Spinal Stenosis Clinical Presentation
- Author: John K Hsiang, MD, PhD; Chief Editor: Stephen Kishner, MD, MHA more...
The primary clinical manifestation of spinal stenosis is chronic pain. In patients with severe stenosis, weakness and regional anesthesia may result. Among the most serious complications of severe spinal stenosis is central cord syndrome. Central cord syndrome is the most common incomplete cord lesion. The presentation commonly is associated with an extension injury in a patient with an osteoarthritic spine. In hyperextension injury, the cord is injured within the central gray matter, which results in proportionally greater loss of motor function of upper extremities than loss of motor function of lower extremities, with variable sensory sparing.
Patients with spinal stenosis become symptomatic when pain, motor weakness, paresthesia, or another neurologic compromise causes distress. Spinal stenosis of the thoracic spine is more likely to directly affect the spinal cord because of the relatively narrow thoracic spinal canal.
Spinal stenosis of the cervical and thoracic regions may contribute to neurologic injury, such as development of a central spinal cord syndrome following spinal trauma. Spinal stenosis of the lumbar spine is associated most commonly with midline back pain and radiculopathy. In cases of severe lumbar stenosis, innervation of the urinary bladder and the rectum may be affected, but lumbar stenosis most often results in back pain with lower extremity weakness and numbness along the distribution of nerve roots of the lumbar plexus.
Spinal canal size is not always predictive of clinical symptoms, and some evidence suggests that body mass may play a role in limitations of function in this population.
Severe radiologic stenosis in otherwise asymptomatic individuals suggests inflammation, not just mechanical nerve root compression. Specific inflammation generators may include herniated nucleus pulposus (HNP), ligamentum flavum, and facet joint capsule.
Metastatic and infectious processes that affect the spine may present with both regional pain and signs of central spinal canal narrowing. The regional pain may result from pathologic fractures or nerve root compression by the tumor or abscess. Long tract findings may result from bone fragments, a hemorrhage, an abscess, or a tumor compressing the spinal cord.
Stenosis of the cervical spine causes the clinical syndrome of cervical spondylotic myelopathy (CSM). Initial symptoms may be subtle loss of hand dexterity and mild proximal lower extremity weakness, often without neck or arm pain. With progression, spastic quadriparesis results. Pathologic reflexes such as the Hoffman sign, clonus, and/or the Babinski reflex may augment the diffuse hyperreflexia. Some patients also have associated ataxia from compression of spinocerebellar tracts.[5, 11, 12, 28, 29]
If associated cervical root impingement exists, patients may experience sharp radicular pain into the affected arm, with associated paresthesias and weakness referable to the compressed root. Depending on the level, some upper extremity reflexes (biceps, triceps, brachioradialis) may be depressed or absent in such patients. Males older than 55 years most commonly are affected. Up to two thirds of patients with myelopathy have deteriorating or unchanging conditions. They are also at increased risk of spinal cord injury in the setting of minor trauma.
Katz and colleagues report that the historical findings most strongly associated with lumbar spinal stenosis (LSS) include advanced age, severe lower extremity pain, and absence of pain when the patient is in a flexed position. Fritz and colleagues contend that the most important elements involve the postural nature of the patient's pain, stating that absence of pain or improvement of symptoms when seated assists in ruling in LSS. Conversely, LSS cannot be ruled out when sitting is the most comfortable position for the patient and standing/walking is the least comfortable.
Patients with significant lumbar spinal canal narrowing report pain, weakness, numbness in the legs while walking, or a combination thereof. Onset of symptoms during ambulation is believed to be caused by increased metabolic demands of compressed nerve roots that have become ischemic due to stenosis. This is the hallmark of neurogenic claudication. The pain is relieved when the patient flexes the spine by, for example, leaning on shopping carts or sitting. Flexion increases canal size by stretching the protruding ligamentum flavum, reduction of the overriding laminae and facets, and enlargement of the foramina. This relieves the pressure on the exiting nerve roots and, thus, decreases the pain. The most common nerve affected is the L5, with associated weakness of extensor hallucis longus.
LSS classically presents as bilateral neurogenic claudication (NC). Unilateral radicular symptoms may result from severe foraminal or lateral recess stenosis. Patients, typically aged more than 50 years, report insidious-onset NC manifesting as intermittent, crampy, diffuse radiating thigh or leg pain with associated paresthesias. Indeed, leg pain affects 90% of patients with LSS.
