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Spinal stenosis, osteophytes and ligaments ossification

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Spinal stenosis, osteophytes and ligaments ossification

Spinal stenosis as an independent disease is most often considered at the lumbar level of the spine. But there is a stenosis of the spinal canal and at the cervical and thoracic level of the spine. Spinal stenosis is associated with congenital or acquired anatomical changes in the vertebrae themselves (osteophytes), as well as in the cartilaginous and ligamentous formations that form the spinal canal.

A narrowing of the cross-section of the spinal canal can be either a consequence of an increase in the size of bone formations: arches, articular processes, a proliferation of the posterior surfaces of the vertebral bodies, or as a result of flattening of the vertebrae and their displacement into the lumen of the spinal canal.

Stenosis (narrowing) of the lumen of the spinal canal with the spinal cord compression, hypertrophy of the posterior longitudinal and yellow ligaments.

Also, the narrowing of the spinal canal is caused by hypertrophy of the yellow and posterior longitudinal ligaments, an increase in the thickness of the articular capsules of the intervertebral joints, displacement of the intervertebral discs, and the annulus fibrosus involved in the formation of the spinal canal.

Spinal stenosis can be uniform on all sides, but the narrowing of the spinal canal from front to back is more common. Also, stenosis of the spinal canal can be observed at the level of all or several lumbar vertebrae, but it also occurs at the level of one vertebra.

The narrowing of the spinal canal in the anteroposterior direction may be due to its secondary stenosis, hypertrophy of the posterior longitudinal and yellow ligaments, spondylolisthesis. To establish stenosis of the spinal canal, it is necessary to measure the canal in the sagittal plane. Absolute stenosis is considered to be a decrease in the canal diameter to 10 mm or less. A value of 10-15 mm corresponds to partial stenosis. The thickness of the posterior longitudinal ligament should normally not exceed 2 mm, the yellow ligament - 3 mm.

Degenerative cervical myelopathy.

Stenosis of the spinal canal with compression of the spinal cord with spondylosis at the level of the cervical spine with hypertrophy of the posterior longitudinal and yellow ligaments.

Stenosis of the spinal canal with compression of the spinal cord with spondylosis at the level of the cervical spine with hypertrophy of the posterior longitudinal and yellow ligaments.

Compression of the L3 spinal nerve in the intervertebral foramen with extraforaminal stenosis (narrowing of the lumen).

Stenosis of the spinal canal of the lumbar spine (lumbar stenosis) is a transient chronic compression of the nerve roots of the cauda equina. Stenosis of the lumbar spine (lumbar stenosis) occurs with the congenital narrowness of the spinal canal at the lumbar level, which is exacerbated by disc protrusion and spondylosis of the spine.

Physical activity with stenosis provokes pain in the patient in the buttocks, hips, and calves, radiating along the sciatic nerve. Pain with stenosis of the spinal canal decreases in patients at rest. These pains resemble intermittent claudication of vascular origin and require the consultation of a vascular surgeon to exclude diseases of the arteries of the lower extremities. An increase in pain in comparison with a state of rest is determined by a decrease in deep tendon reflexes and sensitivity in the legs, while when examining blood vessels on ultrasound, no changes are found. Stenosis of the spinal canal of the lumbar spine (lumbar stenosis) and cervical spondylosis is often combined in the same patients, which can provoke periodic spasms and twitching of muscles (fasciculations) in the legs with cervical spondylosis.

 

Diagnosis of spinal stenosis, osteophytes and ligaments ossification

When diagnosing spinal canal stenosis, plain radiographs of the spine (spondylograms) can show enlarged articular processes, thickened roots of the arches, the reduced height of the vertebral bodies, areas of ligament sclerosis, and osteophytes. Positive myelograms show a uniform or constriction of the spinal canal at several levels. In the differential diagnostic plan, it is of great importance to obtain cross-sections at different levels during computed tomography of the spine at the level of the detected spinal canal stenosis.

A CT scan of the spine may be used to check the spine for a herniated disk, stenosis, scoliosis, traumatic injuries, tumors, congenital structural problems such as spina bifida, blood vessel problems, or infections.

In the clinical picture, with stenosis of the spinal canal, monoradicular symptoms can be observed (with protrusion and herniation of intervertebral discs, with an increase in the size of adjacent articular processes, which leads to a decrease in the section of the intervertebral foramen), or symptoms of compression-ischemic myeloradiculopathy, or even a syndrome of transverse spinal cord injury.

