Spinal stenosis, narrowing of the spinal canal, narrowing of the nerve root foramen, degenerative change, back pain, nerve compression, degenerative disease, stenosis, neuralgia, weakness, radiating pain to the lower limbs, difficulty walking, intermittent claudication, neurogenic claudication, numbness in the lower limbs, aging
Spinal canal stenosis, also known as spinal stenosis, results from degenerative changes in the spine that develop with age. These changes lead to a reduction in the space available for nerve and vascular structures, causing compression. Spinal canal stenosis is most commonly found in the lumbar and cervical spine regions; however, in this text, we will focus primarily on lumbar spinal canal stenosis.
Narrowing of the spinal canal is a part of the structural changes brought by aging, and it may not necessarily cause symptoms. For this reason, the term spinal canal stenosis or spinal stenosis is used only when these changes result in symptoms.
Possible symptoms can range from pain and numbness in the lower back, buttocks, thighs or legs and cause difficulties with walking or a sensation of weakness in the back and lower limbs. The pain often worsens with walking and as the condition progresses, the distance one can walk pain-free is reduced. Temporary relief from pain often occurs during rest, particularly in positions where the lower back is rounded. Rounding the lower back increases the space in the spinal canal and reduces pressure on the nerve and vascular structures.
Spinal canal stenosis is thus associated with aging and is most commonly found in individuals over the age of 60.
Despite the prevalence of the condition, there is currently no universally accepted definition of spinal canal stenosis, nor are there clear radiological diagnostic criteria. Diagnosis is based on a combination of symptoms and clinical and radiological findings.
Conservative treatment forms the foundation for managing the condition, but surgery may be necessary in some cases. Surgical treatment for spinal canal stenosis is the most common reason for spinal surgery in patients over the age of 65. The goal of surgery is to increase space in the spinal canal by removing parts of the structures causing the narrowing.
Clinically Relevant Anatomy
Spinal Canal: The spinal canal is an internal cavity within the spine that houses the spinal cord, nerve roots and blood vessels. The canal gradually narrows from its upper opening (foramen magnum) to its lower opening in the sacrum (sacral hiatus). It is mainly formed by the vertebral foramina (foramen vertebrale) of adjacent vertebrae. The spinal cord occupies approximately the upper two-thirds of the canal and ends around the level of the L1 vertebra. After this point, the spinal cord continues as a bundle of nerve roots (Cauda equina) extending towards the sacrum.
A comparison between a healthy spine and a spine affected by spinal canal stenosis.
Structures causing spinal canal stenosis
Intervertebral Discs: Between each pair of vertebrae is an intervertebral disc (except between the first and second cervical vertebrae), which enables movement between the vertebrae and acts as a shock absorber, protecting the bony structures of the spine. As we age, the discs degenerates and flattens, which can reduce the size of the nerve root openings, leading to stenosis.
Facet Joints: The vertebrae are connected by two facet joints, which help stabilize the spine’s movements and provide support. With age, facet joints can wear down, and bony overgrowths (osteophytes) may develop, often narrowing the nerve root openings and spinal canal, leading to stenosis in these areas.
Nerve Root Openings (foramen intervertebrale): These are open spaces between the vertebrae through which the nerves exit the spinal column. The openings can narrow if adjacent structures, such as intervertebral discs or facet joints, degenerate or thicken.
Ligaments: The spine is supported by ligaments that connect the vertebrae and stabilize the spinal column. As we age, these ligaments may thicken and stiffen. Thickening can narrow the spinal canal and compress nerves or blood vessels, contributing to stenosis.
Etiology and Epidemiology
The prevalence of lumbar spinal stenosis increases significantly with age. Spinal stenosis detectable by imaging occurs in approximately 20–30% of individuals over the age of 65, though not all of them experience any related symptoms. The prevalence of acquired, degenerative, spinal stenosis has steadily increased over recent decades as the population ages.
There are several types of spinal stenosis.
The most common being stenosis in the lumbar and cervical spine regions, which can occur separately or together. Thoracic stenosis is rarer. Epidemiological studies estimate the prevalence of cervical stenosis at approximately 1 case per 100,000 people, whereas lumbar stenosis occurs in about 5 cases per 100,000 people. The prevalence of both types of stenosis increases with age.
The etiology of spinal stenosis varies. Some individuals are born with a congenitally narrow spinal canal, but in most cases, the condition develops due to age-related changes. Post-surgical or trauma-related stenosis is also possible, though these are much rarer compared to degenerative (age-related) stenosis.
