Cervical Stenosis

Cervical stenosis refers to a narrowing of the spinal canal in the neck. A compressed nerve root can cause pain in the arm, numbness, or weakness. Impairment of the spinal cord can also affect walking and hand movements. However, stenosis visible on imaging does not always cause symptoms. Treatment depends on your symptoms, the examination, and the imaging results.^{1, 2, 3} At Physioactif, our physical therapists evaluate your condition and refer you to a doctor if necessary.

What is Cervical Stenosis?

Cervical stenosis refers to a narrowing of the spinal canal, the bony passageway in the neck. This narrowing can compress the spinal cord or a nerve root—that is, the part of the nerve that exits the spine. Some people have stenosis that is visible on imaging but do not experience any symptoms.

The cervical spinal canal runs through the seven vertebrae of the neck. It contains the spinal cord, which transmits signals between the brain and the body. Its width varies depending on the individual and the level at which it is measured. In a study of 469 adult skeletons, the measured diameters ranged from 9 to 20.9 mm, with a median value of 14.4 mm. These anatomical measurements alone are not sufficient to determine whether a person has symptoms.³

There are two main types of cervical stenosis:

Central stenosis is potentially more concerning because it can compress the spinal cord itself. To better understand the anatomy of this region, consult our complete guide to neck pain.

What Causes Cervical Canal Narrowing?

Age-related changes in the discs, joints, and ligaments can narrow the cervical spinal canal. Discs may lose height, joints may develop osteoarthritis, and ligaments may thicken. Bone spurs, called osteophytes, can also reduce the space available for the spinal cord or nerves.^{5, 6}

Normal Aging of the Cervical Spine

With age, the intervertebral discs—the cushions located between the vertebrae—can lose water and height. These changes alter the distribution of forces in the cervical spine. They do not automatically cause pain.^{7, 8}

The facet joints are the small joints located at the back of the vertebrae. A loss of disc height can alter the forces they bear. Simulations of the cervical spine show this redistribution of forces, but the pattern varies from person to person.⁹

How Osteoarthritis Contributes to Narrowing

Cervical osteoarthritis becomes more common with age. It may be accompanied by osteophytes, bony growths sometimes called “parrot beaks.” These changes may be present without causing any symptoms.

Osteophytes can reduce the space available for nerve structures. At the back of a vertebra, they can narrow the central canal. On the sides, they can narrow the foramina, the openings through which the nerve roots exit the spine.^{4, 10}

Several changes can contribute to the shrinkage, in no particular order:

Cervical osteoarthritis plays a major role in this process. These changes in the cartilage are accompanied by the formation of bony growths called osteophytes. These growths can encroach on the space within the spinal canal. Sometimes, a cervical disc herniation also contributes to the narrowing.

The Role of Ligaments

The yellow ligament runs along the back of the spinal canal. Its thickening can reduce the space available for the spinal cord. The canal can also narrow further when the neck is tilted backward.^{11, 12, 13}

Some people are born with a narrower spinal canal. As a result, they have less space around the spinal cord, which can lead to symptoms when other changes further reduce that space.^{13, 4}

A history of neck injury, such as whiplash, is one of the factors to be discussed during the evaluation. It does not, on its own, explain stenosis. Many people develop changes in the cervical spine as they age without having experienced any significant trauma.

How to Recognize Symptoms of Nerve Compression?

Nerve compression in the neck can cause pain in one arm, numbness, weakness, or difficulty walking, depending on the structure affected. A compressed nerve root often causes symptoms in one arm. Damage to the spinal cord can also affect the hands and legs. These symptoms may be incomplete or affect the sides of the body unevenly.

