Spinal Stenosis

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Spinal stenosis is the narrowing of the spinal canal and neural foramina. Spinal stenosis has been classified into congenital and acquired types. The more common acquired spinal stenosis is caused by degenerative changes in the intervertebral disks, ligaments, and facet joints surrounding the lumbar canal. These degenerative changes can be caused by disk or joint disease, back surgery, and repetitive trauma. Stenosis initially becomes symptomatic at 40 to 50 years and older. Congenital narrowing of the spinal canal causes symptoms earlier in life and is uncommon.

Spinal stenosis usually occurs at cervical and lumbar segments. Patients with cervical stenosis present with radiating arm pain, numbness, paresthesia, and motor weakness. The common symptoms with lumbar stenosis are insidious low back pain, leg pain, and numbness. The pain is most often bilateral, involving the buttocks and thighs and spreading distally toward the feet. The classic presentation is radiating leg pain (burning or cramping) that begins or worsens with walking and standing and is relieved by sitting or lying down with hips and knees drawn up in a sitting posture (neurogenic claudication). Bending forward diminishes pain. The signs and symptoms of neurogenic claudication should be differentiated from the leg claudication produced by vascular claudication. Vascular disease pain is exercise induced, is localized to the affected group of muscles, and is relieved rapidly with rest in any position. Neurologic symptoms are absent, and vascular disease is associated with skin and trophic changes (pallor, cyanosis, nail dystrophy, decreased or absent pulse).

Severity of symptoms in spinal stenosis may not necessarily be associated with the degree of compression seen on imaging studies. Rarely, patients with spinal stenosis present with

Urinary Incont With Spinal Stenosis

signs or symptoms of muscle atrophy and loss of bowel and bladder control. Physical examination is frequently normal but may include loss of lumbar lordosis, impairment of spinal mobility, asymmetric knee or ankle reflexes, and muscle weakness. Results of straight-leg raising are characteristically negative.

Advanced imaging studies are obtained to establish and confirm the diagnosis of spinal stenosis when surgery is considered. Plain spine radiographs often reveal degenerative changes. MRI is currently the preferred modality, followed by CT scan (Fig. 31-23).

Conservative treatment is the first line of therapy for spinal stenosis, including adequate pain management, physical therapy, exercise, and weight loss. Progressive symptoms or intractable pain warrant surgical intervention. Wide decompression at the level of stenosis can relieve the symptoms.

KEY TREATMENT

Patients with mild to moderate symptoms of spinal stenosis are managed conservatively (pain/physical therapy, exercise, weight loss) (Snyder et al., 2004) (SOR: C).

Patients with severe symptoms of spinal stenosis benefit from surgery (Amundsen et al., 2000) (SOR: B).

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