Rheumatology Therapeutics
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General
Arthritis News
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What
Is Spinal Stenosis?
Spinal
stenosis is a narrowing of spaces in the spine
(backbone) that results in pressure on the spinal
cord and/or nerve roots. This disorder usually
involves the narrowing of one or more of three
areas of the spine: (1) the canal in the center
of the column of bones (vertebral or spinal column)
through which the spinal cord and nerve roots
run, (2) the canals at the base or roots of nerves
branching out from the spinal cord, or (3) the
openings between vertebrae (bones of the spine)
through which nerves leave the spine and go to
other parts of the body. The narrowing may involve
a small or large area of the spine. Pressure on
the lower part of the spinal cord or on nerve
roots branching out from that area may give rise
to pain or numbness in the legs. Pressure on the
upper part of the spinal cord (that is, the neck
area) may produce similar symptoms in the shoulders,
or even the legs. (See figs. 1, 2 and 3.)
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Who
Gets Spinal Stenosis?
This disorder is
most common in men and women over 50 years of
age. However, it may occur in younger people who
are born with a narrowing of the spinal canal
or who suffer an injury to the spine.
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What
Structures of the Spine Are Involved?
The spine is a column
of 26 bones that extend in a line from the base
of the skull to the pelvis (see fig. 1). Twenty-four of the bones are called vertebrae. The
bones of the spine include 7 cervical vertebrae
in the neck; 12 thoracic vertebrae at the back
wall of the chest; 5 lumbar vertebrae at the inward
curve (small) of the lower back; the sacrum, composed
of 5 fused vertebrae between the hip bones; and
the coccyx, composed of 3 to 5 fused bones at
the lower tip of the vertebral column. The vertebrae
link to each other and are cushioned by shock-absorbing
disks that lie between them.
The vertebral column
provides the main support for the upper body,
allowing humans to stand upright or bend and twist,
and it protects the spinal cord from injury. Following
are structures of the spine most involved in spinal
stenosis. (See figs. 1, 2 and 3, and fig. 7.)
-
Intervertebral
disks—pads of cartilage filled with a gel-like
substance which lie between vertebrae and act
as shock absorbers.
-
Facet
joints—joints located on the back of the
main part of the vertebra. They are formed by
a portion of one vertebra and the vertebra above
it. They connect the vertebrae to each other
and permit back motion.
-
Intervertebral
foramen (also called neural foramen)—an
opening between vertebrae through which nerves
leave the spine and extend to other parts of
the body.
-
Lamina—part
of the vertebra at the back portion of the vertebral
arch that forms the roof of the canal through
which the spinal cord and nerve roots pass.
-
Ligaments—elastic
bands of tissue that support the spine by preventing
the vertebrae from slipping out of line as the
spine moves. A large ligament often involved
in spinal stenosis is the ligamentum flavum,
which runs as a continuous band from lamina
to lamina in the spine.
-
Pedicles—narrow
stem-like structures on the vertebrae that form
the walls of the front part of the vertebral
arch.
-
Spinal
cord/nerve roots—a major part of the central
nervous system that extends from the base of
the brain down to the lower back and that is
encased by the vertebral column. It consists
of nerve cells and bundles of nerves. The cord
connects the brain to all parts of the body
via 31 pairs of nerves that branch out from
the cord and leave the spine between vertebrae.
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Synovium—a
thin membrane that produces fluid to lubricate
the facet joints, allowing them to move easily.
-
Vertebral
arch—a circle of bone around the canal through
which the spinal cord passes. It is composed
of a floor at the back of the vertebra, walls
(the pedicles), and a ceiling where two laminae
join.
-
Cauda
equina—a sack of nerve roots that continues
from the lumbar region, where the spinal cord
ends, and continues down to provide neurologic
function to the lower part of the body. It resembles
a "horse's tail" (cauda equina
in Latin).
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What
Causes Spinal Stenosis?
The
normal vertebral canal (see fig. 4) provides adequate room for the spinal cord and cauda
equina. Narrowing of the canal, which occurs in
spinal stenosis, may be inherited or acquired.
