Spinal Stenosis

N. Wilson Holland, MD, FACP, AGSF and Birju B. Patel, MD, FACP, AGSF Reviewed 06/2017
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Subject: Spinal Stenosis

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BASICS

DESCRIPTION

Narrowing of the spinal canal and foramen: 
  • Spondylosis or degenerative arthritis is the most common cause of spinal stenosis, resulting from compression of the spinal cord by disc degeneration, facet arthropathy, osteophyte formation, and ligamentum flavum hypertrophy.

  • The L4-L5 level is most commonly involved.

EPIDEMIOLOGY

The prevalence of spinal stenosis increases with age due to “wear and tear” on the normal spine. 

Incidence

Symptomatic spinal stenosis affects up to 8% of the general population. 

Prevalence

  • The prevalence of spinal stenosis is high if assessed solely by imaging in elderly patients. Not all patients with radiographic spinal stenosis are symptomatic. The degree of radiographic stenosis does not always correlate with patient symptoms. Lumbar MRI shows significant abnormalities in 57% of patients >60 years.

  • Predominant age: Symptoms develop in 5th to 6th decades (congenital stenosis is symptomatic earlier).

ETIOLOGY AND PATHOPHYSIOLOGY

  • Spinal stenosis can result from congenital or acquired causes. Degenerative spondylosis is most common.

  • Disc dehydration leads to loss of height with bulging of the disc annulus and ligamentum flavum into the spinal canal, increasing facet joint loading.

  • Facet loading leads to reactive sclerosis and osteophytic bone growth, further compressing spinal canal and foraminal elements.

  • Other causes of acquired spinal stenosis include:

    • ▪ Trauma
    • ▪ Neoplasms
    • ▪ Neural cysts and lipomas
    • ▪ Postoperative changes
    • ▪ Rheumatoid arthritis
    • ▪ Diffuse idiopathic skeletal hyperostosis
    • ▪ Ankylosing spondylitis
    • ▪ Metabolic/endocrine causes-osteoporosis, renal osteodystrophy, and Paget disease

Genetics

No definitive genetic links 

RISK FACTORS

Increasing age and degenerative spinal disease 

GENERAL PREVENTION

There is no proven prevention for spinal stenosis. Symptoms can be alleviated with flexion at the waist: 
  • Leaning forward while walking

  • Pushing a shopping cart

  • Lying in flexed position

  • Sitting

  • Avoiding provocative maneuvers (back extension, ambulating long distances without resting)

DIAGNOSIS

HISTORY

  • Helps distinguish spinal stenosis from other causes of back pain and peripheral vascular disease.

    • ▪ Insidious onset and slow progression are typical. Discomfort with standing, paresthesias, and weakness (often bilateral) 1[C]
    • ▪ Symptoms worsen with extension (prolonged standing, walking downhill or downstairs).
    • ▪ Symptoms improve with flexion (sitting, leaning forward while walking, walking uphill or upstairs, lying in a flexed position).
  • Neurogenic claudication (i.e., pain, tightness, numbness, and subjective weakness of lower extremities) may mimic vascular claudication.

PHYSICAL EXAM

Neurologic exam may be normal. Key exam areas: 
  • Examine gait (rule out cervical myelopathy or intracranial pathology).

  • Loss of lumbar lordosis

  • Evaluate range of motion of lumbar spine.

  • Pain with extension of the lumbar spine is typical.

  • Straight-leg raise test may be positive if nerve root entrapment is present.

  • Muscle weakness is usually mild and involves the L4, L5, and (rarely) S1 nerve roots.

  • About half of patients with symptomatic stenosis have a reduced or absent Achilles reflex. Some have reduced or absent patellar reflex.

DIFFERENTIAL DIAGNOSIS

  • Vascular claudication. Symptoms of vascular claudication do not improve with leaning forward and usually abate with standing or rest.

  • Disc herniation

  • Cervical myelopathy

DIAGNOSTIC TESTS & INTERPRETATION

Generally a clinical diagnosis. Imaging (MRI is best) is used to stage severity and plan treatment. 

Initial Tests (lab, imaging)

  • CBC, ESR, C-reactive protein (if considering infection or malignancy)

  • New back pain lasting >2 weeks or back pain accompanied by neurologic findings in patients >50 years generally warrants neuroimaging.

