Spinal Stenosis
Updated: Nov 27, 2020
Spinal stenosis occurs when one or more bony openings (foramina) within the spine begin to narrow and reduce space for the nerves.
Depending on the location and how much narrowing occurs over time, a spinal nerve or the spinal cord could become compressed and cause pain, tingling, numbness, and/or weakness.
Spinal Stenosis Signs and Symptoms
Spinal stenosis can greatly vary from person to person. Signs and symptoms may include one or more of the following:
Neurogenic Claudication. Neurogenic claudication, also known as pseudoclaudication, is the most common symptom of lumbar spinal stenosis and describes intermittent leg pain which may involve one or both legs and usually presents as some combination of discomfort, pain, numbness, or weakness in the calves, buttocks, and/or thighs that is precipitated by walking and prolonged standing.
The pain is classically relieved by a change in position or forward bending at the waist. Therefore, patients with Neurogenic Claudication have less disability in climbing steps, pushing carts, and cycling.
Pain. The pain might be dull and confined to the neck or lower back, or it could be an electric-like pain that radiates into the arm(s) or leg(s). The pain can vary over time, possibly flaring up during certain activities. Sometimes the pain is more of a pins-and-needles tingling sensation.
Numbness. Reduced sensation or total numbness may occur in the arm, leg, and/or other areas of the body.
Weakness. Reduced strength or problems with coordination may be experienced in the arm, leg, and/or other parts of the body. Severe compression of the spinal cord or cauda equina (nerve roots running below the spinal cord) could result in bowel and/or bladder dysfunction.
Spinal stenosis does not always cause pain. While rare, numbness or weakness might be present with little or no pain.
Common Causes of Spinal Stenosis
Spinal stenosis is typically caused by one or more of the following factors:
Spinal osteoarthritis. When the smooth cartilage covering the facet joints (which connect the backs of adjacent vertebrae) start to break down, bones begin to rub against each other and may lead to the formation of abnormal bone growth, called osteophytes or bone spurs. The resulting inflammation and osteophyte formation can contribute to narrowing of the foramina.
Degenerative disc disease. When discs lose hydration and start to flatten, the bony openings also start to narrow. A disc bulge can also start to push into the spinal canal. Disc degeneration can also put more pressure on the facet joints and accelerate their degeneration as well.
Ligament thickening or buckling. Ligaments in the spinal canal can ossify (thicken and turn into bony tissue) and encroach upon the spinal cord or nearby spinal nerves. Some ligaments may also become more susceptible to buckling into the spinal canal as spinal degeneration progresses.
Other factors may also contribute to spinal stenosis, such as spinal deformity or cyst growths.
The Course of Spinal Stenosis
The narrowing of the openings in the spine usually develops over time as part of the aging process. While spinal stenosis typically occurs in people age 50 or older, it can also develop sooner due to injury or from birth (congenital factors).
Spinal stenosis may worsen over time, but the rate of progression is variable and may not always produce signs or symptoms. While some people may experience progressive worsening of symptoms, others may find that their symptoms are alleviated by physical therapy, medication, short period of rest, or other nonsurgical treatments.
When neurological deficits, such as numbness or weakness, continue to worsen despite rest and nonsurgical treatments, surgery may need to be considered. Surgery is typically recommended for spinal stenosis when imaging and other diagnostic measures show that signs and symptoms are likely to be relieved by decompressing a spinal nerve and/or the spinal cord.
When Spinal Stenosis Is Serious
Neurological deficits — such as from radiculopathy, myelopathy, and/or cauda equina syndrome — can develop when spinal stenosis becomes severe. If a spinal nerve or the spinal cord is compressed for long enough, permanent numbness and/or paralysis can occur.
It is important to seek immediate medical attention for any numbness or weakness that radiates into the arm(s) or leg(s), or for any problems with coordination or bowel/bladder control.
Types of Spinal Stenosis
Spinal stenosis is a general term for the narrowing of one or more foramina (bony openings) within the spine. There are specific names for spinal stenosis depending on the exact location(s) of where the narrowing and nerve compression occurs.
The two general types of spinal stenosis are foraminal stenosis, also called lateral stenosis, which involves compression or inflammation of a spinal nerve; and central canal stenosis, which involves compression or inflammation of the spinal cord.
Foraminal Stenosis (Lateral Stenosis)
The intervertebral foramen is the bony opening where a nerve exits the spinal canal between two adjacent vertebrae. When one or more of these foramina narrows, it is called foraminal stenosis. With foraminal stenosis, the spinal nerve has less space and may become pinched, painful, and/or dysfunctional.
While foraminal stenosis can occur in any of the intervertebral foramina throughout the spine, it most commonly occurs in the lumbar spine. It can also occur in the cervical spine but rarely in the thoracic spine.
Central Canal Stenosis
The vertebral foramen is the bony opening in the center of the vertebra that protects the spinal cord as it runs down the spinal canal. When one or more of these vertebral foramina narrow, it is called central canal stenosis. With central canal stenosis, the spinal cord has less space and may become compressed, which can lead to pain and/or dysfunction experienced anywhere in the body below the level of compression.
While central canal stenosis can occur in any of the vertebral foramina throughout the spine, it most commonly occurs in the lumbar or cervical spine. It is also possible for both foraminal stenosis and central canal stenosis to occur together.
