Cervical Spinal Stenosis
Cervical spinal stenosis can be the result of a number of causes. Below, you’ll find the most common causes.
- Congenital spinal stenosis. This is a condition you’re born with. The patient is born with a smaller than average canal (just like some people have larger feet or ears).
- Consequences of arthritis
- Degenerative spinal stenosis. This is the normal aging process that can result in ridging of the spinal canal at the disc spaces, and gaps in between.
- Trauma. Trauma can affect and speed up the normal degenerative process. It can also cause a piece of the normal tissue to be displaced into the spinal canal through a herniation of the disc material, fracture of the bones in the canal, or of contents of the facet joints ( synovial cyst).
- Tumors. They can cause spinal stenosis by growing from within the spinal cord, or from one of the nerve roots that arise from the spinal cord. They cover the spinal cord, or in some cases have spread to one of these structures from another place in the body (also known as spinal metastasis).
- Infections. Infections that occur in or around the spine can cause spinal stenosis, often with rapidly progressing and devastating effects.
- Multiple conditions. If you’re living with additional conditions, this can result in having spinal stenosis. An example of this is someone who is living with a congenitally small canal that can develop mild to moderate arthritis or a disc herniation that otherwise might not be large enough to be symptomatic. When two conditions are combined, the result can be worse than just one.
If you’re experiencing any of these causes, you more than likely are living with cervical spinal stenosis. Begin your journey to pain relief by contacting our team today.
What Are the Symptoms of Cervical Spinal Stenosis?
There are various symptoms of cervical stenosis to be aware of. They include:
- Weakness in the hands, arms, legs or trunk muscles
- Impairment of the bladder or bowel function. This can include incontinence such as unable to stop going, experiencing accidents or retention where it’s hard to get rid of contents which makes it hard to get rid of contents. This makes one either constipated or feel as if they can’t go.
- Difficulty controlling arms, legs, or body. This includes uncontrollable spasms, lack of coordination when walking, or loss of control in the hands.
- Pain in the body. This includes sharp, burning, or electrical pain which can go up or down the neck, back, arms, or legs.
If you’re suffering from any of these symptoms, contact Jenkins NeuroSpine to discuss your options for achieving pain relief.
How is Cervical Spinal Stenosis Treated?
The treatment of cervical spinal stenosis is usually dependent upon the severity of the stenosis. Factors include:
- Associated deformity
- Root cause of the stenosis
Cervical spinal stenosis can be treated with anterior procedures like discectomies or corpectomies. They can also be treated with posterior procedures in the neck including a laminectomy with or without fusion, laminoplasty, or minimally invasive treatments when appropriate.
Below are treatment options that can effectively treat cervical spinal stenosis.
An anterior cervical discectomy is one of the oldest procedures performed by spinal surgeons. It’s part of the current standard of care for disc herniations when combined with another treatment. Many of the other treatments are commonly used today for a number of reasons. Occasionally, there is a reason for performing the simple discectomy without any other treatment. A few reasons it has fallen out of favor is because there are several potential consequences such as:
- Chronic neck pain
- Once the disc is removed, it collapses and the neck becomes more kyphotic, which can put more strain on adjacent levels in the spine
- When the disc is removed, the space between the bodies become smaller which results in a greater likelihood of pinching the nerves where they leave the spine
Although most spine surgeons do still perform this procedure, most have abandoned doing the procedure by itself. Most favor performing a discectomy and either a fusion or an artificial disc replacement where appropriate.
Discectomy with Fusion
In the 1950s, Cloward, Smith, and Robinson popularized different techniques of placing a bone graft where the disc used to be to prevent the consequences listed below. In theory, by keeping the alignment in the neutral lordosis, there should be less degeneration in adjacent levels over time. By keeping the two vertebral bodies apart, there should be less pinching of nerves over time.
By encouraging the bones to fuse together, there is typically less neck pain as the two vertical vertebral bones no longer rubbed against each other without the benefit of a disc in between. The distraction of the two bodies kept the ligaments in the spinal canal from bulging into the canal and spinal cord preventing delayed spinal stenosis. At this time most surgeons who perform a discectomy with a fusion will do so using a plate on the front of the spine to help the fusion along. This is called instrumentation.
Discectomy with Total Disc Replacement (TDR)
Instead of replacing the disc material with a bone graft, some surgeons may choose instead to replace the disc (in a limited number of patients who are deemed candidates for the procedure) with an artificial disc implant that normally allows for some movement at the level operated on, instead of fusing and eliminating movement at that level. The theoretical advantage is that it preserves some motion at that level, even if it is not completely normal motion. It has the same advantages fusion has over simple discectomy, in that it prevents collapse and kyphosis, and most of the consequences listed above.
The FDA-approved indications for cervical TDR are for single-level disease without significant facet disease and are primarily indicated for a disc herniation with nerve root compression. Any use other than above is considered “off-label”, including more than one level of disc implantation. Some patients do go on to fuse around the artificial disc. Outcomes after both an artificial disc replacement and after discectomy and fusion are generally good, with a return to function. One exception is that professional athletes such as NFL players, and combat pilots in the military are not usually cleared to return to active duty or play after an artificial disc replacement. There is generally a much longer follow-up experience for after a fusion than there is after a disc replacement. A newer generation of disc replacement will likely come along, and additional information about the long-term results in such high-performance athletes may change these recommendations.
