Cervical Spine Stenosis - A Complete Guide

what is cervical stenosis hello this is Dr Grant Cooper at Princeton's mind and Joint Center in this video I would like to discuss an unfortunately very common problem that I see on a daily basis cervical stenosis is one of the most common causes of neck and arm pain and it has the potential to be dangerous so it's a very serious problem for multiple reasons there's a lot to understand about cervical stenosis so let's just Dive Right In now first of all cervical stenosis literally means narrowing of the cervical spine specifically it means that the holes where the nerves are traveling in the cervical spine have narrowed so now there's less room for the nerves to exist in their holes and do their jobs because of this stenosis or narrowing of the holes there's a greater chance that the nerves will become irritated and inflamed which would then cause pain in other serious symptoms the first thing to realize about cervical stenosis is that a lot of people actually have it and never develop any symptoms from it now imagine that it's a very important point it means that if you do happen to have symptoms from cervical stenosis then you can often make the symptoms go away and live the rest of your life without those symptoms without necessarily surgically opening up those holes the narrowing of the holes in and of themselves aren't what causes the symptoms but rather the symptoms occur when the body responds to that stenosis that narrowing with an inflammatory reaction and it's then the inflammation that needs to be eliminated in order to take away the symptoms now more on that in just a bit but before we get to that let's talk for a moment about how the holes in the spine get narrowed in the first place and where specifically they get narrowed inside of the cervical spine the stenosis can occur in one of two basic places it can occur in the middle of the spine where the spinal cord is in which case it can cause something called a myelopathy or it can narrow where the nerves are exiting the spine when cervical stenosis is in the center we call that Central spinal stenosis when the stenosis is where the nerves are exiting the spine we call that foraminal spinal stenosis most people if they develop symptoms from cervical stenosis develop their symptoms from foraminal stenosis it's an important distinction because some treatments will work for one but not the other type of stenosis also there are particular dangers with Central cervical stenosis that we'll get to in just a bit now first what actually causes the stenosis well stenosis can come from many places in the spine the most common reason that someone might develop cervical stenosis is a herniated disc where the intervertebral disc has moved and it's now making the holes where the nerves travel smaller another really common reason particularly common in older people is something called Facet Joint arthropathy you have these little small joints in the back of your spine called facet joints facet joints are joints just like other synovial joints in your body like your knees fingers hips shoulders toes you've seen in older people that sometimes they develop knobby joints in their fingers where the joints over grow now the same thing can happen and often does happen in the facet joints in the spine and when that happens the bone spurs and that the general bony overgrowth makes the holes where the nerves are traveling smaller what generally happens particularly in older people is that there's a Confluence of these different degenerative changes including in the facet joint and the disc and they all come together with a net effect that the holes where the nerves are traveling just become smaller now when cervical stenosis causes symptoms what are those symptoms what do they tend to be well and the more common foraminal stenosis the most common symptoms are going to be radiating pain into the arm the pain is generally described as sharp or burning it can also be achy as well usually the pain is worse when the person looks to the side of the symptoms this is because when you turn your head to the side of the symptoms and particularly if you look over the shoulder you're closing the foramina you're closing the holes where the nerves exit the spine on that side now sometimes in addition to or instead of pain the person might feel numbness and or tingling in their arm the symptoms will generally follow the distribution of the nerve root that's inflamed so if it's the C5 nerve root the symptoms generally refer to the outside of the shoulder the C6 nerve root generally will refer symptoms down the arm into the pointer finger in the hand although sometimes it'll also go into the thumb as well if the C7 nerve root is involved the pain generally refers into the triceps and into the middle finger the C8 nerve root will generally refer symptoms into the fourth finger and the T1 nerve root will generally refer into the pinky now it's important to recognize that these are good general rules of thumb to go by but there's going to be a lot of individual variation in how any one person will present with their nerves particularly when the symptoms are pain and numbness or tingling sometimes the symptoms will include weakness if a C5 nerve root is involved then the person may have weakness in their shoulder abduction and in their biceps if the C6 nerve Roots involved and they may have weakness in their wrist extensors if they have C7 nerve root involvement and they may have weakness in their triceps with their elbow extension if they have C8 nerve root involvement then they may have weakness in their finger flexors and if they have T1 nerve involvement they may have