In a retrospective review of 75 patients with radiographically confirmed LSS, reports of weakness, numbness or tingling, radicular pain, and NC were in almost equal proportions. The most common symptom was numbness or tingling of the legs.
NC pain is exacerbated by standing erect and downhill ambulation and is alleviated with lying supine more than prone, sitting, squatting, and lumbar flexion. Getty and colleagues documented 80% pain diminution with sitting and 75% with forward bending. Lumbar spinal canal and lateral recess cross-sectional area increases with spinal flexion and decreases with extension. Furthermore, cross-sectional area is reduced 9% with extension in the normal spine and 67% with severe stenosis. The Penning rule of progressive narrowing implies that the more narrowed the canal by stenosis, the more it narrows with spinal extension. Schonstrom and colleagues have shown that spinal compressive loading from weight bearing reduces spinal canal dimensions.
NC, unlike vascular claudication, is not exacerbated with biking, uphill ambulation, and lumbar flexion and is not alleviated with standing. Patients with LSS compensate for symptoms by flexing forward, slowing their gait, leaning onto objects (eg, over a shopping cart) and limiting distance of ambulation. Unfortunately, such compensatory measures, particularly in elderly osteoporotic females, promote disease progression and vertebral fracture. Pain radiates downward in NC and, in contrast, upward in vascular claudication. Hall and colleagues note the presence of radiculopathy in 6% and NC in 94% of patients with LSS.
Distinguishing between neurogenic and vascular claudication is important because the treatments, as well as the implications, are quite different. Vascular claudication is a manifestation of peripheral vascular disease and arteriosclerosis. Other vessels, including the coronary, vertebral, and carotid, are also often affected. Further complicating diagnosis and treatment in some patients, neurogenic and vascular claudication may occur together. This is because both conditions frequently occur in the elderly population.
Patients with cervical stenosis usually present with cervical radiculopathy, with or without myelopathy. Typically, the condition involves the lower cervical spine. Patients frequently complain of radiating arm pain with numbness and paresthesia in the involved dermatomes. Occasionally, associated weakness occurs in the muscles supplied by that nerve root. If the stenosis is severe enough, or if it is positioned centrally in the spine, patients may present with signs and symptoms of myelopathy (spinal cord dysfunction). Typically, these patients complain of finger numbness, clumsiness, and difficulty walking due to spasticity and loss of position sense. In more severe cases, the patients can have bowel and bladder control dysfunction. Upon examination, these patients have "long-tract signs" such as hyperreflexia, positive Hoffman sign, positive Babinski sign, and/or clonus.
Katz and colleagues report physical examination findings most strongly associated with lumbar spinal stenosis (LSS) include wide-based gait, abnormal Romberg test, thigh pain following 30 seconds of lumbar extension, and neuromuscular abnormalities ; however, Fritz and colleagues state physical examination findings do not seem helpful in determining the presence or absence of LSS.
Patients with LSS usually present with a constellation of symptoms that include lower back pain, radiating leg pain (unilateral or bilateral), and possible bladder and bowel difficulties. The classic presentation is radiating leg pain associated with walking that is relieved by rest (neurogenic claudication). When patients bend forward, the pain diminishes. Rarely, patients with LSS present with cauda equina syndrome (bilateral leg weakness, urinary retention due to atonic bladder).
Physical examination findings are frequently normal in patients with LSS. Nevertheless, review of the literature suggests diminished lumbar extension appears most consistently, varies less, and constitutes the most significant finding in LSS. Other positive findings include loss of lumbar lordosis and forward-flexed gait. Charcot joints may be present in long-standing disease. Radiculopathy may be noted with motor, sensory, and/or reflex abnormalities. Asymmetric muscle stretch reflexes and focal myotomal weakness with atrophy occur more with lateral recess than central canal stenosis. Some report objective neurologic deficits in approximately 50% of LSS cases. Provocative maneuvers include pain reproduction with ambulation and prone lumbar hyperextension. Pain alleviation occurs with stationary biking and lumbar flexion.
Patients may also have a positive result from the stoop test, which was described by Dyck in 1979. This is performed by having the patient walk with an exaggerated lumbar lordosis until NC symptoms appear or are worsened. The patient is then told to lean forward. Reduction of NC symptoms is a positive result and is suggestive of NC.
Negative findings in the physical examination include skin color, turgor, and temperature; normal distal lower extremity pulses; and an absence of arterial bruits.
