Lumbar Stenosis
As we have covered several times, the vast majority of lower back pain out there is “discogenic” in nature, which means coming form the disc. There are, however, many other sources of lower back pain that we treat at CCRC; today I want to discuss one of these - stenosis.
Stenosis is fancy medical speak for “narrowing”. In the case of spinal stenosis, we are talking about narrowing of the holes and/or canals in the spine. These holes/canals are created by the bones of the spine (vertebrae). There are two main types of stenosis in the spine, neural foramenal stenosis and spinal canal stenosis. Neural foramenal stenosis is narrowing of the hole(s) out which the nerve roots come.
Spinal canal stenosis is narrowing of the spinal canal where the spinal cord lives. The two regions of the spine where stenosis typically occurs are the cervical spine (neck) and lumbar spine (lower back). More on why these areas tend to get most of the stenotic changes later.
Before I get into what stenosis is (what causes it, and what you might be able to do to help with symptoms), I want to cover who gets this and what are the symptoms.
What are the symptoms of stenosis? Early on in the process, patients will experience aching is the back part of the spine around the area. In the neck, it will be the neck and shoulders. In the lumbar spine, it will be across the lower back and maybe a little into the glutes. Patients will occasionally experience sharp pain in the spine with movement, typically involving twisting. Later in the process, patients may experience aching/tightness radiating into their extremities. In the neck, this radiation will go into the arms. In the lumbar spine, the radiation will typically be in the back of the thighs and the calves.
What activities provoke symptoms in patients with stenosis? In the neck, the activity is most often prolonged sitting. Oddly enough, sitting provides relief for patients with stenosis in the lumbar spine. For these patients, the provocative activities are standing and walking.
Who typically gets stenosis? Stenosis typically occurs in older populations - or what I will call the less young. The older you are, the more likely you will get stenosis.
How does stenosis occur? Stenosis is nothing more than bony adaptation to chronic load…and by ‘chronic’ I don’t mean days, or even months; I mean years. Bones will increase or decrease strength to tolerate whichever environment they in which they live. This is why people who people who weight train tend to have better bone density. Carrying more load consistently stimulates the bones to increase density. It's also the reason why astronauts’ bones become dangerously weak after a long stretch in space. In space, gravity is no longer compressing their bones, so the bones weaken because of the lack of stimulus to remain thick and strong.
Vertebrae have a thick and strong area called the vertebral body on the front and a much thinner and weaker area on the back called the neural arch (Images 1 & 2). As you may have guessed, the thicker portions are better suited for load. The neural arch, on the other hand, is designed to protect the spinal cord and block excessive movement. The neural arch has not evolved to handle chronic load like the vertebral body. Stenosis happens when such a chronic load is placed on the neural arch. To handle this load the arch becomes thicker. As it thickens, the holes (also known as foramen) become smaller. As the neural foramina (aka nerve holes) continue to shrink, the walls begin to encroach on the nerves, resulting in the pain described above.
The load placed on the spine that results in stenosis is mal-aligned posture. In the neck that is a forward head posture (when upper back is flexed and your head is pushed out in front of your chest). This results in hyper-extension of the cervical spine. It is the hyperextension that shifts the load from the vertebral body to the neural arch. Sitting tends to accentuate this pathological posture, which is why these patients get their symptoms with prolonged sitting.
In the lumbar spine, the mal-aligned posture is when the lower back is hyper-extended, often the result of tight hips and/or a poor core stabilizing strategy that I call an Extension/Compression Stabilizing Strategy. As with the neck, in this hyperextended position, the load is shifted to the neural arch, resulting in the bony thickening that produces stenosis.
With this condition, there is good news and bad news. I’ll start with the bad news. Because stenosis is caused by structural (bony) adaptation, it is not “fixable” in the sense that one would be able to structurally change the size of the neural foramina or the spinal canal. Technically, this can be done, but involves an invasive surgery about which you should consult a physician if you think you need this. You probably don’t.
The good news is that the vast majority of the time, the symptoms can be reduced and even eliminated by restoring proper posture and function to the spine. In both cervical and lumbar stenosis, the segments that have stenosed are in the area of hyper-extension. There are many causes for hyper-extension, several of which we CAN address in the clinic and you CAN address at home.
Here’s what can be done to address stenosis:
For cervical stenosis, getting an elevated monitor is often life changing. The aforementioned forward head posture is caused and exacerbated by a poor work set-up. Having a lower monitor, or having the monitor too far away from you, pulls you into the position which causes stenosis. Setting up your work station properly can have a profound affect on your symptoms. (Insert corresponding video below. This is, or at least it should be, on our YouTube page.)
Start foam rolling your thoracic spine to improve extension (arching backwards). Many stenotic, both cervical and lumbar, have excessively flexed thoracic spines, which force hyper-extension in the lumbar and cervical spines. I would suggest starting with 2-3 minutes, twice a day. (Insert corresponding video below, Brad should have uploaded this)
For lumbar stenosis, perform frequent knee-to-chest stretches. This is a safe a gentle stretch that takes the pressure of the affected area, giving breathing room so to speak to the nerves. I would suggest sets of 10-20 reps performed throughout the day. (Insert corresponding video below, Brad should have uploaded this)
For lumbar stenosis, you need to stretch your hip-flexors, which, when tight, pull the pelvis forward resulting in hyperextension of the lumbar spine. If you can lengthen your hip-flexors, you will reduce the amount of lumbar extension you experience in standing and walking. This will increase the time and distance you can stand and walk without symptoms. I would suggest starting with 3 sets of 10 reps each side twice a day. (Insert corresponding video below, Brad should have uploaded this)
IMPORTANT!!! If you feel like you might be experiencing stenosis, I would say give these exercises a try. If, for whatever reason, your symptoms start to worsen or you develop new symptoms from these exercises, consult with a physician. Each of these interventions are safe, but may not produced the desired results in everyone. We want to help you all as much as possible, but your safety is more important.
If you have any questions about you, a family member, a friend, or a colleague, do not hesitate to email us at office@columbuscrc.com
Have a great day!
Dr. Ulm