Cervical Stenosis

Cervical stenosis refers to a narrowing of the spinal canal in the neck, usually due to degenerative arthritis of the spine joints or bulging from a disc in between two vertebrae. Symptoms occur when the narrowing is severe enough to exert pressure on the spinal cord, the nerve roots, or both.

Pressure on the spinal cord causes myelopathy, which a patient may experience as numbness/tingling or a loss of dexterity in the hands, neck pain, and trouble with gait or balance. Physical examination signs of myelopathy include muscle weakness or atrophy, loss of sensation, and exaggerated reflex responses.

Pressure on the nerve roots from cervical stenosis causes radiculopathy, in which a patient may experience shooting pain from the neck down into the arm. There may be muscle weakness, sensory loss, or a tingling sensation in the affected parts of the arm, too.

Cervical stenosis is a degenerative condition, meaning that medications and physical therapy have limited roles in reversing it. Surgery is the mainstay of treatment for patients with severe symptoms, and there are surgical options from both the front and the back of the neck (i.e. "anterior" and "posterior").

Anterior options for surgery include cervical discectomy and fusion (ACDF) and cervical disc replacement (arthroplasty). Posterior approaches include cervical laminectomy with or without fusion and laminoplasty. Each of these options has benefits and drawbacks. The right option for you will depend on your symptoms, the number of spinal levels affected, and factors related to your medical history, age, and spinal anatomy.

Cervical Radiculopathy

Cervical radiculopathy refers to irritation or dysfunction of one or more of the nerve roots that arise from the spinal cord in the neck and travel down into the arm. Symptoms may include pain that radiates down the arm, weakness of corresponding arm muscles, a loss of sensation (numbness), and tingling in the arm or hand. Patients may have just one or any combination of the above symptoms.

The cause of cervical radiculopathy is often compression of a cervical nerve root where it emerges from the spinal cord. This can be due to a herniated disc, degenerative arthritis, infection, or other problems. Certain causes may resolve with time (for example, a herniated disc), while others tend not to improve with time - even with medications and physical therapy. Surgery should be considered for patients with severe symptoms that have not resolved despite trials of several non-surgical treatments over an adequate period of observation.

Surgical options for cervical radiculopathy are similar to those for cervical stenosis, described above.

Lumbar Stenosis

Lumbar stenosis refers to a narrowing of the spinal canal in the lower part of the back. The most common causes are degenerative arthritis of the spine joints, a herniated intervertebral disc, and slippage of one vertebrae on another (spondylolisthesis). Narrowing of the spinal canal exerts pressure on the nerve roots that travel down and supply strength and sensation to the legs.

Lumbar stenosis classically causes pain that radiates down one or both legs. There may also be muscle weakness, numbness, or tingling in the affected leg. Symptoms may be brought on by activity or walking, and some patients find relief by bending forward or lying down. Severely affected patients can have bowel or bladder dysfunction, including incontinence. Certain causes of lumbar stenosis, notably spondylolisthesis, may also cause back pain.

As with cervical stenosis, treatment is focused on removing pressure from the affected nerve roots. This can be accomplished directly by performing a laminectomy and/or indirectly by changing the alignment and spacing of the vertebrae with a lumbar fusion.

A spinal fusion should be considered when there is evidence of abnormal movements of the vertebrae ("instability"). There is an alphabet soup of techniques for fusing the lumbar spine: ALIF, OLIF, TLIF, PSF, and so on. Fundamentally, a fusion involves inserting metal hardware to limit motion of a segment of the spine. Once the affected segment is immobilized, the goal is for your spine bones to grow across it, stabilizing it permanently. If a fusion is needed, your surgeon will review with you possible techniques along with their benefits and drawbacks.

Lumbar Radiculopathy

Lumbar radiculopathy refers to irritation or dysfunction of one or more of the nerve roots that arise from the spinal cord in the low back and travel down into the leg. Symptoms may include pain that radiates down the leg, weakness of corresponding leg muscles, a loss of sensation (numbness), and tingling in the leg or foot. Patients may have just one or any combination of the above symptoms.

Some causes of lumbar radiculopathy, such as a herniated lumbar disc, may improve on their own over time without surgery. Other problems are less likely to improve with time. Physical therapy, medication, steroid injections, and yoga therapy all have a role to play in helping symptoms. For patients who do not find relief from these measures, surgery should be considered.

Surgical options mirror those used for lumbar stenosis, described above. Some patients may need only a laminectomy or removal of bone around the affected nerve root, a procedure called a foraminotomy, while others may need a more extensive operation or even a fusion to correct instability in the spine. Your symptoms, medical history, MRI findings, and X-rays will all factor in to this decision.

Spondylolisthesis

Spondylolisthesis refers to slippage or abnormal movement of one vertebra on another. It is a sign of instability in the spine, and it can have many causes, some congenital, and some acquired over time. Symptoms can include pain in the neck or back at that level as well as compression of nearby nerve roots or even the spinal cord. Surgical treatment sometimes requires a spinal fusion.

Herniated Disc

Intervertebral or spinal discs are present between neighboring vertebrae in the spine. They are rubbery pads that act as shock absorbers and also provide flexibility to the spine. As we age, the discs are subject to wear and tear. A sudden stress on the spine - for example lifting a heavy object - can sometimes cause a piece of a disc to herniate into the spinal canal. Herniated discs cause symptoms when they press on a nerve root or the spinal cord.

Compression of a spinal nerve root by a herniated disc can cause a radiculopathy, experienced as pain, weakness, and sensory changes in an arm or leg. The herniated disc fragment will often dissolve away over time, so a patient's symptoms may disappear after a few months. In this way, many herniated discs will not need surgery.

Rarely, a herniated disc can cause severe spinal cord or nerve root compression, resulting in severe pain or even weakness. In situations like this, surgery may be needed to decompress the spinal cord or nerves. The type of surgery depends on the nature and location of the herniation, along with the patient's symptoms.

Failed Back Surgery Syndrome

Failed back surgery syndrome is a condition in which a patient experiences severe, chronic pain in the low back and/or legs after one or more operations on the lumbar spine. It is estimaed to affect 20-40% patients who have low back surgery, and the risk appears to increase with number of surgeries a patient has had. The term is not meant to imply that there was a problem with one of a patient's surgeries but rather that symptoms have persisted.

Clinical studies have suggested that additional corrective surgeries on the lumbar spine (e.g. fusions and laminectomies) are unlikely to improve symptoms in patients with features of failed back surgery syndrome. For patients who experience persistent, disabling pain despite medications, physical therapy, and injections, spinal cord stimulation can be an excellent therapy. Randomized controlled trials have supported the effectiveness of spinal cord stimulation for both back and leg pain. You can read more about spinal cord stimulation here.