Spinal Stenosis: Symptoms, Causes & Treatment Guide

What Is Spinal Stenosis?

Spinal stenosis is a narrowing of the spaces within your spine, which puts pressure on the nerves traveling through the spine. It most commonly occurs in the lower back (lumbar stenosis) and neck (cervical stenosis), typically developing gradually in people over 50 due to age-related wear and tear on the spine.

The spine is made up of a series of connected bones called vertebrae, stacked on top of each other. Between each vertebra is a cushioning disc made of cartilage. Running through the center of this bony column is the spinal canal, a tunnel that houses and protects the spinal cord and the nerve roots that branch off from it. In spinal stenosis, this canal becomes narrowed, leaving less room for the nerves and causing them to become compressed or pinched.

The narrowing process is usually gradual, occurring over many years as the structures of the spine change with age. The intervertebral discs lose water content and height, causing the vertebrae to move closer together. The body responds by forming bone spurs (osteophytes) to stabilize the spine, and the ligaments that hold the vertebrae together can thicken. All of these changes contribute to reducing the space available for the nerves, eventually causing symptoms when the compression becomes significant enough to affect nerve function.

Spinal stenosis is classified based on its location in the spine. Lumbar spinal stenosis, affecting the lower back, is the most common type and typically causes symptoms in the legs and buttocks. Cervical spinal stenosis, affecting the neck, is less common but potentially more serious because it can affect the spinal cord itself, leading to symptoms in both the arms and legs. Some people have stenosis in both areas, though this is relatively uncommon.

Understanding the anatomy

To understand spinal stenosis, it helps to know the basic anatomy of the spine. The spinal column consists of 33 vertebrae: 7 cervical (neck), 12 thoracic (mid-back), 5 lumbar (lower back), 5 fused sacral, and 4 fused coccygeal bones. The lumbar spine bears the most weight and is most susceptible to degenerative changes, which is why lumbar stenosis is most common.

The spinal canal runs through the center of the vertebrae, containing the spinal cord in the cervical and thoracic regions, and the cauda equina (a bundle of nerve roots resembling a horse's tail) in the lumbar region. Nerve roots exit the spinal canal through small openings called foramina on each side of the spine. Stenosis can occur in the central canal, in the lateral recesses where nerve roots prepare to exit, or in the foramina themselves, and the location of narrowing affects which symptoms you experience.

Who gets spinal stenosis?

Spinal stenosis primarily affects people over 50 years old, with the prevalence increasing significantly with age. Studies show that up to 50% of people over 60 have some degree of spinal stenosis visible on imaging, though not all will have symptoms. It is the most common reason for spinal surgery in people over 65 and affects men and women roughly equally, though some studies suggest men may be slightly more affected in the lumbar region.

While age-related degeneration is the primary cause, certain factors can increase your risk of developing symptomatic spinal stenosis. These include having a naturally narrow spinal canal (congenital stenosis), previous spinal injuries, osteoarthritis, rheumatoid arthritis, scoliosis (abnormal curvature of the spine), Paget's disease of bone, and achondroplasia (a form of dwarfism). People who have had previous spinal surgery may also be at increased risk due to scar tissue formation.

What Are the Symptoms of Spinal Stenosis?

The hallmark symptoms of lumbar spinal stenosis include leg pain, numbness, and weakness that worsen with standing or walking and improve when sitting or bending forward. Cervical stenosis can cause similar symptoms in the arms and hands, along with balance problems and, in severe cases, difficulty with coordination.

Symptoms of spinal stenosis develop gradually over time, often progressing so slowly that people adapt to them without realizing how much their function has declined. The nature and severity of symptoms depend on the location and degree of nerve compression. Many people with radiographic evidence of stenosis have no symptoms at all, while others experience debilitating pain and disability.

The classic symptom pattern of lumbar spinal stenosis is called neurogenic claudication (also known as pseudoclaudication). This refers to leg pain, heaviness, weakness, or numbness that develops with standing or walking and is relieved by sitting down or bending forward. People with this condition often notice they can walk much farther when pushing a shopping cart or walker (which allows them to lean forward) than when walking upright. This is because bending forward opens up the spinal canal by 10-15%, providing more space for the compressed nerves.

Symptoms of lumbar spinal stenosis

Lumbar spinal stenosis, the most common form, typically causes symptoms in the lower back, buttocks, and legs. The symptoms may affect one or both legs and often vary in intensity from day to day. Common symptoms include:

• Leg pain: Aching, cramping, or burning pain in one or both legs that worsens with walking or standing
• Numbness and tingling: Sensations of pins and needles or decreased sensation in the legs, feet, or buttocks
• Weakness: A feeling of heaviness or weakness in the legs, especially after walking
• Back pain: Dull aching in the lower back, though leg symptoms often predominate
• Balance problems: Difficulty with balance and coordination, particularly when walking
• Relief with flexion: Symptoms improve when sitting, lying down with knees bent, or leaning forward

It's important to understand that symptoms often come in waves. You may have periods of more intense symptoms followed by times when you feel relatively well. For some people, symptoms remain stable for years, while others experience gradual worsening. About one-third of people with symptomatic lumbar stenosis will improve over time, one-third will remain stable, and one-third will worsen without treatment.

