Cervical spinal stenosis refers to a set of symptoms related to narrowing of the spinal canal in the neck seen with aging and degeneration. The spinal canal is like a tunnel which runs up and down the human spine. This canal sits directly behind the bony blocks which make up the spine (vertebrae) and contains the nerves (spinal cord and nerve roots) running from the brain to all areas of the body. The nerves exit the cervical spinal canal and travel through the arms. The rest traverse down the legs.
Stenosis is the gradual result of aging and “wear and tear” on the spine as well as a genetic predisposition. With age, the disc space decreases in height and bulges posteriorly toward the spinal canal. The facet joints and ligaments also enlarge and bulge toward the spinal canal. The ligaments of the spine can thicken and harden (calcification). Bones and joints may also enlarge when arthritis develops in the small joints of the spine (facets), and bone spurs (osteophytes) may form compressing nerves or the spinal card. Spondylolisthesis, the slipping of one vertebra onto another, also may occur and leading to compression.
Stenosis in the neck can both affect the individual spinal nerves causing arm pain (radiculopathy), or may affect the spinal cord resulting in imbalance, coordination difficulty (myelopathy), or both. The pain and the compression on the nerves are generally worse when the patient extends the neck. The pressure on the spinal cord can result in irreversible weakness and atrophy of muscles of the hand and of the trunk and legs. When the spinal cord is squeezed, the damage may become progressive and in some patients irreversible nerve damage can result.
The symptoms of cervical stenosis can be very mild or unnoticeable even when significant stenosis is present. This is because the spinal cord has the ability to accommodate to some degree. A sudden force such as a car accident or fall that would not cause damage in a healthy spine can result in severe symptoms in a patient with pre-existing cervical stenosis.
If the nerves are being sufficiently pinched in the neck, the patient can experience unremitting arm pain. When the neuroforamina are reduced in size due to surrounding buildup of tissue, the nerves react to the pressure by swelling thereby causing irritation to the nerves. Also, if the spinal cord is compressed, balance problems, problems with coordination, and bowel and bladder incontinence may develop. This condition, when it significantly affects the quality of living, can be treated surgically by removing the offending discs, overgrown ligaments and bone.
Cervical Stenosis Treatment
Neck pain due to a degenerative disc disorder is usually treated non-operatively. Everybody will eventually develop some degenerative disc disease, some more than others. Most degenerated discs are not symptomatic. The reason that surgery is usually not necessary for neck pain due to degenerative disc disease is that the degeneration process is known to result in gradual stabilization and even auto-fusion/stabilization of the disc.
While the first line of treatment is almost always non-surgical, the exception is when there is bladder or bowel incontinence or progressive weakness. A vast majority of patients suffering from neck and arm pain will naturally recover given time and non-operative treatment. Non-operative treatments include strengthening exercises, physical therapy, chiropractic, acupuncture, traction, epidural injections, pain medications, and anti-inflammatory medications including steroids.
For arm pain and mild weakness (radicular symptoms), generally at least 6 weeks of non-operative treatment is pursued to monitor for natural recovery. The waiting period is based on the knowledge that 80-90% of radicular symptoms are known to spontaneously recover. If recovery is progressing, more non-operative treatment may be prescribed.
Surgical treatment may be suggested to treat pain that has not responded to non-operative treatment or if there is severe neurologic deficit such as bowel or bladder incontinence or progressive weakness in vital muscle groups. With the exception of the presence of severe neurologic deficits, the decision to proceed with surgery is a quality of life decision.
Surgical options for a cervical spinal stenosis are listed below. These surgical options often include a combination of surgical treatments (i.e. decompression, fusion, instrumentation). For a detailed explanation of the individual treatments, please visit the Surgical Treatments section of the web site.
1. Anterior Cervical Decompression and Fusion with Instrumentation
The procedure involves removal of the disc including its compression on the nerves or spinal cord. The resulting void is filled with bone (either from the patient or a bone bank) to fuse the motion segment. The motion segment is held together with instrumentation (plate and screws).
2. Anterior Cervical Corpectomy with Fusion
It is often necessary to remove the vertebral body to remove the pressure on the spinal cord. The resulting void needs to be filled with bony fusion, and this is most often stabilized with instrumentation.
3. Combined Anterior and Posterior Cervical
Decompression and Fusion with Instrumentation
Sometimes it is necessary to decompress or stabilize the spine both anteriorly and posteriorly.
4. Posterior Cervical Foraminotomy
With this procedure, the compression on the nerve is removed from the back of the neck. This procedure is not indicated if the spinal cord is being compressed.
5. Posterior Cervical Laminaplasty
The compression on the spinal cord is removed by reconstruction of the lamina.
6. Anterior Cervical Decompression and Fusion without Instrumentation
For one level fusion, the fusion rates are high without instrumentation, and therefore some surgeons prefer not to use the plate and screws.
7. Posterior Cervical Laminectomy
The compression on the spinal cord is relieved by removal of the lamina.
Cervical Stenosis Case Study
This 70 year old female has had a five year history of increasing weakness in both her arms and legs. She has lost her balance often, and has difficulties with fine motor dexterity and coordination. Her MRI scan shows marked compression of the spinal cord (Images A & B). Note the hourglass compression of the spinal cord at multiple levels, especially C5-6. The red reveals the dimensions of the spinal canal, the blue the dimensions of a normal spinal canal.
On the axial MRI images C-E, note the marked compression of the spinal cord especially at C5-6. The space available for the spinal cord has been essentially fully occupied by the disc. Note that even though the spinal canal is patent at C6-7 (Image E), the spinal cord itself is significantly atrophied due to the chronic compression.
A posterior cervical laminaplasty was performed, followed by an anterior C5-6 discectomy and fusion. Note the abundant room for the spinal cord on the postoperative sagittal MRI scan (Image F). Note the axial MRI scans at C4-5 and even at C5-6, which show abundant room for the spinal cord (Images G & H).