Welcome back amazing nerds.
Today’s text aims at continuing to inform about the most common musculoskeletal complaint: back pain. More specifically, it is about a pathology that can be linked to back pain, can sound really scary, and sometimes is not well understood even by healthcare professionals. I’m going to be discussing spinal stenosis. I will start by covering what it is and what can lead to it happening in our bodies.
The term stenosis basically means narrowing, so spinal stenosis means narrowing of the spaces in our spine where the nerves, blood vessels, and the spinal cord pass through (Urits et al, 2019; Wei et al, 2021). This has the potential to cause compression and/or ischemia of these structures (Ammendolia et al, 2022): what is commonly called a “trapped nerve”. This could happen at different levels of the spine (McCartney et al, 2018; Urits et al, 2019). This narrowing often is caused by changes that are usually grouped into what is called degenerative changes, or osteoarthritis, which can include disc herniation, osteophyte formation, or ligament thickening but in very rare cases can be caused by a more concerning mass occupying the available space for the previously mentioned structures (McCartney et al, 2018; Wei et al, 2021).
Common symptoms of spinal stenosis include pain around the affected spinal area that can irradiate to arms or legs, one or both sides, following the distribution of a dermatome, depending on the level of the stenosis, as well as pins and needles and/or numbness (Ammendolia et al, 2022; Hartvigsen, 2018; McCartney et al, 2018; Urits et al, 2019). A particular group of symptoms that is very common and often limits someone’s ability to walk is something called neurogenic claudication, which is a clinical presentation involving buttock or leg pain, pins and needles, numbness, weakness or fatigue, independent of back pain, that worsens with standing or walking and improves with rest and/or lumbar spine flexion (Ammendolia et al, 2022; Hartvigsen, 2018). See, flexing your spine isn’t really as bad as it is often made to be. It is also important to note that weakness is not as common as sensory changes, but can still be present and usually matches a specific myotomal depending on the level of the spine affected (McCartney et al, 2018).
Currently, the expert consensus for the diagnosis of spinal stenosis requires that both the signs and symptoms matching the condition are present and that there is confirmation of narrowing of either the foramina (holes on the side of the spine) or the spinal canal at the level that correlates with symptoms (Hartvigsen, 2018). But what exactly can we see on imaging? Let’s look at some of the more common findings.
This is what is commonly called a ‘slipped disc’, which is basically the worst name you can give as it in no way describes what is happening with our intervertebral disc as these do not slip out of place. Our spines aren’t Jenga towers. So, if you’re reading this, please do me a favour – never again use that term.
What actually happens in a disc herniation is that part of the gel-like substance that makes ups the nucleus of the disc starts pushing through the outer layers of the intervertebral disc, sometimes even oozing out (Fardon et al, 2014; Yamaguchi and Hsu, 2019). In simple terms, part of the disc bulges. In some instances, it can happen due to some forms of trauma, but more often than not it happens as part of normal age-related changes (Yamaguchi and Hsu, 2019). I use the term normal because if we look across people without any sort of back pain or any spine symptoms, the probability of them having a disc herniation on imaging without being aware ranges from 50% on 40-year-olds to 84% on 80-year-olds (Brinjikji et al, 2015). Different terms like ‘disc protrusion’, disc extrusion’, and ‘disc sequestration’ are all different magnitudes of disc herniations as classified by the Combined Task Force (Fardon and Milette, 2001; Fardon et al, 2014).
Summarising, the data shows that disc bulges are common, normal things and not catastrophic injuries that will leave you paralyzed. And they may not need special treatment as our body can on its own improve and sometimes even completely reabsorb the disc herniation, with the worse-looking disc bulges being the ones more likely to improve (Chiu et al, 2015). And don’t trust anyone who says they will be pushing the disc back in using their hands or a certain exercise – there is no evidence that is possible.
This hard-to-pronounce term is used to describe when one vertebra moves out of alignment with the one under it (Kreiner et al, 2016; Samuel, Moor and Cunnigham, 2017). This is the only condition in which your vertebrae move out of place, despite what some pseudo-scientific professions would like you to think, and before you run to call a surgeon to scan or operate on your back because of your back pain, let’s first understand how spondylolisthesis is classified and its clinical relevance, or lack thereof.
Spondylolisthesis is somewhat common, with its prevalence ranging between 19.1% and 43.1% in the general population, with its prevalence being higher in older adults (Bydon, Alvi and Goyal, 2019)
Spondylolisthesis is classified between Grade I and Grade V through the Meyerding classification depending on the percentage of misalignment of the vertebrae, however, so far, the evidence points to there not being an association between clinical symptoms and progression of misalignment on scans (Akkawi and Zmerly, 2021). Although spondylolisthesis can lead to back pain and spinal stenosis, unless some very specific neurological symptoms are present, spondylolisthesis is commonly benign and not having specific treatments does not lead to further progression of the misalignment or of the clinical symptoms (Wei et al, 2021).
Yes, you read that right. Even in a condition where a vertebra is misaligned, the amount of misalignment does not correspond to the symptoms you get in terms of pain or neurological changes. Isn’t it amazing how robust and adaptive our body is? And no, we don’t that have any data showing that some will be able to re-align the vertebrae using their hands or weird gadgets or tools. The treatments often offered by chiropractors and osteopaths are pseudo-scientific treatments for pseudo-scientific problems and there is no evidence they are beneficial for spondylolisthesis.
These are the most common pathologies that can lead to some narrowing in some parts of our spine. There are other conditions that can also lead to this, but they are very, very rare even something like a spinal fracture will only be present in less than 1% of people when they have back pain following a fall (Finucane et al, 2020). And something really serious like cancer is present in less than 1% of cases of back pain (Finucane et al, 2020). So, despite what Google may tell you, unless you have a very specific medical history, your back pain is 99% unlikely to be cancer or anything serious.
However, remember that these texts have the goal to inform, not diagnose, so if you’re in doubt, book an assessment with a qualified physiotherapist. Considering this, I hope this has helped you understand a bit more about spinal stenosis, the different things that can lead to it, and how common it is. In the next couple of texts, I will be exploring if scans are helpful and how this condition is usually managed.
I hope to see you amazing nerds in the next one,
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