Symptoms of cervical spinal stenosis

Cervical stenosis affects the neck region and can compress either the nerve roots exiting the spine or the spinal cord itself. When the spinal cord is compressed (a condition called cervical myelopathy), symptoms can be more severe and widespread. Symptoms of cervical stenosis include:

• Neck pain and stiffness: Aching or stiffness in the neck that may radiate to the shoulders
• Arm symptoms: Pain, numbness, tingling, or weakness in one or both arms and hands
• Hand clumsiness: Difficulty with fine motor tasks like buttoning clothes or writing
• Balance and gait problems: Unsteady walking, feeling like walking on cotton, or frequent stumbling
• Leg symptoms: In severe cases (myelopathy), stiffness, weakness, or numbness in the legs
• Bladder problems: In advanced myelopathy, urgency or difficulty controlling urination

What Causes Spinal Stenosis?

The most common cause of spinal stenosis is age-related degenerative changes in the spine, including disc degeneration, bone spur formation, and ligament thickening. Less common causes include congenital narrowing, spinal injuries, tumors, and certain bone diseases like Paget's disease.

Understanding what causes spinal stenosis helps explain why it's so common in older adults and why certain treatments are effective. The spine undergoes significant changes as we age, and these changes can progressively narrow the spinal canal. In most cases, stenosis results from a combination of several degenerative processes occurring simultaneously.

The intervertebral discs, which act as cushions between the vertebrae, begin to lose water content and elasticity starting in our 30s. As discs lose height and become less effective at absorbing shock, the vertebrae move closer together and experience increased stress. This triggers a cascade of changes: the facet joints (the joints that connect adjacent vertebrae) develop arthritis, bone spurs form along the edges of the vertebrae and joints, and the ligaments that support the spine become thicker and less flexible.

Degenerative causes

Degenerative changes are by far the most common cause of spinal stenosis and include several interconnected processes:

• Disc degeneration: As discs lose height and bulge, they can protrude into the spinal canal and reduce available space for the nerves
• Facet joint arthritis: Osteoarthritis of the facet joints causes enlargement and bone spur formation that narrows the spinal canal and foramina
• Ligamentum flavum hypertrophy: The ligamentum flavum, which runs along the back of the spinal canal, thickens with age and can buckle into the canal
• Spondylolisthesis: When one vertebra slips forward over another, it can cause or worsen stenosis

Other causes of spinal stenosis

While degenerative stenosis is most common, other conditions can cause or contribute to spinal canal narrowing:

• Congenital stenosis: Some people are born with a naturally narrow spinal canal, which makes them more likely to develop symptomatic stenosis earlier in life
• Spinal injuries: Fractures, dislocations, or other trauma can cause immediate or delayed narrowing of the spinal canal
• Tumors: Growths within the spinal canal or abnormal bone growths can compress the nerves
• Paget's disease: This condition causes abnormal bone remodeling that can lead to enlarged vertebrae
• Previous surgery: Scar tissue from spinal surgery can sometimes cause secondary stenosis

How Is Spinal Stenosis Diagnosed?

Diagnosis of spinal stenosis involves a thorough medical history, physical examination, and imaging studies. MRI is the gold standard for visualizing nerve compression, while CT scans provide detailed views of bony changes. X-rays may be used initially to assess spinal alignment and rule out other conditions.

Diagnosing spinal stenosis begins with a detailed conversation about your symptoms. Your doctor will ask about the nature, location, and duration of your symptoms, what makes them better or worse, and how they affect your daily activities. The characteristic pattern of neurogenic claudication—leg symptoms that worsen with walking and standing but improve with sitting or bending forward—is highly suggestive of lumbar stenosis.

The physical examination includes assessment of your posture, gait, flexibility, and neurological function. Your doctor will test the strength, sensation, and reflexes in your arms and legs, looking for patterns that suggest which nerves are affected. They may ask you to walk and observe your gait, noting any difficulty with balance or tendency to lean forward. Specific tests like the "shopping cart sign" (relief of symptoms when leaning forward) help distinguish stenosis from other conditions.

Imaging studies

MRI (Magnetic Resonance Imaging) is the imaging study of choice for spinal stenosis because it provides excellent visualization of the soft tissues, including the spinal cord, nerve roots, discs, and ligaments. MRI can show exactly where and how severely the nerves are compressed and helps distinguish stenosis from other conditions like tumors or infections. However, it's important to note that MRI findings don't always correlate with symptoms—many people with significant stenosis on MRI have few or no symptoms, while others with seemingly mild stenosis may have severe symptoms.