Examples of stenosis caused by degenerative changes:
Degenerative spondylosis, or vertebral arch instability, can occur when intervertebral discs wear out due to aging or trauma, causing them to bulge backward, which increases the load on the posterior parts of the vertebrae. This increased load can lead to the formation of osteophytes (bony spurs), enlargement of facet joints, joint cysts or thickening of the ligamentum flavum. Any of these factors, individually or in combination, can narrow the spinal canal or foramina (nerve root openings).
Degenerative spondylolisthesis or vertebral slippage, is a condition where instability between vertebrae causes one vertebra to slip over the one below it. Most often, the upper vertebra slides forward relative to the one beneath it, but backward slippage is also possible. Vertebral slippage narrows the spinal canal and foramina, compressing them.
Other causes of spinal stenosis include space-occupying lesions, post-surgical fibrosis and rheumatic conditions. Additionally, various bone diseases, such as ankylosing spondylitis (spinal arthritis) or diffuse idiopathic skeletal hyperostosis (DISH) can cause stenosis. Inflammatory spondyloarthritis, disc herniations, thickening of the vertebral ligaments, tumors, infections or metabolic bone diseases such as Paget's disease can also lead to narrowing of the spinal canal or foramina.
Symptoms
The most typical symptom of spinal canal stenosis located in the lumbar region is pain in the back, buttocks and lower limbs, which worsens during prolonged walking, standing or extension of the lumbar spine. Symptoms are alleviated by movements and positions that round the back, so sitting for a moment during a walk can allow for the continuation of walking.
Pain experienced while walking, known as neurogenic claudication, is one of the most common symptoms of lumbar spinal canal stenosis and is often sufficient on its own to suspect spinal canal stenosis as the cause of the pain. Symptoms develop slowly and worsen over time. Pain radiating to the lower limbs can be so severe that even walking short distances becomes unbearable. Patients often find themselves needing to sit or lean forward to relieve the pain. Neurogenic claudication causes radiating symptoms that extend to the buttocks, groin and front of the thigh, as well as the lower back area. In addition to pain, symptoms may include feelings of fatigue, heaviness in the legs, weakness and/or other sensory disturbances. Nocturnal cramps, bladder-related symptoms or erectile dysfunction are also possible.
Symptoms can be unilateral, but more commonly they occur in both lower limbs, albeit asymmetrically. Most patients experience lower back pain, numbness and tingling. Numbness and tingling in lumbar stenosis generally affect the entire leg and rarely just one nerve root area. That is more common in lumbar disc herniation of witch you can read more here.
About half of the patients also experience muscle weakness. Patients may also report that walking upstairs is easier than going downstairs, as a forward-bent position reduces symptoms while on stairs.
It is important to remember that not everyone with spinal canal stenosis experiences symptoms, so the term "spinal canal stenosis" is reserved to describe situations where this stenosis causes symptoms.
Treatment
The primary treatment for symptomatic spinal canal stenosis is conservative. Treatment methods combine pharmacological and non-pharmacological pain management techniques along with physical therapy. Spinal canal stenosis rarely leads to progressive neurological damage, so non-surgical treatment options should always be tried before making a decision regarding potential surgery.
The goals of conservative treatment are to alleviate pain and enhance functional and work capacity. This is achieved through a combination of guidance and counseling, a precise and progressive exercise program and manual therapy. Some patients may also benefit from a lumbar support brace aimed at reducing the narrowing of the spinal canal during various activities.
Pharmacological treatment typically involves a combination of pain relievers and anti-inflammatory medications, but in more challenging cases, medications that increase pain tolerance may also be considered. Engaging in activities while experiencing severe pain often complicates recovery and can, in the worst cases, lead to chronic pain symptoms.
Surgical treatment should be considered if conservative therapy does not achieve the desired outcome or if symptoms worsen despite treatment.
The surgical method is always chosen individually, but the primary goal of surgery is to relieve pressure and free the damaged or compressed nerves and blood vessels. In certain cases, it may also be necessary to stabilize the spine, in which case, in addition to relieving the stenosis, a fusion surgery may be performed. No single procedure resolves all types of stenosis and the fundamental principle of surgery is to achieve sufficient relief of the neural structures. For the best possible results of surgery, it's important to continue with a post operative treatment protocol with your local physical therapist.
