Expertise · Diagnosis & treatment
Spinal Stenosis
In spinal stenosis, the canal through which the spinal cord and nerve roots pass is narrowed by wear. The hallmark symptom is what is often nicknamed the "shop window disease" of the back: pain and heaviness in the legs on walking, which ease quickly on sitting down or bending forward.
What is spinal stenosis?
The spinal canal is the bony canal within the spine through which the spinal cord and nerve roots pass. Decades of wear can cause the intervertebral discs to bulge, the facet joints to enlarge, and the posterior longitudinal ligament to thicken – together, these narrow the canal.
Stenosis occurs mainly in the lower lumbar spine (lumbar stenosis), less often in the cervical spine. In its mild form it is very common after age 60 and often asymptomatic; the characteristic symptoms only develop once the narrowing becomes clinically relevant.
Symptoms
The characteristic pattern of spinal stenosis is neurogenic claudication – to be distinguished from vascular claudication caused by circulatory disease:
- Pain, heaviness or numbness in both legs on walking – after a certain walking distance that becomes progressively shorter
- Rapid relief on stopping or sitting down – and especially on bending forward (the "shopping trolley sign")
- Back pain – often less prominent than the leg symptoms
- Walking uphill often easier than downhill – because forward flexion of the trunk widens the canal
- Cycling usually pain-free – the flexed back relieves pressure on the canal
Causes and risk factors
Spinal stenosis is almost always a condition of ageing – a process that develops over decades:
- Disc degeneration – bulging into the canal
- Enlargement of the facet joints (facet arthrosis) – including bone spur formation
- Thickening of the posterior longitudinal ligament (ligamentum flavum)
- Spondylolisthesis – can worsen an existing stenosis
- Congenitally narrow spinal canal – some people have less reserve space from birth
Diagnosis
- Clinical examination – walking distance test, neurological examination, provocation and relief manoeuvres
- MRI – gold standard; shows the extent of the narrowing and the affected nerve structures
- CT – for assessing bony structures, planning complex procedures
- Standing X-ray / flexion-extension views – to exclude instability
Imaging findings must always be interpreted in the clinical context: radiologically severe stenosis can be low in symptoms, while moderate stenosis can cause substantial complaints.
Treatment
Conservative therapy
For mild to moderate symptoms, a trial of conservative therapy is reasonable:
- Physiotherapy – core muscle strengthening, flexion-oriented exercises
- Interventional pain therapy – periradicular therapy (PRT), epidural injections
- Pain medication – NSAIDs, neuropathic analgesics if needed
- Walking aids and adjustment of daily activities – a rollator, cycling as an alternative
When is surgery indicated?
Decompression surgery is indicated for:
- Relevant impairment of quality of life and walking distance despite conservative therapy
- Progressive neurological deficits
- Cauda equina syndrome – immediate surgery
Surgical techniques
Endoscopic decompression
Minimally invasive widening of the spinal canal through tiny incisions, without significant damage to the back muscles – particularly gentle for older, multimorbid patients.
Microsurgical decompression
An established open technique performed under general anaesthesia. Targeted removal of the narrowing tissue under the microscope. Also suitable for multilevel stenosis or when simultaneous stabilisation is required.
Whether decompression alone is sufficient or an additional fusion is required depends largely on the presence of instability (e.g. spondylolisthesis). This decision is made individually, based on the imaging findings.
My approach
Spinal stenosis often affects older patients with comorbidities, in whom the anaesthetic risk must be carefully weighed. Tissue-sparing, minimally invasive techniques are especially important here; I tailor the choice of surgical approach and anaesthesia individually to the findings and the patient's resilience.
The question of decompression alone versus decompression with fusion is one of the most debated in spine surgery. My decision-making is based on clinical and radiological instability – not on fusion as a routine indication. The current evidence (including NORDSTEN, Försth 2016) supports this measured approach.
More on endoscopic and minimally invasive techniques →What does the research say?
SPORT trial, stenosis: surgery vs. conservative therapy (NEJM 2008)
The SPORT trial followed surgically and conservatively treated patients with lumbar stenosis over 4 years. Surgically treated patients showed significantly greater improvements in pain, function and quality of life – most pronounced in the first year. Weinstein JN et al., NEJM 2008, PMID 18525028 →
Decompression with or without fusion? (NEJM 2016)
Försth et al. compared, in the SWESPINE study (n=247), decompression alone with decompression plus fusion for lumbar stenosis with and without degenerative spondylolisthesis. At 2 years there were no significant differences in clinical outcome – the fusion rate was considerably higher, without a measurable benefit for the patient. Försth P et al., NEJM 2016, PMID 27276561 →
NORDSTEN trial: fusion in degenerative slippage (NEJM 2021)
Austevoll et al. (NORDSTEN) randomised patients with stenosis and degenerative spondylolisthesis to decompression alone vs. decompression plus fusion. At 2 years the clinical difference was not significant, but the fused group had longer operating times and more complications. Austevoll IM et al., NEJM 2021, PMID 34879207 →
Questions about your situation?
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