Importantly, remember the 5 P s of vascular claudication, as follows:
The absence of these problems, excluding pain and paresthesias, which are common to neurogenic and vascular claudication, should give the clinician confidence in the diagnosis of NC. If vascular claudication is suspected, referral to an internist for a workup is indicated. This includes a serum cholesterol level, arterial Doppler studies, ankle-brachial index values, and, in some cases, arteriography.
Dural tension signs should be unremarkable. Lumbar segment mobilization often fails to reproduce pain, and trigger points are typically not present.
Greenberg MS. Spinal stenosis. Handbook of Neurosurgery. Lakeland, Fla: Greenburg Graphics, Inc; 1997. Vol 1: 207-217.
White AA III, Panjabi MM. Clinical Biomechanics of the Spine. 2nd ed. Philadelphia, Pa: JB Lippincott; 1990. 342-378.
Kalichman L, Cole R, Kim DH, Li L, Suri P, Guermazi A, et al. Spinal stenosis prevalence and association with symptoms: the Framingham Study. Spine J. 2009 Jul. 9(7):545-50. [Medline].
Bernhardt M, Hynes RA, Blume HW, White AA 3rd. Cervical spondylotic myelopathy. J Bone Joint Surg Am. 1993 Jan. 75(1):119-28. [Medline].
Heller JG. The syndromes of degenerative cervical disease. Orthop Clin North Am. 1992 Jul. 23(3):381-94. [Medline].
Caputy AJ, Luessenhop AJ. Long-term evaluation of decompressive surgery for degenerative lumbar stenosis. J Neurosurg. 1992 Nov. 77(5):669-76. [Medline].
Harkey HL, al-Mefty O, Marawi I, Peeler DF, Haines DE, Alexander LF. Experimental chronic compressive cervical myelopathy: effects of decompression. J Neurosurg. 1995 Aug. 83(2):336-41. [Medline].
Amundsen T, Weber H, Lilleås F, Nordal HJ, Abdelnoor M, Magnaes B. Lumbar spinal stenosis. Clinical and radiologic features. Spine (Phila Pa 1976). 1995 May 15. 20(10):1178-86. [Medline].
Alexander JT. Natural history and nonoperative management of cervical spondylosis. Menezes AH, Sonntag VKH, et al, eds. Principles of Spinal Surgery. New York, NY: McGraw-Hill; 1996. Vol 1: 547-557.
Benner BG. Etiology, pathogenesis and natural history of discogenic neck pain, radiculopathy, and myelopathy. The Cervical Spine Research Society Editorial Committee. The Cervical Spine. 3rd ed. Philadelphia, Pa: Lippincott; 1998. 735-740.
Crandall PH, Batzdorf U. Cervical spondylotic myelopathy. J Neurosurg. 1966 Jul. 25(1):57-66. [Medline].
Teresi LM, Lufkin RB, Reicher MA, Moffit BJ, Vinuela FV, Wilson GM, et al. Asymptomatic degenerative disk disease and spondylosis of the cervical spine: MR imaging. Radiology. 1987 Jul. 164(1):83-8. [Medline].
Young WF. Cervical spondylotic myelopathy: a common cause of spinal cord dysfunction in older persons. Am Fam Physician. 2000 Sep 1. 62(5):1064-70, 1073. [Medline].
Matz PG, Anderson PA, Holly LT, Groff MW, Heary RF, Kaiser MG, et al. The natural history of cervical spondylotic myelopathy. J Neurosurg Spine. 2009 Aug. 11(2):104-11. [Medline].
Keim HA, Hajdu M, Gonzalez EG, Brand L, Balasubramanian E. Somatosensory evoked potentials as an aid in the diagnosis and intraoperative management of spinal stenosis. Spine (Phila Pa 1976). 1985 May. 10(4):338-44. [Medline].
Daffner SD, Wang JC. The pathophysiology and nonsurgical treatment of lumbar spinal stenosis. Instr Course Lect. 2009. 58:657-68. [Medline].
Panjabi MM, Krag MH, Chung TQ. Effects of disc injury on mechanical behavior of the human spine. Spine (Phila Pa 1976). 1984 Oct. 9(7):707-13. [Medline].
Jenis LG, An HS. Spine update. Lumbar foraminal stenosis. Spine (Phila Pa 1976). 2000 Feb 1. 25(3):389-94. [Medline].
