Spinal Stenosis - Lumbar and Cervical
Spinal stenosis is a narrowing of
the spinal canal, which places pressure on the spinal cord. If the
stenosis is located on the lower part of the spinal cord it is
called lumbar spinal stenosis. Stenosis in the upper part of the
spinal cord is called cervical spinal stenosis. While spinal
stenosis can be found in any part of the spine, the lumbar and
cervical areas are the most commonly affected.
What Causes Spinal Stenosis?
Some patients are born with this narrowing, but most often spinal
stenosis is seen in patients over the age of 50. In these patients,
stenosis is the gradual result of aging and "wear and tear"
on the spine during everyday activities. There most likely is a
genetic predisposition to this since only a minority of individuals
develops advanced symptomatic changes. As people age, the ligaments
of the spine can thicken and harden (called calcification). Bones
and joints may also enlarge, and bone spurs (called osteophytes) may
form. Bulging or herniated discs are also common. Spondylolisthesis
(the slipping of one vertebra onto another) also occurs and leads to
compression. When these conditions occur in the spinal area, they
can cause the spinal canal to narrow, creating pressure on the
Symptoms of Stenosis
The narrowing of the spinal canal itself does not usually cause any
symptoms. It is when inflammation of the nerves occurs at the level
of increased pressure that patients begin to experience problems.
Patients with lumbar spinal stenosis may feel pain, weakness, or
numbness in the legs, calves or buttocks. In the lumbar spine,
symptoms often increase when walking short distances and decrease
when the patient sits, bends forward or lies down. Cervical spinal
stenosis may cause similar symptoms in the shoulders, arms, and
legs; hand clumsiness and gait and balance disturbances can also
occur. In some patients the pain starts in the legs and moves upward
to the buttocks; in other patients the pain begins higher in the
body and moves downward. This is referred to as a "sensory
march". The pain may radiate like sciatica or may be a cramping
pain. In severe cases, the pain can be constant. Severe cases of
stenosis can also cause bladder and bowel problems, but this rarely
occurs. Also paraplegia or significant loss of function also rarely,
if ever, occurs.
How Stenosis is Diagnosed
Before making a diagnosis of stenosis, it is important for the
doctor to rule out other conditions that may have similar symptoms.
In order to do this, most doctors use a combination of tools,
Non-surgical Treatment of Spinal Stenosis
The doctor will begin by asking the patient to describe any
symptoms he or she is having and how the symptoms have changed
over time. The doctor will also need to know how the patient has
been treating these symptoms including what medications the
patient has tried.
- Physical Examination
The doctor will then examine the patient by checking for any
limitations of movement in the spine, problems with balance and
signs of pain. The doctor will also look for any loss of
extremity reflexes, muscle weakness, sensory loss, or abnormal
reflexes which may suggest spinal cord involvement.
After examining the patient, the doctor can use a variety of
tests to look at the inside of the body. Examples of these tests
- X-rays - these tests can show the
structure of the vertebrae and the outlines of joints and
can detect calcification.
- MRI (magnetic resonance imaging) - this
test gives a three-dimensional view of parts of the back and
can show the spinal cord, nerve roots, and surrounding
spaces, as well as enlargement, degeneration, tumors or
- Computerized axial tomography (CAT scan)
- this test shows the shape and size of the spinal canal,
its contents and structures surrounding it. It shows bone
better than nerve tissue.
- Myelogram - a liquid dye is injected into
the spinal column and appears white against bone on an x-ray
film. A myelogram can show pressure on the spinal cord or
nerves from herniated discs, bone spurs or tumors.
- Bone Scan - This test uses injected
radioactive material that attaches itself to bone. A bone
scan can detect fractures, tumors, infections, and
arthritis, but may not tell one disorder from another.
Therefore, a bone scan is usually performed along with other
There are a number of ways a doctor can treat stenosis without
surgery. These include :
Surgical Treatment of Spinal Stenosis
- Medications, including non-steroidal anti-inflammatory drugs
(NSAIDs) to reduce swelling and pain, and analgesics to relieve
- Corticosteroid injections (epidural steroids) can help reduce
swelling and treat acute pain that radiates to the hips or down
the leg. This pain relief may only be temporary and patients are
usually not advised to get more than 3 injections per 6-month
- Rest or restricted activity (this may vary depending on
extent of nerve involvement).
- Physical therapy and/or prescribed exercises to help
stabilize the spine, build endurance and increase flexibility.
