The spinal cord – the bundle of nerves that extends down from the brain and branches off to supply nerve function to every part of the body – runs through a canal in the middle of the spine. Each vertebra – bone of the spine – has a hole in it and together they form a long, protective passageway for the spinal cord.
Sometimes, this passageway can become narrower than it should be, and this can put pressure on the nerves of the spinal cord, which can cause a range of problems. This narrowing is known as spinal stenosis.
What causes spinal stenosis?
- Arthritis: The most common cause of spinal stenosis is changes in the bones caused by arthritis. Rubbing and deterioration caused by arthritis can cause thickened, raised areas of bone known as bone spurs which can cause pressure on the spinal cord.
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Illustration showing spinal canal stenosis lumbar vertebra with intervertebral disc and herniated nucleus pulposus
Injury: An injury that affects the bones of the spine can cause movement or inflammatory changes that affect the width of the spinal canal. Surgery on the spine for any reason also increases the risk of developing spinal stenosis in future.
- Tumours: Tumours can be cancerous or benign growth; either way, they can invade the spinal canal and put pressure on the cord.
- Paget’s Disease: Bones are just like other tissues of the body in that they are broken down and renewed. In people with Paget’s disease, the cells are broken down faster than they’re renewed, which causes thinning of the bones, making them very fragile. These weak, fragile bones gradually change shape, sometimes causing movement and pressure within the spinal column itself, or changes in the way the spine curves.
- Hypertrophy of the ligaments: This means a thickening and hardening of the ligaments, and when it affects the ligaments of the spinal column it can cause narrowing of the spinal canal.
Types of Spinal Stenosis
Spinal stenosis affects either the vertebrae that make up the neck – known as the cervical or c-spine, or the vertebrae at the lumbar or l-spine. Some people have stenosis in both of these areas of the spine.
Cervical
The cervical spine is the part of the spine that makes up the neck, and comprises the top seven vertebrae below the skull.
Lumbar
The lumbar spine is the 5 vertebrae that make up the lower back above the sacrum.
Symptoms of spinal stenosis
Symptoms of cervical spinal stenosis include:
- Neck pain
- Numbness
- Odd sensations like pins and needles or tingling in the one or more limbs
- Back pain
- Changes to gait and balance
Symptoms of lumbar spinal stenosis include:
- Cramping pain in one or both legs
- Lower back pain
Spinal stenosis can sometimes cause problems with bladder or bowel control, and occasionally with sexual function. The pain associated with spinal stenosis can become very severe, and can have a significant negative impact on a person’s life, mobility, fitness, and general health.
The majority of cases of spinal stenosis are caused by arthritis or other chronic degenerative bone disease. In these cases it begins slowly so there can be a fairly significant narrowing of the spinal canal before symptoms are really noticeable. When they do begin they usually develop gradually and worsen over time.
Spinal stenosis that is caused by injury can start much more quickly if the injury leads to long-term narrowing of the spinal canal. When someone has an injury involving the spine, there are short-term inflammatory processes which can cause compression on the spinal cord but don’t necessarily mean there will be long-term spinal stenosis.
Spinal stenosis caused by a tumour can also cause symptoms to develop more quickly than stenosis caused by chronic deterioration.
Diagnosing spinal stenosis
A person’s symptoms and risk factors for spinal stenosis will be considered when they first present, normally at their GP. A physical examination, usually to demonstrate the movement of the spine and any accompanying symptoms, will also help to suggest a diagnosis.[i]
An absolute diagnosis can be confirmed with the use of medical imaging. The type of imaging requested can depend on whether there is any suspicion of certain other conditions or causes. Tests can include:
- X-rays – these give a good picture of the bones, and so can be used to spot any changes in bone structure that might cause pressure on the spinal cord.
- CT (computed tomography) scans – these give a more detailed picture of the structures around the spinal cord, and can show problems like herniated discs and tumours.
- MRI (magnetic resonance imaging) scans – these give a very detailed picture of the tissues of the body, and can give doctors a lot of detail about any changes in the bones and the soft tissues. MRI scans can indicate areas of damage or inflammation, tumours and other problems.