Ooi Y, Mita F, Satoh Y. Myeloscopic study on lumbar spinal canal stenosis with special reference to intermittent claudication. Spine (Phila Pa 1976). 1990 Jun. 15(6):544-9. [Medline].
Fritz JM, Delitto A, Welch WC, Erhard RE. Lumbar spinal stenosis: a review of current concepts in evaluation, management, and outcome measurements. Arch Phys Med Rehabil. 1998 Jun. 79(6):700-8. [Medline].
Porter RW, Hibbert C, Evans C. The natural history of root entrapment syndrome. Spine (Phila Pa 1976). 1984 May-Jun. 9(4):418-21. [Medline].
Johnsson KE, Rosén I, Udén A. The natural course of lumbar spinal stenosis. Clin Orthop Relat Res. 1992 Jun. 82-6. [Medline].
Malmivaara A, Slätis P, Heliövaara M, et al. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976). 2007 Jan 1. 32(1):1-8. [Medline].
Geisser ME, Haig AJ, Tong HC, Yamakawa KS, Quint DJ, Hoff JT, et al. Spinal canal size and clinical symptoms among persons diagnosed with lumbar spinal stenosis. Clin J Pain. 2007 Nov-Dec. 23(9):780-5. [Medline].
Thomas NW, Rea GL, Pikul BK, Mervis LJ, Irsik R, McGregor JM. Quantitative outcome and radiographic comparisons between laminectomy and laminotomy in the treatment of acquired lumbar stenosis. Neurosurgery. 1997 Sep. 41(3):567-74; discussion 574-5. [Medline].
Watson JC, Broaddus WC, Smith MM, Kubal WS. Hyperactive pectoralis reflex as an indicator of upper cervical spinal cord compression. Report of 15 cases. J Neurosurg. 1997 Jan. 86(1):159-61. [Medline].
Katz JN, Dalgas M, Stucki G, Katz NP, Bayley J, Fossel AH, et al. Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination. Arthritis Rheum. 1995 Sep. 38(9):1236-41. [Medline].
Goh KJ, Khalifa W, Anslow P, Cadoux-Hudson T, Donaghy M. The clinical syndrome associated with lumbar spinal stenosis. Eur Neurol. 2004. 52(4):242-9. [Medline].
Getty CJ. Lumbar spinal stenosis: the clinical spectrum and the results of operation. J Bone Joint Surg Br. 1980 Nov. 62-B(4):481-5. [Medline].
Schönström N, Lindahl S, Willén J, Hansson T. Dynamic changes in the dimensions of the lumbar spinal canal: an experimental study in vitro. J Orthop Res. 1989. 7(1):115-21. [Medline].
Hall S, Bartleson JD, Onofrio BM, Baker HL Jr, Okazaki H, O'Duffy JD. Lumbar spinal stenosis. Clinical features, diagnostic procedures, and results of surgical treatment in 68 patients. Ann Intern Med. 1985 Aug. 103(2):271-5. [Medline].
Dyck P. The stoop-test in lumbar entrapment radiculopathy. Spine (Phila Pa 1976). 1979 Jan-Feb. 4(1):89-92. [Medline].
Burgstaller JM, Schuffler PJ, Buhmann JM, et al. Is There An Association Between Pain and Magnetic Resonance Imaging Parameters in Patients with Lumbar Spinal Stenosis?. Spine (Phila Pa 1976). 2016 Mar 2. [Medline].
[Guideline] Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2. 147(7):478-91. [Medline]. [Full Text].
[Guideline] Chou R, Qaseem A, Owens DK, Shekelle P, Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011 Feb 1. 154(3):181-9. [Medline]. [Full Text].
Pearson A, Lurie J, Tosteson T, Zhao W, Abdu W, Weinstein J. Who Should Have Surgery for Spinal Stenosis?. Spine (Phila Pa 1976). 2012 Jun 11. [Medline].
Ikuta K, Tono O, Tanaka T, Arima J, Nakano S, Sasaki K, et al. Evaluation of postoperative spinal epidural hematoma after microendoscopic posterior decompression for lumbar spinal stenosis: a clinical and magnetic resonance imaging study. J Neurosurg Spine. 2006 Nov. 5(5):404-9. [Medline].
Lee JW, Kim SH, Lee IS, Choi JA, Choi JY, Hong SH, et al. Therapeutic effect and outcome predictors of sciatica treated using transforaminal epidural steroid injection. AJR Am J Roentgenol. 2006 Dec. 187(6):1427-31. [Medline].
