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Spinal Stenosis – Narrowing of the Spine
Spinal stenosis is the narrowing of the spinal canal in the lumbar (lower back) region, resulting in pressure on the lumbar nerves (cauda equina). Spinal stenosis usually becomes symptomatic after the age of 50. It is caused by degeneration of the spine (with rare exceptions in patients born with a congenitally narrow canal). In most patients, symptom onset begins with an acute event, such as a lumbar injury or a herniated disc.
What are the symptoms of spinal stenosis?
Symptoms of spinal stenosis include:
- Pain, weakness, or numbness in the legs, mainly from the buttocks to the calves, which worsens when walking and improves when sitting. Patients often walk a short distance and then need to sit (intermittent claudication).
- Stooped posture and easier walking while leaning on a shopping cart (shopping cart sign).
- Lower back pain, which usually improves when bending forward or sitting.
- Burning, tingling, or “pins and needles” sensation in the lower limbs.
- Weakness in a specific nerve, e.g., difficulty walking on the heel or tiptoe.
- Rarely, patients may have bowel or bladder disturbances.
How is the diagnosis made?
Diagnosis is based on a combination of medical history, which usually includes difficulty walking distances (walking interrupted by the need to sit, i.e., intermittent claudication), and physical examination findings.
During the physical exam, patients may show weakness in certain nerves, affecting specific muscle groups in the legs. They may also show limited motion or reduced sensation. A thorough exam should always include the hips (which often mimic spinal stenosis) and the lower limb blood vessels, since vascular stenosis of the legs can produce similar symptoms.
What diagnostic tests and exams are needed?
- X-rays in a standing position to assess spinal stability.
- CT scan and especially MRI to show the extent of spinal canal narrowing and nerve compression, particularly before possible surgery.
- Electromyography (EMG) is still sometimes prescribed, but it is neither necessary for diagnosis nor does it guide treatment.
Is there conservative treatment for spinal stenosis?
Spinal stenosis is a progressive disease for two reasons:
- Degeneration continues, reducing the spinal canal diameter, potentially leading to complete obstruction.
- Nerve damage is ongoing and cumulative; in neglected cases, it may be irreversible.
Walking distance gradually decreases, and the longer nerve compression persists, the less recovery of walking ability is possible.
Conservative treatment is not curative, only symptomatic relief.
- Most cases of mild stenosis can be managed initially with painkillers and anti-inflammatories.
- In rare cases of acute pain, epidural steroid injections or oral steroids may be used.
- Activity limitation and wearing a lumbar brace can help reduce symptoms.
- Bed rest should be avoided, as prolonged immobility can lead to other complications.
- Physical therapy is useful, including heat therapy, electrical currents, ultrasound, and exercises to strengthen muscles, improve endurance, flexibility, and spinal mobility.
Surgery – Simple decompression
The goal of surgery is to widen the spinal canal and decompress the nerves.
- The basic surgery is a laminectomy, removing the posterior part of the spinal canal (the lamina).
- If the entire lamina does not need removal, only a portion can be removed (partial laminectomy).
- Large herniated discs may also be removed to further decompress the canal.
- The lateral foramina are also decompressed (foraminotomy).
Surgery – Decompression and spinal fusion
Spinal fusion is indicated only in specific cases:
- Absolute indications: scoliosis greater than 20° or slippage of one vertebra over another (spondylolisthesis).
- Relative indications: severe stenosis, significant disc disease, or notable back pain.
During fusion surgery, after decompression, screws and rods are used to stabilize the vertebrae. Bone grafts are then applied to achieve permanent fusion.
Postoperative Rehabilitation: Walking – Exercises – Physical Therapy
- Most patients get out of bed the same day or the day after surgery.
- Surgical pain is managed with common painkillers and anti-inflammatories for 1–2 weeks.
- Activity is gradually increased. After surgery (or 2–3 days if spinal fusion was performed), patients can return home.
At home:
- Mobilization is encouraged, but rest is necessary until surgical stress subsides (a few days).
Activity progression depends on the extent of surgery, previous activity level, and type of surgery:
- Return to work or driving: ~2–4 weeks
- Return to light exercise and walking: ~1.5–3 months
- Return to contact sports (e.g., basketball): ~3–6 months
Frequently Asked Questions about Spinal Stenosis
What is spinal canal stenosis?
Spinal stenosis is the narrowing of the canal in the lumbar spine, which puts pressure on the lumbar nerves (cauda equina). It is the result of degeneration of the spine and in most cases causes symptoms from the age of 50 onwards. A few patients are born with a narrow canal.
What are the symptoms of spinal stenosis?
The most typical symptom is pain, weakness or numbness in the legs, mainly from the buttocks to the calves, which gets worse with walking and better when sitting (intermittent claudication). Patients often stand bent forward and walk more easily when leaning on a supermarket trolley, and may have lower back pain that improves when bending forward or sitting, burning or tingling in the legs and weakness of one nerve. Rarely, there may be problems with bowel movements or urination.
Why does spinal stenosis make walking difficult?
The pain, weakness or numbness in the legs, mainly from the buttocks to the calves, gets worse with walking and better when sitting. So the patient walks a little and then sits down (intermittent claudication), and walks more easily bent forward, as when pushing a supermarket trolley. Because the condition progresses, the walking distance keeps getting shorter, and the later the nerves are freed, the less walking ability is regained.
Does physiotherapy help with spinal stenosis?
Yes, physiotherapy has a place in conservative treatment, with physical methods (heat, electrical stimulation, diathermy, ultrasound) and with exercises for muscle strength, endurance, flexibility and stretching of the spine. However, conservative treatment does not cure the condition; it only brings relief, because spinal stenosis is a progressive disease.
What does surgery for spinal stenosis involve?
The aim of surgery is to widen the spinal canal and decompress the nerves. The main operation is laminectomy, in which the lamina (the back part of the spinal canal) is removed and the side openings of the canal are also freed. Spinal fusion has strict indications, and it is always needed when there is also scoliosis greater than 20° or spondylolisthesis. Most patients get out of bed on the same day or the day after surgery.