Focus

The StenosisDiagnosis:

Multiple Factors

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f you watched the old Carol Burnett Show in the1970s, you’ll remember Tim Conway’s “little oldman.” In a shaggy gray wig, the comedian shuf-fled his way through sketch after sketch. Butwhat Conway probably didn’t realize was thathis comic little-old-man gestures were a dead-onimpersonation of a relatively common, and often

confounding, spinal problem: lumbar spinal stenosis.

“That bent-forward, shuffling stance, the tiny steps—it’sclassic,” says Edward L. Maurer, DC, DACBR, and amember of the postgraduate faculty in radiology at theNational University of Health Sciences. “That’s how I jok-ingly talk about it with my patients—I remind them of theTim Conway sketches.” The term for it is “simianstance/posture,” a flexed-forward position that helpsrelieve pressure on the stenotic area by opening up thespinal canal when the person is walking upright.

But despite Conway’s perfect mimicry, spinal stenosis—acondition with multifactorial causes as well as clinical man-ifestations—can frequently be overlooked or misdiag-nosed. “Because of its complexity of presentation, thepractitioner may overlook stenosis because he’s thinking ofan acute circumstance like a herniated disc or something ofthat nature,” says Dr. Maurer, the author of the spinalstenosis chapter in Mosby’s 1995 Advances in Chiropracticyearbook. “I’ve had numerous conversations with severalneurosurgeons about this, and I’d say that the vast majori-ty of these stenosis conditions are under- or misdiagnosedprobably half the time. At some point, the practitionerstarts to realize that the treatment he’s been rendering for,say, a herniated or degenerative disc isn’t working. That’swhen a DC considers an MRI or other studies, and real-izes that spinal stenosis is involved.”

But stenosis is one of those conditions that absolutelyshould not be overlooked or dismissed. Indeed, althoughpopulation-based studies have not been done to determineits exact prevalence, it is a relatively common condition,says Dr. Maurer. If ignored or undertreated too long, itcan lead to irreversible nerve damage.

The Signs of StenosisStenosis can be most simply defined as a narrowing orstricture of the vertebral or neural canals of the spine. “Itcan be due to intrinsic changes—changes in the actualstructures of the canal—or extrinsic changes, meaningsomething new came into the canal,” says Ronald Evans,DC, FACO, a senior staff doctor of chiropractic withICON Whole Health in Des Moines and a trustee withthe Foundation for Chiropractic Education and Research(FCER).

A quick check on the probability of stenosis as the sourceof low-back pain can be done using the patient’s age.Stenosis is often a degenerative condition, and it may existasymptomatically for years before pain begins to set in.“We can categorize incidences of low-back pain almostexactly by the decades in which they occur. When we’relooking at someone 20 or younger, we might think ofmechanical disorders of the lower back. For people in their30s or 40s, the incidence and instances of disc syndromesoften rises above all other mechanical disorders. By their50s and 60s, the incidence of low-back pain takes ondegenerative qualities, and we no longer think so muchabout frank disc protrusions, but stenosis as a very realpossibility,” Dr. Evans says. “Stenosis, generally, is a time-dependent, time-driven event in the aging lumbar spine. Itdevelops because of other mechanical problems or abnor-malities.”

Clues should appear in the patient’s history. Conditionsthat might be confused with stenosis, like herniated discs,usually have a rapid and unmistakable onset. “The patientwill present with dramatically acute symptoms such asmuscle spasms,” says Dr. Maurer. Stenosis, however, ismore insidious. “It’s more of a gradual onset with thepatient reporting low-back pain for some time, perhaps noteven recognizing a precipitating incident, and then just agrowing type of discomfort in the extremities. It’s not terri-bly difficult to differentiate clinically if you are alert to it,”he says.