CT (Computed Tomography) scanning provides detailed images of the bony structures of the spine and is particularly useful for evaluating bone spurs, fractures, and the overall architecture of the spine. CT may be used when MRI is not possible (such as in patients with certain implanted devices) or when additional bony detail is needed for surgical planning. CT myelography, which involves injecting contrast dye into the spinal fluid before scanning, can provide excellent visualization of nerve compression when MRI is not available.

X-rays may be obtained as an initial study to evaluate spinal alignment, look for obvious abnormalities like fractures or tumors, and assess for instability (when taken in flexion and extension positions). While X-rays cannot directly visualize the nerves or soft tissues, they provide valuable information about the overall condition of the spine.

Electrodiagnostic studies

In some cases, your doctor may recommend nerve conduction studies (NCS) and electromyography (EMG) to evaluate nerve function. These tests can help distinguish spinal stenosis from peripheral neuropathy (nerve damage in the legs) or other nerve conditions that can cause similar symptoms. They're particularly useful when the diagnosis is uncertain or when multiple conditions may be contributing to symptoms.

How Is Spinal Stenosis Treated?

Treatment for spinal stenosis typically begins with conservative approaches including physical therapy, pain medications, and lifestyle modifications. Epidural steroid injections may provide temporary relief. Surgery (decompression) is considered when conservative treatment fails or when there are severe or progressive neurological symptoms.

The good news about spinal stenosis is that most people can be effectively treated without surgery. Studies show that 60-80% of patients experience significant improvement with conservative treatment alone. The goals of treatment are to relieve pain, improve function, and prevent worsening of symptoms. A personalized treatment plan typically combines several approaches for best results.

Treatment decisions are based on the severity of your symptoms, how much they affect your daily life, your overall health, and your personal preferences. Because spinal stenosis often has a variable course—with symptoms that come and go and may improve or worsen over time—treatment may be adjusted based on how you respond and how your condition evolves.

Physical therapy and exercise

Physical therapy is a cornerstone of conservative treatment for spinal stenosis. A physical therapist can design an exercise program tailored to your specific condition that focuses on several key areas:

• Flexion-based exercises: Exercises that involve bending forward, like knee-to-chest stretches and pelvic tilts, open up the spinal canal and reduce pressure on the nerves
• Core strengthening: Strong abdominal and back muscles help support the spine and may reduce symptoms
• Aerobic conditioning: Low-impact activities like cycling (which keeps the spine flexed), swimming, and walking help maintain overall fitness without aggravating symptoms
• Flexibility exercises: Stretching helps maintain mobility and may reduce stiffness and pain

Medications

Several types of medications can help manage spinal stenosis symptoms:

• Over-the-counter pain relievers: Acetaminophen (paracetamol) and NSAIDs (like ibuprofen or naproxen) can help with pain and inflammation
• Prescription NSAIDs: Stronger anti-inflammatory medications may be prescribed for more severe symptoms
• Muscle relaxants: These may help if muscle spasms are contributing to pain
• Neuropathic pain medications: Gabapentin or pregabalin may help with nerve-related pain, numbness, and tingling
• Antidepressants: Certain antidepressants (like duloxetine or amitriptyline) can help with chronic pain

Epidural steroid injections

Epidural steroid injections involve injecting a corticosteroid medication and local anesthetic into the epidural space around the compressed nerves. These injections can provide significant temporary relief of leg symptoms in many patients, typically lasting weeks to months. They're particularly useful for managing flare-ups of symptoms and may help patients participate more fully in physical therapy.

While epidural injections don't cure stenosis or stop its progression, they can be a valuable tool for managing symptoms and may delay or prevent the need for surgery in some patients. Most guidelines recommend limiting the number of injections to three to four per year due to potential side effects of repeated steroid administration.

Surgical treatment

Surgery is typically considered when conservative treatment has failed after 3-6 months, when there are severe or progressive neurological symptoms, or when symptoms significantly impact quality of life. The most common surgery for lumbar stenosis is decompression laminectomy, which involves removing the bone, bone spurs, and ligament tissue that are compressing the nerves.

Surgery for spinal stenosis is generally very effective, with 80-90% of patients experiencing significant improvement in leg symptoms. Most patients can return to normal activities within 6-12 weeks after surgery. However, surgery does carry risks including infection, blood clots, nerve damage, and the possibility of needing additional surgery in the future. The decision to have surgery should be made carefully after discussing the potential benefits and risks with your surgeon.

What Exercises Help Spinal Stenosis?

