Brief overview
- Treatment: Mostly conservative, combination of physiotherapy, back training, heat therapy, electrotherapy, support corset (orthosis), pain management and therapy; rarely surgery
- Causes and risk factors: Often wear and tear (degeneration), rarely congenital, risk of spinal surgery, bulging or herniated discs, hormonal changes, bone diseases such as Paget’s disease
- Symptoms: Often asymptomatic at first; later back pain with leg radiation, restricted movement; sensory disturbances in the legs, limping, bladder and rectal disorders, impaired sexual function; very rarely paralysis
- Diagnosis: Based on the symptoms, imaging procedures (magnetic resonance imaging, computer tomography)
- Progression and prognosis: Usually very slow progression without therapy; can be treated well with conservative therapy
- Prevention: Not specifically possible; otherwise back-friendly behavior, for example when carrying heavy loads
What is spinal canal stenosis?
Spinal canal stenosis is a narrowing of the spinal canal through which the spinal cord with nerves and blood vessels runs.
It often affects older people due to wear and tear of the movable parts of the spine. However, there are also congenital forms. However, these are rare.
What forms of spinal canal stenosis are there?
The most common form of spinal canal stenosis is that of the lumbar spine – lumbar spinal canal stenosis.
Other forms are cervical spinal canal stenosis, which affects the cervical spine (HWS), and, rarely, thoracic spinal canal stenosis, which affects the thoracic spine (BWS).
Spinal canal stenosis has only been defined as an independent clinical picture since 1996. The World Health Organization (WHO) assigns it several diagnostic codes depending on its severity: the codes M48 (Other spondylopathies), M99 (Biomechanical dysfunctions, not elsewhere classified) and G55 (Compression of nerve roots and plexuses in diseases elsewhere classified).
Grading of spinal canal stenosis
As a criterion for the severity of spinal canal stenosis, the doctor uses imaging techniques such as magnetic resonance imaging to measure how much the spinal canal is narrowed. Doctors differentiate between
- Relative spinal canal stenosis with a canal diameter of less than twelve millimetres
- Absolute spinal canal stenosis with a canal diameter of less than ten millimetres
Treatment
In most cases, spinal stenosis can be treated well with conservative therapy methods. Only rarely (in very severe cases) is surgical intervention necessary.
Conservative treatment
Conservative forms of treatment for spinal stenosis include
- Physiotherapy (exercise therapy, baths, muscle-relaxing treatments and others) to relieve and stabilize the spine
- Heat therapy to relax the back muscles
- Electrotherapy for pain treatment and muscle relaxation
- Support corsets (orthoses) to relieve pressure on the spine
- Back training (targeted strengthening training for the back and abdominal muscles, tips for back-friendly postures, behavioral tips)
- Psychological pain management training
- Pain therapy
In most cases, several of the above measures are combined. This is known as a modular therapy concept.
Medication
Effective pain treatment is a cornerstone of conservative stenosis therapy. Doctors use different active substances depending on the intensity of the pain.
Some painkillers irritate the stomach lining if taken over a longer period of time. This is why doctors often prescribe so-called proton pump inhibitors to accompany them. As “stomach protection”, these medications ensure that the body produces less stomach acid.
In addition to the classic painkillers, doctors may also prescribe mild antidepressants. In small doses, these help with chronic pain, as they act at the neurotransmitter level.
Sometimes muscle relaxants can help with spinal canal stenosis. If the pain is very severe, high-dose cortisone therapy may be an option: cortisone reduces the swelling of the soft tissue pressing on the spinal canal. This leaves a little more space in the canal.
The various active ingredients with analgesic, anti-inflammatory, local anaesthetic and/or decongestant effects can often be administered by mouth (as a tablet, capsule or similar). They can often be injected directly into the affected area of the spinal canal stenosis.
In studies on injection therapy, patients were given ineffective substances (placebo), often simple table salt, instead of real medication. Despite this sham treatment, many patients subsequently experienced less pain. The researchers discovered that the placebo injections released the body’s own “painkillers” (endorphins).