Another set of clues comes from the sources of thepatient’s pain. One of the most common symptoms ofspinal stenosis is neurogenic claudication: pain, numbness,tingling, weakness, or cramping in one or both legs.Usually, the pain begins in the lower back or buttocks andradiates into one or both legs. Again, that’s similar to acommon case of sciatica—but stenosis patients have aunique experience. “These are the patients who willdescribe—classically, this is almost textbook—that leg painis experienced on the exertion of walking or prolongedstanding,” Dr. Evans says. “The typical scenario is a manor woman who goes to the shopping mall and can get allthe way into the store, and do a little shopping, but then heor she has to sit down to relieve profound leg pain.”Indeed, sitting down alone doesn’t help; the patient usuallywill have to lean forward and sit in a flexed position totake the pain away. This contrasts with the patient whohas sciatica due to a herniated disc. “They have what’scalled arborization of the nerve root by the bulging disc tosuch a degree that only one or two analgic positions willrelieve the pain,” Dr. Evans says. “They stand in an oddposition that helps lessen pain. Change that position, andthey’re in terrible pain. The spinal stenosis patient, con-versely, has an acceptable range of motion, and the arcs ofspinal movement aren’t so acutely painful.”

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Someone with a herniated disc, then, feels pain at differ-ent times and from different types of activity than some-one with stenosis. “For example, if a patient has painwhen standing or walking, that suggests stenosis ratherthan a herniated disc. With a herniated disc, walking orstanding typically reduces pain levels,” Dr. Maurer says.His chart of differential pain patterns (Fig. 1) shows theconsiderable differences in stenosis pain versus disc pain.

Figure 1

Differential Pain Patterns

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Discogenic

Activity Low-Back Pain Spinal

Stenosis

__________________________________________________

Standing/walking Decrease Increase

Sitting Increase Decrease

Bending Increase No change

Lifting Increase No change

Valsalva maneuver Increase No change

Bed rest Decrease Varies

__________________________________________________

Vascular disease may also cause pain, numbness, andweakness in the lower extremities; neurogenic claudicationand vascular claudication have similar clinical features. Thedoctor of chiropractic who thinks his patient may havestenosis will want to be sure to eliminate vascular problemsas a possibility. Here again, tracking pain patterns and dif-ferentiating clinical findings offer clues. Claudicationcaused by vascular disease most often occurs after walking

a fixed distance, while patients who have spinal stenosiswalk variable distances before symptoms set in. Activitieslike riding a bike and walking up a hill can cause pain inpatients with vascular claudication, while they don’t tend tocause pain in the stenotic patient. On the other hand,standing makes pain worse for stenotic patients, while itrelieves vascular claudication. (See Fig. 2)

If a patient does have the kind of heavy, leaden, woodenfeeling in the lower extremities signaling either neuro-genic or vascular claudication, there’s another syndromeDCs should be wary of: Leriche’s syndrome. “This is avery serious condition stemming from coarctation of theaorta (e.g., atherosclerotic stenosis). It occurs at or belowthe bifurcation of the abdominal aorta, and when it hap-pens, the area that the aorta serves in the lower extremi-ties no longer has good circulation. It feels just like lum-bar stenosis or nerve compression might feel,” Dr. Evansexplains. The consequences of untreated Leriche’s syn-drome can be severe: it’s the precursor to an abdominalaortic aneurysm. “The DC must differentiate by lookingfor changes in the pulses of the femoral artery and thelower pedal arteries. That’s the big determination. If thosepulses are altered, the doctor of chiropractic can assumethat more of a vascular event is presenting than some-thing of neurogenic origin.”

