Overview

Spinal stenosis is a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine. Spinal stenosis occurs most often in the lower back and the neck.

Some people with spinal stenosis may not have symptoms. Others may experience pain, tingling, numbness and muscle weakness. Symptoms can worsen over time.

Spinal stenosis is most commonly caused by wear-and-tear changes in the spine related to osteoarthritis. In severe cases of spinal stenosis, doctors may recommend surgery to create additional space for the spinal cord or nerves.

Types of spinal stenosis

The types of spinal stenosis are classified according to where on the spine the condition occurs. It's possible to have more than one type. The two main types of spinal stenosis are:

• Cervical stenosis. In this condition, the narrowing occurs in the part of the spine in your neck.
• Lumbar stenosis. In this condition, the narrowing occurs in the part of the spine in your lower back. It's the most common form of spinal stenosis.

Symptoms

Many people have evidence of spinal stenosis on an MRI or CT scan but may not have symptoms. When they do occur, they often start gradually and worsen over time. Symptoms vary depending on the location of the stenosis and which nerves are affected.

In the neck (cervical spine)

• Numbness or tingling in a hand, arm, foot or leg
• Weakness in a hand, arm, foot or leg
• Problems with walking and balance
• Neck pain
• In severe cases, bowel or bladder dysfunction (urinary urgency and incontinence)

In the lower back (lumbar spine)

• Numbness or tingling in a foot or leg
• Weakness in a foot or leg
• Pain or cramping in one or both legs when you stand for long periods of time or when you walk, which usually eases when you bend forward or sit
• Back pain

When to see a doctor

See your doctor if you have any of the symptoms listed.

Causes

The backbone (spine) runs from your neck to your lower back. The bones of your spine form a spinal canal, which protects your spinal cord (nerves).

Some people are born with a small spinal canal. But most spinal stenosis occurs when something happens to narrow the open space within the spine. Causes of spinal stenosis may include:

• Overgrowth of bone. Wear and tear damage from osteoarthritis on your spinal bones can prompt the formation of bone spurs, which can grow into the spinal canal. Paget's disease, a bone disease that usually affects adults, also can cause bone overgrowth in the spine.
• Herniated disks. The soft cushions that act as shock absorbers between your vertebrae tend to dry out with age. Cracks in a disk's exterior may allow some of the soft inner material to escape and press on the spinal cord or nerves.
• Thickened ligaments. The tough cords that help hold the bones of your spine together can become stiff and thickened over time. These thickened ligaments can bulge into the spinal canal.
• Tumors. Abnormal growths can form inside the spinal cord, within the membranes that cover the spinal cord or in the space between the spinal cord and vertebrae. These are uncommon and identifiable on spine imaging with an MRI or CT.
• Spinal injuries. Car accidents and other trauma can cause dislocations or fractures of one or more vertebrae. Displaced bone from a spinal fracture may damage the contents of the spinal canal. Swelling of nearby tissue immediately after back surgery also can put pressure on the spinal cord or nerves.

Risk factors

Most people with spinal stenosis are over the age of 50. Though degenerative changes can cause spinal stenosis in younger people, other causes need to be considered. These include trauma, congenital spinal deformity such as scoliosis, and a genetic disease affecting bone and muscle development throughout the body. Spinal imaging can differentiate these causes.

Complications

Rarely, untreated severe spinal stenosis may progress and cause permanent:

• Numbness
• Weakness
• Balance problems
• Incontinence
• Paralysis

Diagnosis

To diagnose spinal stenosis, your doctor may ask you about signs and symptoms, discuss your medical history, and conduct a physical examination. He or she may order several imaging tests to help pinpoint the cause of your signs and symptoms.

Imaging tests

These tests may include:

• X-rays. An X-ray of your back can reveal bony changes, such as bone spurs that may be narrowing the space within the spinal canal. Each X-ray involves a small exposure to radiation.
• Magnetic resonance imaging (MRI). An MRI uses a powerful magnet and radio waves to produce cross-sectional images of your spine. The test can detect damage to your disks and ligaments, as well as the presence of tumors. Most important, it can show where the nerves in the spinal cord are being pressured.
• CT or CT myelogram. If you can't have an MRI, your doctor may recommend computerized tomography (CT), a test that combines X-ray images taken from many different angles to produce detailed, cross-sectional images of your body. In a CT myelogram, the CT scan is conducted after a contrast dye is injected. The dye outlines the spinal cord and nerves, and it can reveal herniated disks, bone spurs and tumors.

Treatment

Treatment for spinal stenosis depends on the location of the stenosis and the severity of your signs and symptoms.

Talk to your doctor about the treatment that's best for your situation. If your symptoms are mild or you aren't experiencing any, your doctor may monitor your condition with regular follow-up appointments. He or she may offer some self-care tips that you can do at home. If these don't help, he or she may recommend medications or physical therapy. Surgery may be an option if other treatments haven't helped.

Medications

Your doctor may prescribe:

• Pain relievers. Pain medications such as ibuprofen (Advil, Motrin IB, others), naproxen (Aleve, others) and acetaminophen (Tylenol, others) may be used temporarily to ease the discomfort of spinal stenosis. They are typically recommended for a short time only, as there's little evidence of benefit from long-term use.
• Antidepressants. Nightly doses of tricyclic antidepressants, such as amitriptyline, can help ease chronic pain.
• Anti-seizure drugs. Some anti-seizure drugs, such as gabapentin (Neurontin) and pregabalin (Lyrica), are used to reduce pain caused by damaged nerves.
• Opioids. Drugs that contain codeine-related drugs such as oxycodone (Oxycontin, Roxicodone) and hydrocodone (Norco, Vicodin) may be useful for short-term pain relief. Opioids may also be considered cautiously for long-term treatment. But they carry the risk of serious side effects, including becoming habit forming.