Symptoms of Cervical Radiculopathy

A compressed nerve root can cause symptoms in an arm. Treatment often begins without surgery, provided the condition does not require prompt surgical evaluation. Significant or worsening weakness requires medical evaluation.^{1, 14, 15}

Characteristic symptoms include:

• Pain that radiates from the neck to the shoulder and arm, also known as brachial neuralgia
• Numbness or tingling in a specific path
• Weakness in certain arm muscles
• Symptoms usually on one side

The C7 and C6 nerve roots are located in the lower part of the neck. In a study of 561 people, the C7 nerve root was the most commonly affected, followed by the C6.¹⁶ Symptoms and physical examination are used to guide the diagnosis.¹⁴ The painful area may correspond to the compressed nerve, but the areas of pain and numbness often overlap.¹⁷

Most people with cervical radiculopathy improve over time, with or without specific treatment. However, some may require surgery, especially if the pain remains debilitating or if significant weakness develops.^{15, 16, 14} Our page on cervicobrachialgia or cervical radiculopathy explains these symptoms.

Symptoms of Cervical Myelopathy

Myelopathy refers to a disorder affecting the functioning of the spinal cord. In cervical spinal stenosis, it can result from compression and cause the following symptoms:

• Clumsiness in one or both hands: difficulty buttoning a garment or changes in handwriting
• Weakness in both arms or both legs
• Difficulty walking or loss of balance
• Feeling of heavy or stiff legs
• Numbness in all four limbs

A person may have myelopathy without exhibiting all of these signs. No single symptom can confirm or rule out the diagnosis. The evaluation combines symptoms, physical examination, and imaging.^{18, 19}

Myelopathy can affect the arms and legs because the nerve pathways in the spinal cord connect the brain to these areas. Symptoms may differ from one side of the body to the other.

Asymptomatic Stenosis

Images of the spine often show age-related changes in adults who are pain-free.²⁰ Visible compression in the neck does not automatically mean that the spinal cord is malfunctioning. The doctor interprets the images in conjunction with your symptoms and physical examination.

An anatomical study of 469 skeletons estimated the prevalence of a narrow cervical canal at 4.9% among adults, 6.8% among those aged 50 and older, and 9% among those aged 70 and older. These estimates describe the anatomy, not the prevalence of people who have symptoms.³

The presence of compression on imaging alone is not sufficient to predict future symptoms. The risk also depends on the test results and the course of the condition. When spinal cord compression is accompanied by radiculopathy, the risk of myelopathy is higher. In the absence of myelopathy or radiculopathy, guidelines recommend educating patients about signs to watch for and clinical follow-up rather than preventive surgery.^{21, 2, 22}

Some people with spinal cord compression but no myelopathy go on to develop myelopathy during follow-up. This risk varies depending on existing symptoms and certain MRI findings. Your doctor will tailor your follow-up care to your specific situation and explain what changes you should report.^{23, 22, 24}

Finding out you have a stenosis can be worrisome. Talking with your healthcare provider can help you understand what the imaging results mean in your specific situation, without automatically concluding that surgery will be necessary.

What are the Warning Signs Requiring Urgent Consultation?

Any weakness that develops or worsens, difficulty walking, or increasing clumsiness in the hands requires urgent medical evaluation. New-onset loss of bladder or bowel control, a sudden inability to walk, or significant, rapidly developing weakness warrant an immediate visit to the emergency room. Call 911 if you cannot get there safely.

• New or worsening weakness in an arm or leg
• Unsteady gait or frequent stumbling
• Increasing clumsiness with precise movements
• New-onset loss of bladder or bowel control
• New numbness in several limbs, especially accompanied by weakness or difficulty walking

These symptoms may indicate spinal cord damage or another neurological problem. A prompt evaluation helps identify the cause and select the appropriate treatment. Do not wait for a physical therapy appointment if urgent symptoms appear.²²

Long-standing, stable neck pain is usually not an emergency. However, new or persistent numbness warrants an evaluation. The onset of weakness, difficulty walking, or a change in bladder or bowel control alters the level of urgency.

How is cervical stenosis diagnosed?