Finally, imaging techniques can fine-tune your assessmentof stenosis. “One of the easiest tools to determine develop-mental or congenital stenosis with anatomical shorteningor underdevelopment is plain-film radiography,”

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Figure 2

Differential Clinical Findings between Neurogenic and Vascular Claudication

___________________________________________________________________________________________

Vascular Neurogenic

___________________________________________________________________________________________

Walking distance Fixed Variable

Exercise Worse Variable

Relief of pain Standing Sitting-flexed

Standing Relief Worse

Lying flat Relief Variable

Walking uphill Pain No pain

Stationary bicycle Pain No pain

Sensory Stocking deficits Poorly localized

Type of pain Cramp, tightness Numbness, sharp, ache

Pulses Absent Present

Bruit Present Absent

Skin Hair loss Normal

Atrophy Rarely Occasionally

Weakness Rarely Occasionally

Back Pain Uncommon Common

Spinal movement limitation Uncommon Worse with hyperextension

Genitourinary Impotence Variable

______________________________________________________________________________________________

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continuedFocusDr. Maurer says. “We’re able tomeasure the spinal canal on plain-film radiographs for congenital ordevelopmental stenosis by taking themeasurement from the posteriormargin of the vertebra to the spin-ous-lamina junction (Fig. 3).Anything less than 10 mm is steno-sis.” The normal sagittal diameter, heexplains, is approximately 15 mm ormore. “When you reach 12 mm,that’s a relative stenosis. At less than10 mm, you have a frank or anabsolute stenosis.” In “either-or”cases, the doctor of chiropractic willturn to MRI or CT scans. The axialviews of CT or MR will permit visu-alization of any stenotic narrowing,such as from spondylosis (Fig. 4).Once stenosis is confirmed, thesemore sophisticated scans can alsohelp narrow down its cause—notalways an easy task.

CTs and MRIs can also help thedoctor of chiropractic determineexactly where the stenosis is occur-ring, a determination that plays akey role in the choice of treatmentoptions. “With MRI and CT, it’smuch easier than it used to be todetermine whether it’s the spinalcanal or the neural canal that’sinvolved,” Dr. Maurer says. “They’reside by side, and you can have clini-cal expression from either; that’swhy imaging is key. If it’s in theneural canal, then it’s far more likelythat you need to get into surgerymore quickly because smaller thingsget crowded faster than in the spinalcanal.”

Detective Work: TrackingDown the Source of StenosisOnce the doctor of chiropracticknows to be alert for it, stenosis isnot hard to diagnose. But that’s justthe beginning of the detective work.“The real crux of the problem comeswith regard to the numerous factorsthat can cause stenosis,” Dr. Maurersays. Once you’ve come to the con-

Figure 3. A: Schematic demonstrating the normal sagittal measurement of the spinalcanal. The measurement is taken from the posterior aspect of the vertebral body, orspondylotic intrusion, to the spinous process-laminae junction. B: Line tracing of thespinal canal size and shape in A.1

Figure 4. A: Schematic of normal C6 vertebra. Arrows indicate the normal sagittalmeasurement taken from the posterior vertebral margin to the spinous process-laminaejunction. Note the wide lateral recesses and wide, smooth foraminal canals. B: Spondylotic changes have produced stenosis or narrowing of the vertebral canal withdecrease of the sagittal diameter. The lateral recess on the left and the foraminal canalsare intruded upon by osteophytic spurs of the articular facet and covertebral joints ofLuschka. Note obstruction and obliteration of the foramen transversarium. C: Gross spondylotic changes of the articular facets, mostly on the right, as well as theposterior vertebral margin. Compression and stenosis of the spinal canal, foraminalcanals and vascular foramen.1

clusion that you’re dealing withstenosis, the question becomes, ‘Is ita thickened ligament, does it have todo with a congenital or developmen-tal anomaly, degenerative changes,or does it relate to a spinal cordtumor?’”

Here’s where the confounding fac-tors come in because the list of sus-pects is somewhat long. “We have tolook at issues like an expanding

infection abscess. We have to look atvertebral tumors, medullary tumors,extramedullary tumors, fractures ofthe vertebra or its components, dis-location of the vertebra, and degen-eration of the vertebral motion com-plex,” cites Dr. Evans. Something like an abscess or aninfection will require blood workand clinical lab studies to diagnose,while vertebral tumors and spinaltumors will require finely tuned

imaging. “A vertebral tumor is aspace-occupying mass, so it presentsalmost exactly like a bulging disc.Medullary and extramedullarytumors are often easily confused orinvisible in early stages on plain x-ray, and yet they create exactly thesame compression problems neuro-logically as a bulging disc,” Dr. Evans says. “So to best rulethese out, the MRI is the imagingelement of choice.”

