Spinal stenosis is a narrowing of the canal through which the spinal cord and nerve roots run. It develops slowly through wear and tear and is widespread in older age — more often on the scan than in the symptoms. This page explains the narrowing in the lumbar spine with its typical sign, a short walking distance, and the narrowing in the cervical spine, where the spinal cord is involved.
A narrowing on the MRI is not a reason for treatment. What is treated is what limits you in everyday life — and in many cases that can be relieved without an operation.
What is it?
The spinal canal is bounded by the vertebral bodies, the discs, the small vertebral joints and the yellow ligament. As these structures wear, they grow into the canal, and the space for the nerves shrinks. Depending on the location, this is called central stenosis (the main canal), lateral recess stenosis (the side niche where the root branches off) or foraminal stenosis (the opening between two vertebrae through which the root exits).
In the lumbar spine the narrowing compresses the nerve roots to the legs; in the cervical spine it also compresses the spinal cord itself, and the consequence is called myelopathy. In older age the narrowing is often seen: in around 20 to 30 out of 100 people over 60, MRI shows spinal stenosis of the lumbar spine, but only about one in five of them has symptoms because of it.
What symptoms occur?
The leading symptom of lumbar stenosis is called neurogenic claudication. When walking and standing, the legs become heavy, numb or painful, often both legs, often from the buttocks downwards. After a certain distance you have to stop — and standing still alone does not help; you have to sit down or bend forwards. Many people know the shopping trolley they lean on and suddenly can walk further. Cycling is often no problem, because the spine is bent forwards.
If the narrowing is in the nerve exit opening, a one-sided pain runs into the leg like sciatica, worse when standing and walking, better when sitting — similar to a herniated disc, but developed slowly and usually in older age.
Cervical stenosis causes either nerve root pain into the arm, as with a herniated disc of the cervical spine, or the quiet signs of myelopathy: clumsy hands, unsteady walking, stiff legs, a feeling of walking on cotton wool, and, late on, bladder problems too.
Causes
It all begins with the disc. As it loses height, the vertebrae move closer together, the small joints become overloaded and respond with thickening and bony outgrowths, and the yellow ligament folds into the canal; sometimes a vertebra additionally slips forwards. Each change on its own is harmless; their sum produces the narrowing. The level most often affected is L4/5, and in the cervical spine C5/6 and C6/7.
How is it diagnosed?
The most important information is your history: how far can you walk, what happens then, what helps? In lumbar stenosis the examination at rest is often unremarkable — that is typical. We test strength, sensation and reflexes in the legs, the hips and the pulses in the feet, because a circulatory disorder causes similar symptoms when walking: there, standing still alone helps, walking uphill is worse, and the pulses are absent. In case of doubt a vascular examination settles it; osteoarthritis of the hip and nerve damage in diabetes can also be misleading.
MRI shows the narrowing and its cause. It makes sense when the symptoms limit everyday life and treatment depends on it — not as a routine. If myelopathy is suspected, a neurological examination and, where appropriate, electrical measurements of the nerve pathways are part of the work-up. The terms in your report are explained on the page on understanding your MRI report.
Warning signs
Lumbar stenosis is almost never an emergency. The exceptions are numbness around the buttocks and the area between the legs, a new problem with bladder or bowel control, and paralysis that increases rapidly. For the cervical spine: unsteadiness when walking or clumsiness of the hands that gets worse within weeks needs prompt assessment, even without pain. More on this on the page Warning signs.
Conservative treatment
In lumbar stenosis, treatment without an operation comes first, and it is worthwhile because the symptoms often remain stable for years. In one observational study over three years, they improved in around 30 out of 100 people, stayed the same in around 50 out of 100, and got worse in around 20 out of 100.
- Exercise — walking as far as possible, cycling, aqua aerobics. Do not rest up.
- Physiotherapy — exercises that encourage forward bending and strengthen the trunk, postures that relieve the strain, walking training.
