View source for Spinal Stenosis

{{Infobox disease
| Name            = Spinal stenosis
| Image           = LUMBAR TREFOIL CANAL.JPG|thumb
| Alt             = 
| Caption         = Lumbar trefoil canal| 
| DiseasesDB      = 
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| OMIM            = 
| MedlinePlus     = 000441
| eMedicineSubj   = 
| eMedicineTopic  = 
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| GeneReviewsNBK  = 
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}}
{{SI}}
'''Spinal stenosis''' is an abnormal narrowing ([[stenosis]]) of the [[spinal canal]] that may occur in any of the regions of the spine. This narrowing causes a restriction to the spinal canal, resulting in a [[neurological deficit]]. Symptoms include pain, numbness, [[paraesthesia]], and loss of motor control. The location of the stenosis determines which area of the body is affected.<ref name=eMed>{{cite web|url= http://emedicine.medscape.com/article/1264527-overview |title= Spinal Stenosis |author= Vokshoor A |date= February 14, 2010 |accessdate= December 30, 2010 |publisher=eMedicine}}</ref> With spinal stenosis, the spinal canal is narrowed at
the [[vertebral canal]], which is a [[foramen]] between the vertebrae where the spinal cord (in the cervical or thoracic spine) or nerve roots (in the lumbar spine) pass through.<ref>http://www.niams.nih.gov/Health_Info/Spinal_Stenosis/spinal_stenosis_ff.asp</ref>
There are several types of spinal stenosis, with [[lumbar stenosis]] and [[cervical spinal stenosis|cervical stenosis]] being the most frequent. While lumbar spinal stenosis is more common, cervical spinal stenosis is more dangerous because it involves compression of the [[spinal cord]] whereas the lumbar spinal stenosis involves compression of the [[cauda equina]]. 

== Types == 

The most common forms are cervical spinal stenosis, at the level of the neck, and [[lumbar spinal stenosis]], at the level of the lower back. Thoracic spinal stenosis, at the level of the mid-back, is much less common.<ref name=eMed/>

In lumbar stenosis, the spinal [[nerve roots]] in the lower back are compressed which can lead to symptoms of [[sciatica]] (tingling, weakness, or numbness that radiates from the low back and into the buttocks and legs).

Cervical spinal stenosis can be far more dangerous by compressing the spinal cord. Cervical canal stenosis may lead to serious symptoms such as major body weakness and paralysis. Such severe spinal stenosis symptoms are virtually absent in  [[lumbar stenosis]], however, as the spinal cord terminates at the top end of the adult lumbar spine, with only nerve roots (cauda equina) continuing further down.<ref name= Waxman>{{cite book | last=Waxman | first = SG | title=Correlative Neuroanatomy | edition=24th | date = 2000}}</ref> Cervical spinal stenosis is a condition involving narrowing of the [[spinal canal]] at the level of the [[neck]]. It is frequently due to chronic degeneration,<ref name=Meyer08>{{cite journal |author=Meyer F, Börm W, Thomé C |title=Degenerative cervical spinal stenosis: current strategies in diagnosis and treatment |journal=Dtsch Arztebl Int |volume=105 |issue=20 |pages=366–72 |date=May 2008 |pmid=19626174 |pmc=2696878 |doi=10.3238/arztebl.2008.0366 |url=}}</ref> but may also be congenital or traumatic. Treatment frequently is surgical.<ref name=Meyer08/>

== Signs and symptoms ==
[[File:Spinal Stenosis.png|thumb|Illustration depicting spinal stenosis and spinal cord compression]]
===Common===
* Standing discomfort (94%)
* Numbness (63%)
* Weakness (43%)
* Bilateral symptoms (68%)
* Discomfort above and below knee (78%)
* Buttock / Thigh only (15%)
* Below the knee (7%)<ref name="Mazanec">Mazanec, D.J., Podichetty, V.K., Hsia, A. (2002) Lumbar Canal Stenosis: Start with nonsurgical therapy. Cleveland Clinic Journal of Medicine 69(11).</ref>