Anterior Keyhole Foraminotomy
For those patients whose spinal stenosis is caused by a single off-centered disc herniation or bone spur from the disc space (anterior osteophyte), a small procedure with a similar approach as the discectomy can remove the compression without complete removal of the disc, and without a fusion. This procedure involves less disruption of the rest of the disc space, and so the majority of the native disc material is left untouched, and the patient is able to maintain their pre-operative range of motion. The restrictions are slightly less after an anterior foraminotomy for discectomy or decompression, and so consequently the procedure is slightly easier to recover from.
However, this procedure does have a significant recurrence rate (precisely because it does not involve removal of the entire disc material, which typically requires a fusion or total disc replacement.), This does result in some damage to the disc. Although most surgeons who perform this procedure will not completely immobilize the patient after surgery in a collar, strenuous activity is typically curtailed initially.
A more complete removal of the vertebral body is required if:
- Compression is more than just disc material or bone spurs at the disc level
- A major deformity is involved
- Removal of the entire vertebral body is necessary because of a tumor of another disease involve the bone
This is called a vertebrectomy or a corpectomy. Whenever a corpectomy is performed, either a fusion or instrumentation is usually performed. This is to maintain a more ideal position. The corpectomy is more destructive than a discectomy and fusion, and may have a higher nonunion rate. Multilevel procedures are more likely to require a second procedure to provide supplemental instrumentation from the posterior approach to ensure a solid fusion.
Posterior Cervical Procedures
Laminectomy has been performed for more than 80 years by taking the back of the spinal canal off, like opening a convertible roof or a can of sardines. By removing the back of the canal (an “-ectomy” or removal of the lamina or back of the spine), the contents of the spinal canal (the spinal sac, with its column of spinal fluid and the spinal cord and nerve roots) can expand backward and be less compressed. This usually alleviates or improves the neurological symptoms caused by the compression and gives the best environment to recover in.
However, there are many circumstances where the removal of the bone in the back results in delayed kyphosis or forward tipping. This forward tipping essentially bends and stretches the spinal cord over the disc spaces and bone spurs, and over time this can result in more neurological symptoms. For this reason, most spine surgeons will perform instrumentation and fusion with a laminectomy when done for spinal canal stenosis. Especially if there is already forward or kyphotic tipping of the spine, or if there is a significant weakness to suggest that the muscles of the neck will be too weak to hold the neck in position over time.
Laminectomy with Fusion
Fusion, when performed as part of a laminectomy procedure, will eliminate movement in the levels fused. This is usually achieved with some form of instrumentation to hold the bones rigidly until the bone heals, and adds stability to the neck (assuming the fusion heals properly). Most skilled practitioners believe that getting the spinal alignment to fuse in as close to the normal neutral lordosis will keep the remaining levels from degenerating as quickly. There are various competing forces and issues (difficulty in getting the alignment of the spine corrected, risks of being more aggressive, among others.) Where possible, we try to restore or maintain a 20 degree or more curve within the entire cervical spine (normal is generally considered 20 to 40 degrees.)
The consequences of the procedures include reduced range of motion in the neck (and the amount of reduced range of motion depends on the levels so fused), slightly increased risks associated with the more extensive nature of placing screws, cables, or other forms of instrumentation into the spine, the need to observe the patient over the year or so after the operation to make sure the fusion takes and the development of pseudoarthrosis [failed fusion, see the section on re-operations].
Laminotomy or Foraminotomy
When the area of stenosis is less extensive or off to one side, a smaller procedure can be performed. Some disc herniations can also be treated by a small procedure from the back of the neck, which doesn’t require a fusion to achieve the goal of decompression of the nerves or spinal cord. The indications for a “keyhole” foraminotomy [because the surgery is small like an old-fashioned keyhole] may be different from that of a discectomy, laminectomy, and in some cases, either procedure may be appropriate.
Laminoplasty is used to repair or treat (“-plasty” or repair) the lamina when there is significant spinal stenosis. This procedure has the advantage of maintaining most of the range of motion they had pre-operatively (as opposed to a fusion) but still significantly increasing the canal area (almost doubles the space available for the cord). The procedure allows for the retention of the majority of the normal anatomy of the spine, which keeps the spine from tipping forward over time. While there are several techniques for performing a laminoplasty of the cervical spine, the one Dr. Jenkins usually employs is known as the “open door” technique.
Essentially, the back of the spine (lamina) is hinged open on one side after cutting it free and elevating it from the other side, held in place usually by a custom titanium miniplate designed just for this procedure. It’s like raising the roof on one side of the house, but because the roof is curved or with a reverse “V” shape, once elevated, it takes on a shape like the top of an octagon.
This procedure should not be applied to patients whose spines are already severely tipped forward (Kyphotic) or in those for whom instability is present.
This procedure can be performed either as a laminoplasty at all levels (Case 1), or when part of the region to be operated on is already somewhat unstable and requires instrumentation and fusion, a hybrid procedure can be performed in the part that is not unstable (Case 2).