What are the symptoms and treatment options for cervical spinal stenosis?

Symptoms of Cervical Spinal Stenosis

Cervical spinal stenosis typically presents with low-back pain, weakness, radiculopathy, claudication, and bowel or bladder dysfunction, with symptoms often progressing slowly over time. 1

Common Clinical Presentations

Neurological Symptoms

• Pain (99% of patients) and numbness (56% of patients) are the most common neurological symptoms 2
• Weakness in upper and/or lower extremities due to cord compression 1
• Radiculopathy (nerve root compression symptoms) presenting as radiating pain, numbness, or tingling in arms 1
• Cervical myelopathy (spinal cord dysfunction) manifesting as:
  • Gait disturbances and balance problems 1
  • Bowel or bladder dysfunction in advanced cases 1
  • Fine motor skill deterioration in hands 1

Characteristic Pain Patterns

• Neurogenic claudication (52% of patients) - pain with walking or standing that improves with rest 1
• Back pain (15% of patients) 1
• Sciatica (8% of patients) 1
• Pain that may worsen with neck extension or prolonged positions 1

Respiratory and Bulbar Symptoms

• In severe cases, particularly with high cervical stenosis:
  • Respiratory difficulties 1
  • Apnea/cyanosis (can affect between 48% and 85% of individuals with cervicomedullary compression) 1
  • Bulbar dysfunction affecting speech and swallowing 1

Diagnostic Findings

Physical Examination

• Hyperreflexia (>3+ deep tendon reflexes) 3
• Positive Hoffman sign (pathological reflex indicating upper motor neuron disease) 3
• Tremor 3
• Absent gag reflex in severe cases 3
• Spasticity 4

Imaging Findings

• MRI is the gold standard for diagnosis, showing:
  • Spinal canal narrowing (cervical canal diameter ≤10 mm indicates absolute stenosis) 4
  • Cord signal changes on T2-weighted images (a sign of myelopathy) 1
  • Kang MRI grading system shows strong agreement with clinical symptoms (K = 0.81) 2

Natural History and Progression

• The disease course is mixed, with many patients experiencing slow, stepwise decline 1
• Long periods of quiescence (no progression) are common 1
• A subgroup of patients may experience interim improvement 1
• Untreated severe cervicomedullary compression carries a mortality rate of 16% 1
• Long periods of severe stenosis can lead to demyelination of white matter and potentially irreversible neurological deficits 1

Treatment Options

Conservative Management

• May be appropriate for younger patients with mild symptoms (mJOA score >12) 1
• Clinical gains after non-operative treatment are often maintained over 3 years in 70% of cases 1

Surgical Intervention

• Indicated for:
  • Symptomatic patients with progressive neurological deficits 1
  • Patients with cord signal change or syringomyelia 1
  • Severe and/or long-lasting symptoms 1
• Surgical options include:
  • Decompression (laminectomy) 1
  • Decompression with fusion (provides better long-term outcomes) 1
  • Anterior cervical disc replacement 3

Treatment Outcomes

• Surgical treatment reliably arrests progression of myelopathy and often improves neurological deficits 5
• Approximately 97% of patients have some recovery of symptoms after surgery 1
• Laminectomy alone is associated with higher risk of reoperation due to restenosis, adjacent-level stenosis, and postoperative spinal deformity 1
• Decompression with fusion has better long-term outcomes for pain relief, functional improvement, and quality of life 1

Important Clinical Considerations

• Early surgical intervention is often recommended to prevent irreversible neurological damage 5
• Cervical and lumbar spinal stenosis can coexist, requiring careful assessment of both regions 4
• Epidural steroid injections may provide short-term pain relief and disability reduction in cervical radiculopathy, but evidence for their effectiveness in cervical spinal stenosis is insufficient 6
• Asymptomatic radiographic stenosis does not require intervention 1