Spinal canal is the bony tube made of the vertebrae, through which passes the spinal cord and the nerves. In between each vertebra, there is a space called as intervertebral disc. It is a gel like region which forms a cushion between two vertebrae and prevents friction between them and allows movement to occur. The nerve root branches off at each level and forms nerves of the arms and hands. The neck region is called cervical spinal region, the mid back is thoracic spinal region and the lower back is the lumbar spinal region. The neck region is made of 7 vertebrae.
Spinal stenosis is a condition wherein the spinal cord narrows down. It can happen in any region of the spine viz., cervical, thoracic, lumbar and are known as cervical spinal stenosis, thoracic spinal stenosis, lumbar spinal stenosis etc., respectively. Cervical spinal stenosis is the most frequently occurring condition. Let us have a look at the condition in detail.
What is Cervical Spinal Stenosis?
Spinal stenosis is a medical condition where the spinal canal narrows down unusually and produces discomfort. When the spinal canal becomes narrow to a size that it disturbs the spinal cord in the neck region, it is called as the Cervical Spinal Stenosis. It is most frequent among all types of stenosis and is dangerous too. When the pressure on the spinal cord increases and results in reduced blood supply it results in a medical condition called Myelopathy. Cervical spinal stenosis with myelopathy is more frequently seen in elderly people.
Symptoms of Cervical Spinal Stenosis
In most cases cervical spinal stenosis develops in the later phases of life due to degeneration. The symptoms of cervical spinal stenosis include:
- Discomfort during standing
- Jerky walking
- Pain and numbness due to nerve pressure
- Weakness in the muscle supplied by the nerve
- Loss of motor control
- Loss of muscle power in the legs and is called as spasticity.
All these symptoms of cervical spinal stenosis do not occur all at once, but occur gradually.
In case of Myelopathy, there are symptoms such as
- Numb and clumsy hands
- Loss of bladder and bowel movement
Epidemiology of Cervical Spinal Stenosis
Cervical spinal stenosis is common in men and women who are 50 years or above. However, it can also occur in younger people who are born with the congenital defect of narrowing down of the spinal canal.
Prognosis of Cervical Spinal Stenosis
Most patients when treated surgically or non-surgically get relief from cervical spinal stenosis. Surgical treatment is more effective than non-surgical treatment for cervical spinal stenosis. The patients have less leg pain and are able to walk better following surgery. Patients with badly damaged nerves and with degenerative process are likely to experience the numbness and pain even after surgery.
Causes of Cervical Spinal Stenosis
Some of the common causes of cervical spinal stenosis include:
- Cervical Spinal Stenosis Caused Due to Spinal Instability: Spinal instability means extra movement of the bones of the spine or the vertebra slips forward on another vertebra. In case the supporting ligaments of the cervical spine has been overstretched or torn due to injury, instability can happen. For example, Rheumatoid arthritis can cause problem of spinal instability.
- Cervical Spinal Stenosis Caused Due to Disc Herniation: Cervical spinal stenosis occurs when intervertebral disc in the neck ruptures (herniates).
- Degenerative Conditions: Disc degeneration is the most common cause of cervical spinal stenosis. Degeneration occurs due to wear and tear, aging and stress and strain on the spine.
- Constriction of the Blood Supply: Disc herniation and degeneration often leads to many structural changes which can stop the blood supply to the spinal cord. Due to which the sections of spinal cord cannot function normally and show symptoms of cervical spinal stenosis and myelopathy.
- Congenital Cervical Spinal Stenosis: Some people are born with narrow spinal canal and they often face more problems in old age since the canal becomes narrower as a result of aging.
- Trauma: Accidents and trauma/injuries can dislocate the spine causing cervical spinal stenosis.
- Tumors as a Cause Cervical Spinal Stenosis: There is irregular growth of soft tissues which press on the nerves and spinal cord.
Pathophysiology of Cervical Spinal Stenosis
The spinal cord passes through a protective bony tube, the spinal canal. The spinal canal has enough space of 17-18 mm around the spinal cord. Due to some conditions, when the spinal canal gets narrowed to 13 mm or less, it squeezes the spinal cord. When this narrowing occurs in the neck region, it is called as the cervical spinal stenosis. When size becomes less as 10 mm, it leads to a pressure against the spinal cord which leads to reduced blood supply and results in a medical condition called Myelopathy.
Complications of Cervical Spinal Stenosis
Rarely, untreated cases of severe cervical spinal stenosis may progress and cause the permanent damage in form of:
- Balance problems
The common complications after surgical treatment for cervical spinal stenosis include a tear in membrane covering the spinal cord at the site of operation, infection or problems in blood circulation.
