Spinal Stenosis

Article Author:
Avais Raja
Article Author:
Stanley Hoang
Article Author:
Parini Patel
Article Editor:
Fassil Mesfin
7/28/2020 12:11:15 PM
PubMed Link:
Spinal Stenosis


Spinal stenosis is a condition in which the nerve roots are compressed by a number of pathologic factors, leading to symptoms such as pain, numbness, and weakness. The upper neck (cervical) and lower back (lumbar) areas most frequently are affected, although the thoracic spine also can be compressed most frequently by a disk herniation. Three different anatomic sites in the spine can be affected by spinal stenosis. First, the central canal, which houses the spinal cord, can be narrowed in an anterior-posterior dimension, leading to compression of neural elements and reduction of blood supply to the spinal cord in the cervical area and the cauda equina in the lumbar area. Secondly, the neural foramen, which are openings through which the nerve roots exit the spinal cord, can be compressed as a result of disk herniation, hypertrophy of the facet joints and ligaments, or unstable slippage of one vertebral body relative to the level below. Lastly, the lateral recess, which is seen in the lumbar spine only and is defined as the area long the pedicle that a nerve root enters just before its exit through the neural foramen, can be compressed from a facet joint hypertrophy. [1][2][3] Depending on the level of the spine affected, each type of compression can lead to different symptoms that warrant a particular treatment modality.

Most patients will experience some type of pain associated with the spine but luckily, even without surgery, the majority will have an uneventful recovery. Only 1-3% will have a herniated disc and less than 2% will have compression of a nerve root.

Spinal stenosis is common with aging but predicting which individual will develop symptoms is not possible. In most cases, the degenerative process can be controlled by changes in lifestyle.


In the cervical spine, stenosis can be caused by a combination of factors. Some individuals can have a congenitally narrowed spinal canal that is exacerbated by pathologic factors. Disk herniation together with the formation of osteophytic spurs, hypertrophy of the articular facets and ligamentum flavum, and ossification of posterior longitudinal ligaments can lead to central and foraminal stenosis. Structural factors such as subluxation from disk and facet joint degeneration and changes in the normal lordotic curvatures of the spine can lead to spinal compression. In the thoracic spine, disk herniation either from degenerative causes or trauma can lead to stenosis at specific levels. In the lumbar spine, hypertrophy of the facet joints and ligamentum flavum in the setting of disk herniation or spondylolisthesis can lead to worsening stenosis. Spondylolisthesis in the lumbar spine, defined as anterior subluxation of one vertebral body on top of another, is seen most commonly at L5 on S1 and L4 on L5. This can lead to compression of the nerve that exits below the pedicle of the anteriorly subluxed vertebra and results in neurogenic claudication.[4][5][6]


Risk factors that lead to the development of spinal stenosis are multifactorial. There is a genetic influence as demonstrated in the study of twins. Cumulative trauma can lead to the progression of the disease. Osteoporosis can be a contributing factor. Cigarette smoking in several epidemiological studies has been shown to lead to back pain and degenerative spinal diseases. In the lumbar spine, obesity and loss of muscle tone can lead to stresses and dependence on the bony and ligamentous structures of the spine for structural support.


Many theories regarding the pathophysiology of spinal stenosis suggest a number of confluent mechanisms. The spinal cord can be directly compressed by osteophytic bones and ligamentous hypertrophy. Compression of local vascular structures can lead to ischemia of the spinal cord from arterial insufficiency and venous stasis. A herniated disk can exert repeated local trauma to the spinal cord or nerve root during repetitive flexion and extension movements, especially in the unstable spine with multiple levels of subluxations.

In the cervical spine, segments C5-6 and C6-7 are often affected.