  • MRI is the modality of choice.

  • CT myelography is an alternative to MRI but is invasive and has higher risk of complications.

  • Plain radiography helps exclude other causes of new back pain (e.g., malignant lytic lesions) but does not reveal the underlying pathology.

  • Radiologic abnormalities in general do not correlate with the clinical severity.

Diagnostic Procedures/Other

Surgical decompression is definitive for patients who are symptomatic after nonoperative treatment: 
  • Spinal stenosis generally does not lead to neurologic damage.

  • Surgery may be required for pain relief to increase mobility and improve quality of life.

Test Interpretation

Common radiographic findings include decreased disc height, facet hypertrophy, and spinal canal and/or foraminal narrowing. 

TREATMENT

  • In general, nonoperative interventions are preferred in the absence of progressive or debilitating neurologic symptoms:

    • ▪ Physical therapy, exercise, weight management, medications, and epidural steroid injections are options. There is insufficient evidence to definitively guide clinical practice.
    • ▪ Patients should understand that the benefits of surgery may diminish over time.
    • ▪ Rule out other neuropathies and peripheral vascular disease.
  • Spinal decompression and physical therapy yield similar effects 2[A].

  • There is controversy about fusion being performed with decompression because of a future spondylolisthesis risk 3[C].

MEDICATION

First Line

  • Acetaminophen: caution in those with preexisting liver disease; increased warnings for hepatotoxicity; limit daily dosing in the elderly.

  • NSAIDs: Consider potential for GI side effects, fluid retention, and renal failure.

Second Line

  • Tramadol—currently a schedule IV controlled substance; has the potential to cause confusion, dizziness, lower seizure threshold, and increase fall risk in the elderly; should be used with caution

  • The available evidence does not support the routine use of epidural steroid injections. Judicious injections may be reasonable in certain cases.

  • Use opioids sparingly and only when other treatments have failed to control severe pain.

Geriatric Considerations

  • Anti-inflammatory medications should be used with caution in the elderly due to the risks of GI bleeding, fluid retention, renal failure, and cardiovascular risks.

  • Side effects of opioids include constipation, confusion, urinary retention, drowsiness, nausea, vomiting, and the potential for dependence and abuse.

  • >10% of elderly lack Achilles reflexes.

ISSUES FOR REFERRAL

Patients in unremitting pain or with a neurologic deficit should see a neurosurgeon. 

ADDITIONAL THERAPIES

  • Patients with spinal stenosis are typically able to ride a bicycle (leaning forward tends to relieve symptoms).

  • Aquatic therapy (helpful for muscle training and general conditioning)

  • Strengthening of abdominal and back muscles

  • Gait training

  • While a brace or corset may help in the short term, use is not recommended for prolonged periods due to development of paraspinal muscle weakness.

  • Encourage physical activity to prevent deconditioning.

SURGERY/OTHER PROCEDURES

  • Surgery is indicated when symptoms persist despite conservative measures.

  • Age alone should not be an exclusion factor for surgical intervention. Cognitive impairment, multiple comorbidities, and osteoporosis may increase the risk of perioperative complications in the elderly.

  • Lumbar decompressive laminectomy is the mainstay of treatment. The traditional approach is laminectomy and partial facetectomy.

  • Controversy exists about whether the decompression should be supplemented by a fusion procedure:

    • ▪ There is evidence that fusion (simple or complex), as opposed to decompression procedure alone, may be associated with higher risk of major complications, increased mortality, and increased resource use in the elderly.
  • A less invasive alternative, known as interspinous distraction (X STOP implant), is an option 4[B].

  • The evidence for use of the Aperius interspinous implant device is inconclusive 5[C].

  • A unilateral partial hemilaminectomy combined with transmedial decompression may adequately treat stenosis with less morbidity in the elderly 6[C].

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

  • Admission criteria/initial stabilization: acute or progressive neurologic deficit

  • Discharge criteria: improved pain or after neurologic deficit has been addressed

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Follow up based on progression of symptoms.

  • No limitations to activity; patients may be as active as tolerated. Exercise should be encouraged.

Patient Monitoring

Patients are monitored for improvement of symptoms and development of any complications. 

DIET

Optimize nutrition for weight management. 

PATIENT EDUCATION

  • Activity as tolerated, if no other pathology is present (e.g., fractures)

  • Patients should present for care if they develop progressive motor weakness and/or bladder/bowel dysfunction.

