Lumbar spinal canal stenosis

Anatomy and what happens with stenosis

The spinal canal of the lumbar spine arises between the vertebral bodies, intervertebral discs, vertebral arches and ligaments. Nerve roots run through it on their way to the legs and the cauda equina.

• Intervertebral discs: lie between the vertebral bodies and serve as buffers.
• Facet joints: small vertebral joints that guide and cushion movements.
• Ligamentum flavum: elastic band on the back wall of the canal.
• Neural foramina: exit holes of the nerve roots.

In the case of stenosis, degeneration and thickening (e.g. in the ligamentum flavum), bony attachments (osteophytes) and wear of the intervertebral disc lead to a narrowing of the canal or nerve canals (foramina). Osteoarthritis of the facet joints is often present at the same time.

The narrowing is often dynamic: the diameter worsens in an upright position with a hollow back, and increases when bending forward. This explains the typical relief of symptoms when sitting or walking bent forward (e.g. with a shopping cart).

Causes and risk factors

The most common cause is age-related wear and tear. Structural changes add up over years and lead to narrowing.

• Degeneration of the intervertebral discs with loss of height
• Facet joint osteoarthritis and osteophytes
• Thickening of the ligamentum flavum
• Spondylolisthesis (slipping of the vertebrae) with relative tightness
• Rare: congenitally narrow canal, cysts, tumors, scars after surgery

Risk factors include: Older age, genetic predisposition, physically demanding work, obesity, lack of exercise and smoking. Metabolic diseases (e.g. diabetes) can make nerves more sensitive.

Typical symptoms

The main symptom is neurogenic claudication: exercise-dependent pain, abnormal sensations or weakness in one or both legs, which worsens when standing or walking and improves when sitting or bending forward.

• Dull back and buttock pain radiating to the legs
• Tingling, numbness, burning in thighs, lower legs or feet
• Shortened walking distance (“intermittent claudication” due to neurogenic causes)
• Improvement when sitting, cycling or bending forward
• Sometimes unsteady gait, rarely bladder/rectal disorders (warning signs)

Important: Neurogenic claudication usually improves when cycling, while circulatory problems in the legs (vascular claudication) are more dependent on stress and cold and do not improve significantly with prevention.

When should I seek medical advice? Warning signs

Please seek medical help promptly if the following symptoms occur:

• New, progressive paralysis in the leg or foot
• Disturbance of bladder or bowel function, numbness in the saddle area (suspected cauda equina syndrome – emergency)
• Severe nighttime pain with fever, chills, weight loss
• Pain after an accident or with known osteoporosis
• History of cancer with new back/leg pain

Diagnostics in our practice

Diagnosis is based on history, physical examination and imaging tests. The crucial thing is to attribute the symptoms to the effort and posture.

• Anamnesis: walking distance, improvement in forward lean, course, previous operations
• Clinical: neurological status (strength, reflexes, sensitivity), provocation tests, posture
• Imaging: MRI of the lumbar spine as the method of choice for imaging stenoses and nerves
• X-ray (if necessary in flexion/extension) to assess instabilities/spondylolisthesis
• CT for bony issues or if MRI is not possible

Not every tightness visible on the MRI causes symptoms. We always evaluate findings in the context of your symptoms to avoid overdiagnosis and unnecessary interventions.

Differential diagnoses: Herniated disc, facet joint syndrome, SIJ problems, hip osteoarthritis, peripheral neuropathies and vascular claudication in peripheral arterial disease.

Conservative therapy: our first step

Most patients benefit from well-structured, conservative treatment. The aim is to relieve pain, improve function and increase walking distance relevant to everyday life.

• Education: Understanding postural dependency and self-help strategies
• Physiotherapy: exercises with emphasis on flexion, mobilization, trunk stabilization
• Walking training: measured interval walking, if necessary slightly bent (e.g. on the treadmill with an incline)
• Everyday life/ergonomics: de-lordosis postures, breaks, adapted lifting
• Heat or short-term cold depending on tolerance to relax muscles

Medication can overcome symptoms, but they do not replace active therapy. We choose individually and for a limited time:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) or paracetamol for short periods
• In the case of neuropathic components, possibly low-dose neuromodulators after consideration
• Stomach protection and side effects testing, especially in the case of previous illnesses

Aids: A walking stick, hiking poles or a rollator with forearm supports can enable longer walking distances. A lumbar orthosis can provide short-term relief, but should not lead to inactivity.

Lifestyle: Weight loss, abstinence from nicotine and regular, moderate exercise improve resilience.

Targeted injections – when does it make sense?

If symptoms persist despite active therapy, injections can provide temporary relief and improve the ability to exercise. We discuss the benefits and risks transparently in advance.

• Epidural steroid injections (interlaminar or transforaminal) to reduce inflammation and pain
• Periradicular therapy (PRT) with a dominant radicular component
• Facet joint infiltration in relevant facet joint arthrosis

Injections offer short- to medium-term symptom reduction in selected patients. They do not replace active therapy and are no guarantee of long-term freedom from symptoms.

Regenerative procedures such as PRP currently do not play an established role in spinal canal stenosis. We do not routinely recommend them outside of studies.

Surgical therapy – when is it considered?

Surgery may be considered if a relevant limitation persists or neurological deficits increase despite consistent conservative treatment over several months. If cauda equina syndrome is suspected, rapid action is required.

• Decompression (microsurgical): Removal of constricting structures to relieve pressure on the nerves
• Bilateral decompression via unilateral access: gentle on tissue with suitable anatomy
• Fusion/fusion only in cases of instability (e.g. high-grade spondylolisthesis) or severe deformity
• Interspinous spacers: indication reserved, evidence heterogeneous

As with any procedure, there are risks (e.g. infection, bleeding, dural opening, residual discomfort). We provide open-ended advice and take personal goals, general illnesses and imaging into account.

A structured rehabilitation and training program is also crucial for patients who have undergone surgery to return to everyday life and work.

Everyday life, work and sport

Movement is central. Choose activities that slightly flex the lumbar spine and improve walking distance without provoking pain.

• Recommended: cycling (also ergometer), walking with sticks, swimming (back/chest with head under water), water aerobics
• Strengthening: trunk stabilization, hip and leg muscles, mobility of the hip flexors and hamstring muscles
• In everyday life: frequent short breaks, lifting loads close to the body, controlling rotating movements
• Workplace: Vary your sitting position, do not keep your lumbar spine excessively hollow, if necessary use a standing desk with a slightly inclined surface

Avoid long, static standing and strong arching of the back under load. Increase the volume gradually and monitor your symptom limits.

Course and prognosis

Spinal canal stenosis often has a fluctuating course. Many sufferers achieve a noticeable improvement in function and greater walking distances with conservative treatment.

An operation can improve resilience in selected cases, but is no guarantee of complete freedom from symptoms. What is crucial is setting realistic goals and sticking to active strategies.

With a tailor-made plan of exercise, pain management and everyday assistance, the quality of life can often be significantly improved.

Your supply in Hamburg

At Dorotheenstrasse 48, 22301 Hamburg, we offer structured diagnostics, conservative treatment programs and - if necessary - an independent second opinion on the indication for surgery.

• Individual training plans and physiotherapy control
• Targeted injections according to strict indications
• Coordination with family doctors and vascular medicine in the case of mixed syndromes
• Transparent discussion of imaging during patient consultations