History and Physical

Initial evaluation of a patient with spinal stenosis often begins with a detailed history of symptoms and physical exam, with a focus on sensation, motor strength, reflexes, and gait. Stenosis in the cervical spinal can lead to radicular symptoms due to nerve root compression and myelopathy due to spinal cord compression. Radicular symptoms are dependent on the level affected, with the nerve root affected being the one that exists at that level. For example, a C5-6 disk herniation leads to a C6 radiculopathy. C6-7 disk herniation is the most common, leading to a wrist drop and paresthesia in the 2 and three fingers. C5-6 disk herniation is the next common, resulting in weakness in forearm flexion and paresthesia in the thumb and radial forearm. C7-T1 disk herniation can lead to weakness in the hand intrinsics muscles and numbness in the 4 and five digits. Lastly, a C4-5 disk herniation can lead to deltoid weakness and shoulder paresthesia. Patients also can experience pain and paresthesia in the head, neck, and shoulder.  Cervical spondylotic myelopathy can be seen in patients with greater than 30% spinal narrowing, leading to gait disturbance, lower extremity weakness, and ataxia. Stenosis in the lumbar spine can lead to neurogenic claudication, myeloradiculopathic symptoms, sensory disturbances, motor weakness, and pathologic reflexes. Disk herniation is most common at the L4-5 and L5-S1 levels. A herniated disk at L5-S1 can lead to plantarflexion weakness, decrease sensation in the lateral foot, and cause pain in the posterior leg. A disk herniation at L4-5 can lead to a foot drop and numbness in the large toe web and dorsal aspect of the foot. Lastly, an L3-4 disk herniation can lead to knee extension weakness, numbness in the medial foot, and pain in the anterior thigh.


Diagnosis can be made through imaging with extended release x-ray, CT, and MRI. With the availability of MRI, a plain radiograph is of limited value although dynamic views in flexion and extension modes can demonstrate dynamic instability or spondylolisthesis. CT can help differentiate calcified disks or bone osteophytes from “soft disks,” differentiate ossification of the posterior longitudinal ligament from a thickened posterior longitudinal ligament and detect bone fractures or lytic lesions. MRI is the gold standard; it is able to show intrinsic cord abnormalities, the degree of spinal stenosis, and differentiate other conditions such as tumors, hematoma, or infection. If a patient has a pacemaker and cannot obtain an MRI, a CT myelogram can be performed to identify the level and degree of stenosis.[7][8][9]

Treatment / Management

In patients who suffer from cervical stenosis without myelopathy, conservative management with bracing, rest, or anti-inflammatory medications initially can be employed. For those with myelopathy, surgical decompression can provide some relief from pain and sensory loss and can prevent the exacerbation of myelopathy. Depending on the levels involved and the pathology, an anterior or posterior decompression and fusion can be employed to relieve the compression and stabilize the spine. In the lumbar spine, initial management of back pain can be done with NSAIDs and physical therapy followed by interventional pain management strategies for persistent back pain. When conservative management is inadequate, or the patient develops progressive myelopathy, neurologic deficits, or spinal instability, surgical decompression and fusion are recommended. Depending on the nature of the pathology, a variety of approaches, including anterior, lateral, or posterior can be employed to restore lumbar lordosis, decompress the stenosis, and promote fusion.[10][11][12][11]

Differential Diagnosis

  • Lumbar Compression Fracture
  • Lumbar Degenerative Disk Disease
  • Lumbar Facet Arthropathy
  • Lumbar Spondylosis
  • Mechanical Low Backpain
  • Rehabilitation for Osteoarthritis
  • Rheumatoid Arthritis
  • Spondylodiskitis
  • Spondylolisthesis Imaging

Enhancing Healthcare Team Outcomes

Patients with spinal stenosis are often first encountered by the nurse practitioner, primary care physician, emergency department physician and internist. If the patients are asymptomatic, there is usually no treatment necessary. Patients with pain should be encouraged to participate in an exercise program, discontinue smoking and maintain a healthy weight. The few patients with nerve compression should be referred to an orthopedic or neurosurgeon. However, the primary care providers should educate the patient on potential complications of surgery, which can be disabling. For those who maintain a sedentary lifestyle, the quality of life is poor. [13](Level V)

  • Contributed by S. Dulebohn, M.D.
    (Move Mouse on Image to Enlarge)
    • Image 33 Not availableImage 33 Not available
      Contributed by S. Dulebohn, M.D.


