Cervical Spinal Stenosis
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A Patient's Guide to Cervical Spinal Stenosis
Most neck pain is due to degenerative changes that occur in the intervertebral discs of the cervical spine and the joints between each vertebra. Perhaps the most serious of the problems caused by degeneration of the spinal segment in the cervical spine is the condition of spinal stenosis.
In the late stages of spinal degeneration, bone spurs from the degenerative process can cause a condition known as spinal stenosis. As the bone spurs form, the size of the spinal canal becomes smaller. The bone spurs begin to press on the spinal cord or the nerve roots. Pressure on the nerves in the spinal cord can cause numbness, tingling, or pain in the arms, hands, and legs. This condition is sometimes called cervical myelopathy. It is from the simpler problem where only one nerve root is being pinched by a herniated disc or a bone spur.
The purpose of this information is to help you understand:
- The anatomy of the cervical spine
- The causes and symptoms of cervical spinal stenosis
- How the condition is diagnosed
- The treatments available for cervical spinal stenosis
In order to understand your symptoms and treatment choices, you should start with some understanding of the general anatomy of your neck. This includes becoming familiar with the various parts that make up the neck, and how these parts work together.
Please review the document, entitled:
To really understand cervical spinal stenosis you first need an understanding of the wear and tear process, called disc degeneration. To help you understand disc degeneration, compare a spinal segment to two vanilla wafers (the "vertebrae") and a marshmallow (the "disc"). Imagine a fresh marshmallow between the two wafers. When you press the wafers close together, the marshmallow gives or "squishes out". Suppose you leave the marshmallow out for a week and it starts drying out. When you press it between the wafers, it is not quite as spongy. If you press hard enough, the outside of the marshmallow may even tear or split. Suppose you left the marshmallow out for a month. It would probably be so dried out it would be hard and very thin and would not have any "shock absorbing" ability.
As we age, the disc loses some of its water content and, as a result, some of its shock absorbing ability. Like the marshmallow, the first changes that occur in the disc are tears in the outer ring of the disc, called the annulus. Tears in the annulus may occur without symptoms. Therefore, you may not notice when they occur or what caused them. These tears heal by forming scar tissue. Scar tissue is weaker than normal tissue. Repeated injuries and tears cause more wear and tear to the disc. As the disc wears, it loses more of its water content. It becomes less and less "spongy", eventually no longer able to act as a shock absorber.
As the disc continues to wear, it begins to collapse. The space between each vertebra becomes smaller. The collapse also affects the way that the facet joints in the back of the spine "line up". Like any other joint in the body, the change in the way the bones fit together causes abnormal pressure on the articular cartilage. Articular cartilage is the smooth shiny material that covers the end of the bones in any joint. Over time, this abnormal pressure causes wear and tear arthritis (osteoarthritis) of the facet joints.
Bone spurs may form around the disc and facet joints. It is thought that too much motion in a spinal segment causes the bone spurs to form. Eventually, bone spurs can form around the nerves of the spine, causing a condition called spinal stenosis.
When there is narrowing of the spinal canal, the bony tube through which the spinal cord runs, the whole spinal cord may be affected. This is different than when the bone spurs only narrow one of the foramen - the openings where the nerve roots exit. The symptoms are much different. A pinched nerve from either a herniated disc or a bone spur rarely affects the legs. Cervical myelopathy can affect both the arms and the legs.
Pressure on the spinal cord, as it runs through the cervical spine, can cause many symptoms. Cervical stenosis can cause weakness and spasticity in the legs. Spasticity means you to lose control over your legs and you may have a great deal of difficulty walking due to loss of control of where you place your feet. You may have numbness in both the upper extremities and the lower extremities. Your reflexes may be increased in the legs. You may lose the strength in your legs. You may lose your "position sense". This is the sensation that allows you to "know" where your arms and legs are when you have your eyes closed. For example, you may not be able to tell whether your arm is up in the air or down by your side, unless you can see it.
Finding the cause of your neck problem begins with a complete history and physical examination. After the history and physical exam, your doctor will have a good idea of the cause of your pain. To make sure of the exact cause of your neck pain, your doctor can use several diagnostic tests. These tests are used to find the cause of your pain, not make your pain better. Regular X-rays, taken in the doctor's office, are usually a first step in looking into any neck problem and will help determine if more tests are needed.