In many cases, non-surgical treatments do not treat the conditions
that cause spinal stenosis, however they might temporarily relieve
pain. Severe cases of stenosis often require surgery. The goal of
the surgery is to relieve pressure on the spinal cord or spinal
nerve by widening the spinal canal. This is done by removing,
trimming, or realigning involved parts that are contributing to the
The most common surgery in the lumbar spine is called decompressive
laminectomy in which the laminae (roof) of the vertebrae are removed
to create more space for the nerves. A surgeon may perform a
laminectomy with or without fusing vertebrae or removing part of a
disc. Various devices (like screws or rods) may be used to enhance
fusion and support unstable areas of the spine.
Other types of surgery to treat stenosis include the following :
Overhead View of a Cervical Vertebra
- Laminotomy - when only a small portion of the
lamina is removed to relieve pressure on the nerve roots;
- Foraminotomy - when the foramin (the area
where the nerve roots exit the spinal canal) is removed to
increase space over a nerve canal. This surgery can be done
alone or along with a laminotomy;
- Medial Facetectomy - when part of the facet
(a bony structure in the spinal canal) is removed to increase
- Anterior Cervical Discectomy and Fusion - the
cervical spine is reached through a small incision in the front
of the neck. The intervertebral disc is removed and replaced
with a small plug of bone, which in time will fuse the
- Cervical Corpectomy - when a portion of the
vertebra and adjacent intervertebral discs are removed for
decompression of the cervical spinal cord and spinal nerves. A
bone graft, and in some cases a metal plate and screws, is used
to stabilize the spine.
- Laminoplasty - a posterior approach in which
the cervical spine is reached from the back of the neck and
involves the surgical reconstruction of the posterior elements
of the cervical spine to make more room for the spinal canal.
- Spinous Process
- Zygapophysial Joint (Facet)
- Posterior Tubercle
If nerves were badly damaged before the surgery, the patient
may still have some pain or numbness after the surgery. Or there may
be no improvement at all. Also, the degenerative process will likely
continue, and pain or limitation of activity may reappear 5 or more
years after surgery.
Most doctors will not consider surgical treatment of spinal
stenosis unless several months of non-surgical treatment methods
have been tried. Since all surgical procedures carry a certain
amount of risk, patients are advised to discuss all treatment
options with their doctor before deciding which procedure is best.
Spondylolisthesis occurs when one vertebra slips forward in
relation to an adjacent vertebra, usually in the lumbar spine. The
symptoms that accompany a spondylolisthesis include pain in the low
back, thighs, and/or legs, muscle spasms, weakness, and/or tight
hamstring muscles. Some people are symptom free and find the
disorder exists when revealed on an x-ray. In advanced cases, the
patient may appear swayback with a protruding abdomen, exhibit a
shortened torso, and present with a waddling gait.
Spondylolisthesis can be congenital (present at birth) or develop
during childhood or later in life. The disorder may result from the
physical stresses to the spine from carrying heavy things,
weightlifting, football, gymnastics, trauma, and general wear and
tear. As the vertebral components degenerate the spine's integrity
Another type of spondylolisthesis is degenerative
spondylolisthesis, occurring usually after age 50. This may create a
narrowing of the spinal canal (spinal stenosis). This condition is
frequently treated by surgery.
Diagnosis of Spondylolisthesis
A routine lateral (side) radiograph taken while standing confirms a
diagnosis of a spondylolisthesis. The x-ray will show the
translation (slip) of one vertebra over the adjacent level, usually
the one below.
Using the lateral (side) x-ray, the slip is graded according to its
degree of severity. The Myerding grading system measures the
percentage of vertebral slip forward over the body beneath. The
grades are as follows :
- Grade 1: 25%
- Grade 2: 25% to 49%
- Grade 3: 50% to 74%
- Grade 4: 75% to 99%
- Grade 5: 100%*
Complete vertebral slippage,
known as spondyloptosis.
If the spondylolisthesis is non-progressive, no treatment except
observation is required. Symptoms often abate once precipitating
activities cease. Conservative treatment includes 2 or 3 days of bed
rest, restriction of activities causing stress to the lumbar spine
(e.g. heavy lifting, stooping), physical therapy, anti-inflammatory
and pain reducing medications, and/or a corset or brace.
A physician may prescribe a custom-made corset or brace. These are
made by an orthotist, a professional who takes the patient's precise
body measurements, which may include making a cast from which the
molded orthoses is made.
Surgical intervention is considered when neurologic involvement
exists or conservative treatment has failed to provide relief from
long-term back pain and other symptoms associated with
A spine surgeon decides which surgical procedure and approach
(anterior/posterior, front or back) is best for the patient. His
decisions are based on the patient's medical history, symptoms,
radiographic findings, as well as the grade and angle of the
vertebral slip. A variety of surgical treatment options are
utilized. You should discuss what is best for your condition with
your spine surgeon.