A doctor might also request blood tests which can include measuring inflammatory markers and markers for autoimmune causes of arthritis.
How bad can spinal stenosis get?
The symptoms of spinal stenosis, such as pain, numbness, mobility problems, and problems with continence, can become very severe. The impact of these kind of symptoms can have a profound effect on someone’s life. Reduced mobility can cause other problems with the muscles, bones and joints.
Problems with bowel and bladder control, particularly combined with reduced mobility, can also be associated with a risk of other problems like pressure damage, moisture lesions, and have a serious impact on a person’s mental health and quality of life.
Chronic pain can be difficult to manage, and even more difficult to live with. Spinal stenosis can seriously affect a person’s quality of life, and ultimately their independence.
Risk Factors for Spinal Stenosis
Most people who develop spinal stenosis do so because of long-term degenerative changes in the bones of the spine, most often caused by arthritis. Arthritis is usually – but not always – associated with the processes of aging, which means that spinal stenosis tends to affect people more as they age. It also affects women more than it affects men, which may be for a range of reasons, including under-diagnosis in men.[ii]
People who have had previous surgery on their spine are more likely to develop spinal stenosis, and it is also more common in people who are overweight or obese.[iii]
People who have curvature of the spine (kyphosis or scoliosis) or other structural changes are also more likely to experience problems from compression of the spinal cord. Rarely, people can be born with unusually narrow spinal canals, and may have problems with pain and movement from a very young age.
Stages of Spinal Stenosis
Once spinal stenosis has developed, it will gradually get worse without treatment.
Treatment depends on the cause, but where spinal stenosis is caused by chronic irreversible degenerative bone disease like osteoarthritis, treatment is only likely to slow progression or manage symptoms.
Spinal Stenosis Treatment
The treatment for spinal stenosis depends on the cause. Most causes of spinal stenosis are not reversible, i.e. cannot be completely removed by treatment. Treatment, therefore, usually focuses on slowing progression, alleviating symptoms, and reducing the risk of complications or side-effects.[iv]
Conservative (non-surgical) treatment
- Medication – anti-inflammatory medication can help reduce compression on the spinal cord and also independently reduce pain. Chronic severe pain can also be managed with stronger pain medication, and there are specialist teams of healthcare professionals whose job is to help people manage chronic pain. Sometimes medications that are usually used for depression or to prevent seizures are also used to manage chronic pain.[v]
- Injections – some medicines are best given as injections, and steroid injections at the site can be very effective, and usually only need to be given every few months.
- Physiotherapy – physiotherapy is an important part of the treatment of spinal stenosis and some of its associated symptoms. Exercises can help to strengthen the muscles supporting the spine, and to maintain good movement and flexibility. Physiotherapy can also help with problems with gait and balance that can arise in people with spinal stenosis and related conditions.[vi]
Surgery for spinal stenosis
Surgery can widen the spinal canal somewhat, but the effectiveness can depend on the cause of the spinal stenosis.[vii] Surgery for spinal stenosis is something of a last resort, and generally only considered when more conservative treatment has been unsuccessful.
Surgery to widen the spinal canal is performed under a general anaesthetic and it can take some months to fully recover. The surgery is performed on the lamina – this is the arched back section of each vertebra. This can take the form of:
- Laminectomy – where the lamina of the affected vertebra or vertebrae is removed, creating more space around the spinal cord. This may be replaced with specially designed surgical metalware which bridges the gap created and maintains strength in the backbone.
- Laminotomy – this is where a small amount of interior arch the lamina is removed, creating a wider spinal canal but leaving the outer part of the vertebra intact.
- Laminoplasty – This is only used in the bones of the c-spine; one side of the lamina is ‘hinged’, opened outwards a few degrees and metalware is used to maintain that position.
If the spinal stenosis is cause by a tumour then removal of the tumour may cure the spinal stenosis. Sometimes tumours around the spine are associated with other areas of thickening and cell overgrowth so some people may have continuing symptoms.