A "complete history" is usually consists of two parts. The first part is written; a form that you fill out while you wait to see the doctor. While you fill out the form, take time to think about everything you can remember that relates to your neck pain and write it down. The more you can tell you doctor, the faster he or she can diagnose the cause and help relieve your pain. The second part of your history will be answering questions. Your doctor will ask you describe when your neck pain began and the type of pain you are having.
Examples of questions that might be asked include:
- When did the pain first begin?
- Do you have weakness in your arms or legs?
- Have you had an injury, or surgery, to your neck at any time?
- Does the pain go down into your arms or legs?
- Have you had problems walking?
- Have you had any problems with your bowels or bladder?
Once most of the information is gathered, your doctor will give you a thorough physical exam. During the exam, your doctor will look at your neck to find out how well your neck is functioning.
- How well you can bend your neck and roll your head in all directions
- How well you can twist your neck
- If there is tenderness around the neck
- If there are muscle spasms around the neck and shoulders
Tests that examine the nerves that leave the spine are also important. These include:
- Testing for numbness in the arms and hands
- Testing the reflexes
- Testing the strength of the muscles in the arms, hands, and legs
- Testing for signs of nerve irritation
X-rays show the bones of the cervical spine. Most of the soft tissue structures of the spine, such as the nerves, discs, and muscles, do not show up on X-ray. X-rays can show problems that affect the bones, such as infection, fractures, or tumors of the bones. X-rays may also give some idea of how much degeneration has occurred in the spine. The X-rays will be useful in showing how much degeneration and arthritis are affecting the neck. They will give your doctor an idea whether cervical spinal stenosis exists.
X-ray Cervical Disc Degeneration
Magnetic Resonance Imaging (MRI)
MRI Scan Cervical Stenosis
The MRI is the most commonly used test to evaluate the spine because it can show abnormal areas of the soft tissues around the spine. The MRI is better than an X-ray because in addition to the bones, it can also show pictures of the nerves and discs. The MRI is done to find tumors, herniated discs, or other soft-tissue disorders. The MRI is painless and lasts about 90 minutes. During the MRI, very detailed computer images of sections of the spine are taken. Unlike most other tests, which use X-rays, the MRI uses magnetic fields and radio waves to see the structures of the neck. Pictures can also be taken in a cross-section view. The MRI allows the doctor to clearly see the nerves and discs without using special dyes or needles. In many cases, the MRI scan is the only special test that needs to be done to find the cause of your neck pain.
Before the MRI, you will be asked to remove any metal objects, such as jewelry. You will also be asked if you have metal implants such as a pacemaker or joint replacement. Because of the strong magnetic field, people with certain types of metal implants cannot undergo an MRI.
The MRI scanner is a very large machine with a tunnel-like area in the center. While you lie on a table, the table slides into the tunnel of the scanner. Once in position, you will be asked to remain very still for the rest of the test. During the test, you will hear the clicking and thumping noises as the scanner moves. While the scanner is taking pictures, the technician can see the pictures on a monitor and record them.
Cervical myelopathy is a serious problem. The pressure on the spinal cord usually will not go away without surgery and the symptoms will most likely continue to get worse. If you do not improve rapidly with non-operative care, your doctor may suggest surgery to relieve the pressure on the spinal cord.
There are several surgical procedures used to treat cervical spinal stenosis that is causing cervical myelopathy. Both types of operations have the same goal - to relieve the pressure on the spinal cord by making the spinal canal larger. In some cases, the surgeon may suggest an operation called a laminectomy. In this operation, the back side of the vertebrae is opened to allow more room for the spinal cord.
In other cases, the surgeon may suggest an operation from the front of the neck - a corpectomy (corpectomy means "remove the body") and strut graft. This operation allows the surgeon to remove the vertebral body of the vertebra, along with any bone spurs pushing into the spinal cord. The vertebrae are then replaced with a solid piece of bone graft (called a strut graft). The strut graft heals over time to create a spinal fusion where the vertebral bodies have been removed.
You can learn more about these surgical procedures by reviewing the following documents, entitled:
For information relating to rehabilitation for cervical spinal stenosis, refer to the document, entitled:
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