How does an operation work?
Almost all patients with spinal canal stenosis are helped by conservative therapy. Surgery is only rarely necessary – usually when important nerves fail. Doctors also operate if conservative treatment fails or the patient is suffering greatly and is significantly restricted in their everyday life.
The aim of surgery is always to relieve the region where the spinal cord is being squeezed. Various methods are available for this:
- Pressure relief (decompression) of the constricted nerves is the method of choice. For this, the vertebral arch at the stenosis site is removed on one or both sides together with the spinous process (hemi-/laminectomy). Sometimes only parts of the vertebral arch are removed (microdecompression).
- Fusion (spondylodesis): Individual vertebrae are joined together and stiffened using material from the iliac crest or screws. This prevents them from slipping into each other and narrowing the spinal canal.
The doctor decides which method is most suitable in each individual case. All three procedures are generally minimally invasive or microsurgical. This means that the doctor does not need to make a large incision to reach the affected region. Several small incisions are sufficient, through which the surgeon inserts a tiny camera with a light source and the fine surgical instruments.
There are certain risks associated with every operation. For example, it is possible for nerves to be damaged during the procedure. In addition, in some cases the “skin” around the spinal cord is damaged, causing spinal fluid to leak out (cerebrospinal fluid fistula). Before operating on a spinal canal stenosis, the doctor will therefore carefully weigh up the expected benefits against the potential risks.
After spinal canal surgery
Aftercare following spinal canal surgery depends on the type and severity of the operation. After minimally invasive procedures, it is usually possible to leave the hospital after a short time, in some cases on the same day as the operation.
After the operation, doctors recommend a period of physical rest – usually around six weeks. Various lighter activities can be resumed earlier.
Sedentary activities such as driving are usually possible again sooner than heavy physical work. The duration of sick leave or incapacity to work therefore depends on the severity of the spinal canal stenosis and the type of surgery as well as the type of activity. As a rule, sedentary activities are possible again after around four weeks, heavy physical work only after around three months.
Alternative methods
Various healthcare professionals offer so-called alternative treatment methods, particularly for pain caused by spinal canal stenosis. These include, for example
- acupuncture
- Axomera therapy
- homeopathy
Although many patients report that they have experienced relief through alternative healing methods, the effects have not yet been proven in evidence-based medicine according to scientific and conventional medical criteria.
Causes
The most common cause of spinal stenosis is wear and tear (degeneration) of the spine: over time, the intervertebral discs between the vertebrae lose fluid. As a result, they become flatter and are less able to absorb movement-related pressure – the vertebral bodies are therefore subjected to greater stress and then press on the spinal canal.
Well-trained back muscles then stabilize the spine so that you are free of symptoms despite spinal canal stenosis. Patients with poorly developed back muscles, on the other hand, often develop typical stenosis symptoms. This is because if the muscles are unable to support the unstable spine, the body forms new bone structures on the vertebrae to stabilize the spine. These newly formed bony structures are called osteophytes. They often not only aggravate spinal stenosis, but also cause it.
Osteoarthritis of the vertebral joints (facet joints) may also lead to new bony formations and thus promote spinal stenosis (facet syndrome).
Rarer causes of spinal canal stenosis are
- Congenital malformations such as a severely hollow back, spondylolisthesis, chondrodystrophy (disorders in the conversion of cartilage to bone tissue during embryonic age). In such cases, the symptoms already appear at the age of 30 to 40.
- Spinal surgery (the excessive formation of scar tissue may narrow the spinal canal)
- Injuries to the vertebral bodies
- Protrusions or prolapse of intervertebral disc material into the spinal canal
- Hormonal changes that affect the bone substance and the stability of the vertebral bodies (e.g. Cushing’s disease)
- Spinal canal narrowed from birth of unknown cause (idiopathic spinal canal stenosis)
Symptoms
Spinal canal stenosis usually occurs in the lumbar vertebrae (lumbar spinal canal stenosis). It does not necessarily lead to symptoms. These only occur when the spinal canal is narrowed to such an extent that nerves or blood vessels are compressed. The specific symptoms, when and to what extent they occur, depend on several factors. These include the severity of the disease, the patient’s posture and the degree of physical strain.