Malmivaara A, Slätis P, Heliövaara M, et al. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976). 2007 Jan 1. 32(1):1-8. [Medline].
Simotas AC, Dorey FJ, Hansraj KK, Cammisa F Jr. Nonoperative treatment for lumbar spinal stenosis. Clinical and outcome results and a 3-year survivorship analysis. Spine (Phila Pa 1976). 2000 Jan 15. 25(2):197-203; discussions 203-4. [Medline].
Swezey RL, Swezey AM, Warner K. Efficacy of home cervical traction therapy. Am J Phys Med Rehabil. 1999 Jan-Feb. 78(1):30-2. [Medline].
Tosteson AN, Tosteson TD, Lurie JD, et al. Comparative effectiveness evidence from the spine patient outcomes research trial: surgical versus nonoperative care for spinal stenosis, degenerative spondylolisthesis, and intervertebral disc herniation. Spine (Phila Pa 1976). 2011 Nov 15. 36(24):2061-8. [Medline].
Pochon L, Kleinstuck FS, Porchet F, Mannion AF. Influence of gender on patient-oriented outcomes in spine surgery. Eur Spine J. 2015 Jul 5. [Medline].
[Guideline] Kreiner DS, Shaffer WO, Baisden JL, Gilbert TJ, Summers JT, Toton JF, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J. 2013 Jul. 13(7):734-43. [Medline].
NASS Evidence-Based Clinical Guidelines Committee. Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis (2011 Revised). 2011. Available at https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf.
Yaksi A, Ozgönenel L, Ozgönenel B. The efficiency of gabapentin therapy in patients with lumbar spinal stenosis. Spine (Phila Pa 1976). 2007 Apr 20. 32(9):939-42. [Medline].
Matsudaira K, Seichi A, Kunogi J, Yamazaki T, Kobayashi A, Anamizu Y, et al. The efficacy of prostaglandin E1 derivative in patients with lumbar spinal stenosis. Spine (Phila Pa 1976). 2009 Jan 15. 34(2):115-20. [Medline].
[Guideline] Bogduk N. Practice Guidelines for Spinal Diagnostic and Treatment Procedures. 2nd ed. San Francisco, CA: International Spine Intervention Society; 2013.
Manchikanti L, Falco FJ, Benyamin RM, et al. Assessment of bleeding risk of interventional techniques: a best evidence synthesis of practice patterns and perioperative management of anticoagulant and antithrombotic therapy. Pain Physician. 2013 Apr. 16(2 Suppl):SE261-318. [Medline].
Helft G. Optimal duration of dual antiplatelet therapy after drug-eluting stent implantation. Arch Cardiovasc Dis. 2013 May. 106(5):271-3. [Medline].
Sachdeva A, Bavisetty S, Beckham G, et al. Discontinuation of long-term clopidogrel therapy is associated with death and myocardial infarction after saphenous vein graft percutaneous coronary intervention. J Am Coll Cardiol. 2012 Dec 11. 60(23):2357-63. [Medline].
Weimar C, Cotton D, Sha N, et al. Discontinuation of antiplatelet study medication and risk of recurrent stroke and cardiovascular events: results from the PRoFESS study. Cerebrovasc Dis. 2013. 35(6):538-43. [Medline].
Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg. 1994 Dec. 79(6):1165-77. [Medline].
Manchikanti L, Knezevic NN, Boswell MV, Kaye AD, Hirsch JA. Epidural Injections for Lumbar Radiculopathy and Spinal Stenosis: A Comparative Systematic Review and Meta-Analysis. Pain Physician. 2016 Mar. 19 (3):E365-410. [Medline].
Wallbom AS, Geisser ME, Haig AJ, Koch J, Guido C. Alterations of F wave parameters after exercise in symptomatic lumbar spinal stenosis. Am J Phys Med Rehabil. 2008 Apr. 87(4):270-4. [Medline].
Forsth P, Olafsson G, Carlsson T, et al. A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis. N Engl J Med. 2016 Apr 14. 374 (15):1413-23. [Medline].
Davis RJ, Errico TJ, Bae H, et al. Decompression and Coflex interlaminar stabilization compared with decompression and instrumented spinal fusion for spinal stenosis and low-grade degenerative spondylolisthesis: two-year results from the prospective, randomized, multicenter, Food and Drug Administration Investigational Device Exemption trial. Spine (Phila Pa 1976). 2013 Aug 15. 38(18):1529-39. [Medline].