weakness particularly in their ability to abduct their pinky finger like this when nerves are inflamed or injured usually pain comes first then numbness and tingling and then maybe weakness for doctors the signs and symptoms that are most concerning for the health of the nerves are true numbness and weakness now when doctors talk about true numbness what we mean is the arm doesn't just feel numb to the patient but when the arm is actually examined the patient actually doesn't feel the doctor touching them as much that is the patient has a lost sensation to touch and this suggests much more nerve root involvement than if the person feels like they have a numb arm but they don't actually report numbness when they're being examined so for example if the patient can close their eyes and you can touch their arm and they feel you touching them just fine that's a lot more reassuring weakness is the most concerning symptoms from a nerve root being in flame standpoint weakness suggests that the nerve is very significantly impacted this becomes particularly important when we think of how we're going to go about treating a patient because at a certain point nerves don't get better so you want to make sure that even if there are lots of symptoms and maybe the patient feels really awful we want to know that the nerves are healthy and that way we can focus on the symptoms and not have to worry about the actual health of the nerve if the nerve root health is in serious Jeopardy then it suggests that we may need to take a more aggressive treatment course that might even include surgery at least to be considered sooner than later because we don't want to allow the nerve to get to a point where it won't be able to to improve won't be able to get better now this is rare but it's important to be aware of one way to determine the actual health of a nerve is to get something called an electrodiagnostic study or an EMG in this case in this test you're interrogating which nerve is affected and how badly the nerve is involved you can think of a nerve as like a wire in the wall there's the wire and then there's the insulation in a nerve there's the axon and then there's the myelin which is like the insulation around the Axon when a nerve is inflamed but healthy it means the insulation is irritated but the axon itself is healthy on a nerve test this will mean that the nerves will fire slower than normal now if the axon itself starts to become irritated and involved in the amplitude of the nerve on the test will get smaller and then we start worrying about the actual health of the nerve itself and inflamed by Otherwise healthy nerve can still cause horrific symptoms that can include awful pain numbness and even sometimes weakness but the difference in these cases is that the health of the nerve is not in question so then it really becomes more a question and an open question as to how aggressively to go about treating the nerve when the health of the nerve is in question it's still ultimately obviously the patient's Choice as to how to go about treatment but there is or there there should be more urgency to the treatment in order to give the nerve the best chance of making a full recovery now let's discuss how we go about treating foraminal cervical stenosis and then we'll talk about Central cervical stenosis okay how do we treat foraminal cervical stenosis again this is the most common type of cervical stenosis where the nerves are inflamed as they exit the spine causing what you would also call as a cervical radiculopathy or you might just say simply a pinched nerve in the neck I recall that not everyone with cervical stenosis develops symptoms in fact after the age of 60 close to 100 of people have at least some degree of cervical stenosis and most don't have symptoms from that and might never develop them a quick story will illustrate this point well I did most of my training at New York Presbyterian Hospital in New York City and the chair of the Cornell department at the time was a man named Willie nagler now Dr nagler was an amazing doctor who was pretty old by the time that I was there in his Heyday he had been the the doctor to President Kennedy just about every celebrity in New York he was a very very nice guy he had a great story that he liked to tell where he had gotten an MRI for something that was totally unrelated to his spine one time and the radiologist called him and he said really we need to talk now that was unusual for a radiologist to do and so it was a bad sign so Dr nagler thought that maybe they'd found cancer or or something really bad the radiologist told Dr nagler that he had such terrible spinal stenosis that he needed surgery immediately Dr nagler thought about that about what the radiologist had said and he thought well I feel fine I swim every day I play tennis I think I won't follow that advice and you know he lived until he was 90 years of age and though I lost touch with him at the end I'm pretty sure that he never had any spine surgery now Dr nigler liked to tell that story to the young doctors because I underlined the important point that an MRI is really just an MRI and just because you see stenosis in the spine on an MRI it doesn't necessarily mean you have to do anything about it because it might never cause any symptoms now there will be a slight exception to this when we discuss Central cervical stenosis but it's a good story and a general good rule of thumb to keep in mind when we think about these things and with that said cervical stenosis is not irrelevant and it certainly does set the stage for symptoms now the symptoms come when there's an inflammatory reaction to the stenosis inflammation is a protein response