Some people inherit a small spinal canal (see fig. 5) or have a curvature of the spine (scoliosis) that
produces pressure on nerves and soft tissue and
compresses or stretches ligaments. In an inherited
condition called achondroplasia, defective bone
formation results in abnormally short and thickened
pedicles that reduce the diameter (distance across)
of the spinal canal.
 
Acquired conditions
that can cause spinal stenosis are explained in
more detail in the sections that follow.
Degenerative Conditions
Spinal stenosis most
often results from a gradual, degenerative aging
process. Either structural changes or inflammation
can begin the process. As people age, the ligaments
of the spine may thicken and calcify (harden from
deposits of calcium salts). Bones and joints may
also enlarge: when surfaces of the bone begin
to project out from the body, these projections
are called osteophytes (bone spurs).
When
the health of one part of the spine fails, it
usually places increased stress on other parts
of the spine. For example, a herniated (bulging)
disk may place pressure on the spinal cord or
nerve root (see fig. 6). When a segment of the spine becomes too mobile,
the capsules (enclosing membranes) of the facet
joints thicken in an effort to stabilize the segment,
and bone spurs may occur. This decreases the space
(neural foramen) available for nerve roots leaving
the spinal cord.
Spondylolisthesis,
a condition in which one vertebra slips forward
on another, may result from a degenerative condition
or an accident, or, very rarely, may be acquired
at birth. Poor alignment of the spinal column
when a vertebra slips forward onto the one below
it can place pressure on the spinal cord or nerve
roots at that place.
Aging with secondary
changes is the most common cause of spinal stenosis.
Two forms of arthritis that may affect the spine
are osteoarthritis and rheumatoid arthritis.¹
¹The
National Institute of Arthritis and Musculoskeletal
and Skin Diseases Information Clearinghouse has
separate information packages on osteoarthritis
and rheumatoid arthritis. Single copies are free.
Osteoarthritis—Osteoarthritis
is the most common form of arthritis and is more
likely to occur in middle-aged and older people.
It is a chronic, degenerative process that may
involve multiple joints of the body. It wears
away the surface cartilage layer of joints, and
is often accompanied by overgrowth of bone, formation
of bone spurs, and impaired function. If the degenerative
process of osteoarthritis affects the facet joint(s)
and the disk, the condition is sometimes referred
to as spondylosis. This condition may be accompanied
by disk degeneration, and an enlargement or overgrowth
of bone that narrows the central and nerve root
canals.
Rheumatoid Arthritis—Rheumatoid
arthritis usually affects people at an earlier
age than osteoarthritis does and is associated
with inflammation and enlargement of the soft
tissues (the synovium) of the joints. Although
not a common cause of spinal stenosis, damage
to ligaments, bones, and joints that begins as
synovitis (inflammation of the synovial membrane
which lines the inside of the joint) has a severe
and disrupting effect on joint function. The portions
of the vertebral column with the greatest mobility
(for example, the neck area) are often the ones
most affected in people with rheumatoid arthritis.
Other Acquired
Conditions
The following conditions
that are not related to degenerative disease are
causes of acquired spinal stenosis:
· Tumors of the spine
are abnormal growths of soft tissue that may affect
the spinal canal directly by inflammation or by
growth of tissue into the canal. Tissue growth
may lead to bone resorption (bone loss due to
overactivity of certain bone cells) or displacement
of bone.
· Trauma (accidents)
may either dislocate the spine and the spinal
canal or cause burst fractures that produce fragments
of bone that penetrate the canal.
· Paget's disease of bone
is a chronic (long-term) disorder that typically
results in enlarged and abnormal bones. Excessive
bone breakdown and formation cause thick and fragile
bone. As a result, bone pain, arthritis, noticeable
bone structure changes, and fractures can occur.
The disease can affect any bone of the body, but
is often found in the spine. The blood supply
that feeds healthy nerve tissue may be diverted
to the area of involved bone. Also, structural
problems of the involved vertebrae can cause narrowing
of the spinal canal, producing a variety of neurological
symptoms. Other developmental conditions may also
result in spinal stenosis.
· Fluorosis is an excessive
level of fluoride in the body. It may result from
chronic inhalation of industrial dusts or gases
contaminated with fluorides, prolonged ingestion
of water containing large amounts of fluorides,
or accidental ingestion of fluoride-containing
insecticides. The condition may lead to calcified
spinal ligaments or softened bones and to degenerative
conditions like spinal stenosis.
