Treatment may involve medications,bracing, or surgery.[6] Medications may includeNSAIDs,acetaminophen, anticonvulsants (gabapentinoids) orsteroid injections.[8][7] Stretching and strengthening exercises may also be useful.[1] Limiting certain activities may be recommended.[6] Surgery is typically only done if other treatments are not effective, with the usual procedure being adecompressive laminectomy.[7]
Spinal stenosis occurs in as many as 8% of people.[4] It occurs most commonly in people over the age of 50.[9] Males and females are affected equally often.[10] The first modern description of the condition is from 1803 byAntoine Portal, and there is evidence of the condition dating back toAncient Egypt.[11]
The most common forms arelumbar spinal stenosis, at the level of the lower back, andcervical spinal stenosis, which are at the level of the neck.[12] Thoracic spinal stenosis, at the level of the mid-back, is much less common.[13]
In lumbar stenosis, the spinalnerve roots in the lower back are compressed which can lead to symptoms ofsciatica (tingling, weakness, or numbness that radiates from the low back and into the buttocks and legs).[citation needed]
Cervical spinal stenosis can be far more dangerous by compressing the spinal cord. Cervical canal stenosis may lead tomyelopathy, a serious condition causing symptoms including major body weakness and paralysis.[14] Such severe spinal stenosis symptoms are virtually absent inlumbar 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.[15] Cervical spinal stenosis is a condition involving narrowing of thespinal canal at the level of theneck. It is frequently due to chronic degeneration,[16] but may also be congenital or traumatic. Treatment frequently is surgical.[16]
Cervical (spondylotic) myelopathy,[18] a syndrome caused by compression of the cervical spinal cord which is associated with "numb and clumsy hands", imbalance, loss of bladder and bowel control, and weakness that can progress to paralysis.
Intermittentneurogenic claudication[17][20][21] characterized by lower limb numbness, weakness, diffuse orradicular leg pain associated withparesthesia (bilaterally),[20] weakness and/or heaviness in buttocks radiating into lower extremities with walking or prolonged standing.[17] Symptoms occur withextension of spine and are relieved with spineflexion. Minimal to zero symptoms when seated orsupine.[17]
Radiculopathy (with or withoutradicular pain),[20] a neurologic condition in which nerve root dysfunction causes objective signs such as weakness, loss of sensation, and loss of reflex.
Cauda equina syndrome:[22] lower extremity pain, weakness, numbness that may involveperineum and buttocks, associated with bladder and bowel dysfunction.
Lower back pain[17][21] due to degenerative disc or joint changes.[23]
Accidents and injuries may dislocate the spine and the spinal canal or causeburst fractures that yield fragments of bone that go through the canal.[32]
Patients with cervical myelopathy caused by narrowing of the spinal canal are at higher risk of acute spinal cord injury if involved in accidents.[33]
The diagnosis of spinal stenosis involves a complete evaluation of the spine. The process usually begins with a medical history and physical examination. X-ray andMRI scans are typically used to determine the extent and location of the nerve compression.[citation needed]
The medical history is the most important aspect of the examination as it will tell the physician about subjective symptoms, possible causes of spinal stenosis, and other possible causes of back pain.[34]
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, irregularreflexes, and any muscular weakness.[34]
MRI has become the most frequently used study to diagnose spinal stenosis. The MRI uses electromagnetic signals to produce images of the spine. MRIs are helpful because they show more structures, including nerves, muscles, and ligaments than seen onX-rays orCT scans. MRIs are helpful in showing exactly what is causing spinal nerve compression.[citation needed]
In CT myelography,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 for patients in which MRI is contraindicated, such as those with implanted pacemakers.[citation needed]
Treatment options are either surgical or non-surgical. The overall evidence is inconclusive whether non-surgical or surgical treatment is better for lumbar spinal stenosis.[35]
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 the progression of the stenosis
Physical therapy to support self-care.[37] Also may give instructions on stretching and strength exercises that may lead to a decrease in pain and other symptoms.
Lumbar epidural steroid or anesthetic injections have low quality evidence to support their use.[36][38]
Lumbar decompressive laminectomy: This involves removing the roof of bone overlying the spinal canal and thickened ligaments in order to decompress the nerves and sacs of nerves. 70–90% of people have good results.[39]
Interlaminar implant: This is a non-fusion U-shaped device that 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.[40]
Surgery for cervical myelopathy is either conducted from the front or from the back, depending on several factors such as where the compression occurs and how the cervical spine is aligned.
Anterior cervical discectomy and fusion: A surgical treatment of nerve root or spinal cord compression by decompressing the spinal cord and nerve roots of the cervical spine with a discectomy in order to stabilize the corresponding vertebrae.
Posterior approaches seek to generate space around the spinal cord by removing parts of the posterior elements of the spine. Techniques includelaminectomy, laminectomy and fusion, andlaminoplasty.
Decompression plus fusion appears no better than decompression alone, while spinal spacers appear better than decompression plus fusion but not better than decompression alone.[41][42] No differences were found in the type of decompression.[42]
In a study of 146 patients with lumbar spinal stenosis (mean age, 68 years, 42% women) who did not undergo surgery, followed up for 3 years, the study reported that approximately one-third of participants indicated improvement; approximately 50% reported no change in symptoms; and approximately 10% to 20% of patients condition worsened.[41]
^abcCostantini A, Buchser E, Van Buyten JP (October 2010). "Spinal cord stimulation for the treatment of chronic pain in patients with lumbar spinal stenosis".Neuromodulation.13 (4):275–9, discussion 279–80.doi:10.1111/j.1525-1403.2010.00289.x.PMID21992882.S2CID19179148.
^abGoren A, Yildiz N, Topuz O, Findikoglu G, Ardic F (July 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.PMID20530650.S2CID22912838.
^abDoorly TP, Lambing CL, Malanga GA, Maurer PM, Rashbaum RF (August 2010). "Algorithmic approach to the management of the patient with lumbar spinal stenosis".The Journal of Family Practice.59 (8 Suppl Algorithmic): S1–8.PMID20733968.
^Mazanec DJ, Podichetty VK, Hsia A (November 2002). "Lumbar canal stenosis: start with nonsurgical therapy".Cleveland Clinic Journal of Medicine.69 (11):909–17.doi:10.3949/ccjm.69.11.909.PMID12430977.
^Park JB, Lee JK, Park SJ, Riew KD (December 2005). "Hypertrophy of ligamentum flavum in lumbar spinal stenosis associated with increased proteinase inhibitor concentration".The Journal of Bone and Joint Surgery. American Volume.87 (12):2750–2757.doi:10.2106/JBJS.E.00251.PMID16322626.
^Chou R, Hashimoto R, Friedly J, Fu R, Bougatsos C, Dana T, et al. (September 2015). "Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis".Annals of Internal Medicine.163 (5):373–381.doi:10.7326/M15-0934.PMID26302454.S2CID25696028.
^Deen Jr HG (2008)."Back and Neck Pain". In Sirven JI, Malamut BL (eds.).Clinical Neurology of the Older Adult (2nd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 220.ISBN978-0-7817-6947-1.
^abKatz, Jeffrey N.; Zimmerman, Zoe E.; Mass, Hanna; Makhni, Melvin C. (2022-05-03). "Diagnosis and Management of Lumbar Spinal Stenosis".JAMA.327 (17). American Medical Association (AMA):1688–1699.doi:10.1001/jama.2022.5921.ISSN0098-7484.PMID35503342.S2CID248503972.
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