In lumbar stenosis, the spinal nerve roots in the lower back are compressed, or choked, and this can produce symptoms of sciatica — tingling, weakness or numbness that radiates from the low back and into the buttocks and legs — especially with activity.
Spinal stenosis pain in the neck (cervical spinal stenosis) can be far more dangerous by compressing the spinal cord. Spinal cord stenosis may lead to serious symptoms, including major body weakness or even paralysis. Such severe spinal stenosis symptoms are virtually impossible in the lumbar spine, however, as the spinal cord is not present in the lumbar spine.
Cervical stenosis is a slowly progressive condition that pinches the spinal cord. Cervical myelopathy refers to this compression of the cervical spinal cord as a result of spinal stenosis. Cervical spinal stenosis with myelopathy is more common in elderly patients. People with cervical stenosis with myelopathy may note one or more of the following spinal stenosis symptoms:
- Heavy feeling in the legs.
- Inability to walk at a brisk pace.
- Deterioration in fine motor skills (such as handwriting or buttoning a shirt).
- Intermittent shooting pains into the arms and legs (like an electrical shock), especially when bending their head forward (known as Lermitte’s phenomenon Arm pain (cervical radiculopathy).
Myelopathy affects the nerve tracts that run inside the spinal cord (long tracts) and deficits in these long tracts can be picked up on physical exam. For example:
- Muscular tone in the legs will be increased
- Deep tendon reflexes in the knee and ankle will be accentuated (hyperreflexia)
- Forced extension of the ankle may cause the foot to beat up and down rapidly (clonus)
- Scratching the sole of the foot may cause the big toe to go up (Babinski reflex) instead of down (normal reflex).
- Flicking the middle finger may cause the thumb and index finger to flex (Hoffman’s reflex)
- Compromised coordination may be evidenced by difficulty walking and placing one foot in front of the other (tandem walking)
Most cases of cervical stenosis are successfully treated with non-surgical techniques such as pain and anti-inflammatory medications. Depending on the extent of nerve involvement, some patients may need to temporarily restrict their activities and wear a cervical collar or neck brace for a time.
If non-surgical measures do not work, your doctor may recommend surgery to treat your stenosis. There are a number of surgical techniques that can be used to treat this condition. The goal of each of these surgical decompression treatments is to widen the spinal canal and relieve the pressure on the spinal cord by removing or trimming whatever is causing the compression.
- Laminoplasty: One option for removing compression from multiple levels in the neck is called a cervical laminoplasty. A laminoplasty is performed via an incision in the back of the neck which is called a posterior approach. Instead of removing the bone and other compressive structures, the bone overlying the spinal cord (the “lamina”) is partially cut on both the right and left sides. This creates a hinge on one side of the lamina and a small opening on the other side. This vastly increases the space available for the spinal cord and takes the pressure off of it. A spacer made out of bone, metal, or plastic, is usually inserted to hold the spinal canal open. If there are any herniated or bulging discs, the disc may also be removed (this is called a discectomy) to increase canal space. Sometimes the foramen (the area where the nerve roots exit the spinal canal) also needs to be enlarged through foraminotomy.
- Foraminotomy: Foraminotomy is a surgical procedure for widening the area where the spinal nerve roots exit the spinal column. A foramen is the opening around the nerve root, and otomy refers to the medical procedure for enlarging the opening. In this procedure, surgeons widen the passageway to relieve pressure where the spinal nerve is being squeezed in the foramen.
Surgical Procedure. The surgeon makes an incision down the middle of the back of the neck. The surgeon may use a small, rotary cutting tool (a burr) to shave the inside edge of the facet joint. This opens up the outer rim of the neural foramen. The burr is sometimes used to shave a small section of the bony ring on the back of the vertebra above and below the affected nerve root. The muscles and soft tissues are put back in place, and the skin is stitched together. Patients are sometimes placed in a soft collar after surgery to keep the neck positioned comfortably. For those patients who need surgical repair on more than one level or who have significant spinal instability, spinal fusion may be done in addition to the decompression surgery.
What is the cervical spine?
The cervical spine refers to the upper portion of the spine, consisting of 7 vertebral bodies that consists what we know as the neck. Subsequent vertebral bodies are separated by a gel-like disc that provides a cushion between the bones and facilitates the motion. The bones of the spine serve to protect the spinal cord and nerve roots, which branch off the spinal cord at each level and make up the nerves to the arms and hands. Also, there are ligaments in order to stabilize the whole system.
Most neck pain is due to degenerative changes. This changes occur in the intervertebral discs and the joints between each vertebra. A very serious problems caused by degeneration of the spinal segment in the cervical spine, lead to spinal stenosis. Spinal cervical stenosis refers to narrowing of the spinal canal in the neck, or the bony tube in which the spinal cord and the nerve roots travel.
As mentioned above, Stenosis of the cervical spine is mostly due to degenerative changes in the spine that caused by “wear and tear” usage and often progresses as people get older. To understand disc degeneration, compare the vertebrae to two vanilla wafers and the disc to a marshmallow. When the marshmallow is fresh and you press the wafers close together, the marshmallow squishes out. In case of leaving marshmallow out for a week, it starts drying out and by pressing the wafer the outside of the marshmallow may even tear or split. After a month, it would be hard and very thin and would not be able to absorb the shock. As the degenerative changes progress, the discs may collapse and decrease in height, ligaments of the spine may thicken and bone spurs may form on the vertebral bodies cause the narrowing of the spinal column which leaves less room for the nerves. Rarely, one may be born with congenital stenosis. Trauma, tumor, infection, or calcification of the ligaments are another potential reason.
Numbness, weakness or tingling in a leg, foot, arm or hand. Many people also report problems with walking and balance. Nerves to the bladder or bowel may be affected, leading to incontinence.
Cervical stenosis is usually suspected based on the patient’s history and physical examination. X-rays may show bone spurs or narrowing of the space between vertebral bodies, caused by collapse of the discs. The MRI will show the condition of the intervertebral discs, the ligaments, and the spinal cord and nerves.
Medications are NSAIDs, Muscle relaxants, Antidepressants, Anti-seizure drugs, Opioids. If you do not improve rapidly with non-operative care, your doctor may suggest surgery to relieve the pressure on the spinal cord.
There are several surgical procedures used to treat cervical spinal stenosis based on relieving the pressure on the spinal cord by making the spinal canal larger. In some cases, the surgeon may suggest an operation called a laminectomy. In this operation, the back side of the vertebrae is opened to allow more room for the spinal cord.
In other cases, the surgeon may suggest an operation from the front of the neck, corpectomy and strut graft. This operation allows the surgeon to remove the vertebral body of the vertebra, along with any bone spurs pushing into the spinal cord. The vertebrae are then replaced with a solid piece of bone graft (called a strut graft). The strut graft heals over time to create a spinal fusion where the vertebral bodies have been removed.