Spinal Stenosis Symptoms and Diagnosis
There are a number of potential signs and symptoms of spinal stenosis. The specific signs and symptoms are mainly determined by the location and severity of the stenosis in the spine.
Radicular pain that can radiate from the spine into an arm or leg, or less commonly into both arms or legs. This pain can range from a dull ache or tenderness to an electric-like pain or burning sensation.
Radiculopathy, which involves neurological deficits stemming from spinal nerve root compression, such as tingling, numbness, or weakness that goes into an arm or leg.
Myelopathy, which involves neurological deficits stemming from spinal cord compression, such as tingling, numbness, or weakness that goes into both arms and/or legs. Myelopathy could also involve dysfunction elsewhere in the body, such as problems with bladder/bowel control.
Cauda equina syndrome, which results in neurological deficits from compression of the cauda equina (spinal nerve roots that continue below the spinal cord). Numerous signs and symptoms may develop in the lower extremities, including saddle anesthesia and/or bowel/bladder incontinence. Cauda equina syndrome requires immediate medical attention to avoid permanent nerve damage.
Neurogenic Claudication. Neurogenic claudication, also known as pseudoclaudication, is the most common symptom of lumbar spinal stenosis and describes intermittent leg pain which may involve one or both legs and usually presents as some combination of discomfort, pain, numbness, or weakness in the calves, buttocks, and/or thighs that is precipitated by walking and prolonged standing.
The pain is classically relieved by a change in position or forward bending at the waist. Therefore, patients with Neurogenic Claudication have less disability in climbing steps, pushing carts, and cycling.
Onset of Spinal Stenosis Symptoms
Overall, spinal stenosis symptoms are often characterized as:
Developing slowly over time, or slow onset
Coming and going, as opposed to continuous pain
Occurring during certain activities (such as walking or biking while holding the head upright with lumbar stenosis) and/or positions (such as standing upright with lumbar stenosis)
Feeling relieved by rest (sitting or lying down) and/or any flexed (forward bending) position
While rare, it is also possible for spinal stenosis to present primarily as neurological deficits, such as numbness and/or weakness, rather than pain.
Spinal Stenosis Symptoms by Location
Depending on the site of occurrence, the signs and symptoms of spinal stenosis can differ. Common signs and symptoms for different locations are highlighted below.
Lumbar spinal stenosis
Spinal stenosis in the lumbar spine may compress a lumbar spinal nerve(s) and send pain, tingling, numbness, and/or weakness into the leg(s). If the cauda equina (spinal nerves that run down the lumbar spinal canal) becomes compressed, cauda equina syndrome may occur.
Cervical spinal stenosis
Spinal stenosis in the cervical spine may compress a cervical spinal nerve(s) and send pain, tingling, numbness, and/or weakness into the arm(s). If the spinal cord becomes compressed, pain and/or neurological deficits may be experienced anywhere in the body beneath the level of compression, including the legs.
Thoracic spinal stenosis
Spinal stenosis in the thoracic spine may compress a thoracic spinal nerve(s) and send pain, tingling, numbness, and/or weakness into the chest or abdomen. If the spinal cord becomes compressed in the thoracic spine, pain and/or neurological deficits may be experienced at the level of compression (mid back) or below.
Spinal stenosis is most common in the lumbar spine and cervical spine. It rarely occurs in the thoracic spine. Spinal stenosis may also occur in multiple places, such as in both the cervical spine and lumbar spine (tandem stenosis).
Diagnosis of Spinal Stenosis
Getting an accurate diagnosis for spinal stenosis typically requires a 3-step process:
Patient history. A careful review of the patient’s medical history, including recent signs and symptoms, helps to narrow the list of possible causes.
Physical examination. A medical professional observes and palpates (feels) the spine, such as along the neck or lower back. In addition to testing the spine’s range of motion, clinical tests may also be performed for leg and/or arm strength, reflexes, and sensation (tingling/numbness).
Medical imaging. While the patient history and physical examination may suggest spinal stenosis, the diagnosis must be confirmed with medical imaging. When imaging shows narrowing of the intervertebral foramen and/or vertebral foramen that corresponds with the patient’s symptoms, spinal stenosis is diagnosed.
An MRI is the most common imaging used to diagnose spinal stenosis, but CT with myelography may be used in cases where MRI is not an option. It is also important to note that many people have spinal stenosis based on what is seen on medical imaging but have no symptoms and need no treatment.
Spinal Stenosis Treatment
Most cases of spinal stenosis can be treated with a combination of surgical and nonsurgical treatments, such as physical therapy, pain medication, activity modification, and/or epidural injections. When severe pain and/or neurological deficits continue to worsen despite nonsurgical treatments, surgical options may be considered.
Physical Therapy
A suitable program of physical therapy and exercise may be a component of spinal stenosis treatment process but this should always be undertaken after consultation with a Spine Doctor (Neurosurgeon or Ortho-spine surgeon) since exercises or physical therapy are not a cure but it is important for patients to remain active as tolerated and not become additionally debilitated from inactivity.
The treating Spine Doctor may prescribe a supervised physical therapy program. After a period of physical therapy instruction, most people can then transition to their own exercise program. The key is to start slowly, and build strength and tolerance over time.