Landspitali - University Hospital
Diagnosis of a herniated disc
Spinal canal stenosis in lumbar spine
Spinal Canal Stenosis in the Lumbar Spine
Spinal canal stenosis, or narrowing of the spinal canal, is most commonly an acquired condition, occurring as part of age-related degeneration of the spine. The narrowing is caused by thickening of the facet joints and ligamentum flavum, along with bone spur formation on the edges of the intervertebral discs.
The development of spinal stenosis occurs gradually over time, and symptoms appear slowly and progressively, unlike disc herniation, which tends to present more suddenly.
Indications for Surgery
Surgical intervention is considered for patients who have:
Daily, quality-of-life impairing radicular pain from the lower back radiating down the legs, occurring while standing or walking.
Radiating nerve pain extending from the lower back past the knee into the calves or shins.
Confirmed nerve root compression on MRI, performed within the last six months.
Surgery is mainly beneficial for relieving nerve-conduction pain down the legs.
Background and Symptoms
Degenerative changes in the lumbar spine typically present with centralized pain that radiates to the surrounding areas of the lower back, including the sacrum, pelvis, hips, groin, buttocks, and upper thighs. These symptoms are position- and load-dependent, often worsening when putting strain on the back, lifting objects, or extending the spine.
Symptoms tend to worsen with prolonged standing and walking but improve when the spine is flexed forward or rested. Many individuals find relief by sitting down or leaning forward, such as supporting themselves on a shopping cart. This often alleviates the pain within minutes, with further improvement after lying down and resting. At this stage, MRI may show spinal canal stenosis.
This symptom pattern is primarily related to musculoskeletal pain, which does not improve with lumbar surgery, even if stenosis is visible on MRI.
Progression to Radicular Symptoms
As spinal canal stenosis worsens, the narrowing can increase pressure on the nerve root sac, leading to radiating nerve pain down the legs, extending below the knee. The pain remains position-dependent, similar to musculoskeletal pain, but radicular pain is now also present. Like musculoskeletal pain, it worsens with prolonged standing and walking and improves when sitting, leaning forward, or resting.
At this stage, a combination of musculoskeletal pain and radicular pain is present.
Typical radicular pain radiates down to the buttocks, thighs, and calve.
It may be accompanied by numbness in the feet, as well as some loss of control and weakness.
Neurological examination often does not reveal significant motor deficits.
It is crucial to determine whether the patient is more affected by lower back pain and its surrounding musculoskeletal pain or by radicular pain in the legs. This distinction is key in evaluating whether lumbar surgery would be beneficial.
Physical Therapy as First-Line Treatment
Physical therapy plays a key role in the treatment of spinal canal stenosis.
It alleviates musculoskeletal pain, which is often the primary limitation in daily life.
For many patients, physical therapy alone is sufficient as a treatment.
Therefore, physical therapy is recommended as the first-line treatment.
Reevaluation after physical therapy is essential to better assess the impact of true radicular pain on the patient's quality of life.
It is important to educate patients experiencing quality-of-life impairing pain from spinal stenosis that this condition is a part of the natural ageing process of the spine and is benign in nature, often not requiring surgery.
Additionally, patients should be encouraged to stay active and exercise within their ability. Studies suggest that education and movement are among the most effective treatments for this condition.
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