Davis R, Auerbach JD, Bae H, et al. Can low-grade spondylolisthesis be effectively treated by either coflex interlaminar stabilization or laminectomy and posterior spinal fusion? Two-year clinical and radiographic results from the randomized, prospective, multicenter US investigational device exemption trial: clinical article. J Neurosurg Spine. 2013 Aug. 19(2):174-84. [Medline].
Kim HY, Choi BW. Change of radiological parameters after interspinous implantation (X-stop®) in degenerative spinal stenosis. Eur J Orthop Surg Traumatol. 2013 Apr. 23(3):281-5. [Medline].
Stromqvist BH, Berg S, Gerdhem P, et al. X-stop versus decompressive surgery for lumbar neurogenic intermittent claudication: randomized controlled trial with 2-year follow-up. Spine (Phila Pa 1976). 2013 Aug 1. 38(17):1436-42. [Medline].
Slätis P, Malmivaara A, Heliövaara M, Sainio P, Herno A, Kankare J, et al. Long-term results of surgery for lumbar spinal stenosis: a randomised controlled trial. Eur Spine J. 2011 Jul. 20(7):1174-81. [Medline].
Sobottke R, Herren C, Siewe J, Mannion AF, Roder C, Aghayev E. Predictors of improvement in quality of life and pain relief in lumbar spinal stenosis relative to patient age: a study based on the Spine Tango registry. Eur Spine J. 2015 Jul 3. [Medline].
Hermansen E, Romild UK, Austevoll IM, et al. Does surgical technique influence clinical outcome after lumbar spinal stenosis decompression? A comparative effectiveness study from the Norwegian Registry for Spine Surgery. Eur Spine J. 2016 Jun 4. [Medline].
Ciol MA, Deyo RA, Howell E, Kreif S. An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations. J Am Geriatr Soc. 1996 Mar. 44(3):285-90. [Medline].
Atlas SJ, Keller RB, Robson D, Deyo RA, Singer DE. Surgical and nonsurgical management of lumbar spinal stenosis: four-year outcomes from the maine lumbar spine study. Spine (Phila Pa 1976). 2000 Mar 1. 25(5):556-62. [Medline].
Barz T, Melloh M, Staub L, Roeder C, Lange J, Smiszek FG, et al. The diagnostic value of a treadmill test in predicting lumbar spinal stenosis. Eur Spine J. 2008 May. 17(5):686-90. [Medline]. [Full Text].
Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Mar. 72(3):403-8. [Medline].
Bridwell KH, Sedgewick TA, O'Brien MF, Lenke LG, Baldus C. The role of fusion and instrumentation in the treatment of degenerative spondylolisthesis with spinal stenosis. J Spinal Disord. 1993 Dec. 6(6):461-72. [Medline].
Burnett MG, Stein SC, Bartels RH. Cost-effectiveness of current treatment strategies for lumbar spinal stenosis: nonsurgical care, laminectomy, and X-STOP. J Neurosurg Spine. 2010 Jul. 13(1):39-46. [Medline].
Cavusoglu H, Kaya RA, Türkmenoglu ON, Tuncer C, Colak I, Aydin Y. Midterm outcome after unilateral approach for bilateral decompression of lumbar spinal stenosis: 5-year prospective study. Eur Spine J. 2007 Dec. 16(12):2133-42. [Medline]. [Full Text].
Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine (Phila Pa 1976). 2009 May 1. 34(10):1094-109. [Medline].
Conneely M, Park J, Demos TC. Radiologic case study. Cervical spine trauma: unstable fractures, C2-C7 injuries, and imaging guidelines. Orthopedics. 2008 Aug. 31(8):818. [Medline].
de Graaf I, Prak A, Bierma-Zeinstra S, Thomas S, Peul W, Koes B. Diagnosis of lumbar spinal stenosis: a systematic review of the accuracy of diagnostic tests. Spine (Phila Pa 1976). 2006 May 1. 31(10):1168-76. [Medline].
Detwiler PW, Marciano FF, Porter RW, Sonntag VK. Lumbar stenosis: indications for fusion with and without instrumentation. Neurosurg Focus. 1997 Aug 15. 3(2):e4; discussion 1 p following e4. [Medline].
Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010 Apr 7. 303(13):1259-65. [Medline]. [Full Text].
diPierro CG, Helm GA, Shaffrey CI, et al. Treatment of lumbar spinal stenosis by extensive unilateral decompression and contralateral autologous bone fusion: operative technique and results. J Neurosurg. 1996 Feb. 84(2):166-73. [Medline].
Dumitru D, Dreyfuss P. Dermatomal/segmental somatosensory evoked potential evaluation of L5/S1 unilateral/unilevel radiculopathies. Muscle Nerve. 1996 Apr. 19(4):442-9. [Medline].
Engelhorn T, Rennert J, Richter G, Struffert T, Ganslandt O, Doerfler A. Myelography using flat panel volumetric computed tomography: a comparative study in patients with lumbar spinal stenosis. Spine (Phila Pa 1976). 2007 Aug 15. 32(18):E523-7. [Medline].
Epstein NE. Beta tricalcium phosphate: observation of use in 100 posterolateral lumbar instrumented fusions. Spine J. 2009 Aug. 9(8):630-8. [Medline].
Feffer HL, Wiesel SW, Cuckler JM, Rothman RH. Degenerative spondylolisthesis. To fuse or not to fuse. Spine (Phila Pa 1976). 1985 Apr. 10(3):287-9. [Medline].
Fessler RG, Steck JC, Giovanini MA. Anterior cervical corpectomy for cervical spondylotic myelopathy. Neurosurgery. 1998 Aug. 43(2):257-65; discussion 265-7. [Medline].
Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am. 1991 Jul. 73(6):802-8. [Medline].
Ikuta K, Tono O, Tanaka T, Arima J, Nakano S, Sasaki K, et al. Surgical complications of microendoscopic procedures for lumbar spinal stenosis. Minim Invasive Neurosurg. 2007 Jun. 50(3):145-9. [Medline].
Johnsson KE, Rosén I, Udén A. Neurophysiologic investigation of patients with spinal stenosis. Spine (Phila Pa 1976). 1987 Jun. 12(5):483-7. [Medline].
Johnsson KE, Udén A, Rosén I. The effect of decompression on the natural course of spinal stenosis. A comparison of surgically treated and untreated patients. Spine (Phila Pa 1976). 1991 Jun. 16(6):615-9. [Medline].
Johnsson KE, Willner S, Johnsson K. Postoperative instability after decompression for lumbar spinal stenosis. Spine (Phila Pa 1976). 1986 Mar. 11(2):107-10. [Medline].
Kapural L, Mekhail N, Bena J, McLain R, Tetzlaff J, Kapural M, et al. Value of the magnetic resonance imaging in patients with painful lumbar spinal stenosis (LSS) undergoing lumbar epidural steroid injections. Clin J Pain. 2007 Sep. 23(7):571-5. [Medline].
Kohno K, Kumon Y, Oka Y, Matsui S, Ohue S, Sakaki S. Evaluation of prognostic factors following expansive laminoplasty for cervical spinal stenotic myelopathy. Surg Neurol. 1997 Sep. 48(3):237-45. [Medline].
Kraft GH. A physiological approach to the evaluation of lumbosacral spinal stenosis. Phys Med Rehabil Clin N Am. 1998 May. 9(2):381-9, viii. [Medline].
Kumar VG, Rea GL, Mervis LJ, McGregor JM. Cervical spondylotic myelopathy: functional and radiographic long-term outcome after laminectomy and posterior fusion. Neurosurgery. 1999 Apr. 44(4):771-7; discussion 777-8. [Medline].
Lohman CM, Tallroth K, Kettunen JA, Lindgren KA. Comparison of radiologic signs and clinical symptoms of spinal stenosis. Spine (Phila Pa 1976). 2006 Jul 15. 31(16):1834-40. [Medline].
Lurie JD, Tosteson AN, Tosteson TD, Carragee E, Carrino JA, Kaiser J, et al. Reliability of readings of magnetic resonance imaging features of lumbar spinal stenosis. Spine (Phila Pa 1976). 2008 Jun 15. 33(14):1605-10. [Medline]. [Full Text].
Macdonald RL, Fehlings MG, Tator CH, et al. Multilevel anterior cervical corpectomy and fibular allograft fusion for cervical myelopathy. J Neurosurg. 1997 Jun. 86(6):990-7. [Medline].
Markwalder TM. Surgical management of neurogenic claudication in 100 patients with lumbar spinal stenosis due to degenerative spondylolisthesis. Acta Neurochir (Wien). 1993. 120(3-4):136-42. [Medline].
