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Spinal Stenosis

What is Spinal Stenosis?

The term “stenosis” comes from Greek and means a “choking”. Spinal stenosis is a narrowing of the spinal canal and foramen, which results in “choking” of the spinal cord and/or nerve roots.

In lumbar spinal stenosis, the spinal nerve roots in the lower back are compressed, or ‘choked’, and this can produce symptoms of pain, tingling, weakness or numbness that radiates from the low back and into the buttocks, legs and feet.

Spinal stenosis can also occur in the cervical spine (neck) causing similar symptoms into the arms and sometimes even into the legs.

What Causes Spinal Stenosis?

While stenosis is a gradual onset condition that deteriorates with age it is commonly started by an acute injury.

The most likely cause of spinal stenosis is bone growth encroaching upon the spinal canal as your spine degenerates.

For example, a damaged intervertebral disc, your spines built-in shock absorber, can rupture or partially tear. As a result, it becomes less effective at shock absorbing, much like a flat tyre on your car. This results in more stress transferring through your bony vertebrae (eg your car’s chassis).

However, unlike your car, the additional stress through the bone prompts your body to automatically grow more bone to cope with the addition stress. Unfortunately the bone grows outwards in cross-sectional area and narrows the spinal canal. This extra bone narrows the tunnel that your spinal cord must travel through.

The pressure on the spinal nerves stops them working effectively. Think of your nerves like a garden hose. If you apply too much pressure by standing on it, the water flow will slow and may eventually stop. The same goes for your nerves. The messages they are attempting to pass up or down can be blocked and cause pins and needles, numbness, muscle weakness and absent reflexes eg. Knee jerk.

Is Stenotic Pain Permanent?

In the early stages it won’t be. The extra swelling or fluid in the region as a result of back injuries can cause temporary symptoms that will respond to physiotherapy treatment. However, as your condition deteriorates the tunnel that your spinal cord travels through narrows and can trap the cord permanently.

Who is Likely to Suffer Spinal Stenosis?

Spinal stenosis is most common in men and women over 50 years of age and is related to degenerative changes in the spine. However, it may occur in younger people who are born with a narrowing of the spinal canal or who suffer an injury to the spine.

Why Does Age Cause Spinal Stenosis?

The ageing process is your worst enemy.

As people age, the ligaments of the spine can thicken and calcify (harden from deposits of calcium salts).

Bones and joints may enlarge: when surfaces of the bone begin to project out, these projections are called osteophytes (bone spurs)

With age, the discs in between the vertebra become dehydrated and lose their height. This disc shrinkage is also associated with the development of conditions such as a herniated disc, degenerative disc disease and spondylosis.

When a segment of the spine becomes too mobile, the capsules (enclosing membranes) of the facet joints thicken in an effort to stabilize the segment, and bone spurs may occur. This decreases the space (neural foramen) available for nerve roots leaving the spinal cord.

What Else Can Lead to Stenosis?

Spondylolisthesis

Spondylolisthesis is a condition in which one vertebra slips forward on another. It may result from a degenerative condition or an accident, or, very rarely, may be acquired at birth. Poor alignment of the spinal column when a vertebra slips forward onto the one below it can place pressure on the spinal cord or nerve roots at that place.

Two forms of arthritis that may also affect the spine are Osteoarthritis and Rheumatoid Arthritis.

Osteoarthritis

Osteoarthritis is the most common form of arthritis and is more likely to occur in middle-aged and older people. It is a chronic, degenerative process that may involve multiple joints of the body. It is the result of everyday wear and tear of the joints, and is often accompanied by overgrowth of bone, formation of bone spurs, and impaired function. Spondylosis is a term used which refers to the degeneration of the facet joint(s) and the discs of the spine.

Rheumatoid Arthritis

Rheumatoid Arthritis usually affects people at an earlier age than osteoarthritis does and is associated with inflammation and enlargement of the soft tissues of the joints. Although not a common cause of spinal stenosis, damage to ligaments, bones, and joints that begins as synovitis (inflammation of the synovial membrane which lines the inside of the joint) has a severe and disrupting effect on joint function. The portions of the vertebral column with the greatest mobility (for example, the neck area) are often the ones most affected in people with rheumatoid arthritis.