· Ossification of the posterior
longitudinal ligament occurs when calcium
deposits form on the ligament that runs up and
down behind the spine and inside the spinal canal
(see fig. 7). These deposits turn the fibrous tissue of the ligament
into bone. (Ossification means "forming bone.")
These deposits may press on the nerves in the
spinal canal.
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What
Are the Symptoms of Spinal Stenosis?
The space within
the spinal canal may narrow without producing
any symptoms. However, if narrowing places pressure
on the spinal cord, cauda equina, or nerve roots,
there may be a slow onset and progression of symptoms.
The neck or back may or may not hurt. More often,
people experience numbness, weakness, cramping,
or general pain in the arms or legs. If the narrowed
space within the spine is pushing on a nerve root,
people may feel pain radiating down the leg (sciatica).
Sitting or flexing the lower back should relieve
symptoms. (The flexed position "opens up"
the spinal column, enlarging the spaces between
vertebrae at the back of the spine.) Flexing exercises
are often advised, along with stretching and strengthening
exercises.
People with more
severe stenosis may have problems with bowel and
bladder function and foot disorders. For example,
cauda equina syndrome is a severe, and very rare,
form of spinal stenosis. It occurs due to compression
of the cauda equina, and symptoms may include
loss of control of the bowel, bladder, or sexual
function and/or pain, weakness, or loss of feeling
in one or both legs. Cauda equina syndrome is
a serious condition requiring urgent medical attention.
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How
Is Spinal Stenosis Diagnosed?
The doctor may use
a variety of approaches to diagnose spinal stenosis
and rule out other conditions.
-
Medical
history—the patient tells the doctor details
about symptoms and about any injury, condition,
or general health problem that might be causing
the symptoms.
-
Physical
examination—the doctor (1) examines the
patient to determine the extent of limitation
of movement, (2) checks for pain or symptoms
when the patient hyperextends the spine (bends
backwards), and (3) checks for normal neurologic
function (for instance, sensation, muscle strength,
and reflexes) in the arms and legs.
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X
ray—an x-ray beam is passed through the
back to produce a two-dimensional picture. An
x ray may be done before other tests to look
for signs of an injury, tumor, or inherited
problem. This test can show the structure of
the vertebrae and the outlines of joints, and
can detect calcification.
-
MRI
(magnetic resonance imaging)—energy from
a powerful magnet (rather than x rays) produces
signals that are detected by a scanner and analyzed
by computer. This produces a series of cross-sectional
images ("slices") and/or a three-dimensional
view of parts of the back. An MRI is particularly
sensitive for detecting damage or disease of
soft tissues, such as the disks between vertebrae
or ligaments. It shows the spinal cord, nerve
roots, and surrounding spaces, as well as enlargement,
degeneration, or tumors.
-
Computerized
axial tomography (CAT)—x rays are passed
through the back at different angles, detected
by a scanner, and analyzed by a computer. This
produces a series of cross-sectional images
and/or three-dimensional views of the parts
of the back. The scan shows the shape and size
of the spinal canal, its contents, and structures
surrounding it.
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Myelogram—a
liquid dye that x rays cannot penetrate is injected
into the spinal column. The dye circulates around
the spinal cord and spinal nerves, which appear
as white objects against bone on an x-ray film.
A myelogram can show pressure on the spinal
cord or nerves from herniated disks, bone spurs,
or tumors.
-
Bone
scan—an injected radioactive material attaches
itself to bone, especially in areas where bone
is actively breaking down or being formed. The
test can detect fractures, tumors, infections,
and arthritis, but may not tell one disorder
from another. Therefore, a bone scan is usually
performed along with other tests.
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Who
Treats Spinal Stenosis?
Nonsurgical treatment
of spinal stenosis may be provided by internists
or general practitioners. The disorder is also
treated by specialists such as rheumatologists,
who treat arthritis and related disorders; and
neurologists, who treat nerve diseases. Orthopaedic
surgeons and neurosurgeons also provide nonsurgical
treatment and perform spinal surgery if it is
required. Allied health professionals such as
physical therapists may also help treat patients.