At the beginning of the disease, the symptoms are not very characteristic and are varied. These non-specific complaints include
- Back pain in the lumbar region (lumbago), which usually radiates to one side of the legs (lumboischialgia)
- Reduced mobility in the lumbar vertebrae area
- Muscle tension in the lumbar region
If the stenosis progresses further, the following complaints are possible:
- Sensory disturbances in the legs
- Sensations of discomfort in the legs, such as burning, formication, feeling cold, feeling of absorbent cotton under the feet
- Feeling of weakness in the leg muscles
- Pain-related limping (spinal claudication)
- Bladder and/or rectal disorders (problems with bowel movements and urination or incontinence)
- Impaired sexual function
Limping due to spinal canal stenosis (spinal claudication) must be distinguished from temporary limping due to circulatory disorders in “intermittent claudication” (PAD). The latter is called intermittent claudication.
Very rarely, spinal canal stenosis leads to a so-called paraplegic syndrome: both legs are paralyzed and there are problems with bowel movements and urination.
Sometimes the narrowing of the spinal canal does not affect the lumbar vertebrae but the cervical vertebrae (cervical spinal canal stenosis). Those affected often have neck pain that radiates into the arms. Over time, they may also develop sensory disturbances in the legs as well as rectal and bladder problems.
Examinations and diagnosis
During the initial consultation (anamnesis), the doctor asks the patient in detail about their symptoms and known pre-existing or underlying conditions (herniated disc, osteoarthritis, osteoporosis and similar). This is followed by a physical examination: among other things, the doctor usually asks the patient to bend their upper body backwards and then forwards. If spinal canal stenosis is present, the back hurts when leaning back, while the symptoms disappear when the trunk is bent.
Alternatively, the spine can be imaged using computer tomography with a contrast medium. However, this so-called myelo-CT exposes the patient to a certain amount of radiation.
Not every narrowing of the spinal canal that is visible in an MRI or other imaging procedure actually causes symptoms!
In some cases, the doctor will also X-ray the patient in a standing position and in certain postures (functional images).
Electrophysiological examinations can be used to clarify spinal canal stenosis. These include, for example, electromyography (EMG) and so-called evoked potentials. These methods help to assess the function of nerves.
Progression and prognosis
Even if it is not treated, spinal canal stenosis usually progresses very slowly. The course of the disease also varies greatly depending on the cause. In some cases, the pain caused by the pressure on the nerve tracts remains constant or decreases with certain movements or over time. The pain may also come and go constantly. Sometimes the symptoms even decrease with age as the spine becomes less mobile. This is because the nerves are then irritated less frequently, meaning that movement-related pain occurs less often.
In some cases, however, spinal canal stenosis is acute: if, for example, intervertebral disc tissue becomes displaced (protrusion, prolapse), capsular swelling occurs in osteoarthritis, or fluid accumulates near the nerve tracts, it is possible that the symptoms of spinal canal stenosis will suddenly worsen. One side of the body is often particularly affected.
Overall, spinal canal stenosis can be treated well in most cases with conservative therapy methods, so that those affected can lead a relatively symptom-free life.
Severely disabled status for spinal canal stenosis?
If spinal canal stenosis cannot be treated and leads to limitations, it is possible that a so-called degree of disability (GdB) will be determined in the sense of recognition as a severe disability. As a rule, the responsible pension office determines such a degree of disability on application.
In the case of damage to the spine, this depends on the individual case, in particular on the severity of the restriction of movement and the effects.
Prevention
There is no known targeted prevention of spinal canal stenosis. However, as it is generally a wear and tear disease, it can be prevented (as can most back diseases in general), at least in principle, through so-called back-healthy behavior.