  • Patients should know the natural history of the condition and how best to relieve symptoms.

PROGNOSIS

  • Spinal stenosis is generally benign, but the pain can lead to limitation in ADLs and progressive disability.

  • Surgery usually improves pain and symptoms in patients who fail nonoperative treatment.

  • Surgical outcomes are similar in terms of pain relief and functional improvement for patients of all ages.

COMPLICATIONS

  • Severe spinal stenosis can lead to bowel and/or bladder dysfunction.

  • Surgical complications include infection, neurologic injury, chronic pain, and disability.

REFERENCES

Suri  P, Rainville  J, Kalichman  L, et al. Does this older adult with lower extremity pain have the clinical syndrome of lumbar spinal stenosis? JAMA.  2010;304(23):2628–2636.  [View Abstract]
Delitto  A, Piva  SR, Moore  CG, et al. Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial. Ann Intern Med.  2015:162(7):465–473.  [View Abstract]
Deyo  RA, Ching  A, Matsen  L, et al. Use of bone morphogenetic proteins in spinal fusion surgery for older adults with lumbar stenosis: trends, complications, repeat surgery, and charges. Spine (Phila Pa 1976).  2012;37(3):222–230.  [View Abstract]
Miller  LE, Block  JE. Interspinous spacer implant in patients with lumbar spinal stenosis: preliminary results of a multicenter, randomized, controlled trial. Pain Res Treat.  2012;2012:823509.  [View Abstract]
Surace  MF, Fagetti  A, Fozzato  S, et al. Lumbar spinal stenosis treatment with Aperius perclid interspinous system. Eur Spine J.  2012;21(Suppl 1):S69–S74.  [View Abstract]
Morgalla  MH, Noak  N, Merkle  M, et al. Lumbar spinal stenosis in elderly patients: is a unilateral microsurgical approach sufficient for decompression? J Neurosurg Spine.  2011;14(3):305–312.  [View Abstract]

SEE ALSO

Algorithm: Low Back Pain, Acute 

CODES

ICD10

  • M48.00 Spinal stenosis, site unspecified

  • M48.06 Spinal stenosis, lumbar region

  • M48.04 Spinal stenosis, thoracic region

  • M48.05 Spinal stenosis, thoracolumbar region

  • M48.08 Spinal stenosis, sacral and sacrococcygeal region

  • M48.07 Spinal stenosis, lumbosacral region

  • M48.02 Spinal stenosis, cervical region

  • M48.01 Spinal stenosis, occipito-atlanto-axial region

  • M47.9 Spondylosis, unspecified

  • M48.03 Spinal stenosis, cervicothoracic region

ICD9

  • 724.00 Spinal stenosis, unspecified region

  • 724.02 Spinal stenosis, lumbar region, without neurogenic claudication

  • 724.01 Spinal stenosis, thoracic region

  • 724.09 Spinal stenosis, other region

  • 723.0 Spinal stenosis in cervical region

  • 721.90 Spondylosis of unspecified site, without mention of myelopathy

  • 724.03 Spinal stenosis, lumbar region, with neurogenic claudication

SNOMED

  • 76107001 Spinal stenosis (disorder)

  • 18347007 Spinal stenosis of lumbar region

  • 41341006 Spinal stenosis of thoracic region

  • 370471003 Lumbosacral stenosis (disorder)

  • 8847002 Spondylosis (disorder)

  • 83561009 Spinal stenosis in cervical region

  • 202783003 Degenerative thoracic spinal stenosis (disorder)

  • 202761002 Degenerative cervical spinal stenosis (disorder)

  • 202788007 Degenerative lumbar spinal stenosis (disorder)

CLINICAL PEARLS

  • Spinal stenosis typically presents as neurogenic claudication (pain, tightness, numbness, and subjective weakness of lower extremities), which can mimic vascular claudication.

  • Flexion of the spine generally relieves symptoms associated with spinal stenosis.

  • Spinal extension (prolonged standing, walking downhill, and walking downstairs) can worsen symptoms of spinal stenosis.

  • Consider urgent surgery for patients with cauda equina/conus medullaris syndrome or progressive bladder dysfunction. Other patients with lumbar spinal stenosis typically do well with initial conservative management.

 
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