- Painkillers — anti-inflammatory medicines for a limited time, in older age with an eye to the kidneys, the stomach and other medicines.
- Targeted injections (PRT, epidural) — under image guidance at the constricted root or into the canal. They can ease pain for a few weeks; they do not change the narrowing itself. We offer this treatment in our practice.
- Multimodal pain therapy — may be considered when pain and limitation have taken on a life of their own.
When an operation is considered
In the lumbar spine, an operation comes into question if the symptoms persist for months, the walking distance is so short that everyday life suffers, and treatment without an operation has been exhausted — or if strength and sensation are declining. The narrowing on the scan must match the symptoms. There is no time pressure: those who can live with their limitations may wait; those who no longer wish to put up with them may have the operation.
In the cervical spine the situation is different as soon as the spinal cord is affected. In myelopathy with marked or increasing deficits, an operation is advised to prevent further deterioration; with mild, stable signs, close observation is also justifiable. What has already been lost does not always return — which is why the decision here is made sooner rather than later.
Surgical options
The basic principle is called decompression: the nerves are given room by removing what is constricting them. In the lumbar spine this is done microsurgically, through a small approach and with preservation of the load-bearing structures. We offer this procedure. Only where instability has been demonstrated — such as a slipped vertebra — is a fusion with screws and rods additionally considered, which we also offer; as a routine it is not indicated.
- ProcedureUnder general anaesthetic and lying face down, parts of the vertebral arch, the thickened yellow ligament and the constricting parts of the joints are removed under the microscope through a short incision in the back, until the nerve roots and the dural sac lie free. The hospital stay is usually a few days.
- RisksIn general: infection, bleeding, thrombosis and the risks of anaesthesia. Specific to this procedure: an injury to the membrane around the nerves with leakage of spinal fluid; rarely nerve damage with sensory disturbance or weakness; later instability; renewed narrowing due to scarring or wear; and the possibility that the symptoms ease only partially. With a fusion, there are additionally the risks of screw malposition, failure of the bone to heal and increased wear of the adjacent levels.
- AftercareGetting up on the day after the operation, walking from the start. No heavy lifting for a few weeks. Physiotherapy and walking training as soon as the wound allows; after a fusion more slowly and with follow-up X-rays. The walking distance often improves quickly, strength and sensation more slowly.
In the cervical spine, depending on its location, the narrowing is treated from the front — with removal of the disc and insertion of a spacer, which we offer — or from the back; procedures in which the vertebral arch is removed or hinged open may be considered for narrowing across several levels. In myelopathy the aim is to relieve the pressure on the spinal cord and halt deterioration.
Alternatives
The most important alternative is to continue treatment without an operation, with a realistic goal: not to eliminate the narrowing, but to be able to walk as far as possible with it. A rollator is not a surrender but bending forwards on wheels, and it often extends the walking distance considerably. If you have been advised to have an operation, you can obtain a second opinion from us.
What to expect
Lumbar stenosis usually progresses slowly, and in many people it stays for years at a level they can live with. After an operation many patients report a longer walking distance; some of the symptoms may remain, and wear at other levels continues. Check for yourself: walk the same route once a week and notice whether the distance is getting shorter; for the cervical spine, do up buttons and stand with your eyes closed. If any of this gets worse, get in touch.
Frequently asked questions
Does spinal stenosis always get worse?
No. The narrowing on the scan increases with age, but the symptoms do not necessarily. In many people they stay the same for years; in some they improve.
Does the operation have to include a fusion?
Usually not. Decompression alone is the standard; a fusion is added if the segment is unstable or a vertebra is slipping. If you have been recommended a fusion, ask for the reason.
What does “myelopathy signal” in the report mean?
A signal change in the spinal cord itself that indicates damage from pressure. This finding should be assessed by a doctor promptly, even with minor symptoms — not a case for the ambulance service, but a reason not to wait for months.