Q&A: Spinal Stenosis
Bennie W. Chiles III, M.D., F.A.A.N.S., F.A.C.S.
Q. What exactly is spinal stenosis?
A. The word stenosis has both Latin and Greek origins, and in medical terms refers to narrowing of any body passage or opening. Spinal stenosis more specifically means narrowing of the space or spaces within the spinal column through which travel the spinal cord and spinal nerve roots.
Q. What are the major types of stenosis?
A. Central spinal stenosis refers to narrowing of the main spinal canal running centrally within the spinal column. This can occur anywhere starting from the junction of the skull and the first cervical vertebra, all the way down to the sacrum, or tailbone. Central spinal stenosis can cause compression of the spinal cord and lead to neurologic disturbances related to compromise of that structure, as well as adjacent spinal nerve roots. Lateral or foraminal stenosis refers to narrowing of the small bony spaces adjacent to the central spinal canal which serve as the pathways for the spinal nerve roots as they exit the spinal column and head out to the body, and more specifically, to the arms and legs. Clinically, these two subtypes often overlap.
A second way of subdividing spinal stenosis is by actual location within the spinal column. Most commonly, this is the distinction between cervical stenosis and lumbar stenosis. Cervical stenosis refers to narrowing at the level of the spine in the neck, which is typically associated with neurologic symptoms in one or sometimes both arms due to compression of spinal nerve roots. With cervical stenosis, there can also be more widespread neurologic problems if the spinal cord is also involved. Lumbar stenosis refers to narrowing at the level of the spine in the lower back, which will be associated with neurologic symptoms in one or both legs. Stenosis of the thoracic spine, namely the part of the spine between the cervical and lumbar regions, is extremely uncommon.
Q. What causes cervical and lumbar stenosis?
A. Spinal stenosis is a condition that generally occurs gradually over time as a result of age-related degenerative changes and “wear-and-tear” of the tissues that make up the spinal column. Most notably, these tissues include the bones, ligaments, and intervertebral discs. As time passes, these bones and ligaments can enlarge and thicken abnormally, encroaching on the space available for the spinal cord and nerves. The intervertebral discs can progressively bulge or protrude out from the normal location, further aggravating the stenosis, especially centrally. Discs can also become abnormally thinned or collapsed, allowing the surrounding vertebrae to come too close together, which leads to compromise of the exiting spinal nerve roots.
Unlike thoracic vertebrae, which are stabilized by the rib cage, the cervical and lumbar regions are composed of separate vertebrae that are mobile with respect to each other.
It is important to remember that spinal stenosis can be partially congenital, as some people are born with less room around the spinal cord or spinal nerves starting out. In those individuals, the problem can manifest and become symptomatic much earlier in life.
Q. How can I tell if I’m experiencing stenosis symptoms?
A. Not all individuals with spinal stenosis are symptomatic. In those who do develop a clinical problem, the symptoms are typically gradual in onset and slowly progressive. Symptoms of cervical stenosis can include neck pain, radiating pain in one or both arms, and neurologic symptoms such as numbness, tingling, weakness, or clumsiness, again in one or both arms and often prominent in the hands. With spinal cord involvement, there can also be lower extremity symptoms such as loss of balance and difficulty with walking.
With lumbar stenosis, patients can experience lower back pain, radiating pain in either or both legs, and more frank neurologic symptoms such as numbness, tingling, or weakness, again in either or both legs. Additionally, lumbar stenosis often presents with a gradual decline in the ability to walk, a syndrome termed neurogenic claudication. This refers to leg symptoms such as pain and heaviness which are produced by walking or standing, and relieved by sitting, stooping, or resting.
Q. What are my treatment options?
A. Non-surgical treatments can include tailored exercise programs, medications, physical therapy, chiropractic care, and work in pain management utilizing intraspinal injections. In general, non-surgical treatments are appropriate for those who are only mildly or moderately symptomatic, have stenosis which is not severe, who are not manifesting significant neurologic disturbances, who are responding well to non-surgical interventions, or who are too elderly or medically frail to tolerate surgery.
Surgical treatment consists of decompression of the compromised spinal cord and/or spinal nerves via removal of bone, ligament, discs, or any combination of these. This is frequently combined with fusion of the involved vertebrae and spinal structures to maintain proper stability and structural integrity of the spinal column. Surgical treatment should be strongly considered in those individuals with advanced spinal stenosis associated with clear neurologic deficits, particularly patients with cervical stenosis and symptomatic spinal cord compression, or those who fail all reasonable attempts at non-surgical management. Consultation with an experienced spine surgeon should be done early on, as the outcomes with operative treatment are not nearly as good if the underlying disease process is allowed to progress to a late stage prior to definitive surgical intervention. I see many patients in neurosurgical consultation at the time of their initial diagnosis, just to make sure that there are no “red flags” indicating the need for strong consideration of surgical intervention up front.
Bennie W. Chiles III, M.D., F.A.A.N.S., F.A.C.S.
Chief of Neurosurgery
New York-Presbyterian Lawrence Hospital
Clinical Assistant Professor of Neurosurgery
New York Medical College
NY State Neurosurgical Society
Westchester Spine and Brain Surgery, PLLC
280 North Central Ave., Suite 235
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