Stenosis: Signs and Symptoms?

The space in the spine may narrow without actually producing any symptoms. It is only when the narrowing causes the compression of the spinal cord, nerves and nerve roots that there may be an onset of symptoms. The neck or back may not even hurt.

Most commonly people with spinal stenosis experience: numbness, weakness, cramping or general pain in the arms or legs.

Special Tests such as MRI's, CT scans any myelograms can confirm stenosis.

If the narrowed space within the spine is pushing on a nerve root, you may feel pain radiating down the leg (sciatica). However, unlike patients who have sciatica due to slipped disc, this sciatica is relieved by sitting down.

Sitting or bending forward to flex the lower back should relieve the symptoms. The flexed position “opens up” the spinal column and therefore enlarges the spaces between the vertebrae. Because keeping the lower back ‘flexed' (bent forward) relives their symptoms, patients will often walk with a slight stoop forward.

With this adaptive posture, the lower back is often stiff and tightness develops in the hip flexor muscles at the front of the hips.

Standing, walking or bending backwards often makes symptoms worse because this position causes narrowing of the space surrounding the nerves.

For the same reason, walking on flat ground may bring on symptoms of pain or pins and needles in the legs, although walking up a hill may be fine because leaning forwards opens up the space around the nerves.

People with constant or worsening back pain; numbness or pins and needles in the genital region; weakness in both legs; and or disturbances in bladder or bowel function, requires urgent medical attention. Do not delay. Consult your doctor or a hospital immediately.

Stenosis Treatment

How Can Physiotherapy Help?

Manual therapy techniques can be used to help to relieve stiffness and spasm in the lower back. Mobilisation of the vertebral segments can help free up nerves in the lower back. Soft tissue techniques can help to allow greater movement and help to free up the spine to ease pressure in the stenotic area.

Your physiotherapist can provide education regarding pain relieving postures and positions in order to provide some flexion in the lower back and relieve the compression of the nerves.

Self –management of this condition is the key and your physiotherapist can develop a home exercise program to improve the mobility in your lower back and hips and also train the stability muscles which are important to stabilise your spine.

Hydrotherapy is another option as exercise in the water reduces the pressure on the spine and helps to relieve back pain and spasm.

Cardiovascular fitness is important to maintain a healthy heart and lungs and your physiotherapist can help personalize a program for you.

Acupuncture

Acupuncture is an alternative treatment which you can ask your physiotherapist about and its benefits for your management. Research has shown that low back pain is one area in which acupuncture has benefited some people.

Supportive Braces

Braces can be fitted by your physiotherapist are to provide support and pain relief during the acute phase and during flare ups.

Other Treatment Options

Epidural Injections

Provide short term relief for patients with mild to moderate stenosis – usually for those whose pain has not been relieved by other therapies.

Epidural injection usually involves a series of three injections of corticosteroids over several weeks into the epidural space. If successful and pain is relieved, resumption of strengthening and aerobic exercise is recommended to give longer term relief.

While these injections can seldom be considered curative, they can alleviate the pain in about 50% of cases.

Epidural injections should not be used alone but in conjunction with an active rehab program designed by your physiotherapist

There are a number of complications and risks and therefore options should be discussed with your doctor.

Surgery

Surgery may be considered in patients where conservative treatment has been unable to prevent worsening symptoms (over 50% of cases).

Surgery is usually only considered when the patient has severe constant pain that is making everyday tasks impossible and cannot be managed conservatively.

The results of surgery are mixed and there tends to be a poor outcome is patients who have diabetes, hip pain or pain that is predominantly in the back. Surgery is more effective in those people who have leg pain from spinal stenosis.

Surgery will also be considered immediately if you experience numbness or pins and needles in the genital region; weakness in both legs; and or disturbances in bladder or bowel function.

The type of surgical intervention will be based on your specific pathology.

Results of surgical intervention are variable however most studies describe good-to-excellent overall outcomes.

What To Do Now?

We suggest you contact your physiotherapist or doctor for an accurate diagnosis and commence a treatment program. In stubborn or severe cases, you may be a candidate for an epidural injection or decompression surgery.