Cervical spinal stenosis - Clinicals, Diagnosis, and Management

Neurosurgery

Clinicals - History

Fact Explanation
Chronic pain Bony outgrowths occur due to degeneration of cervical vertebral discs; this causes stenosis of the spinal canal. Chronic pain may be due to several mechanisms: compression of the radicular arteries causing ischemia to the spinal cord, compression of spinal cord segments and stenosis of spinal foramina that impinge upon the nerve roots. Chronic pain
Bony outgrowths occur due to degeneration of cervical vertebral discs; this causes stenosis of the spinal canal. Chronic pain may be due to several mechanisms: compression of the radicular arteries causing ischemia to the spinal cord, compression of spinal cord segments and stenosis of spinal foramina that impinge upon the nerve roots.
Regional anesthesia Cervical cord compressive myelopathy due to bony spurs that reduce the saggital diameter of the spinal canal. Regional anesthesia
Cervical cord compressive myelopathy due to bony spurs that reduce the saggital diameter of the spinal canal.
Loss of hand dexterity A disabling symptom, that may impair the patient's Activities of Daily Living (ADL). This may be due to cervical cord compression, where it causes spasticity and a upper motor type of paralysis. Alternatively, narrowing of the spinal foramina may compress the nerve roots, causing a lower motor type flaccid paralysis. Involvement of C8 spinal segment/ nerve root can cause a finger drop. Loss of hand dexterity
A disabling symptom, that may impair the patient's Activities of Daily Living (ADL). This may be due to cervical cord compression, where it causes spasticity and a upper motor type of paralysis. Alternatively, narrowing of the spinal foramina may compress the nerve roots, causing a lower motor type flaccid paralysis. Involvement of C8 spinal segment/ nerve root can cause a finger drop.
Lower extremity weakness This may be the only or the most prominent symptom in some patients. Occurs due to compression of the spinal cord in the cervical region. Lower extremity weakness
This may be the only or the most prominent symptom in some patients. Occurs due to compression of the spinal cord in the cervical region.
Spastic quadriparesis Upper motor neuron lesion of bilateral upper and lower limbs may occur if the stenosis occurs at a high cervical cord level. Compression of the cord causing myelopathy, may even occur due to tumors of the cervical vertebrae. Spastic quadriparesis
Upper motor neuron lesion of bilateral upper and lower limbs may occur if the stenosis occurs at a high cervical cord level. Compression of the cord causing myelopathy, may even occur due to tumors of the cervical vertebrae.
Cerebellar ataxia Will occur due to compression of the cerebellar tracts in the spinal cord. Cerebellar ataxia
Will occur due to compression of the cerebellar tracts in the spinal cord.
More common in the elderly population As the vertebral disc cartilage ages, it loses some of it water content. As a result of this the shock absorbing quality of the cartilage diminishes. Subsequent tears occur in the annulus of the cartilage that heal with formation of scar tissue that is weak and unable to cushion the vertebral facets joints. This leads to osteoarthritis of the facet joints and resultant bony spur formation that causes stenosis of the spinal canal or foramina. More common in the elderly population
As the vertebral disc cartilage ages, it loses some of it water content. As a result of this the shock absorbing quality of the cartilage diminishes. Subsequent tears occur in the annulus of the cartilage that heal with formation of scar tissue that is weak and unable to cushion the vertebral facets joints. This leads to osteoarthritis of the facet joints and resultant bony spur formation that causes stenosis of the spinal canal or foramina.

Clinicals - Examination

Fact Explanation
Upper limb weakness Upper limb weakness can be of the upper motor neuron spastic type or of the lower motor neuron flaccid type. Spastic weakness occurs due to cord myelopathy caused by compression in the spinal canal. Flaccid weakness is due to compression of nerve roots as they travel out of the spinal foramina. Upper limb weakness
Upper limb weakness can be of the upper motor neuron spastic type or of the lower motor neuron flaccid type. Spastic weakness occurs due to cord myelopathy caused by compression in the spinal canal. Flaccid weakness is due to compression of nerve roots as they travel out of the spinal foramina.
Upper limb numbness, parasthesia Occurs due to spinal cord myelopathy. Upper limb numbness, parasthesia
Occurs due to spinal cord myelopathy.
Upper limb spasticity Compression myelopathy of the upper motor neurons of the spinal cord. Upper limb spasticity
Compression myelopathy of the upper motor neurons of the spinal cord.
Exaggerated upper limb reflexes An upper motor neuron sign, that indicates compression myelopathy of the spinal cord. Exaggerated upper limb reflexes
An upper motor neuron sign, that indicates compression myelopathy of the spinal cord.
Spastic quadriplegia Compression myelopathy of the cervical spinal cord at a high level (C1, C2) can cause upper motor neuron spastic quadriparesis. Spastic quadriplegia
Compression myelopathy of the cervical spinal cord at a high level (C1, C2) can cause upper motor neuron spastic quadriparesis.
Cerebellar ataxia A positive Romberg sign, impaired tandem walk, disdiadokokinesia and dysmetria are indicative of compression of the cerebellar tracts in cervical myelopathy. Cerebellar ataxia
A positive Romberg sign, impaired tandem walk, disdiadokokinesia and dysmetria are indicative of compression of the cerebellar tracts in cervical myelopathy.