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What
Are Some Nonsurgical Treatments for Spinal Stenosis?
In the absence of
severe or progressive nerve involvement, a doctor
may prescribe one or more of the following conservative
treatments:
· Nonsteroidal anti-inflammatory
drugs, such as aspirin, naproxen (Naprosyn)², ibuprofen (Motrin, Nuprin, Advil), or indomethacin (Indocin),
to reduce inflammation and relieve pain.
· Analgesics, such as acetaminophen
(Tylenol), to relieve pain.
· Corticosteroid injections
into the outermost of the membranes covering the
spinal cord and nerve roots to reduce inflammation
and treat acute pain that radiates to the hips
or down a leg.
· Anesthetic injections, known
as nerve blocks, near the affected nerve to temporarily
relieve pain.
· Restricted activity (varies
depending on extent of nerve involvement).
· Prescribed exercises and/or
physical therapy to maintain motion of the spine,
strengthen abdominal and back muscles, and build
endurance, all of which help stabilize the spine.
Some patients may be encouraged to try slowly
progressive aerobic activity such as swimming
or using exercise bicycles.
· A lumbar brace or corset
to provide some support and help the patient regain
mobility. This approach is sometimes used for
patients with weak abdominal muscles or older
patients with degeneration at several levels of
the spine.
² Brand
names included in this fact sheet are provided
as examples only. Their inclusion does not mean
that these products are endorsed by the National
Institutes of Health or another government agency.
Also, if a particular brand name is not mentioned,
this does not imply that the product is unsatisfactory.
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What
Are Some Alternative Therapies for Spinal Stenosis?
Alternative (or complementary)
therapies are diverse medical and health care
systems, practices, and products that are not
presently considered to be part of conventional
medicine. Some examples of these therapies used
to treat spinal stenosis follow:
-
Chiropractic
treatment—This treatment is based on the
philosophy that restricted movement in the spine
reduces proper function and may cause pain.
Chiropractors may manipulate (adjust) the spine
in order to restore normal spinal movement.
They may also employ traction, a pulling force,
to help increase space between the vertebrae
and reduce pressure on affected nerves. Some
people report that they benefit from chiropractic
care. Research thus far has shown that chiropractic
treatment is about as effective as conventional,
nonoperative treatments for acute back pain.
-
Acupuncture—This
treatment involves stimulating certain places
on the skin by a variety of techniques, in most
cases by manipulating thin, solid, metallic
needles that penetrate the skin. Research has
shown that low back pain is one area in which
acupuncture has benefited some people.
More research is
needed before the effectiveness of these or other
possible alternative therapies can be definitively
stated. Health care providers may suggest these
therapies in addition to more conventional treatments.
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When
Should Surgery Be Considered and What Is Involved?
In many cases, the
conditions causing spinal stenosis cannot be permanently
altered by nonsurgical treatment, even though
these measures may relieve pain for a period of
time. To determine how much nonsurgical treatment
will help, a doctor may recommend such treatment
first. However, surgery might be considered immediately
if a patient has numbness or weakness that interferes
with walking, impaired bowel or bladder function,
or other neurological involvement. The effectiveness
of nonsurgical treatments, the extent of the patient's
pain, and the patient's preferences may all factor
into whether or not to have surgery.
The purpose of surgery
is to relieve pressure on the spinal cord or nerves
and restore and maintain alignment and strength
of the spine. This can be done by removing, trimming,
or adjusting diseased parts that are causing the
pressure or loss of alignment. The most common
surgery is called decompressive laminectomy: removal
of the lamina (roof) of one or more vertebrae
to create more space for the nerves. A surgeon
may perform a laminectomy with or without fusing
vertebrae or removing part of a disk. Various
devices may be used to enhance fusion and strengthen
unstable segments of the spine following decompression
surgery.
Patients with spinal
stenosis caused by spinal trauma or achondroplasia
may need surgery at a young age. When surgery
is required in patients with achondroplasia, laminectomy
(removal of the roof) without fusion is usually
sufficient.
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What
Are the Major Risks of Surgery?