Physical therapy

It's common for people who have spinal stenosis to become less active, in an effort to reduce pain. But that can lead to muscle weakness, which can result in more pain. A physical therapist can teach you exercises that may help:

• Build up your strength and endurance
• Maintain the flexibility and stability of your spine
• Improve your balance

Steroid injections

Your nerve roots may become irritated and swollen at the spots where they are being pinched. While injecting a steroid medication (corticosteroid) into the space around impingement won't fix the stenosis, it can help reduce the inflammation and relieve some of the pain.

Steroid injections don't work for everyone. And repeated steroid injections can weaken nearby bones and connective tissue, so you can only get these injections a few times a year.

Decompression procedure

With this procedure, needle-like instruments are used to remove a portion of a thickened ligament in the back of the spinal column to increase spinal canal space and remove nerve root impingement. Only patients with lumbar spinal stenosis and a thickened ligament are eligible for this type of decompression.

The procedure is called percutaneous image-guided lumbar decompression (PILD). It has also been called minimally invasive lumbar decompression (MILD), but to avoid confusion with minimally invasive surgical procedures, doctors have adopted the term PILD.

Because PILD is performed without general anesthesia, it may be an option for some people with high surgical risks from other medical problems.

Surgery

Surgery may be considered if other treatments haven't helped or if you're disabled by your symptoms. The goals of surgery include relieving the pressure on your spinal cord or nerve roots by creating more space within the spinal canal. Surgery to decompress the area of stenosis is the most definitive way to try to resolve symptoms of spinal stenosis.

Research shows that spine surgeries result in fewer complications when done by highly experienced surgeons. Don't hesitate to ask about your surgeon's experience with spinal stenosis surgery. If you have any doubts, get a second opinion.

Examples of surgical procedures to treat spinal stenosis include:

• Laminectomy. This procedure removes the back part (lamina) of the affected vertebra. A laminectomy is sometimes called decompression surgery because it eases the pressure on the nerves by creating more space around them.

  In some cases, that vertebra may need to be linked to adjoining vertebrae with metal hardware and a bone graft (spinal fusion) to maintain the spine's strength.

• Laminotomy. This procedure removes only a portion of the lamina, typically carving a hole just big enough to relieve the pressure in a particular spot.
• Laminoplasty. This procedure is performed only on the vertebrae in the neck (cervical spine). It opens up the space within the spinal canal by creating a hinge on the lamina. Metal hardware bridges the gap in the opened section of the spine.

• Minimally invasive surgery. This approach to surgery removes bone or lamina in a way that reduces the damage to nearby healthy tissue. This results in less need to do fusions.

  While fusions are a useful way to stabilize the spine and reduce pain, by avoiding them you can reduce potential risks, such as post-surgical pain and inflammation and disease in nearby sections of the spine. In addition to reducing the need for spinal fusion, a minimally invasive approach to surgery has been shown to result in a shorter recovery time.

In most cases, these space-creating operations help reduce spinal stenosis symptoms. But some people's symptoms stay the same or get worse after surgery. Other surgical risks include infection, a tear in the membrane that covers the spinal cord, a blood clot in a leg vein and neurological deterioration.

Potential future treatments

Clinical trials are underway to test the use of stem cells to treat degenerative spinal disease, an approach sometimes called regenerative medicine. Genomic medicine trials are also being done, which could result in new gene therapies for spinal stenosis.

Alternative medicine

Integrative medicine and alternative therapies may be used with conventional treatments to help you cope with spinal stenosis pain. Examples include:

• Massage therapy
• Chiropractic treatment
• Acupuncture

Talk with your doctor if you're interested in these treatment options.

Lifestyle and home remedies

You'll have regular follow-up appointments with your doctor to monitor your condition. He or she may suggest that you incorporate several home treatments into your life, including:

• Trying pain relievers. Over-the-counter medications such as aspirin, ibuprofen (Advil, Motrin IB, others), naproxen (Aleve, others) and acetaminophen (Tylenol, others) can help reduce pain and inflammation.
• Applying hot or cold packs.Some symptoms of cervical spinal stenosis may be relieved by applying heat or ice to your neck.
• Maintaining a healthy weight. Aim to keep a healthy weight. If you're overweight or obese, your doctor may recommend that you lose weight. Losing excess weight can reduce pain by taking some stress off the back, particularly the lumbar portion of the spine.
• Exercising. Flexing, stretching and strengthening exercises may help open up the spine. Talk with a physical therapist or your doctor about what exercises are safe to do at home.
• Using a cane or walker. In addition to providing stability, these assistive devices can help relieve pain by allowing you to bend forward while walking.

Preparing for an appointment

If your primary care doctor thinks you have spinal stenosis, he or she may refer you to a doctor who specializes in disorders of the nervous system (neurologist). Depending on the severity of your symptoms, you may also need to see a spinal surgeon (neurosurgeon, orthopedic surgeon).

What you can do

Before the appointment, you might want to prepare a list of answers to the following questions:

• When did you first notice this problem?
• Has it worsened with time?
• Have your parents or siblings ever had similar symptoms?
• Do you have other medical problems?
• What medications or supplements do you take regularly?
• What spine surgeries or injections have you had done?

What to expect from your doctor

Your doctor may ask some of the following questions:

• Do you have pain? Where is it?
• Does any position ease the pain or worsen it?
• Do you have any weakness, numbness or tingling?
• Do you feel more clumsy lately?
• Have you had any difficulty controlling your bowel or bladder?
• What treatments have you tried already for these problems?