Investigations - Diagnosis

Fact Explanation
Spinal radiographs Anterior and lateral cervical spine X-Rays are an initial investigation, routinely indicated if cervical spinal trauma is suspected in the secondary survey of the ATLS protocol. In patients with chronic pain, imaging is not necessary if there is no neurological deficit and there is no suspicion of an underlying medical condition. Spinal radiographs
Anterior and lateral cervical spine X-Rays are an initial investigation, routinely indicated if cervical spinal trauma is suspected in the secondary survey of the ATLS protocol. In patients with chronic pain, imaging is not necessary if there is no neurological deficit and there is no suspicion of an underlying medical condition.
CT myelogram CT scan is performed after intra thecal administration of contrast media by a lumbar puncture. Less favored when compared to MRI due to radiation exposure and invasive nature of contrast administration. CT myelogram
CT scan is performed after intra thecal administration of contrast media by a lumbar puncture. Less favored when compared to MRI due to radiation exposure and invasive nature of contrast administration.
MRI MRI is usually preferred over CT for the investigation of neck and back pain in the elderly as it causes less radiation exposure and has better soft-tissue visualization. Enables direct evaluation of the spinal cord with calculation of four parameters: Pavlov's ratio, sagittal diameter, spinal cord area, and spinal canal area. This gives an objective assessment of the degree of spinal canal stenosis. MRI
MRI is usually preferred over CT for the investigation of neck and back pain in the elderly as it causes less radiation exposure and has better soft-tissue visualization. Enables direct evaluation of the spinal cord with calculation of four parameters: Pavlov's ratio, sagittal diameter, spinal cord area, and spinal canal area. This gives an objective assessment of the degree of spinal canal stenosis.
Nerve conduction studies Nerve conduction studies of the peripheral nerves are useful in differentiating compression myelopathy from other causes of neuropathy. Nerve conduction studies
Nerve conduction studies of the peripheral nerves are useful in differentiating compression myelopathy from other causes of neuropathy.

Management - Supportive

Fact Explanation
Lifestyle modifications and home remedies Gives symptomatic relief from pain. Maybe appropriate for mild cervical spinal stenosis. Patients can avoid complications and potential risks of surgery. Advise to avoid hyper-extended or hyper-flexed positions, falls, intense exercise and any other dangerous activity. Lifestyle modifications and home remedies
Gives symptomatic relief from pain. Maybe appropriate for mild cervical spinal stenosis. Patients can avoid complications and potential risks of surgery. Advise to avoid hyper-extended or hyper-flexed positions, falls, intense exercise and any other dangerous activity.
Pharmacological management of pain : Analgesics and muscle relaxants First line drugs are NSAIDs, these reduce inflammation and thereby reduce pain. Tri cyclic anti (TCA) depressants are also useful in the management of neuropathic pain. Oral opiods may be prescribed if other oral drugs prove ineffective, alternatively anti convulsants such as Gabapentin/ Carbamezapine are also useful in neuropathic pain due to their neural membrane stabilizing properties. Analgesics can be combined with muscle relaxants to improve pain relief. Pharmacological management of pain : Analgesics and muscle relaxants
First line drugs are NSAIDs, these reduce inflammation and thereby reduce pain. Tri cyclic anti (TCA) depressants are also useful in the management of neuropathic pain. Oral opiods may be prescribed if other oral drugs prove ineffective, alternatively anti convulsants such as Gabapentin/ Carbamezapine are also useful in neuropathic pain due to their neural membrane stabilizing properties. Analgesics can be combined with muscle relaxants to improve pain relief.
Epidural steroid injections Methyl prednisolone and local anesthetic agents such as Bupivacaine can be administered epidurally. Administration at the site of maximal stenosis ensures that the highest concentration of steroid and anesthetic are delivered to the area of maximal nerve irritation, resulting in better pain management. Epidural steroid injections
Methyl prednisolone and local anesthetic agents such as Bupivacaine can be administered epidurally. Administration at the site of maximal stenosis ensures that the highest concentration of steroid and anesthetic are delivered to the area of maximal nerve irritation, resulting in better pain management.

Management - Specific

Fact Explanation
Physical therapy Continuos cervical traction (Good Samaritan traction) can be applied; the patient's neck is placed in a slightly flexed position for up to 8 hours a day, for a two week period. Physical therapy
Continuos cervical traction (Good Samaritan traction) can be applied; the patient's neck is placed in a slightly flexed position for up to 8 hours a day, for a two week period.
Cervical laminectomy The most commonly performed surgery for cord myelopathy. Complications encountered are segmental instability and post laminectomy kyphosis. Cervical laminectomy
The most commonly performed surgery for cord myelopathy. Complications encountered are segmental instability and post laminectomy kyphosis.
Cervical laminoplasty An alternative surgical option to laminectomy. Avoids possible complications of laminectomy such as spinal cord injury, post-op progression of cervical kyphosis and worsening of neurological deficit due to scar tissue. Cervical laminoplasty
An alternative surgical option to laminectomy. Avoids possible complications of laminectomy such as spinal cord injury, post-op progression of cervical kyphosis and worsening of neurological deficit due to scar tissue.
Interlaminar implant In severe cases of spinal stenosis, multi segmental laminectomy with posterior fixation may be indicated. In such instances titanium mesh implants with a bone graft can be used. Interlaminar implant
In severe cases of spinal stenosis, multi segmental laminectomy with posterior fixation may be indicated. In such instances titanium mesh implants with a bone graft can be used.
Post operative rehabilitation and physical therapy A lengthy hospital stay should be expected following surgical intervention. Therefore it is important for these patients to resume their normal mobility and ADL, post operatively. Post-op physical therapy can be combined with pain management strategies to facilitate quick rehabilitation. Post operative rehabilitation and physical therapy
A lengthy hospital stay should be expected following surgical intervention. Therefore it is important for these patients to resume their normal mobility and ADL, post operatively. Post-op physical therapy can be combined with pain management strategies to facilitate quick rehabilitation.

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