All surgery, particularly
that involving general anesthesia and older patients,
carries risks. The most common complications of
surgery for spinal stenosis are a tear in the
membrane covering the spinal cord at the site
of the operation, infection, or a blood clot that
forms in the veins. These conditions can be treated
but may prolong recovery. The presence of other
diseases and the physical condition of the patient
are also significant factors to consider when
making decisions about surgery.
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What
Are the Long-Term Outcomes of Surgical Treatment
for Spinal Stenosis?
Removal of the obstruction
that has caused the symptoms usually gives patients
some relief; most patients have less leg pain
and are able to walk better following surgery.
However, if nerves were badly damaged prior to
surgery, there may be some remaining pain or numbness
or no improvement. Also, the degenerative process
will likely continue, and pain or limitation of
activity may reappear after surgery.
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What
Research on Spinal Stenosis Is Being Supported
by the NIAMS?
The National Institute
of Arthritis and Musculoskeletal and Skin Diseases
(NIAMS), a part of the Department of Health and
Human Services' National Institutes of Health,
is supporting several research projects on spinal
stenosis. For example, in a 5-year clinical trial
involving 11 sites throughout the country, researchers
are attempting to determine whether surgical or
nonsurgical treatment is more effective at treating
spinal stenosis and other back problems. Another
project will try to find out if specific MRI findings
will help physicians determine if they can identify
groups who will fare better with surgical or nonsurgical
treatments.
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What
Are Other Sources of Information on Spinal Stenosis?
National Institute
of Arthritis and Musculoskeletal and Skin Diseases
(NIAMS)
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484 or 877-22-NIAMS (877-226-4267)
(free of charge)
Fax: 301-718-6366
TTY: 301-565-2966
E-mail: NIAMSinfo@mail.nih.gov
www.niams.nih.gov
The National Institute of Arthritis and Musculoskeletal
and Skin Diseases (NIAMS) provides information
about rheumatic, bone, muscle, and skin diseases.
It distributes patient and professional education
materials and refers people to other sources of
information. Additional information and updates
are available on the NIAMS Web site.
National Institute
of Neurological Disorders and Stroke
NIH Neurological Institute
P.O. Box 5801
Bethesda, MD 20824
Phone: 301-496-5751 or 800-352-9424 (free of charge)
TTY: 301-468-5981
www.ninds.nih.gov
The National Institute of Neurological Disorders
and Stroke collects and disseminates research
information related to neurological disorders.
American Academy
of Orthopaedic Surgeons
P.O. Box 2058
Des Plaines, IL 60017
Phone: 800-824-BONE (2663)
www.aaos.org
The academy provides education and practice management
services for orthopaedic surgeons and allied health
professionals. It also serves as an advocate for
improved patient care and informs the public about
the science of orthopaedics. The orthopaedist's
scope of practice includes disorders of the body's
bones, joints, ligaments, muscles, and tendons.
For a single copy of an AAOS brochure, send a
self-addressed stamped envelope to the address
above or visit the AAOS Web site.
American College
of Rheumatology
1800 Century Place, Suite 250
Atlanta, GA 30345
Phone: 404-633-3777
Fax: 404-633-1870
E-mail: acr@rheumatology.org
www.rheumatology.org
This national professional organization can provide
referrals to rheumatologists and allied health
professionals, such as physical therapists. One-page
fact sheets are available on various forms of
arthritis. Lists of specialists by geographic
area and fact sheets are also available on the
American College of Rheumatology's Web site.
North American
Spine Society
22 Calendar Court, 2nd floor
La Grange, IL 60525
Phone: 877-SpineDr (877-774-6337)
www.spine.org
This professional association can identify specialists
throughout the country who treat disorders of
the spine.
Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
Phone: 404-872-7100 or 800-283-7800 (free of charge)
or contact your local chapter (listed in your
local telephone directory)
www.arthritis.org
The foundation has a free brochure on back pain
and several free brochures about coping with arthritis,
taking nonsteroid and steroid medicines, and exercise.
The foundation also provides referrals to doctors
treating various forms of arthritis.
Spondylitis
Association of America
P.O. Box 5872
Sherman Oaks, CA 91413
Phone: 818-981-1616 or 800-777-8189 (free of charge)
Fax: 818-981-9826
E-mail: info@spondylitis.org
www.spondylitis.org
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