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Cervical Spinal Stenosis
Stenosis is defined as “a narrowing of the space within the spinal canal, intervertebral foramina, or nerve root canal and can occur in any portion of the spine. This narrowing may be at one or more levels and may affect the nerve root canals, intervertebral foramen, or the spinal canal itself. Cervical Spinal Stenosis specifically targets the neck and upper part of the spine. It is a “chronic (long- term) condition” that can be treated with interventions such as medication, therapy, and surgery if necessary (CareNotes, 2019).
The most basic way to understand stenosis and its effect is to first explain the significance of the spine and its purpose in the body. The spine is made up of 33 bones called vertebrae which are divided into five sections. These include “7 cervical, 12 thoracic, 5 lumbar vertebrae, 5 fused sacral, and 4 fused coccyx vertebrae.” Their job is to “provide support for the head, to attach the ribs, and to protect the spinal cord and cauda equina.”(Best, 2002) Each bone in the spine is separated by “discs and ligamentous bands” (Rao, 2009) that “provide "shock absorption" for the compressive forces placed on the vertebrae”(Garfin et al., 1999) (Best, 2002). When these discs are compromised they may narrow the spinal canal limiting the amount of healthy space provided for the spinal cord. “Narrowing can be congenital, acquired, or a combination of the two (Fritz et al., 1998; Garfin et al., 1998; Hilibrand & Rand, 1999)” (Best, 2002). Stenosis is often caused by “bone spurs, bulging discs, and thickened ligaments”, narrowing the space in the spinal canal (“Cervical Spinal Stenosis). Other causes include “ osteoarthritis, dwarfism, osteitis deformans, skeletal fluorosis, spinal tumor, or adverse effects of weight may have a higher risk of developing spinal stenosis. Those with a back injury or a flexion-extension injury have increased risks too” (Sayler & Shamie 2007).
Stenosis does not differentiate between race, ethnicity or socioeconomic boundaries. Symptoms usually “appear around age 50 to 60 and lead to increasing pain and disability as the condition progresses” although this is not always the case (Best, 2002). While many are prone to stenosis “others are asymptomatic, meaning they suffer no adverse effects” (Emory). For those who do present symptoms, “it will mainly be caused by associated cervical radiculopathy or cervical myelopathy” (Physiopedia). Radiculopathy is a condition provoked from “pressure on a spinal nerve root” and is often described as a "pinched nerve" feeling. A sensation of “pins and needles” may be produced as a result of an “irritated or inflamed nerve root”, as well as “sharp, shooting” and “deep, dull, and achy” pain radiating through the surrounding nerves. Myelopathy is pressure placed on the spinal cord and unlike radiculopathy, is taken much more “seriously because severe myelopathy that is not treated may lead to permanent nerve or spinal cord damage”. Symptoms include but are not limited to numbness in extremities, loss of muscle control in the legs called spasticity which “may impair normal walking”, and failure to control “bowel and bladder function” (“Cervical Spinal Stenosis”). Additional symptoms involved are “ neck pain, cervicogenic headaches, and vertebral slippage” (Sayler & Shamie 2007).
Diagnosing Stenosis can be achieved using various methods such as “X-rays, MRIs, CT scans, CT myelogram, or bone scans” (Emory). Each of these allows doctors to narrow down and pinpoint the root of the problem. Patients presenting “degenerative changes in the disc spaces or facet joints” will use an X-ray to reveal possible “slip-slide” between the neck vertebrae”. MRIs are utilized by doctors to “visualize structures that may be impinging on the spinal cord or the nerve branches” (Rao,2009).
In some patients, “Computed tomographic (CT) scans are performed to visualize the bony structures and the shape and size of the vertebral canal. The use of contrast dye allows the visualization of the nerve roots and the subarachnoid space” (Best, 2002)
Although there is no cure for this chronic illness, there are ways to manage the progressive nature of the symptoms and delay the process. Treatments available include medication, therapies, and surgery if necessary. These will not reverse the effects of Stenosis but rather manage and regulate the pain. According to the North American Spine Society (NASS) "In mild cases of cervical stenosis with or without myelopathy," which is any disease involving the spinal cord, "nonoperative treatment may be suitable. However, in cases with increasing weakness, pain or the inability to walk, surgical treatment is usually recommended.” (Sayler & Shamie 2007)
Possible non-operative interventions include medication, injections, therapy, and assistive devices. Although treatments such as these “do not change the narrowing of the spinal canal”, each “is aimed at reducing pain and increasing the patient's function” (Physiopedia). Medication generally prescribed to combat pain, are NSAIDs (Non-steroidal anti-inflammatory medication). Ibuprofen, aspirin, and naproxen are “common over-the-counter drugs” that “decrease swelling and pain”(acsneuro). Stronger medications such as muscle relaxers may also be prescribed to decrease muscle spasms (CareNotes, 2019).
When Medications and therapy fail to be as effective as needed, injections are usually the next step in treating stenosis. Nerve blocks and epidural steroid injections both provide short term pain relief that can be crucial to the functionality of a patients daily life. A nerve block “is an injection of numbing medicine” (CareNotes, 2019) while a steroid injection is infused into the epidural space between the spinal cord and the vertebrae to reduce inflammation (Best, 2002).