but the best way to think of it in this context is that it's like a fire and there are two ways that we can put out a fire the first is to move away the gas and the sticks and move away all the fuel you clear away the fuel to the fire and the fire burns itself out in a surgeon's world that means surgery it means literally going in and decompressing the spine in order to alter the anatomy and take the pressure off of the nerves in the conservative World which is really my world it means targeted exercise it means Physical Therapy it means training the muscles to support the spine in order to take the pressure off the nerves and let them rest so sometimes that works great other times you do that and the fire just keeps on burning or there's just too much inflammation and pain to even do the exercises in the first place now in these situation it's often helpful to take a fire hose and put it on the fire and in this instance the best fire hose is going to be an epidural steroid injection in this procedure a needle is placed under x-ray guidance next to the inflamed nerve root an anti-inflammatory medication is then placed on the nerve the nice thing about this procedure is that it tends to be very effective in taking away the inflammation and therefore also the symptoms in foraminal stenosis now note that it's not a Band-Aid it's not a painkiller an epidural steroid injection when it works is removing the inflammation which is what's causing the symptoms but the limiting part of this procedure is that it doesn't do anything to address the underlying biomechanics that led to the inflammation in the first place so if all you were to do were epidural steroid injections they tend to give you about three months or so of relief now during those three months and sometimes the relief is longer sometimes the relief is shorter but but basically during that time when the inflammation and the symptoms are better if you do nothing else then you know usually slowly the nerves have a tendency to get aggravated again by the same biomechanics because those biomechanics haven't changed so it's important that if an epidural steroid injection is used then it should be used as a window of opportunity during which the patient can learn and perform targeted exercises to stretch and strengthen the appropriate muscles in order to unload the spine so that as the steroids wear off the inflammation doesn't return we have a video on the best exercises for neck pain and the best exercises for good posture both of these videos are excellent for this purpose but also working with a physical therapist is a great idea now once you're feeling up to it I think an exercise routine such as Pilates can be an excellent way to continue to strengthen and stretch the right muscle groups to help keep to help keep you strong and limber and ultimately pain-free into the future now sometimes despite the best conservative efforts the inflammation just keeps on burning or sometimes there's so much stenosis that the nerve is truly compressed and it's just not going to get better with conservative care in these instances surgery can be the best option now there are in fact two concrete surgical indications in cervical foraminal stenosis first is if there's Progressive neurologic loss so if you're getting weaker and weaker then surgery should be considered sooner than later in order to save the health of the nerve and allow for a full recovery and second if the symptoms are severe despite good conservative care then surgery should at least be considered when it comes to surgery there are two basic types that are considered the first is a decompression and the other is a decompression and diffusion to make the symptoms of cervical foraminal stenosis go away you really only need to generally perform a decompression surgery in which the nerve undergoes essentially a Roto-Rooter procedure or anything that's causing this stenosis or contributing to the stenosis is removed so now there's more room for the nerve to exist in the hole without being irritated the trouble is that in some people particularly if there's a lot of underlying arthritis taking away parts of the bone can destabilize the rest of the spine it's like a game of Jenga right where if you take away too many pieces you can unfortunately jeopardize the stability of the structure if the surgeon feels that by taking away the stenosis the spine may become destabilized then the surgeon will have to fuse the spine as well as decompress it in this procedure the surgeon will typically put in Hardware Hardware into to the spine and the difference between a decompression and a decompression with a fusion is huge in terms of operation time and certainly in terms of recovery a decompression can be a relatively short recovery with people getting up and about within a few weeks or so a Fusion on the other hand can take 6 to 12 months before a patient is feeling back to themselves so as you can see it's really a very big difference from that standpoint alone not to mention a fusion is going to put more pressure on the other parts of the spine above and below it because now the normal motion of the spine isn't going to be able to go through that segment so other parts of the spine will have to take up that slack that's something that can lead to what we would call adjacent segment disease where other parts of the spine start to have a problem because of the extra stress that they now undergo from the adjacent surgery okay let's talk now about cervical Central stenosis in cervical stenosis of the central part of the spine the spinal cord itself is compressed in the middle of the spine now this doesn't tend to cause pain but it tends to cause