Stenosis of the spinal canal with compression of the spinal cord at the level of the lumbar spine with hypertrophy of the posterior longitudinal and yellow ligaments.

It all starts with a neurological and orthopedic examination by a doctor. According to its results, the following additional diagnostic procedures can be prescribed: It all starts with a neurological and orthopedic examination by a doctor. According to its results, the following additional diagnostic procedures can be prescribed:

  • X-ray of the lumbosacral spine with functional tests
  • CT scan of the lumbosacral spine
  • MRI of the lumbosacral spine

However, the main symptoms of true stenosis of the spinal canal are prolonged pain in the lumbar spine without any "side" and irradiation along with the nerve roots. Lower back pain can be permanent and does not change with a change in the position of the body in space (sometimes in the supine position, the pain even intensifies). As the disease progresses, the smoothness of the lumbar lordosis joins, scoliosis, muscle contractures, and antalgic deformities of the spine appear.

Narrowing of the spinal canal with compression of the spinal cord on MRI of the thoracic spine by a tumor.

Foraminal stenosis is a narrowing of the foramen, the opening in the bones of the spine that allows nerve roots to exit the spinal canal. Foraminal stenosis is commonly investigated with radiological methods in patients with radiating pain in extremities.

Schematic illustration of the Park system for cervical foraminal stenosis based on oblique sagittal MRI.

Park system for cervical foraminal stenosis based on oblique sagittal MRI:

Grade
MRI Presentation
Grade 0 no stenosis and no perineural fat obliteration
Grade 1  < 50% perineural fat obliteration
Grade 2  > 50% perineural fat obliteration
Grade 3 morphologically collapsed nerve root with severe perineural fat obliteration

Schematic illustration of the Lee system for lumbar foraminal stenosis based on sagittal MRI.

Lee system for lumbar foraminal stenosis based on sagittal MRI:

Grade
MRI Presentation
Grade 0 no foraminal stenosis or perineural fat obliteration
Grade 1 transverse or vertical narrowing with perineural fat obliteration
Grade 2 complete perineural fat obliteration with surrounding foraminal narrowing from all directions but no morphological change to the nerve root
Grade 3 total fat obliteration and a morphological collapse of the nerve root

 

Treatment of spinal stenosis, osteophytes and ligaments ossification

When treating stenosis of the spinal canal, depending on the severity of clinical manifestations and the causes of stenosis of the spinal canal, the patient may have the following actions aimed at improving the patient's condition:

  • drug therapy (NSAIDs, analgesics, hormones)
  • therapeutic injections - injection of drugs into the canal cavity
  • manual therapy (muscle, articular and radicular technique)
  • physiotherapy (UHF, TENS, etc.)
  • acupuncture
  • surgical treatment

When determining the indications for surgery in the case of a diagnosis of spinal stenosis, the prevalence of the process should be taken into account. For operations on one or two levels of the vertebrae and unilateral symptoms of root compression, interlaminotomy or hemilaminectomy can be used.

With bilateral symptoms of compression of neurovascular formations of the spinal canal and at several levels, bilateral hemilaminectomy can be performed with preservation of the spinous processes and interspinous ligament, excision of the hypertrophied ligamentum flavum, osteophytes. It is advisable for stenosis of the spinal canal parallel foraminotomy. In some cases of spinal stenosis, it is necessary to use metal structures to stabilize the spine.

Hemilaminectomy operation for spinal stenosis with compression of the spinal cord at the level of the cervical spine with hypertrophy of the posterior longitudinal and yellow ligaments.

MRI of the lumbar spine shows spinal stenosis and post-endoscopic decompression at the L3-L4 and L4-L5 levels.

Sometimes, in patients with of the spinal stenosis, it is advisable to divide the operation into two stages. At the first stage, decompression of the most suffering roots of the spinal cord is performed, a course of intensive vasoactive and neurostimulating therapy is carried out. And, if improvement and relief of the patient's condition are not achieved, the second stage of the operation can be proposed - a wider decompression (bilateral hemilaminectomy) and the creation of additional reserve spaces for spinal stenosis.

Lumbar spinal stenosis affects approximately 103 million people worldwide and 11% of older adults in the US. First-line therapy is activity modification, analgesia, and physical therapy. Long-term benefits from epidural steroid injections have not been established. Selected patients with continued pain and activity limitation may be candidates for decompressive surgery.