===Neurological disorders===
* [[Radiculopathy|Pinched nerve]],<ref name=AAOS>{{cite web|title=Cervical Radiculopathy (Pinched Nerve)|url=http://orthoinfo.aaos.org/topic.cfm?topic=A00332|work=[[American Academy of Orthopaedic Surgeons|AAOS]]|accessdate=13 December 2011}}</ref> causing numbness.
* Intermittent neurogenic [[claudication]] <ref name="Mazanec" /><ref name="Costantini">Costantini, A., Buchser, E., Van Buyten, J.P. (2009). Spinal Cord Stimulation for the Treatment of Chronic Pain in Patients with Lumbar Spinal Stenosis. Neuromodulation, 13(4), 275-380. {{doi|10.1111/j.1525-1403.2010.00289.x}}</ref><ref name="Goren">Goren, A., Yildiz, N., Topuz, O., Findikoglu, G., & Ardic, F. (2010). Efficacy of exercise and ultrasound in patients with lumbar spinal stenosis: A prospective randomized controlled trial. Clinical Rehabilitation, 24(7), 623-631. {{doi|10.1177/0269215510367539}}</ref> characterized by lower limb numbness, weakness, diffuse or radicular leg pain associated with paresthesis (bilaterally),<ref name="Costantini" /> weakness heaviness in buttocks radiating into lower extremities with walking or prolonged standing.<ref name="Mazanec" /> Symptoms occur with [[Extension (kinesiology)|extension]] of spine and are relieved with spine [[flexion]]. Minimal to zero symptoms when seated or [[supine position|supine]].<ref name="Mazanec" />  
[[Image:Illu vertebral column.jpg|thumb|A [[human vertebral column]]]]
* Radiculopathy (with or without [[radicular pain]]) <ref name="Costantini" /> neurologic condition - nerve root dysfunction causes objective signs such as weakness, loss of sensation and of reflex.
* [[Cauda equina syndrome]] <ref name="Doorly">Doorly, T.P., Lambing, C.L., Malanga, G.A., Maurer, P.M., Ralph R., R. (2010). Algorithmic approach to the management of the patient with lumbar spinal stenosis. Journal of Family Practice, 59 S1-S8</ref> Lower extremity pain, weakness, numbness that may involve [[perineum]] and buttocks, associated with bladder and bowel dysfunction.

===Other===
* Fever
* Nocturnal pain
* [[Gait]] disturbance
* Structural deformity
* Unexplained weight loss
* Previous [[carcinoma]]
* Severe pain upon lying down
* Recent trauma with suspicious fracture
* Presence of severe or progressive [[neurologic]] deficit <ref name="Doorly" />
* Lower back pain <ref name="Mazanec" /><ref name="Goren" /> due to degenerative disc or joint changes  <ref>Mazanec, D.J., Podichetty, V.K., Hsia, A. (2002) LumbarClinic Journal of Medicine 69(11).</ref> 
* Narrowing of spinal canal, nerve root canal or intervertebral Canal Stenosis: Start with nonsurgical therapy. Cleveland ral [[foramina]] <ref name="Goren" />

==Causes==

Aging:
All the factors below may cause the spaces in the spine to narrow,
* Body’s [[ligaments]] can thicken (ligamentum flavum)
* [[Bone spurs]] develop on the bone and into the spinal canal
* [[Intervertebral discs]] may bulge or herniate into the canal
* Facet joints break down
* Compression fractures of the spine, which are common in osteoporosis
* Cysts form on the facet joints causing compression of the spinal sack of nerves (thecal sac)

Arthritis:
Two types,
* [[Osteoarthritis]]
* [[Rheumatoid arthritis]]—much less common cause of spinal problems

Heredity:
* Spinal canal is too small at birth
* Structural deformities of the vertebrae may cause narrowing of the spinal canal

Instability of the spine, or [[spondylolisthesis]]:
* A vertebra slips forward on another

Trauma:
* Accidents and injuries may dislocate the spine and the spinal canal or cause [[burst fractures]] that yield fragments of bone that go through the canal <ref>http://www.mayoclinic.com/health/spinal-stenosis/DS00515/DSECTION=causes</ref>

[[Tumors]] of the spine:
* Irregular growths of soft tissue will cause inflammation 
* Growth of tissue into the canal pressing on nerves, the sac of nerves, or the spinal cord.

==Diagnosis==
Making the diagnosis of spinal stenosis involves a complete evaluation of the spine. The process always begins with a medical history and physical [[File:SPINAL STENOSIS.JPG|thumb|MRI exhibiting areas of lumbar stenosis]]examination. Imaging studies (x-ray, MRI, etc.) are often used to determine the extent and location of the nerve compression.

===Medical history===
The medical history is the most important aspect of the examination as it will tell the physician about subjective symptoms, possible causes for spinal stenosis, and other possible causes of back pain.<ref name="orthopedics.about">Cluett, Jonathan, M.D.  (2010) How is spinal stenosis diagnosed, spinal stenosis, http://orthopedics.about.com/cs/spinalstenosis/a/spinalstenosis_2.htm</ref>

===Physical examination===
The physical examination of a patient with spinal stenosis will give the physician information about exactly where nerve compression is occurring. Some important factors that should be investigated are any areas of sensory abnormalities, numbness, irregular [[reflexes]], and any muscular weakness.
<ref name="orthopedics.about" />

===MRI===
The [[MRI]] has become the most frequently used study to diagnose spinal stenosis. The MRI uses magnetic signals (instead of x-rays) to produce images of the spine. MRIs are helpful because they show more structures, including nerves, muscles, and ligaments, than seen on x-rays or [[CT scans]]. MRIs are helpful at showing exactly what is causing spinal nerve compression.<ref name="orthopedics.about" />

===CT myelogram===
A spinal tap is performed in the low back with dye injected into the spinal fluid.  X-Rays are performed followed by a CT scan of the spine to help see narrowing of the spinal canal.
This is a very effective study in cases of lateral recess stenosis.  It is also necessary in patients with a pacemaker as they cannot undergo an MRI.