neurologic loss and it can be dangerous depending on the extent of stenosis if spinal cord is affected symptoms might include decreased balance or decreased coordination in your hands or legs if the spinal cord is very badly affected you can have incontinence of bowel and bladder incontinence of bowel and or bladder is very rare but it's a clear surgical emergency Central cervical stenosis can also cause weakness in the arms or the legs when the spinal cord is involved in the cervical spine it's called a cervical myelopathy this is a potentially very dangerous problem because if it progresses it can lead to further neurologic deterioration which can become permanent if cervical Central stenosis is causing neurologic symptoms surgery really should be considered epidural steroid injections work very well for inflammation from foraminal stenosis but unfortunately they really don't work for Central stenosis and actually might be counterproductive by increasing the pressure in and around the spine Physical Therapy can still be very helpful to manage the symptoms and maximize function in a cervical myelopathy but therapy alone won't be able to take much of the mechanical pressure off of the spinal cord if the compression is severe surgery is really going to be the only way to do that now sometimes a patient is asymptomatic and they happen to get an MRI of the neck or sometimes and this I've seen too many times to count a patient comes in and has clear symptoms from cervical foraminal stenosis we treat the pherominal stenosis symptoms and the patient becomes asymptomatic but the MRI of the cervical spine also happened to show severe Central cervical stenosis so what do you do in this type of case the answer is that it really depends on a lot of factors one factor is how severe is the stenosis another factor is whether there's any evidence of damage in the spinal cord itself something that we would call myelomaia then you also have to consider the age of the patient and the likelihood that the stenosis will progress with time you also have to consider what type of surgery would be needed in order to decompress the spine there'd be a lower threshold for surgery if the surgery could be a simple decompression the threshold will naturally be higher if a bigger surgery that would involve Fusion is needed now sometimes you don't need to do anything at all but you just educate the patient as to what signs and symptoms to look out for in case the stenosis were worsens sometimes you might just follow a patient with another MRI in a year or two and sometimes even in the absence of symptoms the risk of catastrophic spinal cord injury is just too great so it becomes one of those very rare times that you end up doing surgery as a preventative measure in the absence of active symptoms ultimately as you can see it's a huge decision and it needs to be considered very carefully from multiple angles now I'd be remiss to not mention a few other treatment treatment modalities for foraminal stenosis gentle Chiropractic Care can be helpful to increase the mobility in the neck but it should be done with Extreme Caution if they're sensual stenosis in my mind gentle Chiropractic Care works best when it's paired with good physical therapy exercises medications can help to manage the symptoms of cervical stenosis but they won't help fix the underlying problem it's important to note that only about two percent of an oral medication actually makes it to the spine so taking anti-inflammatory medications can help with symptoms by reducing pain and maybe by reducing overall inflammation in the body but they won't generally be able to reduce the inflammation at the site of the nerve root in the cervical spine now the notable exception to this would be high dose oral steroids but taking enough oral steroids to impact the spine will often cause lots of side effects in the rest of the body so an epidural steroid injection that uses a small fraction of the amount of oral steroid but delivers that little bit of medication directly to where it needs to go is generally a better and far more effective option of course an epidural steroid injection the cervical spine does have risks of the procedure as well and so it needs to be done with great care and obviously only by an experienced specialist there are nerve membrane stabilizing medications such as Neurontin and Lyrica and these can be particularly helpful for some people for radiating pain they don't tend to work very well on numbness and they won't do anything at all for weakness and of course they do carry side effects most notably they can affect mood they can make people tired dizzy they can give you memory problems these medications don't change the underlying problem but they can be thought of as pain medications for nerves it's worth remembering that most cases of cervical foraminal stenosis are successfully treated with conservative care once the symptoms are resolved no matter how you get there it's important to think about learning and doing a set of exercises and learning about the biomechanics of your spine so that you can keep your spine healthy far far into the future I hope you found this video useful please remember to like this video and please consider subscribing to our Channel if you haven't already as always if you have any questions or comments or suggestions for a future video then I would love to hear from you in the comments section thank you very much for watching for watching I wish you all the best of health

Channel: Princeton Spine & Joint Center

Views: 43,815

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Id: 2W72Y9QlePk

Length: 22min 56sec (1376 seconds)

Published: Tue Aug 29 2023