Lumbar Spinal Stenosis

Patologie della Colonna Vertebrale

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Definition and Etiology

Stenosis is a narrowing of the spinal canal. Some people are born with a certain degree of stenosis, but more commonly it is the result of degenerative processes in the osteo-ligament structures that occur during physiological aging.

As this pathological condition progresses, the spinal canal that hosts the nerve roots and the spinal cord gradually narrows, and exerts pressure on them.

Symptoms

Cervical spinal Stenosis

Pain is the initial manifestation of the disease. The pain can be localized only in the neck area (cervicalgia) or irradiated to the upper limbs (cervical-brachialgia). When the stenosis is particularly severe, there is a compression and deficit of the spinal cord (myelopathy), which manifests itself with numbness, weakness in all four limbs, difficulty in walking with possible spasticity or dysfunctions related to the sphincter functions or sexual functions. Lhermitte’s sign (a sensation of electrical shock triggered when bending the neck) may be present.

Lumbar spinal Stenosis

As far as the stenosis of the lumbar section is concerned, the pain is less intense when the patient is seated, while it becomes more intense when standing and while walking. Often the patient tends to walk with the body bent forward because the spinal canal stenosis tends to be less intense during flexion. Other patients show signs of compression of the cauda equina that manifest the symptomatology of neurogenic claudication characterized by pain in the lower limbs with hyposthenia (feeling of heaviness), which increases while walking and is less intense during rest, so that the patient is forced to stop and rest more and more often, gradually decreasing the autonomy of a normal pace.

Diagnosis

Cervical spinal Stenosis

The diagnosis is easily formulated by means of a cervical MRI. Thanks to this test all the necessary information concerning the degree of stenosis, the prevalence of anterior or posterior compression, ligament hypertrophy, whether or not there are protrusions or disc herniations, and if there is a bone marrow injury, can be collected. A Cervical CT provides more information about the bone component.

As mentioned earlier, the radiological tests shall be combined with neurophysiological ones, such as electromyography, somatosensory evoked potentials and motor responses to document the level of impairment of the nerve roots and spinal cord.

Lumbar spinal Stenosis

It is diagnosed after accurate anamnestic studies, accompanied by radiological images such as lumbosacral spine MRI, CT and electromyography of the lower limbs.

Treatment

Cervical spinal Stenosis

For cases of mild stenosis, with scarce symptoms, physiotherapy is often used in conjunction with medications. For severe stenosis with neurological disorders, it is instead advisable to surgically intervene.

The surgical decompression of the vertebral canal can be performed with an anterior, posterior or combined approach depending on whether the spinal cord compression is predominant on the anterior or posterior side or on both.

The anterior approach is similar to the one used to remove cervical herniations.

In the posterior approach, a posterior midline cervical incision extending approximately 15 cm

is performed; the paravertebral muscles are bilaterally detached reaching the laminae. At this point, it is possible to decide whether to proceed with a laminectomy (complete removal of the laminae) or with the so-called "open-door" laminotomy (the laminae are cut only on one side and weakened on the opposite side so the opening is in one piece, like with a zipper).

In the combined approach, decompression surgery is performed both anteriorly and posteriorly. Depending on the patient's age, general conditions and the number of levels that need to be decompressed, the surgeons may decide to perform a double surgery in a single operation session or to perform it at two different times.

The patient is invited to stand up the morning after surgery and is dismissed after two days from the hospital. The patient can resume her/his normal activities although she/he must avoid major strains for about a month.

Lumbar spinal Stenosis

At first, a conservative treatment (painkillers, physiotherapy) is recommended. If the symptomatology becomes disabling or it gets worse, surgery is employed.

The surgery is performed with a posterior approach and consists in a decompressive laminectomy, i.e the removal of the posterior portion of the vertebral canal formed by the laminae in order to expand it. Very often, in order to obtain complete decompression of intra-canal nervous structures, it is necessary to partially remove the facet joints (one of the structures which provides stability to the spine) as they are themselves the cause of stenosis. In these cases, to prevent future vertebral instability, a vertebral stabilization (arthrodesis) is also performed with appropriate fixation devices were needed.

The patient is invited to stand up the morning after surgery and is dismissed from the hospital after two days. The patient can resume her/his normal activities although he/she must avoid major strains for about a month.

Stenosis is a narrowing of the spinal canal, so that nerve roots and/or spinal cord are compressed.

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