Diagnosis of Cervical Spinal Stenosis
The doctor records the complete history and performs physical examination. It is followed with questions regarding the symptoms and how it affects the daily life. The doctor also performs physical examination of the back, neck, movements, skin sensation, and muscle strength.
To know the exact cause of pain, the doctor recommends a number of tests which includes:
- X-Ray to Diagnose Cervical Spinal Stenosis: This is the first step to know the reason of neck pain and if additional diagnostic tests are required. X-ray shows only bones of the cervical region and not the soft tissues such as nerves, disc and muscles. They also show if infection, fractures or tumors are affecting bones.
- MRI and CT Scans to Diagnose Cervical Spinal Stenosis: MRI and CT scans are more specialized tests commonly used since they show abnormal areas of the soft tissues around the spine. This allows understanding of the condition of the intervertebral discs, ligaments, spinal cord and nerves.
- Electrical tests of nerves which goes to the arms and hands are done as follows:
- An electromyography test is used to diagnose whether the nerve present in motor pathway is working correctly or not.
- A somatosensory evoked potential (SSEP) test is done to locate which area of the spinal cord is getting squeezed. This test also measures and records the ability of nerve to transmit sensory information.
How is Cervical Spinal Stenosis Treated?
Treatment of cervical spinal stenosis depends on the severity of the symptoms. If the symptoms are mild then first the non-surgical treatment is preferred and in case of the severe symptoms surgical treatment is given. Both the treatment methods are given as follows:
- Nonsurgical Treatment for Cervical Spinal Stenosis: These includes:
- Neck should not be kept still for short time.
- The daily activities which are repetitive and heavy should be restricted.
- Stretching and strengthening exercises to be performed.
- Doctors prescribe soft neck collar to be worn for three months.
- The help of physical therapist is taken to ease pain as well as inflammation.
- Traction is used to gently stretch the neck muscles and the joints with special head halter.
- A brief course of oral steroids and/or pain medications are given.
- Special epidural steroid injection (ESI) is given.
When the symptoms persists or become severe then the doctor recommends surgery.
- Surgical Treatment for Treating Cervical Spinal Stenosis: It aims to relieve the pressure on the spinal cord by widening the spinal canal. The procedures used to treat spinal stenosis include:
- Laminectomy: A laminectomy is done when the disc contents and bone spurs have come into the spinal canal. This surgical procedure includes removing or trimming of the lamina bone to widen the spinal canal and create more space for spinal cord. This allows the spinal cord to relax as the pressure is released.
- Anterior Cervical Discectomy and Fusion: A fusion surgery focuses on joining two or more bones into a single solid bone. Most often, the fusion surgery is done through the front part of the neck to fuse the neck bones. The surgeon, during the surgery, takes out the intervertebral disc (discectomy) between two vertebrae. This provides stability to the spine.
- Corpectomy and Strut Graf: A corpectomy helps in relieving pressure of a large part of the spinal cord. The surgeon, during this procedure, removes the front part of the spinal column and also several vertebral bodies. With the help of bone graft materials, the empty spaces are then filled. Following this, metal plates and screws are then used to fix the spine in proper place as it heals. A corpectomy is generally used in severe cases of spinal stenosis.
Alternative Therapies for Cervical Spinal Stenosis
There are alternative therapies to treat cervical spinal stenosis as:
- Chiropractic Treatment for Cervical Spinal Stenosis: It involves employing traction and pulling force to increase the intervertebral space. Chiropractic treatment is based on the philosophy that the restrictions in movement of spine cause problems of neck and back. This treatment strategy has proved to be an effective therapy for acute back pain as well.
- Acupuncture and Acupressure: This treatment involves stimulating certain places on skin by variety of treatments with thin, solid metallic needs that penetrate the skin or by giving pressure on the points by hand.
Coping of Cervical Spinal Stenosis
Patients with mild symptoms follow non-surgical treatment for three to six months. Some have to wear the collar brace for months.
In case, the condition is severe or doesn't get cured by non-surgical treatment, surgery is opted. After surgery, the patient has to stay in the hospital for few days and follow exercises as advised by the physical therapist which do not put any strain on the neck. During recovery a patient may be placed into a halo vest or a rigid neck brace which restricts the movement in the neck and allow fusion of the bones and their healing. This treatment is continued for five to six months. Most patients rehabilitate at home. Bone fusions may take several months.
Cervical Spinal Stenosis is a progressive disease and most of its symptoms are experienced in old age. It is mainly caused due to the wear and tear of the spinal canal which affects the internally placed spinal cord. If not treated, it may turn dangerous and result into myelopathy. Surgical treatments are considered to be effective in severe cases of cervical spinal stenosis. However, permanent nerve damage and degeneration causing pain cannot be treated. Such patients can obtain relief from alternative therapies. When the patient starts feeling better they can perform their previous activities. However, they need to modify their daily activities in order to avoid problems in future.