[1] Tang C,Moser FG,Reveille J,Bruckel J,Weisman MH, A Review of Cauda Equina Syndrome in Ankylosing Spondylitis: Challenges in Diagnosis, Management, and Pathogenesis. The Journal of rheumatology. 2019 Apr 1;     [PubMed PMID: 30936280]
[2] Glassman DM,Magnusson E,Agel J,Bellabarba C,Bransford RJ, The impact of stenosis and translation on spinal cord injuries in traumatic cervical facet dislocations. The spine journal : official journal of the North American Spine Society. 2019 Apr;     [PubMed PMID: 30914130]
[3] Bindal S,Bindal SK,Bindal M,Bindal AK, Non-instrumented Lumbar Fusion with BMP for Spinal Stenosis with Spondylolisthesis in the Elderly. World neurosurgery. 2019 Mar 20;     [PubMed PMID: 30904805]
[4] Messiah S,Tharian AR,Candido KD,Knezevic NN, Neurogenic Claudication: a Review of Current Understanding and Treatment Options. Current pain and headache reports. 2019 Mar 19;     [PubMed PMID: 30888546]
[5] Urits I,Burshtein A,Sharma M,Testa L,Gold PA,Orhurhu V,Viswanath O,Jones MR,Sidransky MA,Spektor B,Kaye AD, Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Current pain and headache reports. 2019 Mar 11;     [PubMed PMID: 30854609]
[6] Bagley C,MacAllister M,Dosselman L,Moreno J,Aoun S,El Ahmadieh T, Current concepts and recent advances in understanding and managing lumbar spine stenosis. F1000Research. 2019;     [PubMed PMID: 30774933]
[7] Shim DM,Kim TG,Koo JS,Kwon YH,Kim CS, Is It Radiculopathy or Referred Pain? Buttock Pain in Spinal Stenosis Patients. Clinics in orthopedic surgery. 2019 Mar;     [PubMed PMID: 30838112]
[8] Stienen MN,Ho AL,Staartjes VE,Maldaner N,Veeravagu A,Desai A,Gautschi OP,Bellut D,Regli L,Ratliff JK,Park J, Objective measures of functional impairment for degenerative diseases of the lumbar spine: a systematic review of the literature. The spine journal : official journal of the North American Spine Society. 2019 Mar 2;     [PubMed PMID: 30831316]
[9] Kaye AD,Manchikanti L,Novitch MB,Mungrue IN,Anwar M,Jones MR,Helander EM,Cornett EM,Eng MR,Grider JS,Harned ME,Benyamin RM,Swicegood JR,Simopoulos TT,Abdi S,Urman RD,Deer TR,Bakhit C,Sanapati M,Atluri S,Pasupuleti R,Soin A,Diwan S,Vallejo R,Candido KD,Knezevic NN,Beall D,Albers SL,Latchaw RE,Prabhakar H,Hirsch JA, Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain physician. 2019 Jan;     [PubMed PMID: 30717501]
[10] Lavi ES,Pal A,Bleicher D,Kang K,Sidani C, MR Imaging of the Spine: Urgent and Emergent Indications. Seminars in ultrasound, CT, and MR. 2018 Dec;     [PubMed PMID: 30527521]
[11] Deer TR,Grider JS,Pope JE,Falowski S,Lamer TJ,Calodney A,Provenzano DA,Sayed D,Lee E,Wahezi SE,Kim C,Hunter C,Gupta M,Benyamin R,Chopko B,Demesmin D,Diwan S,Gharibo C,Kapural L,Kloth D,Klagges BD,Harned M,Simopoulos T,McJunkin T,Carlson JD,Rosenquist RW,Lubenow TR,Mekhail N, The MIST Guidelines: The Lumbar Spinal Stenosis Consensus Group Guidelines for Minimally Invasive Spine Treatment. Pain practice : the official journal of World Institute of Pain. 2019 Mar;     [PubMed PMID: 30369003]
[12] Williamson E,Ward L,Vadher K,Dutton SJ,Parker B,Petrou S,Hutchinson CE,Gagen R,Arden NK,Barker K,Boniface G,Bruce J,Collins G,Fairbank J,Fitch J,French DP,Garrett A,Gandhi V,Griffiths F,Hansen Z,Mallen C,Morris A,Lamb SE, Better Outcomes for Older people with Spinal Trouble (BOOST) Trial: a randomised controlled trial of a combined physical and psychological intervention for older adults with neurogenic claudication, a protocol. BMJ open. 2018 Oct 18;     [PubMed PMID: 30341124]
[13] Koenders N,Rushton A,Verra ML,Willems PC,Hoogeboom TJ,Staal JB, Pain and disability after first-time spinal fusion for lumbar degenerative disorders: a systematic review and meta-analysis. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2019 Apr;     [PubMed PMID: 29995169]