==Treatments==
Non-surgical treatment includes:

* '''[[Chiropractic]]'''; How is stenosis treated?
Conservative [[chiropractic]] approach, which includes [[manipulation]], exercise and self-care techniques; and surgery. The source of the stenosis often dictates the treatment.
Ultimately, stenosis is a chronic condition that cannot be “cured,” but it often can be improved, and improvement can be maintained over the long term. Patients can work with a health care provider, such as a doctor of chiropractic, to reduce symptoms and improve their quality of life. <ref name = "ACA">{{cite web
| last = Staff Writer
| title = Spinal stenosis
| work = ACA Today
| publisher = [[American Chiropractic Association]]
| url = http://www.acatoday.org/content_css.cfm?CID=3126
| accessdate = 6/11/2014}}</ref>

* Education about the course of the condition and how to relieve symptoms

* Medicines to relieve pain and inflammation, such as [[acetaminophen]], [[nonsteroidal anti-inflammatory drug]]s (NSAIDs), and DMARDs [disease modifying anti-rheumatic drug], such as methotrexate (http://en.wikipedia.org/wiki/Methotrexate), Enbrel (http://en.wikipedia.org/wiki/Enbrel), and Humira (http://en.wikipedia.org/wiki/Humira).

* Exercise, to maintain or achieve overall good health, [[aerobic exercise]], such as riding a stationary bicycle, which allows for a forward lean, walking, or swimming can relieve symptoms

* Weight loss, to relieve symptoms and slow progression of the stenosis

* [[Physical therapy]], to provide education, instruction, and support for self-care; physical therapy instructs on stretching and strength exercises that may lead to a decrease in pain and other symptoms <ref>http://www.webmd.com/back-pain/tc/lumbar-spinal-stenosis-treatment-overview</ref>

* Lumbar Epidural Steroid Injections - these may provide some temporary relief and sometimes work for a few years.  If the stenosis is severe, these are not very beneficial.

===Surgical Treatment===
* Lumbar decompressive laminectomy - Removing the roof of bone overlying the spinal canal and thickened ligaments in order to decompress the nerves and sac of nerves. 70-90% of people have good results.<ref>{{cite book|last=Malamut|first=edited by Joseph I. Sirven, Barbara L.|title=Clinical neurology of the older adult|date=2008|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins|location=Philadelphia|isbn=9780781769471|page=220|url=http://books.google.ca/books?id=c1tL8C9ryMQC&pg=PA220|edition=2nd ed.}}</ref>

* Interlaminar implant - A non-fusion U-shaped device which is placed between two bones in the lower back that maintains motion in the spine and keeps the spine stable after a lumbar decompressive surgery. The U-shaped device maintains height between the bones in the spine so nerves can exit freely and extend to lower extremities.<ref>http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm327502.htm</ref>

==Epidemiology==
* Swedish study defined spinal stenosis as a canal of 11mm or less found an incidence of 5 per 100,000 inhabitants.<ref>http://www.vancouverspinecarecentre.com/con_spinalstenosis</ref>
* National Low Back Pain Study recorded that out of 2,374 patients with low back pain, 35% had bone related spinal nerve compression.
* Data from National Ambulatory Medical Care survey suggests 13-14% of patients with low back pain may have spinal stenosis.
* The NAMCS data shows the incidence in the U.S. population to be 3.9% of 29,964,894 visits for mechanical back problems.<ref>Spinal Stenosis. (2011) In SpinalStenosis.org. Retrieved 2/29/12, from http://www.spinalstenosis.org/.</ref>
* The Longitudinal Framingham Heart Study found 1% of men and 1.5% of women had vertebral slippage at mean age of 54. Over the next 25 years, 11% of men and 25% of women developed degenerative vertebral slippage.<ref>Treatment of Degenerative Lumbar Spinal Stenosis: Summary of Evidence Report/Technology Assessment, No. 32. (2001). In AHRQ Archive--Home Page. Retrieved 2/29/2012, fromhttp://archive.ahrq.gov/clinic/epcsums/stenosum.htm.</ref>
* 250,000-500,000 U.S. residents have symptoms of spinal stenosis.

== References ==
{{reflist}}

==External links==
* http://www.uvm.edu/medicine/documents/CMS_Monsey_Spinal_Stenosis_Resources_101210.pdf
* http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001477/

[[Category:Geriatrics]]
[[Category:Spinal cord disorders]]
[[Category:Vertebral column disorders]]
[[Category:Conditions DC's treat]]