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Finding the source of the stenosisoften dictates the treatment pattern.In some cases, surgery is the firstand only option. “If you have loss ofbowel and bladder function, orparesthesias that are creating seriouslower-extremity pain and claudica-tion, then you want to go right tosurgery—you don’t want to messaround with it. And of course, in thecase of spinal cord tumors, you defi-nitely want to investigate that quick-ly,” Dr. Maurer says.

Some 30 percent of cases result fromgrave disorders. Dr. Evans includesexpanding abscesses; vertebral,medullary, and extramedullarytumors; and fractures and disloca-tions in this category. “These are allconditions with a high risk of mov-ing toward paraplegia and perma-nent radiculopathies as the diseaseprogresses, or as the canal stenosisbecomes more severe,” he says.“These are syndromes that are irre-versible, so once these symptom pic-tures are identified, practitionershave to move on to immediate inter-ventions, such as surgery.”

Treatment TacticsThere are three basic treatment par-adigms for spinal stenosis, says Dr. Maurer: the medical approach,which frequently involves bed rest,analgesics, local heat, and musclerelaxants; the conservative approach,using chiropractic and self-care tech-niques; and surgery. As noted, certain cases of stenosis,such as those resulting from tumors,immediately put the patient on theroad to surgery. But the majority ofcases of spinal stenosis—about 70 percent—are of degenerative ori-gin. These are amenable—at least toa point—to conservative manage-ment. “The average patient thatcomes in with lumbar stenosis ishaving leg pains and continuing painand discomfort in his low back andlegs. He finds an increase in pain

while standing. He can’t go to thegrocery store with his wife anylonger. The only thing that givesrelief is sitting,” Dr. Maurer says. Inthese cases, the medical approachmay be temporarily effective, but itwill not address the cause of stenosisand can only be pursued for a limit-ed time before side effects appear orsymptoms worsen. Degenerativecanal stenosis can be treated conser-vatively through chiropractic, butnot forever. “Even spinal manipula-tion will not afford a permanentcure, but it will often delay or put offsurgical intervention. If, throughmanipulation, you can maintain themobility of the joints affecting thestenotic area, you can often reducepain expression, help increase themobility of the joint and the functionat the level of involvement, andallow the patient to maintain a rea-sonable lifestyle for many yearswithout the need for surgical inter-vention.”

Without spinal manipulation, how-ever, a typical spinal stenosis patientwill go to a physician and be pre-scribed painkillers. “The next thingyou know, he’s in surgery in a rela-tively short period of time, maybeone to three years. With the conserv-ative process, he may go for yearsand never require surgery, depend-ing on the degree of involvementand pain expression,” Dr. Maurersays.

Spinal stenosis patients generallyrespond well to soft-tissue manage-ment of the low back and any of theclassic physical therapies of ultra-sound and muscle stimulation torelieve secondary muscle spasms.“They also do respond to manipula-tive care to the low back, but gener-ally manipulation of the low back isnot addressing the primary disor-der,” Dr. Evans says. “These are dis-orders of infolding of the ligamen-tum flava in the vertebral elements

and disorders of osteophytic forma-tion of the facet joint, so that long-lever manipulation of the low backdoesn’t solve as much of the problemas the doctor of chiropractic wouldlike it to.”

The Flexion-DistractionSolutionSo if routine manipulation providesonly temporary, symptomatic relief,what is another useful option for thestenotic patient? Dr. Evans suggestsCox flexion-distraction techniques:long-axis flexion and distraction ofthe lumbar spine. “The joints areunloaded in long-axis traction, andthen we have slight flexion, whichremoves the offending extension ofthe low back. The patient is thengiven a home exercise program,” hesays. “He’s often put into pelvic tiltexercises to strengthen the stomachmuscles, keeping the lumbar spineflat. We put patients in a typical rest-ing position at least once a day, lyingon the floor with the legs on a foot-stool or chair in a 90-90 position for30 minutes.”