McAfee P, Khoo LT, Pimenta L, Capuccino A, Sengoz A, Coric D, et al. Treatment of lumbar spinal stenosis with a total posterior arthroplasty prosthesis: implant description, surgical technique, and a prospective report on 29 patients. Neurosurg Focus. 2007 Jan 15. 22(1):E13. [Medline].
Mullin BB, Rea GL, Irsik R, Catton M, Miner ME. The effect of postlaminectomy spinal instability on the outcome of lumbar spinal stenosis patients. J Spinal Disord. 1996 Apr. 9(2):107-16. [Medline].
Naderi S, Benzel EC, Baldwin NG. Cervical spondylotic myelopathy: surgical decision making. Neurosurg Focus. 1996 Dec 15. 1(6):e1. [Medline].
Nasca RJ. Rationale for spinal fusion in lumbar spinal stenosis. Spine (Phila Pa 1976). 1989 Apr. 14(4):451-4. [Medline].
Nasca RJ. Surgical management of lumbar spinal stenosis. Spine (Phila Pa 1976). 1987 Oct. 12(8):809-16. [Medline].
Oertel MF, Ryang YM, Korinth MC, Gilsbach JM, Rohde V. Long-term results of microsurgical treatment of lumbar spinal stenosis by unilateral laminotomy for bilateral decompression. Neurosurgery. 2006 Dec. 59(6):1264-9; discussion 1269-70. [Medline].
Panjabi MM. Biomechanical evaluation of spinal fixation devices: I. A conceptual framework. Spine (Phila Pa 1976). 1988 Oct. 13(10):1129-34. [Medline].
Papadopoulos SM, Hoff JT. Anatomical treatment of cervical spondylosis. Clin Neurosurg. 1994. 41:270-85. [Medline].
Robinson LR. Electromyography, magnetic resonance imaging, and radiculopathy: it's time to focus on specificity. Muscle Nerve. 1999 Feb. 22(2):149-50. [Medline].
Saint-Louis LA. Lumbar spinal stenosis assessment with computed tomography, magnetic resonance imaging, and myelography. Clin Orthop Relat Res. 2001 Mar. 122-36. [Medline].
Sakamaki T, Sairyo K, Sakai T, Tamura T, Okada Y, Mikami H. Measurements of ligamentum flavum thickening at lumbar spine using MRI. Arch Orthop Trauma Surg. 2009 Oct. 129(10):1415-9. [Medline].
Shim JH, Park CK, Lee JH, Choi JW, Lee DC, Kim DH, et al. A comparison of angled sagittal MRI and conventional MRI in the diagnosis of herniated disc and stenosis in the cervical foramen. Eur Spine J. 2009 Aug. 18(8):1109-16. [Medline]. [Full Text].
Silvers HR, Lewis PJ, Asch HL. Decompressive lumbar laminectomy for spinal stenosis. J Neurosurg. 1993 May. 78(5):695-701. [Medline].
Sonntag VK, Marciano FF. Is fusion indicated for lumbar spinal disorders?. Spine (Phila Pa 1976). 1995 Dec 15. 20(24 Suppl):138S-142S. [Medline].
Sortland O, Magnaes B, Hauge T. Functional myelography with metrizamide in the diagnosis of lumbar spinal stenosis. Acta Radiol Suppl. 1977. 355:42-54. [Medline].
Trouillier H, Birkenmaier C, Kluzik J, Kauschke T, Refior HJ. Operative treatment for degenerative lumbar spinal canal stenosis. Acta Orthop Belg. 2004 Aug. 70(4):337-43. [Medline].
Vaccaro AR, Garfin SR. Internal fixation (pedicle screw fixation) for fusions of the lumbar spine. Spine (Phila Pa 1976). 1995 Dec 15. 20(24 Suppl):157S-165S. [Medline].
Voulgaris S, Karagiorgiadis D, Alexiou GA, et al. Continuous intraoperative electromyographic and transcranial motor evoked potential recordings in spinal stenosis surgery. J Clin Neurosci. 2010 Feb. 17(2):274-6. [Medline].
Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. 2009 Jun. 91(6):1295-304. [Medline]. [Full Text].
Wilbourn AJ, Aminoff MJ. AAEM minimonograph 32: the electrodiagnostic examination in patients with radiculopathies. American Association of Electrodiagnostic Medicine. Muscle Nerve. Dec 1998. 21(12):1612-31.