Spinal Stenosis
Spinal stenosis is the narrowing of the spinal canal that may result in bony constriction of the cauda equina and the emerging nerve roots, leading to neurological symptoms including pain, weakness, and potential disability. 1
Definition and Pathophysiology
- Spinal stenosis refers to the narrowing of a hollow tube (the spinal canal), which can occur in the central canal, lateral recess, or intervertebral foramen 2
- This narrowing produces neurovascular compression that may lead to pain and neurological symptoms 2
- The condition can be congenital (present at birth) or acquired (developing over time due to degenerative changes) 2
- Stenosis can affect different regions of the spine, with lumbar and cervical regions being most commonly affected 3
Clinical Presentations
- Neurogenic claudication is a hallmark symptom, characterized by leg pain and occasional weakness when walking or standing, relieved by sitting or spinal flexion 1
- Radiculopathy presents as pain, sensory impairment, weakness, or diminished deep tendon reflexes in a nerve root distribution 1
- Sciatica (pain radiating down the leg below the knee in the sciatic nerve distribution) is common in lumbar stenosis 1
- Cervical stenosis typically presents with neck pain radiating to the shoulders and arms 4
- Myelopathy signs include gait disturbances, balance problems, and fine motor skill deterioration 3
- Bowel or bladder dysfunction may occur in advanced cases 1, 3
- Weakness in upper and/or lower extremities due to cord compression is common 3
Diagnostic Indicators
- MRI is the gold standard for diagnosis, with cord signal changes on T2-weighted images indicating myelopathy 3, 5
- Asymptomatic radiographic stenosis does not require intervention 3
- It's important to note that radiographic changes associated with stenosis are common with aging and may not correlate with symptoms 2
- The diagnosis requires consideration of clinical history, physical examination results, and radiological findings 6
Natural History and Progression
- The disease course is often characterized by slow, stepwise decline with periods of quiescence 3
- Untreated severe cervicomedullary compression carries a mortality rate of 16% 3, 5
- Long periods of severe stenosis can lead to demyelination of white matter and potentially irreversible neurological deficits 3, 5
- Rapid deterioration is rare, with symptoms often waxing and waning or gradually improving 7
Treatment Options
Conservative Management
- Initial treatment for mild to moderate symptoms includes multimodal conservative approaches 6, 8
- Physical therapy focusing on flexion exercises can help alleviate symptoms 8
- Epidural corticosteroid injections may provide temporary relief 4, 8
- Oral analgesics and anti-inflammatory medications are commonly used 8
- Conservative treatment should be tried for 3-6 months before considering surgery in patients without severe symptoms 6
Surgical Management
- Surgical intervention is indicated for symptomatic patients with progressive neurological deficits, cord signal change, or severe/long-lasting symptoms 3
- Decompression with fusion provides better long-term outcomes than decompression alone, with approximately 97% of patients experiencing 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
- Clinically relevant motor deficits or cauda equina syndrome are absolute indications for surgery 6
- Outcomes for leg pain and disability appear better with surgery than non-operative treatment, though evidence quality is variable 7
Special Considerations
- In achondroplasia patients, multilevel stenosis is common, predominantly in the thoracolumbar region 1
- For achondroplasia patients with spinal stenosis, fusion offers better long-term outcomes than spinal decompression alone 1
- The term lumbar spinal stenosis refers not just to the anatomical narrowing but to the clinical syndrome of lower extremity pain caused by neural compression 2
- Not all patients with anatomical narrowing develop symptoms, and the reason for this variability remains unknown 2