Spinal Insights - Spinal Stenosis

Spinal stenosis is a conditioned characterized by the abnormal narrowing of the spinal canal (1). This narrowing compresses the spinal cord and/or the nearby nerves and can cause symptoms that travel from the spine to the arms and legs. It is most commonly seen in patients 50+ years, often caused by the degenerative and arthritic changes related to osteoarthritis. Spinal stenosis predominantly occurs in the lumbar (lower back) and cervical (neck) spine. It is diagnosed with an MRI scan or a CT scan with myelogram (using an X-ray dye in the spinal sac fluid), and sometimes both.

A lot of people do not feel any effects of the narrowing of the spinal canal, but with increasing degenerative changes associated with aging, most people will eventually notice radiating pain, tingling, numbness, or weakness in the arms or legs, secondary to the compression of the spinal nerves or spinal cord. When a person is symptomatic, lumbar (lower back) spinal stenosis causes weakness in the lower back, buttocks, thigh, calf, foot, and claudicating pain (1). Pain is often worse with long periods of standing or walking. When cervical (neck) spinal stenosis is symptomatic, people can experience tingling into the hand, weakness, pain, or numbness in the arm or neck, deterioration of fine motor skills, loss of balance, and co-ordination problems (2). Spinal stenosis, however, can commonly be asymptomatic (3), which highlights the importance of corroborative findings between patient history and clinical examination (4), (5). Spinal stenosis symptoms often develop slowly over time, they come and go as opposed to experiencing continuous pain, and symptoms occur more frequently when standing, walking, or participating in activities in an upright position. Symptoms are relieved by rest (sitting or lying) and/or any forward flexed position.

Whether a patient is asymptomatic, or symptomatic, even after careful examination, management and treatment decisions for people with spinal stenosis remain a challenge that has providentially been described as a “balancing act” (6). This is due to the lack of clear, evidence-based research available on nonsurgical treatment options, and that neurological function deficits are not always associated with the severity or extent of the stenosis present. Some common treatment options for spinal stenosis include:

• Exercise – a suitable, supervised, exercise program designed by a health professional. Although exercise is not a cure for spinal stenosis, it’s important for patients to remain active, and not become further debilitated or de-condition due to inactivity. Start slowly to build up strength and tolerance.
• Activity modification – This doesn’t mean to stop all physical activity, but modify them so you can still ambulate and move around, without causing you increased pain or discomfort. For example, if walking upright aggravates your symptoms, consider a walking aid such as a cane or lean forward on your shopping trolley. Rather than walking for exercise, use a stationary bike (leaning forward over the handlebars). Sit in a recliner instead of an upright, straight-back chair.
• Epidural injections – A cortisone injection administered into the back (into the epidural space) to temporarily relieve symptoms. This is not a cure but a short-term relief for symptoms.
• Medication – pain killers and anti-inflammatory medication may be helpful for short-term alleviation of symptoms. Some Physicians may prescribe a strong course of medication such as muscle relaxants, opioids, or pain killers. Side effects from medication should always be considered and discussed. Work closely with your Physician if deciding to use medication.
• Decompression surgery – There are a number of techniques and opinions regarding surgical treatment for spinal stenosis. Work closely with a neurosurgeon to explore this option and discuss the key components of spinal stenosis surgery to determine if this is the right option for you.

Not all spinal stenosis cases are the same and the level of spinal stenosis will present differently in different people. Future research is needed to focus on expanding treatment options for spinal stenosis, particularly in the area of exercise, physical therapy and nonsurgical interventions. More research is also needed to determine the predictors of failure and success with both nonsurgical and surgical treatment approaches. In the interim, patients, primary care health practitioners, doctors, and surgeons, should engage in shared decision-making that include a full disclosure of the current evidence available for nonsurgical and surgical interventions for spinal stenosis (5) and determine what is the most appropriate option for you.

1. Katz JN, Harris MB. Clinical practice. Lumbar spinal stenosis. N Engl J Med. 2008; 358(4):818-25
2. Spinal stenosis. National Institue of Arthritis and Musculoskeletal and Skin Diseases. http://www.niams.nih.gov/health_info/spinal_stenosis. Accessed: May 4th, 2017-05-04
3. Boden SD. The use of radiographic imaging studies in the evaluation of patients who have degenerative disorders of the lumbar spine. J Bone Joint Surg AM. 1996; 78:114-24
4. Katz JN, Dalgas M, Stucki G, Katz NP, Bayley J, Fossel AH et al. Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination. Arth Rheum. 1995; 38(2):123-438
5. Delitto A, Piva SR, Moore CG, Fritz JM, et al. 2015. Surgery versus nonsurgical treatment of lumbar spine stenosis: A randomized trial. Ann Intern Med. 2015; 162(7):465-73
6. Devo RA. Treatment of lumbar spinal stenosis: a balancing act. Spine J. 2010; 10:625-27

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