The diagnosis of cervical stenosis is based on symptoms, a physical examination, and imaging. The physical examination includes an assessment of reflexes, muscle strength, sensation, and gait. Magnetic resonance imaging (MRI) shows the spinal canal and the spinal cord. It helps confirm compression and look for signs of spinal cord involvement.^{25, 11}

The physical therapist or doctor evaluates the following. The doctor may order medical imaging to complete the evaluation, especially if spinal cord involvement is suspected:

Why doesn't an MRI tell the whole story?

An MRI helps diagnose cervical stenosis, but it does not, on its own, explain your symptoms or your functional abilities. It may show compression in a person who has no symptoms. Conversely, certain abnormalities in the spinal cord or signs of compression can help assess the risk of the condition worsening. Treatment therefore takes into account the imaging results, the physical exam, and your progress.

The anatomical study, which estimates the prevalence of stenosis at 6.8% among people aged 50 and older, describes a narrow spinal canal—not a diagnosis of myelopathy.³ An anatomical measurement, therefore, is no substitute for an evaluation of your functional abilities and symptoms.

The gap between anatomy and symptoms

Two people with a similar narrowing may have different symptoms. The size of the spinal canal alone does not explain how the spinal cord functions. That is why the healthcare professional also checks the patient’s gait, strength, and motor coordination.

A standard MRI shows the neck in a specific position. The spinal canal may narrow further when the neck is tilted backward. In some cases, the doctor may order images taken in different positions to better understand the compression.¹²

Changes in symptoms also provide information that an image alone cannot convey. Any new difficulty walking or loss of manual dexterity should be reported, even if a previous MRI appeared normal.

Treatment decisions are based on a combination of symptoms, functional status, physical examination, and MRI findings. Compression without myelopathy or radiculopathy generally warrants clinical monitoring. Worsening myelopathy requires surgical evaluation, even if the stenosis appears moderate on imaging.²²

How does physiotherapy help depending on the type of symptoms?

Physical therapy can help reduce pain and difficulties with daily activities when a nerve root is affected. It may include exercises, guidance, and appropriate mobilization techniques. When myelopathy is present, the doctor must first assess its severity. Supervised rehabilitation may be considered in some mild cases, while moderate, severe, or worsening cases require a surgical evaluation.

For cervical radiculopathy

Physical therapy is one of the options available for radiculopathy without symptoms requiring immediate intervention. A trial involving 63 people with disc-related compression supports trying a structured program before deciding on surgery in this situation. Symptoms also often improve over time, making it impossible to attribute any improvement to a specific treatment.^{26, 15, 14} Depending on the evaluation, the program may include:

• Mobilization of Cervical Joints
• Nerve-related exercises: gentle neck and arm movements tailored to the symptoms
• Strengthening the muscles that help control neck movements
• Adjustments to posture andergonomics, i.e., adapting work activities and the workstation
• Exercises to Do at Home

Cervical mobilizations are movements applied to the joints of the neck. Along with standard care, certain joint and nerve mobilizations may reduce pain in the short term in cases of radiculopathy. Results vary depending on the individual and the technique used. An improvement in symptoms does not mean that the spinal canal has widened.²⁷

Nerve mobilization techniques use gentle movements to alter the position of the nerve. In cervical radiculopathy, they can reduce pain and certain difficulties with daily activities compared to no treatment. They have not demonstrated clear superiority over the other treatments studied.²⁸

Neck muscle exercises are designed to improve endurance and movement control to make daily activities easier. The progression of these exercises is tailored to your abilities and symptoms. Any new weakness or worsening of neurological symptoms requires a reevaluation, even if you are following an exercise program.

For asymptomatic stenosis

Asymptomatic stenosis does not automatically require physical therapy. Clinical monitoring and awareness of the signs to watch for are key. Your healthcare provider can advise you on your activities based on your examination and your needs.

For mild myelopathy

For mild myelopathy, your doctor may discuss surgery or a structured rehabilitation program under medical supervision. The decision will take into account your abilities, imaging results, and preferences. If neurological symptoms worsen, a surgical consultation is necessary.

