Spinal stenosis, osteophytes and ligaments ossification

 

Diagnosis of spinal stenosis, osteophytes and ligaments ossification

Plain radiographs of the spine (spondylograms) may reveal findings suggestive of spinal canal stenosis, such as enlarged articular processes, thickened laminae, reduced vertebral body height, ligament sclerosis, and osteophytes. Myelography may demonstrate uniform or multilevel constriction of the spinal canal. Computed tomography (CT) of the spine, with cross-sectional imaging at the level of suspected spinal canal stenosis, is crucial for differential diagnosis.

A CT scan of the spine may be utilized to evaluate for herniated discs, spinal stenosis, scoliosis, traumatic spinal injuries, tumors, congenital spinal anomalies such as spina bifida, vascular abnormalities, or infections.

The clinical presentation of spinal canal stenosis may include monoradicular symptoms, often associated with intervertebral disc protrusions or herniations, or with hypertrophy of adjacent articular processes causing foraminal narrowing. More severe cases may present with symptoms of compression-ischemic myeloradiculopathy. In rare instances, a transverse myelopathy syndrome may occur.

A neurological and orthopedic examination initiates the diagnostic process. Based on the examination findings, the following additional procedures may be prescribed:

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

The primary symptoms of spinal canal stenosis include persistent lumbar spine pain, which may or may not radiate along the nerve roots. The lumbar pain is often persistent and may not be alleviated by positional changes; in some cases, it may even worsen in the supine position. With disease progression, loss of lumbar lordosis, scoliosis, muscle contractures, and antalgic spinal deformities may develop.

Foraminal stenosis refers to the narrowing of the intervertebral foramen, the opening in the spinal vertebrae through which nerve roots exit the spinal canal. Radiological methods, such as MRI or CT, are commonly used to investigate foraminal stenosis in patients presenting with radicular pain in the extremities. Imaging is required to confirm the diagnosis.

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

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

Treatment options for spinal canal stenosis vary depending on the severity of symptoms and underlying causes. These options include:

• Pharmacological Treatments:
  • Drug therapy, including nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, and hormones.
  • Therapeutic injections, such as injections of drugs into the spinal canal cavity.
• Manual Therapy: Manual therapy, including muscle, articular, and radicular techniques.
• Physiotherapy: Physiotherapy, such as ultra-high-frequency (UHF) therapy and transcutaneous electrical nerve stimulation (TENS).
• Alternative Therapies: Acupuncture.
• Surgical Treatment.

Treatment for lumbar spinal stenosis varies based on the severity of symptoms, the type of stenosis, and the patient’s overall health. Options range from conservative management to surgical interventions, with a growing focus on minimally invasive techniques. Below is an expanded look at the primary approaches:

1. Mild (Minimally Invasive Lumbar Decompression): This procedure, often abbreviated as mild, involves removing a portion of the ligamentum flavum—a thick ligament that can hypertrophy (thicken) and contribute to spinal canal narrowing. Performed under local anesthetic with sedation, it allows patients to remain awake and provide real-time feedback, enhancing safety and precision. The technique uses small incisions and specialized tools to access the spine, minimizing disruption to surrounding muscles and tissues. While effective for central canal stenosis caused by ligamentum flavum hypertrophy, its success rate hovers around 50%, and it may not address lateral recess or foraminal stenosis effectively.
2. Laminectomy and Fusion: A traditional surgical approach, laminectomy involves the removal of the lamina (the back part of a vertebra) to create more space within the spinal canal. In cases where spinal instability is a concern—such as with degenerative spondylolisthesis (slippage of one vertebra over another)—it is often paired with spinal fusion. Fusion uses bone grafts, screws, and rods to permanently join two or more vertebrae, stabilizing the spine. While effective, this method requires a longer recovery period and can place additional stress on adjacent spinal segments, potentially accelerating degeneration in those areas over time.
3. Foraminotomy: This surgical procedure focuses specifically on relieving pressure on nerve roots by enlarging the foramina—the small openings on either side of the vertebrae through which nerve roots exit the spinal canal. During a foraminotomy, a surgeon removes bone, tissue, or other structures (such as bone spurs or herniated disc material) that are compressing the nerve roots, particularly in cases of foraminal stenosis. It can be performed as a standalone procedure or in conjunction with a laminectomy, depending on the extent of the stenosis. Foraminotomy is often done using minimally invasive techniques, involving small incisions and the use of an endoscope or microscope for precision. While it effectively targets radicular pain (e.g., sciatica), it may not address central canal or lateral recess stenosis, and recovery typically involves a shorter hospital stay compared to more extensive surgeries.
4. Posterior Interspinous Spacing/Fusion: This technique uses devices placed between the spinous processes (bony projections at the back of the vertebrae) to maintain space in the spinal canal and decompress the nerves. It can address all three types of stenosis—central, lateral recess, and foraminal—making it a versatile option. The procedure can be performed minimally invasively, and several specialized devices are available:
   • Minuteman: A minimally invasive implant inserted through a lateral (side) approach, requiring only a small incision. It is designed to stabilize the spine while preserving some natural motion.
   • Zip: A device that attaches to the spinous processes after a small incision, “zipping” into place to hold the vertebrae apart. Variants like the Zip 51 are engineered for specific spinal levels, such as the L5-S1 junction, which is prone to degeneration.
   • Flow Spine: A newer, expandable device that deploys anteriorly (toward the front of the spine), potentially distributing forces more evenly and reducing stress on the bone compared to traditional spacers.

In addition to these surgical options, conservative treatments like physical therapy, anti-inflammatory medications, and epidural steroid injections may be recommended to manage symptoms, particularly in mild cases or for patients who are not surgical candidates.

When determining surgical indications for spinal stenosis, the extent of the stenosis should be considered. For stenosis affecting one or two vertebral levels with unilateral radicular symptoms, such as pain, numbness, or weakness radiating down a limb, interlaminotomy or hemilaminectomy are appropriate surgical options. These surgical procedures are typically considered when conservative treatments have failed to provide relief and when imaging confirms the stenosis correlates with the patients neurological deficit.

For bilateral symptoms of neurovascular compression in multilevel spinal stenosis, a bilateral hemilaminectomy can be performed, preserving the spinous processes and interspinous ligament, and including excision of the hypertrophied ligamentum flavum and osteophytes. Concurrent foraminotomies are advisable in cases of spinal canal stenosis. In certain cases of spinal stenosis, spinal stabilization with metal instrumentation may be required.

In some cases of spinal stenosis, a staged surgical approach may be advisable. The first stage involves decompression of the most severely compressed nerve roots, followed by a course of intensive vasoactive and neurostimulatory therapy. If the patient's condition does not improve, the second stage, involving a more extensive decompression (bilateral hemilaminectomy) and creation of additional space within the spinal canal, may be considered.

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.