Exercise
Professional physiotherapy can be incredibly beneficial in spinal stenosis, strengthening the muscles around the spinal column, maintaining mobility, and managing pain. Referral to a physiotherapist means that treatment and exercise can be tailored to the individual and adjusted over time. There are also some useful exercises to try at home, but a personal physiotherapy plan from a professional is the ideal, especially if there are other complications or conditions affecting a person’s ability to exercise.
Good exercises for most people with spinal stenosis usually focus on maintaining or improving range of motion, so stretching and bending – within an individual’s limits – will make up some of an exercise plan.
Some people with spinal stenosis find that they’re most comfortable bent slightly forward, so cycling, whether on a stationary exercise bike or outdoors, can be a comfortable way of increasing strength.
Swimming is good low impact exercise and can be a comfortable way of improving symptoms and increasing strength and fitness.
Exercise classes that focus on slow, core-strengthening exercises like Pilates or yoga can be helpful, and a gym membership that includes access to a personal trainer with experience in supporting people with spinal problems is ideal.
Exercises to avoid
Everyone has different limits, and while exercise is very beneficial to most people with spinal stenosis, very high impact exercises like running on pavements can cause more pain than they relieve.
Living with Spinal Stenosis
Spinal stenosis is fairly common, so if you’re living with the condition, you’re not alone. There are lots of treatment options, and there are teams of healthcare professionals who specialise in conditions relating to the spine and nerves, to chronic pain, and to improving symptoms with physical therapy and other treatment.
There are also support groups for people living with conditions affecting their usual ability, and the internet is a good place to start to look for online, national, or local organisations or groups.
Whatever your symptoms, there will be some choices for helping to manage them. It’s always okay to ask for support, and it’s a good idea to keep your GP or specialist in the loop if symptoms change, as there might be other ways to manage them.
As with any chronic disease, looking after yourself is key. Maintaining a healthy lifestyle is good for both mental and physical health, and if you’re able to be proactive in gaining treatment, there is help at hand. If you’re unable to easily advocate for yourself, it might be important to ask a family member or friend to help support you with accessing healthcare services.
Maintaining your quality of life is key, and that might require a multi-pronged treatment plan. It’s also important to acknowledge other symptoms that can accompany spinal stenosis – these can include depression, sleeplessness, loneliness and reduced mobility. If you’re able to talk about these problems, there’s always a way to try and make things better.
[i] Haig, A. J., & Tomkins, C. C. (2010). Diagnosis and management of lumbar spinal stenosis. Jama, 303(1), 71-72.
[ii] Sekiguchi, M., Yonemoto, K., Kakuma, T., Nikaido, T., Watanabe, K., Kato, K., … & Konno, S. I. (2015). Relationship between lumbar spinal stenosis and psychosocial factors: a multicenter cross-sectional study (DISTO project). European Spine Journal, 24(10), 2288-2294.
[iii] Wang, C., Chang, H., Gao, X., Xu, J., & Meng, X. (2019). Risk factors of degenerative lumbar scoliosis in patients with lumbar spinal canal stenosis. Medicine, 98(38). https://doi.org/10.1097/MD.0000000000017177
[iv] Melancia, J. L., Francisco, A. F., & Antunes, J. L. (2014). Spinal stenosis. Handbook of clinical neurology, 119, 541-549.
[v] Hylands-White, N., Duarte, R. V., & Raphael, J. H. (2017). An overview of treatment approaches for chronic pain management. Rheumatology international, 37(1), 29-42.
[vi] Özden, F., Tümtürk, İ., Yuvakgil, Z., & Sarı, Z. (2022). The effectiveness of physical exercise in patients with lumbar spinal stenosis: a systematic review. Sport Sciences for Health, 1-12.
[vii] Wei, F. L., Zhou, C. P., Liu, R., Zhu, K. L., Du, M. R., Gao, H. R., … & Qian, J. X. (2021). Management for lumbar spinal stenosis: a network meta-analysis and systematic review. International Journal of Surgery, 85, 19-28.