But you will reach a point in manycases, says Dr. Maurer, where steno-sis progresses to a point that it’s con-tinually encroaching on the spinalstructures, and flexion-distractionand other conservative managementtechniques reach the limit of theirusefulness. Even in the best-case scenarios, Dr. Evans adds, the patient canexpect only about a 50 percentrecovery. “The best recovery is whenwe can get a reduction of, or evenabsence of, the leg discomfort. Theback pain can only be reduced tem-porarily. When patients are up andmoving around, it comes back,” hesays. “But leg pain is strictly a func-tion of how inflamed the nerve rootsare from stenosis, and that’s the partthat the doctors of chiropractic haveto be concerned with. They can have

continuedFocus

the greatest effect on that.” Patientsmust be informed up front that withstenosis, they have a chronic, pro-gressive disorder: the primary causeis not going to “get better.”

“A lot of this is also predicated onwhere Torg ratios on x-ray are. Evenbefore beginning care, if the Torgratios on x-ray are below 4:5, you’vealready got a losing battle. We alwaystry, but all parties concerned knowthat we’re already behind the eightball here, and the probability of suc-cess is lower and lower,” Dr. Evanssays. “But we do try on behalf of thepatient because surgical interventioncan be problematic and some patientsjust aren’t good candidates.” By thetime a doctor of chiropractic seesstenosis patients, many of them maybe in their 60s or 70s, with co-morbidconditions like diabetes or heart dis-ease make them poor surgical candi-dates.

Dr. Maurer works frequently with anumber of neurosurgeons in his area.“When we reach a point in the careof a patient with stenosis where thesymptoms are continuing or worsen-ing, then we’ll do an MRI and con-sult with the neurosurgeon. Betweenthe two of us, we arrive at a conclu-sion as to whether continuing conser-vative treatment is warranted,” hesays. “I have no qualms about thatonce we’ve reached that point.”

When It’s Time for SurgeryWhen a patient can no longer gothrough the basic activities of dailyliving without intolerable pain, whenhis or her walking and standingendurance continues to decline, orwhen major, progressive neurologicaldeficits appear, surgery is usually thenext alternative. Fortunately, sincespinal stenosis usually progresses ona fairly slow timeline, it can often beput off with conservative manage-ment for quite some time, Dr. Maurer notes.

“The whole idea of operating onstenosis is based on the absolute fail-ure of conservative therapy, and Imean that in all sincerity,” agrees R. Harris Russo, MD, FACS, a neu-rosurgeon in private practice inMichigan and a former faculty mem-ber of the University of Michigan’sneurosurgery department. “It’s veryrare for lumbar stenosis to paralyzethe patient or put him into a wheel-chair, so the operation is not reallydesigned to protect from paralysisbut to get the patient back into thework force or into activities of dailyliving.” He urges the doctor of chiro-practic to abide by rigid criteria whenconsidering whether to refer a steno-sis patient for surgery: progressiveloss of function, progressive pain, andinability to walk.

The decision to operate, Dr. Russosays, is “probably a bigger deal thanthe operation itself.” Surgery, whenindicated, usually involves decom-pression of the stenotic area. “Youwant to open up the spinal canal anddecompress the neural elements,” Dr. Russo explains.

The standard operation used in mostspinal stenosis cases is known as adecompression laminectomy. “Oneremoves the posterior elements, thespinous processes, the lamina, andthe facet joints,” Dr. Russo says.“This is the classic approach to steno-sis—the removal of those bony struc-tures. Underneath those structures,the normal supporting ligaments—the ligamenta flavum—are often verythick, and they compound the steno-

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sis. When that’s the case, they need tobe removed, as well. Basically, you’retalking about decompressing nervoustissue that is under pressure. You dothe least amount of damage andinjury by doing the most effective andthe shortest operation.”

