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Spinal Stenosis

BASICS

  • Definition:
    Narrowing of the central spinal canal, lateral recess, and/or neural foramen, causing pain, numbness, tingling, and/or muscle weakness.

EPIDEMIOLOGY

  • Prevalence:
  • Increases with age.
  • 11–38% of adults show lumbar stenosis on imaging (mean age 62).

  • 200,000 affected in the U.S.; commonest reason for spinal surgery >65 yrs.

  • Sites:
  • Lumbar > Cervical > Thoracic.
  • Most often L4-L5 and L5-S1 levels.

ETIOLOGY & PATHOPHYSIOLOGY

  • Causes:
  • Congenital: Short pedicles, achondroplasia, spina bifida, spondyloepiphyseal dysplasias.
  • Acquired: Degenerative spondylosis (most common), spondylolisthesis, trauma, inflammatory arthropathy, tumors/cysts.
  • Mechanisms:
  • Degeneration leads to disc dehydration, bulging, facet arthropathy, osteophytes, ligamentum flavum hypertrophy.
  • Compression and ischemia of nerve roots.
  • Radiologic severity does not always correlate with symptoms.

RISK FACTORS

  • Spinal trauma or surgery
  • Inflammatory arthropathy
  • Vitamin B12 deficiency, osteoporosis, renal osteodystrophy, Cushing disease, acromegaly, Paget disease

COMMONLY ASSOCIATED CONDITIONS

  • Cervical/lumbosacral radiculopathy
  • Spondylolisthesis
  • Pars interarticular fracture
  • Scoliosis
  • Cauda equina syndrome

DIAGNOSIS

HISTORY

  • Insidious onset, slow progression
  • Discomfort with standing; paresthesia, weakness (often bilateral)
  • Worse with extension: (standing, walking downhill, downstairs)
  • Improves with flexion: (sitting, leaning forward, walking uphill/upstairs, pushing cart, biking)
  • Neurogenic claudication: pain, tightness, numbness, aching, cramping in lower extremities, mimics vascular claudication
  • Use Zurich Claudication Questionnaire (ZCQ) for symptom assessment

PHYSICAL EXAM

  • Neurologic: Often normal
  • Inspection: Loss of lordosis, scoliosis
  • Palpation: May reveal tenderness
  • ROM: Limited flexion, extension; pain with extension
  • Strength: L4–L5 (hip abduction, toe flexion); S1 (hip extension)
  • Neurovascular: Sensory changes (L3–S1), reduced reflexes (50% ↓ Achilles)
  • Special tests: Straight leg raise, Trendelenburg, Romberg
  • Gait: Forward flexed, wide-based, or antalgic gait

DIFFERENTIAL DIAGNOSIS

  • Vascular claudication
  • Disc herniation
  • Degenerative joint disease (extremities)
  • Peripheral neuropathy
  • Cervical myelopathy

DIAGNOSTIC TESTS

  • Labs: CBC, ESR, CRP (if infection/malignancy suspected)
  • Imaging:
  • X-ray: Exclude fractures, spondylolisthesis, scoliosis
  • MRI (without contrast): Gold standard for assessing canal/foraminal narrowing, nerve root impingement
  • CT myelography: For MRI contraindications
  • Other: ABI (to rule out peripheral arterial disease), EMG/NCS (if unclear diagnosis)

TREATMENT

GENERAL MEASURES

  • First-line (nonoperative):
  • Multimodal rehab: PT, home exercise, weight management
  • Activity: Core/back exercises, aerobic activity, aquatic therapy, yoga, Pilates
  • Bracing: Controversial—avoid long-term use
  • Injections:
  • Epidural steroids, facet injections, medial branch ablation (short-term relief)

MEDICATIONS

  • First Line:
  • NSAIDs (short term, 2–4 weeks; watch for GI/renal/cardiac side effects)
  • Acetaminophen (mixed efficacy; watch for hepatotoxicity)
  • Second Line:
  • Nonbenzodiazepine muscle relaxants (short-term relief)
  • Chronic pain agents: gabapentin, pregabalin, duloxetine, tramadol (opiate as last resort, caution in elderly)
  • Avoid: Chronic NSAIDs, opioids, adjuncts (acetaminophen, methylcobalamin, calcitonin) for neurogenic claudication
  • Oral steroids, benzodiazepines, antidepressants: not routinely recommended

REFERRAL & SURGICAL OPTIONS

  • Referral:
  • Pain management for refractory pain
  • Spine surgery for progressive myelopathy, worsening radiculopathy, or failed conservative care
  • Surgery:
  • Indications: Severe/progressive symptoms, failed nonoperative therapy
  • Procedures: Minimally invasive decompression (MILD), interspinous spacers, decompressive laminectomy (± fusion)
  • Risks ↑ with age, comorbidities, osteoporosis

COMPLEMENTARY & ALTERNATIVE THERAPIES

  • Osteopathic manipulation, chiropractic, acupuncture, massage, heat/cryotherapy (avoid high-velocity manipulation in severe stenosis)

ONGOING CARE

  • Follow-up: Based on symptom stability/progression
  • Activity: Encourage as tolerated—no strict limitations
  • Nutrition: Weight optimization important for reducing progression

PATIENT EDUCATION

  • Maintain activity, recognize red flags: bowel/bladder dysfunction, saddle anesthesia, progressive weakness/numbness.
  • Discuss conservative and surgical options, prognosis, and complications.

PROGNOSIS

  • Usually manageable with conservative therapy; some will develop disability.
  • Surgery generally relieves pain and improves function if nonoperative care fails.
  • Long-term pain relief and function improvement are possible at any age.

COMPLICATIONS

  • Severe: Bowel/bladder dysfunction, disabling weakness
  • Surgical: Infection, neurologic injury, chronic pain, disability

ICD-10

  • M48.00 Spinal stenosis, site unspecified
  • M48.06 Spinal stenosis, lumbar region
  • M48.04 Spinal stenosis, thoracic region

CLINICAL PEARLS

  • Most common at lumbar spine; presents as neurogenic claudication.
  • Flexion relieves, extension worsens symptoms.
  • MRI = diagnostic test of choice.
  • Always try lifestyle and conservative therapies first; refer for decompression surgery if nonoperative management fails.