Spinal stenosis

Spinal stenosis is characterized by the narrowing of the central spinal canal, intervertebral foramen, and/or lateral recess causing progressive nerve root compression in the cervical, thoracic, or lumbar spine. It is commonly caused by degenerative joint disease in middle-aged or elderly individuals. The main symptoms are neck pain or load-dependent lower back pain with radiation to the buttocks and legs. Spinal extension (standing or walking downhill) exacerbates pseudo- or neurogenic claudication, while back flexion (sitting or walking uphill) improves symptoms. An MRI provides the diagnosis. Treatment involves conservative therapy (analgesia, physiotherapy), while refractory cases require surgical decompression of the spinal cord (laminectomy).

• Prevalence: 5:1000 in persons > 50 years of age
• Age range: middle-aged and elderly population
• Sex: ♀ > ♂ when associated with degenerative disease

References:^[1][2]

Epidemiological data refers to the US, unless otherwise specified.

Progressive narrowing of the central spinal canal, intervertebral neural foramen and/or lateral recess (cervical C2 or lumbar spine L1) caused by:

• Degenerative joint disease (most common)
  • Spondylolisthesis (antero- or posterior)
  • Disc space narrowing
  • Facet joint hypertrophy
• Iatrogenic: following spinal surgery such as laminectomy
• Systemic disease: Paget's disease, ankylosing spondylitis, tumors
• Trauma
• Congenital malformations: spinal dysraphism (uncommon)

References:^[1][2][3]

• Lumbar stenosis
  • Load-dependent lower back pain
  • Unsteady wide-based gait; , reduced lower extremity reflexes
  • Neuropathic claudication: a group of typical symptoms (see table below) of spinal stenosis affected by postural changes

References:^[1][2][4][5]

• X-ray: degenerative joint changes
• MRI (confirmatory test): evidence of spinal stenosis (compression of spinal nerves, nerve roots or spinal cord)
  • Possible alternative: CT

The differential diagnoses listed here are not exhaustive.

• Symptomatic treatment
  • NSAIDS
  • Physiotherapy, which focuses on exercises that promote stability and abdominal muscle strengthening
  • Epidural steroid injections if symptoms persist despite above treatment (may improve ∼ 50% of cases)
• Surgery: if conservative therapy fails
  • Removal of any bony attachments
  • Laminectomy (decompression surgery): removal of the dorsal part of the vertebra (lamina) which covers the spinal cord
  • Recurrence is common

References:^[1][4][5]

1. Hsiang JK. Spinal Stenosis. Spinal Stenosis. New York, NY: WebMD. http://emedicine.medscape.com/article/1913265-overview#a4. Updated: February 13, 2017. Accessed: February 16, 2017.
2. Levin K. Lumbar spinal stenosis: Pathophysiology, clinical features, and diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/lumbar-spinal-stenosis-pathophysiology-clinical-features-and-diagnosis?source=search_result&search=Spinal%20Stenosis&selectedTitle=2~56.Last updated: January 17, 2017. Accessed: February 16, 2017.
3. Park JB, Lee JK, Park SJ, Riew KD . Hypertrophy of ligamentum flavum in lumbar spinal stenosis associated with increased proteinase inhibitor concentration. J Bone Joint Surg Am. 2005; 87 (12): p.2750-2757. doi: 10.2106/JBJS.E.00251 . | Open in Read by QxMD
4. Agabegi SS, Agabegi ED. Step-Up To Medicine. Lippincott Williams & Wilkins ; 2013
5. Le T, Bhushan V, Bagga HS. First Aid for the USMLE Step 2 CK. McGraw-Hill Medical ; 2009
6. Rao D, Scuderi G, Scuderi C, Grewal R, Sandhu SJ. The Use of Imaging in Management of Patients with Low Back Pain. J Clin Imaging Sci. 2018; 8 : p.30. doi: 10.4103/jcis.jcis_16_18 . | Open in Read by QxMD
7. North American Spine Society: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. https://www.spine.org/Portals/0/Assets/Downloads/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf. Updated: January 1, 2011. Accessed: January 8, 2020.
8. Genevay S, Atlas SJ. Lumbar Spinal Stenosis. Best Pract Res Clin Rheumatol. 2010; 24 (2): p.253-265. doi: 10.1016/j.berh.2009.11.001 . | Open in Read by QxMD