Dr. Russo notes that there are othersurgical options, but in most cases, headvises the decompression laminecto-my. “There are other, more theoretic,ways of doing this. For example, oneoption is to remove the posterior ele-ments en bloc and then wire them backin.” The advantage with this type ofsurgery is that the patient has, to adegree, a reconstituted spinal canal;but the operation is significantly morecomplicated and takes a lot longer.“Some neurosurgeons do this becausethey’re hoping to prevent further

instability developing as a result of theoperation, so they attempt to reconsti-tute the normal anatomy of the spine.There’s a lot of controversy aboutthat, and, to my mind, there reallyaren’t any indications for it,” Dr.Russo says.

What are your patient’s odds ofrecovery after surgery for stenosis?Most patients have good or evenexcellent results, Dr. Maurer says,returning to most types of work,shopping, walking, and other dailyactivities with little pain. But even inthe best-case scenarios, they’re notlikely to be able to do everything theyotherwise would. Strenuous lifting,prolonged walking or sitting, andlong-distance car rides can oftencause serious flareups of the oldsymptoms. The worse the symptoms

were before surgery and the longerthey persisted, the more likely it isthat the postoperative results will beless than optimal.

“The surgery itself, in good hands, isrelatively curative,” Dr. Russo says.“What we’re really concerned about ispicking stenosis up early, and pre-venting the progressive loss and pro-gressive pain, particularly becauseyou’re dealing with an older popula-tion. In the face of heart disease andhypertension, once you lose thesemuscles and the ability to walk, thepatient is way behind—no matterwhat you do in the future.” ▼

Reference1. Maurer EL. Practical AppliedRoentgenology. 1983.

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The Specific Problems of Cervical Stenosis

Stenosis, like many other conditions of the spine, can develop in either the lumbar or the cervical spine. Lumbarstenosis is more common, but stenosis of the cervical spine can have far more severe consequences. “The neck issuch a vital pipeline that if we have stenosis of the cervical canal, the consequences are magnified, compared to lum-bar stenosis. Everything rises on an order of magnitude as compared to the low back,” Dr. Evans says.

Canal stenosis in the cervical spine can cause pain, but it can also produce a phenomenon called rhizalgia. In suchcases, the patient feels pain on the same side of the body—in the arm, down the back, and into the leg. “We know, atthat moment, that that patient has some space-occupying mass pressing hard enough on the neural tissue to producearm and ipsilateral pain,” Dr. Evans says. “That can be a disc or canal stenosis. Again, in orders of magnitude, it cango from a radiculopathy to something much worse. If the ultimate consequence of stenosis can be paraplegia forlower extremities, it can be quadriplegia for cervical spine stenosis, or spinal cord stroke because of compression inthe canal.” Depending on where the cervical stenosis occurs, death is a possibility.

“This is where prompt advanced imaging is absolutely imperative,” Dr. Evans says. One clinical sign, in particular,immediately moves everything to the advanced imaging stage. This is Lhermitte’s sign. “When it’s positive, youassume it demonstrates myelopathy of the cervical spine, meaning that there’s something wrong with the spinalcord,” he says. “In the past, everybody had taken that to mean multiple sclerosis. It is not; it only means there ismyelopathy of the cervical spine, and something is encroaching on the cervical spinal cord.” What is Lhermitte’ssign? When the patient, in a sitting position, sharply flexes the chin to the chest, he or she experiences electrical sen-sations or paresthesia into the upper extremities and/or the lower extremities.

“Patients who tell me that whenever they look down at a magazine they get paresthesias into their arms and can alsofeel it in their toes, that’s a positive Lhermitte’s sign,” Dr. Evans says. “If I can reproduce that in the clinic, then I’mlooking at getting a prompt MRI for that patient before anything else.”

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