The best exercises for spinal stenosis are flexion-based movements that open up the spinal canal, core-strengthening exercises, and low-impact aerobic activities like cycling and swimming. Avoid exercises that involve prolonged standing, backward bending, or high-impact activities.

Regular exercise is one of the most effective ways to manage spinal stenosis symptoms and maintain function. The key is choosing activities that minimize stress on the spine while maintaining fitness and strength. Because bending forward opens the spinal canal, exercises and activities that allow or encourage flexion are generally best tolerated.

Before starting any exercise program, it's advisable to work with a physical therapist who can assess your specific condition and design an appropriate program. They can teach you proper form, help you progress safely, and modify exercises as needed. Consistency is important—regular moderate exercise is better than occasional intense workouts.

Recommended exercises

Knee-to-chest stretch: Lie on your back with knees bent. Slowly bring one knee up toward your chest, holding behind the thigh. Hold for 20-30 seconds, then lower and repeat with the other leg. This opens the lower spine and stretches the lower back muscles.

Pelvic tilts: Lie on your back with knees bent and feet flat. Flatten your lower back against the floor by tightening your abdominal muscles and tilting your pelvis slightly. Hold for 5-10 seconds, then relax. This strengthens the core and promotes spinal flexion.

Partial crunches: Lie on your back with knees bent. Cross arms over your chest or put hands behind your head. Tighten abdominal muscles and raise your shoulders off the floor, not pulling on your neck. Hold briefly, then slowly lower. Start with 8-12 repetitions.

Cat-cow stretch: On hands and knees, alternate between arching your back upward (cat position) and letting it sag toward the floor (cow position). Move slowly and focus on the flexion (cat) portion, which opens the spinal canal.

Cycling: Stationary or regular cycling keeps the spine in a flexed position and provides excellent cardiovascular exercise. Start with 10-15 minutes and gradually increase as tolerated.

Swimming and water exercises: Water provides support and resistance while eliminating impact. Backstroke is particularly good because it promotes spinal flexion. Water walking or aqua aerobics are also excellent options.

Exercises to avoid

Certain activities can worsen spinal stenosis symptoms by narrowing the spinal canal or placing excessive stress on the spine:

• Exercises that involve backward bending (extension) of the spine
• Prolonged standing or walking without support
• High-impact activities like running or jumping
• Heavy weightlifting, especially overhead pressing
• Contact sports with risk of spinal injury

When Should You See a Doctor for Spinal Stenosis?

See a doctor if you have persistent back or leg pain, numbness, or weakness that affects your daily activities. Seek emergency care immediately if you experience sudden loss of bladder or bowel control, severe weakness in both legs, or numbness in the groin or genital area.

If you're experiencing symptoms that may be due to spinal stenosis, such as leg pain with walking that improves with sitting, it's reasonable to start with your primary care doctor. They can perform an initial evaluation and, if needed, refer you to a specialist such as a neurologist, orthopedic surgeon, or neurosurgeon for further evaluation and treatment.

You should see a doctor promptly if your symptoms are significantly affecting your quality of life, if you're having difficulty with daily activities, or if over-the-counter treatments aren't providing adequate relief. Don't wait to seek care if symptoms are getting progressively worse, as early treatment may prevent further decline and preserve function.

How Can You Live Well with Spinal Stenosis?

Living well with spinal stenosis involves staying active with appropriate exercises, maintaining a healthy weight, using assistive devices when helpful, modifying activities to minimize symptoms, and working closely with your healthcare team to optimize treatment.

Spinal stenosis is a chronic condition that requires ongoing management, but most people can lead active, fulfilling lives with appropriate self-care and treatment. The key is understanding your condition, knowing what triggers your symptoms, and developing strategies to minimize their impact on your daily life.

Lifestyle modifications

Several practical strategies can help you manage spinal stenosis symptoms in daily life:

• Use a shopping cart or walker: These allow you to lean forward while walking, which opens the spinal canal and reduces symptoms
• Take frequent breaks: When walking or standing, sit down periodically before symptoms become severe
• Maintain good posture: While a slight forward lean is often more comfortable, try to maintain proper posture when sitting
• Choose supportive seating: Use chairs that support a slight forward lean; consider a lumbar support cushion
• Maintain a healthy weight: Excess weight puts additional stress on the spine
• Quit smoking: Smoking accelerates disc degeneration and impairs healing

Symptoms come and go

It's important to know that spinal stenosis symptoms often fluctuate. You may have good days and bad days, and symptoms may worsen during certain seasons or with changes in activity level. This variability is normal and doesn't necessarily mean your condition is getting worse. Many people find that their symptoms remain stable for years with appropriate management.

Keeping a symptom diary can help you identify triggers and patterns, which allows you to make informed decisions about activities and treatment. Note what activities worsen or improve your symptoms, how far you can walk before symptoms develop, and how your symptoms change over time. This information is also valuable to share with your healthcare providers.