What is spinal stenosis?

Spinal stenosis occurs most often in lumbar spine (low back) although not infrequently in the cervical spine (neck). The condition results when ligament thickening, facet osteoarthritis (and spurs), and disc degeneration, all result in narrowing of the spinal canal. At times, the central canal is narrowed and this is called central spinal stenosis. At other times, the outer sides of the canal are narrowed where the nerves exit the spinal cord to supply muscles and/or sensation to the arm or the leg; this is called lateral spinal stenosis (or foraminal stenosis). In either case, these patients will develop radiation of symptoms, weakness, or numbness. In the more common case, lumbar spinal stenosis, the patient may complain of “pseudoclaudication” —the patient cannot walk more than a specific distance before developing a sense of pain, discomfort, or weakness of one or both buttocks and/or legs. The patient must sit down to relieve symptoms before continuing to walk. The complaints suggest, but do not reflect, poor circulation. The complaints of numbness and weakness sound somewhat like sciatica. However, often the examination is less localized neurologically since there is not one particular disc at fault. In more severe cases, bowel or bladder control may be compromised. In this setting, medical advice must be pursued immediately. However, in most patients, this is a condition which develops gradually over the course of months to years as the end result of the “degenerative cascade.”

How is facet osteoarthritis different from spinal stenosis?

Facet osteoarthritis does not cause weakness or numbness. There is no pseudoclaudication. The pain is primarily felt in the back and is worsened by arching (or extending) the back. Excessive motion increases the pain. The pain may radiate down one leg or another but usually not very far beyond the buttock and rarely below the knee. The neurological examination is normal. On the other hand, stenosis results in symptoms of extremity pain, weakness, and/or numbness. Symptoms are worsened by walking and the leg can feel as if it will “give away” or “buckle.” The patient must sit down to obtain relief of symptoms. Radiation of symptoms more closely approximates sciatica, often extending below the knee and even into the foot.

Are there any tests that can differentiate the facet syndrome (osteoarthritis) from lumbar spinal stenosis?

There are many tests, such as a CAT scan, MRI, and EMG, which are often positive and specific for lumbar stenosis. These are all fairly normal in the facet syndrome, failing to show narrowing of the spinal canal, demonstrating only osteoarthritis in the facet joints.

If I have lumbar spinal stenosis, so I need surgery?

Many patients with lumbar stenosis can be helped by conservative measures which avoid the necessity for surgery. Physical therapy can be helpful for several reasons. First, often a substanial component of the pain comes from surrounding muscles and ligaments which may be inflamed or in spasm. These regions of pain may respond to physical therapy modalities, massage, and exercise. Second, the stenosis itself may have a discogenic component in which case treatments such as those used to reduce pain from a slipped disc may help. These include passive extension exercises, pelvic traction, as well as other techniques. In addition to physical therapy, medications can be useful in reducing inflammation, muscle spasm, pain, and indirectly reducing factors which can worsen back pain, such as constipation and sneezing.

Can manipulation help?

Lumbar spinal stenosis is one of those conditions where manipulation is contraindicated; because there is already limited room for nerve fibers, it is unwise to try to “adjust” the spine.