Physiotherapy
The content of physiotherapy varies based on symptoms, the area of pain and any clinically observed findings. Therefore physiotherapy always begins with a thorough assessment of background factors, allowing for the development of an individualized rehabilitation program.
Physiotherapy content is designed on an individual basis, often including a combination of the following methods:
Manual Therapy: Soft tissue treatments and joint mobilizations to reduce muscle tension, promote fluid and blood circulation and improve fascial function.
Movement and Posture Treatments: Aimed at promoting the mobility of nerve structures and reducing increased pressure or pinching on the nerve or nerve root.
Activating Exercises: Intended to promote fluid circulation and maintain muscle function.
Pain Management Techniques: Use of heat or cold therapy, manual therapy, acupuncture or self-directed exercises.
Biomechanical Assessment and Treatment: Identifying and addressing biomechanical challenges to reduce peak loads and enable decreased strain on irritated tissues.
The combination of manual therapy, home exercise programs and time has been shown to produce positive results in the treatment of spinal stenosis.
Here are a few additional physiotherapy treatment methods and their primary goals in the management of spinal stenosis:
Progressive training and load modification aims to:
Manage the overall load on the body.
Alleviate pressure and stretching on sensitive nerve tissues.
Increase fluid and blood circulation to enhance nutrient and oxygen supply to irritated tissues.
Provide relief from discomfort.
Improve sliding properties of irritated nerves by neural tissue mobilization with specific exercises.
Manual therapy aims to:
Provide relief from pain and activate pain-modulating pathways.
Reduce friction and compression on the irritated nerve
Decrease muscle tension by relaxing tense muscles.
Improve muscle and joint performance by enhancing the function of muscles and joints.
Decrease cortisol release in treated tissues.
Enhance blood flow in the targeted areas.
Enhance range of motion.
Reduce the disruptive nature of pain by lessening the impact of pain.
Education and guidance aims to:
Offer information about the nature of the issue, its underlying factors, and the rehabilitation process to ease patient concerns and improve self-efficacy.
Share knowledge about the healing process and prognosis, motivating patients for self-guided rehabilitation.
Address factors influencing prognosis and discuss factors that positively or negatively affect the treatment prognosis and timeline, reducing patient uncertainty and concerns.
Improve coping mechanisms for living with pain.
Read more about the effectiveness of manual therapy and the methods used here.
Self-care
If you want to manage spinal canal stenosis yourself, you can try the following self-care tips. Despite these tips, it’s important to discuss your specific symptoms and their potential causes with a healthcare professional.
Stay active and move within your pain limits: Regular walking has many health benefits and studies show that continuing to walk despite symptoms is an important part of self-care for spinal canal stenosis. If you experience pain or extreme fatigue while walking, you can take a short break and round your back, after which it’s often possible to continue walking. Other good forms of exercise include cycling, water-based activities, or yoga/Pilates.
Learn to maintain a posture that reduces spinal canal narrowing: Avoid excessive arching of the back and learn to control it. Postures that round the back enlarge the nerve root openings and the spinal canal, giving the nerves more space. For sleeping, side-lying with your knees drawn up toward your chest is recommended, as it reduces pressure in the spinal canal and eases symptoms that occur during the night.
Strengthen the core: Strengthening your core muscles helps maintain a less straining posture.
Heat therapy: Heat therapy can reduce muscle tension, increase surface circulation, and relieve symptoms. You can try a heating pad, a warm shower or a bath to ease symptoms. Saunas may also help in managing symptoms.
Over-the-counter medications: You can try pain relievers and anti-inflammatory medications, either in oral form or as creams. However, if symptoms persist, it’s important to consult a doctor.
Weight management: Excess weight, particularly around the abdomen, increases stress on the spine and can narrow the spinal canal and nerve root openings. Reducing daily caloric intake and engaging in regular physical activity form the foundation for weight management.
Strength training: Strengthening the core, pelvic area and lower limbs appears to reduce pain and disability caused by spinal canal stenosis over time. Start training gently, paying attention to your symptoms. Gradually increase the intensity and frequency of the exercises as you progress.
Avoid prolonged sitting or standing: Take breaks and change positions frequently. Prolonged immobility seems to worsen symptoms, so short walks or stretches can help reduce discomfort from staying still.
Mind and body relaxation techniques: Stress and tension can worsen symptoms, so relaxation exercises for the mind and body can help manage pain. You might try meditation, mindfulness or breathing exercises to lessen the additional burden caused by stress.
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