What is spinal stenosis?

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Spinal Stenosis: Definition, Diagnosis, and Management

Spinal stenosis is the narrowing of spaces within the spine that results in compression of the spinal cord and/or nerve roots, most commonly occurring in the lumbar region due to degenerative changes. 1, 2

Anatomical Understanding

Spinal stenosis can occur in different regions of the spine:

  • Cervical stenosis: Narrowing in the neck region
  • Thoracic stenosis: Less common due to limited mobility from rib attachments
  • Lumbar stenosis: Most common form, affecting the lower back

The narrowing can involve:

  • Central canal (affecting spinal cord)
  • Lateral recesses (affecting nerve roots)
  • Neuroforamina (affecting exiting nerve roots)
  • Or combinations of these 3

Types and Causes

By Etiology:

  • Congenital/Developmental:

    • Thickened laminae
    • Short pedicles
    • Decreased anterior-posterior canal diameter 3

  • Acquired:

    • Degenerative: Most common cause
      • Intervertebral disc degeneration
      • Facet joint arthrosis
      • Ligamentum flavum hypertrophy
      • Osteophyte formation
    • Post-traumatic
    • Iatrogenic: Following surgery
    • OPLL (Ossification of Posterior Longitudinal Ligament): More common in cervical spine 1

Clinical Presentation

Lumbar Stenosis:

  • Low back pain
  • Bilateral lower extremity pain
  • Neurogenic claudication (pain with walking that improves with sitting)
  • Pain relief with forward flexion (shopping cart sign)
  • Paresthesias in lower extremities
  • Motor weakness in severe cases 2, 4

Cervical Stenosis:

  • Neck pain
  • Upper extremity pain and paresthesias
  • Myelopathic symptoms (gait disturbance, fine motor difficulties)
  • In severe cases, bowel/bladder dysfunction 1

Vertebral Artery Stenosis (when associated with cervical stenosis):

  • Dizziness
  • Vertigo
  • Diplopia
  • Perioral numbness
  • Blurred vision
  • Tinnitus
  • Ataxia
  • Bilateral sensory deficits
  • Syncope 1

Diagnostic Approach

Imaging:

  1. Plain Radiographs: Initial imaging to evaluate alignment, stability, and degenerative changes

  2. MRI: Gold standard for evaluation

    • Shows neural compression
    • Evaluates soft tissue structures
    • Identifies cord signal changes in myelopathy

  3. CT: Better for bony detail

    • Superior for identifying OPLL
    • May be used when MRI is contraindicated

  4. CT Myelography: Reserved for cases where MRI is contraindicated or inconclusive 1

Diagnostic Criteria:

  • Normal sagittal diameter of lumbar canal: 15-25mm
  • Stenosis confirmed when diameter <12mm
  • Lateral recess height <3mm is suggestive, <2mm is diagnostic 3

Management

Conservative Treatment (First-line for mild to moderate symptoms):

  • Physical therapy focusing on core strengthening and flexibility
  • Pain medications (NSAIDs, acetaminophen)
  • Activity modification
  • Epidural steroid injections
  • Heat/cold therapy 5, 4

Surgical Indications:

  • Failure of conservative management after 3-6 months
  • Progressive neurological deficits
  • Cauda equina syndrome (absolute indication)
  • Severe, disabling symptoms affecting quality of life 6, 2

Surgical Options:

  • Decompressive laminectomy: Removal of bone to relieve pressure
  • Laminectomy with medial facetectomy: For lateral recess stenosis
  • Minimally invasive decompression: Similar outcomes to open procedures
  • Fusion: Added when instability is present 3, 2

Prognosis

  • Most patients with mild symptoms respond to conservative treatment
  • Surgical outcomes are generally better than continued conservative care for severe cases
  • Symptoms may recur due to progressive degenerative changes
  • Delaying surgery after failed conservative treatment does not negatively impact outcomes 4

Common Pitfalls to Avoid

  • Relying solely on imaging findings (asymptomatic stenosis is common in older adults)
  • Recommending prolonged bed rest (may worsen deconditioning)
  • Delaying surgical consultation in cases with progressive neurological deficits
  • Failing to correlate clinical symptoms with imaging findings 2

Spinal stenosis is a complex condition requiring careful clinical and radiological correlation. Treatment should be tailored based on symptom severity, with surgery reserved for cases that fail conservative management or present with neurological compromise.

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

Management of lumbar spinal stenosis.

BMJ (Clinical research ed.), 2016

3
Research

[Lumbar spinal stenosis. Symptomatology and methods of treatment].

Srpski arhiv za celokupno lekarstvo, 1998

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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