Physical therapy intervention plays a major role in the management of Cervical Stenosis. Because of the symptoms plaguing patients with stenosis, activity avoidance is common and may result in overall “reduced flexibility, strength and cardiovascular endurance". To combat these risks, programs may include stretching, modalities, strengthening and postural education. Stretching exercises are encouraged to “restore flexibility to tight muscles” and continued throughout treatment to maintain flexibility gained (Sayler & Shamie 2007). Heat is applied to improve blood circulation to affected muscles while manual therapy such as “cervical and thoracic joint manipulation” are used “to improve or keep a range of motion”. The cervical spine can be greatly impacted by posture and spinal instability. Strengthening exercises and postural re-education have the chance to strengthen the surrounding musculature and relieve some pain in the neck area. Scapular stabilization and changes in position “to avoid sustained postures that compress the spine” are small ways to relive the pressure (Physiopedia). Weight loss, soft cervical collars, and aquatic therapy may decrease the load on the spine as well (Best, 2002).
Surgery is considered when non-operative interventions fail to control symptoms. If a patient displays motor weakness, “decreased ability to perform ADL, leg cramps that interfere with sleep, and inability to walk more than 50 yards or sit longer than 30 minutes”, they are likely candidates for surgery (Best, 2002). “The goal of the surgery is to relieve pressure on the spinal cord by widening the spinal canal” (Emory). Procedures such as laminectomies, discectomies, and fusions are performed to alleviate weight on the spine and nerves. “This is done by removing, trimming, or realigning involved parts that are contributing to the pressure” (Emory). Depending “on the location of the cord compression, number of levels involved, sagittal alignment, instability, associated axial neck pain, and risk factors for pseudarthrosis”, the doctor will decide which approach to take (Physiopedia).
A laminectomy is an operation where the “backside of the vertebrae is opened to allow more room for the spinal cord” (“Cervical Spinal Stenosis”). If disc herniation is the cause of the stenosis, a discectomy, which is “the removal of one or more disks” is executed. This operation may be done anteriorly or posteriorly. The surgeon replaces the disc with a small piece of bone which stabilizes the spine called a fusion (Physiopedia). Many are hesitant to the surgical approach as there are multiple risks involved. Complications following surgery “increase if the patient is elderly, suffers from malnutrition, has cerebral palsy, or has a chronic disease such as diabetes, cardiac, or pulmonary disease”. There is also a higher chance of nonunion and decreased bone formation for patients that smoke (Best, 2002).
Research indicates that taking a conservative approach is often a safer route to take for those with mild cervical stenosis. While this may work for some, others must use invasive means to relieve symptoms and get back to their normal life. Surgery is generally used as a last resort as there is no guarantee that the surgery will have the effect needed to be considered successful. The body will never fully regain the level of function it had prior to surgery.
Cervical Spinal Stenosis is a chronic narrowing of the spinal canal that puts pressure on the spinal cord, which results in weakness, radiating pain and numbness. Although there are currently no cures to fully reverse its effects, there is a recognition that interventions such as medication, therapy, and surgery if necessary, can greatly enhance function, participation, and quality of life for those with Cervical Stenosis.
- Cervical spinal stenosis. (2019). In CareNotes. Truven Health Analytics. Retrieved from http://link.galegroup.com/apps/doc/A587017869/HWRC?u=unioncc&sid=HWRC&xid=53e4689d
- (CareNotes, 2019)
- Best, J. T. (2002). Understanding spinal stenosis. Orthopaedic Nursing, 21(3), 48-54; quiz 54-6. Retrieved from https://weblib.ucc.edu/login?url=https://weblib.ucc.edu:2094/docview/195968532?accountid=14636
- (Best, 2002)
- Sayler, M. H., & Shamie, A. N. (2007). Spinal stenosis. In The Encyclopedia of the Back and Spine Systems and Disorders. New York: Facts On File. Retrieved June 27, 2019, from online.infobase.com/Auth/Index?aid=17310&itemid=WE48&articleId=100505.
- (Sayler & Shamie 2007)
- (n.d.). Retrieved from http://www.ct-ortho.com/beinermd/cervical_spinal_stenosis.htm
- (“Cervical Spinal Stenosis”)
- Orthopedics:Conditions & Treatments. (n.d.). Retrieved from https://www.emoryhealthcare.org/orthopedics/cervical-stenosis-myelopathy.html
- Cervical Stenosis. (n.d.). Retrieved from https://med.virginia.edu/neurosurgery/services/spine-surgery/cervical-stenosis/
- Conditions. (n.d.). Retrieved from https://www.spine.org/KnowYourBack/Conditions/Degenerative-Conditions/Cervical-Stenosis-Myelopathy-and-Radiculopathy
- (Rao, 2009)
- Cervical Stenosis. (2018, May 25). Physiopedia, . Retrieved 20:48, June 27, 2019 from https://www.physio-pedia.com/index.php?title=Cervical_Stenosis&oldid=189005.
- (Physiopedia, 2018)
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