Whether the treatment course is conservative or surgical, it is
important to closely follow the instructions of your physician
and/or physical therapist.
Avoid heavy lifting, stooping, or certain sports such as football
or high impact exercise (i.e. running, aerobics). Any doubts
concerning vocational and recreational restrictions should be
discussed with your physician and/or physical therapist. They will
be able to suggest safe alternatives to help reduce the risk of
further back problems.
Keep your weight close to ideal, continue to follow the exercise
program designed by your physical therapist at home, learn how to
pick up things off the floor correctly, as well as other 'safe'
Lumbar laminectomy is a surgical
procedure most often performed to treat leg pain related to
herniated discs, spinal stenosis, and other related conditions.
Stenosis occurs as people age and the ligaments of the spine thicken
and harden, discs bulge, bones and joints enlarge, and bone spurs
(called osteophytes) form. Spondylolisthesis (the slipping of one
vertebra onto another) can also lead to compression.
The goal of a laminectomy is to relieve pressure on the spinal cord
or spinal nerve by widening the spinal canal. This is done by
removing or trimming the lamina (roof) of the vertebrae to create
more space for the nerves. A surgeon may perform a laminectomy with
or without fusing vertebrae or removing part of a disc. Various
devices (like screws or rods) may be used to enhance the ability to
obtain a solid fusion and support unstable areas of the spine.
Quick Anatomy Lesson
The human spine extends from the skull to the pelvis. It is made up
of individual bones called vertebrae. The vertebrae, which are
stacked on top of each other, are grouped into four regions :
- The cervical spine or neck (which is made up of 7 vertebrae
C1 - C7) which effect neck, arms, hands
- The thoracic spine or chest area (which is made up of 12
vertebrae T1 - T12) which effect torso, parts of the arms
- The lumbar spine or low back (which is made up of 5 vertebrae
T12 - L5) which effect hips, legs
- The sacrum or pelvis area (which has 5 fused, non-separated
vertebrae S1 - S5) which effect groin, toes, parts of the leg
The base of the spine, the coccyx (or tail bone), includes
partially fused vertebrae and is mobile.
The vertebrae are separated from one another by soft pads, called
intervertebral discs, which allow the spine to bend and flex and act
as shock absorbers during regular activity. These discs also prevent
the vertebrae from rubbing against each other. Each disc is made up
of two parts, a soft center called the nucleus and a tough outer
band called the annulus.
Throughout the length of the spine is a central tube, surrounded by
bone and discs, called the spinal canal. Inside the spinal canal are
the spinal cord, the cauda equina, and spinal nerves. The spinal
cord begins at the base of the brain and ends in the lumbar spine
area in a bundle of nerves known as the cauda equina. A pair of
spinal nerves branch out (one to the left and one to the right) at
each vertebral level. These provide sensation and movement to all
parts of the body.
A lumbar laminectomy may be necessary to relieve pressure on the
How the Procedure is Done
The patient is usually positioned face down on an operating frame.
A small incision (usually about 3-4 inches, though it may be longer
depending on how many levels of the spine are affected) is made in
the lower back.
The surgeon uses a retractor to spread apart the muscles and fatty
tissue of the spine and exposes the lamina. A portion of the lamina
is removed to uncover the ligamentum flavum - an elastic ligament
that helps connect two vertebrae.
Next an opening is cut in the ligamentum flavum in order to reach
the spinal canal. Once the compressed nerve can be seen, the cause
of compression can be identified. Most cases of spinal compression
are caused by a herniated disc. However, other sources of pressure
that can cause compression may include :
- A disc fragment (this will often cause more severe symptoms)
- An osteophyte or bone spur (a rough protrusion of bone)
- Protruding/degenerating discs
- Facet arthritis and/or cysts
The surgeon retracts the compressed nerve and the source of
the compression is removed and pressure on the spinal nerve or nerve
components is relieved.
If necessary, the surgeon will perform a spinal fusion with
instrumentation to help stabilize the spine. This occurs when a lot
of bone needs to be removed and/or when multiple levels are operated
on. A spinal fusion involves grafting a small piece of bone (usually
taken from the patient's own pelvis) onto the spine and using spinal
hardware, such as screws and rods, to support the spine and provide
Then the procedure is finished! The surgeon will close the incision
either using absorbable sutures (stitches), which absorb on their
own and do not need to be removed, or skin sutures, which will have
to be removed by the surgeon after the incision has healed.