderate to severe spinal stenosis at the levels of L3/4 and L4/5[further explanation needed]

The diagnosis of spinal stenosis involves a complete evaluation of the spine. The process usually begins with a medical history and physical examination. X-ray and MRI scans are typically used to determine the extent and location of the nerve compression.[citation needed]

Medical history

The medical history is the most important aspect of the examination as it will tell the physician about subjective symptoms, possible causes of spinal stenosis, and other possible causes of back pain.[34]

Physical examination

The physical examination of a patient with spinal stenosis will give the physician information about exactly where nerve compression is occurring. Some important factors that should be investigated are any areas of sensory abnormalities, numbness, irregular reflexes, and any muscular weakness.[34]

MRI

MRI has become the most frequently used study to diagnose spinal stenosis. The MRI uses electromagnetic signals to produce images of the spine. MRIs are helpful because they show more structures, including nerves, muscles, and ligaments than seen on X-rays or CT scans. MRIs are helpful in showing exactly what is causing spinal nerve compression.[citation needed]

Myelography

Main article: Myelography

In CT myelography, spinal tap is performed in the low back with dye injected into the spinal fluid. X-rays are performed followed by a CT scan of the spine to help see narrowing of the spinal canal. This is a very effective study in cases of lateral recess stenosis. It is also necessary for patients in which MRI is contraindicated, such as those with implanted pacemakers.[citation needed]

Red flags

Treatments

Treatment options are either surgical or non-surgical. The overall evidence is inconclusive whether non-surgical or surgical treatment is better for lumbar spinal stenosis.[35]

Non-surgical treatments

The effectiveness of non-surgical treatments is unclear as they have not been well studied.[36]

Surgery

Lumbar decompressive laminectomy: This involves removing the roof of bone overlying the spinal canal and thickened ligaments in order to decompress the nerves and sacs of nerves. 70–90% of people have good results.[39]

Decompression plus fusion appears no better than decompression alone, while spinal spacers appear better than decompression plus fusion but not better than decompression alone.[41][42] No differences were found in the type of decompression.[42]

Epidemiology

Prognosis

In a study of 146 patients with lumbar spinal stenosis (mean age, 68 years, 42% women) who did not undergo surgery, followed up for 3 years, the study reported that approximately one-third of participants indicated improvement; approximately 50% reported no change in symptoms; and approximately 10% to 20% of patients condition worsened.[41]

Research

A RCT is being conducted in Sweden, to compare surgery versus non-surgical treatment for lumbar spinal stenosis.[44]

See also

References

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  2. ^ a b c Canale ST, Beaty JH (2012). Campbell's Operative Orthopaedics E-Book. Elsevier Health Sciences. p. 1994. ISBN 978-0323087186.
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