A supervised program can address specific challenges, such as balance, walking, or hand movements. These exercises are designed to support daily activities. Their benefits in cases of myelopathy remain uncertain, and they are not a substitute for medical care.²⁹

Physical therapy does not remove the structures compressing the spinal cord and is not a substitute for surgery when it is indicated. This limitation does not mean that it is useless: it can be part of an appropriate rehabilitation program under medical supervision. If symptoms worsen, the treatment must be reevaluated promptly.

When is surgery necessary?

Surgery is recommended when myelopathy is moderate or severe, or when it is worsening. For radiculopathy, surgery is considered in particular if significant weakness develops or if debilitating pain persists despite appropriate treatment.^{22, 1, 30} The goal of surgery is to slow the progression of the condition and improve function, although it does not guarantee a full recovery.

Indications Based on Clinical Recommendations

Stenosis without myelopathy or radiculopathy generally does not warrant preventive surgery. Radiculopathy that improves can often be managed without surgery, provided there is no significant weakness or other concerning signs.

Realistic goals of surgery

Surgery aims to slow the progression of myelopathy and may improve symptoms and functional abilities. Some difficulties persist despite surgery, and worsening of the condition remains possible.^{31, 32, 22} Early evaluation is therefore important when myelopathy is progressing.

Surgical procedures aim to create more space for the spinal cord. Decompression can be performed from the front of the neck (anterior approach) or from the back (posterior approach). The choice depends on the precise location of the compression and several other anatomical factors.

More severe myelopathy and symptoms that have been present for a long time are associated with poorer recovery after surgery. Early evaluation allows for discussion of treatment before the condition worsens further, though it does not guarantee that all difficulties will disappear.³³

After surgery for myelopathy, some people regain some of their abilities. Others continue to experience difficulties that require accommodations or rehabilitation.²² Improvement depends largely on the initial severity and duration of the symptoms.

What is the prognosis based on your type of symptoms?

The prognosis for cervical stenosis depends on the symptoms, their progression, the physical examination, and certain MRI findings. Compression without myelopathy may remain stable, but ongoing monitoring is still advisable. Radiculopathy often improves over time. Myelopathy may worsen and requires medical follow-up; surgery is one of the options, depending on its severity.^{23, 15}

Ready to have your condition evaluated?

Our physical therapists at Physioactif can assess your symptoms and develop a plan tailored to your needs. For radiculopathy, this plan may include exercises, advice, and mobilization techniques. Signs of myelopathy require prompt medical evaluation. The urgent signs described above warrant seeking a physical therapy appointment without delay.

Many people live well with cervical stenosis. An evaluation can help clarify what this diagnosis means for you and help you choose the appropriate course of care. Report any changes in strength, walking ability, or bladder or bowel control right away.

To schedule an appointment, visit our page on neck pain or our page on cervicalgia, then contact the Physioactif clinic nearest you.

References

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29. Rhee JM, Shamji MF, Erwin WM, Bransford RJ, Yoon ST, Smith JS, et al. Nonoperative management of cervical myelopathy: a systematic review. Spine (Phila Pa 1976). 2013;38(22 Suppl 1):S55-67. (Back to section 1)
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31. Fehlings MG, Tetreault LA, Kurpad S, Brodke DS, Wilson JR, Smith JS, et al. Change in Functional Impairment, Disability, and Quality of Life Following Surgical Treatment for Degenerative Cervical Myelopathy: A Systematic Review and Meta-Analysis. Global Spine J. 2017;7(3 Suppl):53S-69S. (Back to section: 1)
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33. Tetreault L, Palubiski LM, Kryshtalskyj M, Idler RK, Martin AR, Ganau M, et al. Significant Predictors of Outcome Following Surgery for the Treatment of Degenerative Cervical Myelopathy: A Systematic Review of the Literature. Neurosurg Clin N Am. 2018;29(1):115-127.e35. (Back to section: 1)