Cervical stenosis

# Cervical Stenosis: Understanding, Recognizing, and Treating Spinal Canal Narrowing

Cervical stenosis is the narrowing of the spinal canal in the neck. This narrowing can compress the spinal cord or nerve roots, causing pain, numbness, or weakness. If you have received this diagnosis, here is important information: many people have stenosis visible on imaging without ever developing symptoms. Treatment depends on your actual symptoms, not just what the MRI shows. At Physioactif, our physiotherapists evaluate your overall condition to establish a personalized plan.

What is Cervical Stenosis?

Cervical stenosis is the narrowing of the spinal canal in the neck. This narrowing can compress the spinal cord or nerve roots. Many people have stenosis visible on imaging without ever developing symptoms.

The cervical spinal canal is a bony tunnel that runs through the seven vertebrae of the neck. It contains the spinal cord, which carries all nerve signals between the brain and the body. The normal diameter varies from 14 to 23 mm depending on the level. Stenosis is diagnosed when this diameter decreases below 13 mm.

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?

Stenosis primarily develops due to age-related degenerative changes. Disc wear, joint arthritis, osteophyte formation, and ligament thickening gradually reduce the space available for the nerves.

Normal Aging of the Cervical Spine

As we age, several structures in the cervical spine undergo natural changes. The intervertebral discs gradually lose their water content. This dehydration reduces their ability to absorb shock and decreases their height. When the discs flatten, the vertebrae move closer together.

This closer proximity changes the mechanics of the facet joints, which are the small joints located at the back of each vertebra. These joints then bear more load than they normally should. This overload accelerates the wear and tear of the joint cartilage.

How Osteoarthritis Contributes to Narrowing

Cervical osteoarthritis is the body's response to this joint wear. Osteophytes, which are bone spurs often called "parrot beaks," form at the edges of the vertebrae and joints. The body produces these structures in an attempt to stabilize mobile segments that have become unstable.

Unfortunately, these osteophytes can invade the space of the spinal canal. When they form at the back of the vertebrae, they reduce the diameter of the central canal. When they form laterally, they narrow the foramina, which are the tunnels through which nerve roots exit the spine.

The degenerative process generally follows this sequence over several years:

Cervical osteoarthritis plays a major role in this process. Cartilage wear stimulates the formation of bone growths called osteophytes. These growths can invade the canal space. Sometimes, a cervical disc herniation also contributes to the narrowing.

The Role of Ligaments

The ligamentum flavum, which runs along the back of the spinal canal, tends to thicken with age. This ligament becomes less elastic and more fibrous. Its thickening gradually reduces the space available for the spinal cord, especially when you bend your neck backward.

Other factors can accelerate or worsen stenosis. Even a minor congenital malformation of the canal can predispose someone to develop symptoms earlier. People born with a naturally narrow spinal canal have less "reserve" before the narrowing becomes symptomatic.

Repeated neck trauma, such as that experienced in certain contact sports, can accelerate the degenerative process. However, the vast majority of cervical stenosis cases simply occur with normal aging, without any identifiable major trauma.

How to Recognize Symptoms of Nerve Compression?

Symptoms depend on the compressed structure. Radiculopathy causes pain and numbness in one arm. Myelopathy causes hand clumsiness, walking instability, and weakness in all four limbs. Many people remain asymptomatic.

Symptoms of cervical radiculopathy

When a nerve root is compressed, symptoms typically affect only one arm. The incidence is approximately 83 cases per 100,000 people per year, with a peak between 50 and 54 years of age.¹

Characteristic symptoms include:

• Pain radiating from the neck to the shoulder and arm
• Numbness or tingling in a specific path
• Weakness in certain arm muscles
• Symptoms usually on one side

The good news is that 75 to 90% of cases improve with conservative treatment within three months.¹ This condition is known as cervicobrachialgia or cervical radiculopathy.

Symptoms of cervical myelopathy

Myelopathy, which is spinal cord compression, causes very different and more concerning symptoms:

• Bilateral hand clumsiness (difficulty buttoning, 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

Myelopathy typically affects both sides because the spinal cord transmits signals to both halves of the body.

Asymptomatic stenosis

Studies show that a significant number of adults over 60 have spinal stenosis on MRI without experiencing any symptoms.² If your MRI reveals stenosis but you don't have neurological symptoms, it doesn't mean you will develop them.

The presence of stenosis on imaging does not predict the future onset of symptoms. Many people maintain stable stenosis for years without ever developing pain or weakness. This is why preventive treatment is generally not recommended when there are no symptoms.

This incidental discovery of stenosis during an MRI performed for another reason often causes unnecessary anxiety. Understanding that visible narrowing does not automatically mean a future problem can help you avoid excessive worry.

What are the Warning Signs Requiring Urgent Consultation?

Consult immediately if you experience: progressive weakness in your arms or legs, increasing difficulty walking, loss of balance, bladder control problems, or worsening hand clumsiness. These signs of myelopathy require urgent evaluation.

• Weakness that gets worse week by week
• Unsteady gait or frequent stumbling
• Increasing clumsiness with precise movements
• Urinary or fecal incontinence
• Symptoms affecting both sides of the body

These symptoms suggest spinal cord compression, which can worsen without treatment. A prompt consultation allows for intervention before permanent damage occurs.³

However, stable neck pain, numbness in one arm without weakness, or neck stiffness are generally not emergencies.

How is cervical stenosis diagnosed?

Diagnosis combines symptom history, neurological examination, and imaging. The exam looks for signs of myelopathy: brisk reflexes, Hoffmann's sign, unsteady gait. MRI shows narrowing but doesn't always predict symptoms.

The physiotherapist or doctor will evaluate several elements:

Why doesn't an MRI tell the whole story?

Many people have stenosis visible on an MRI without any symptoms. The correlation between the degree of narrowing and symptoms is weak. Treatment should be based on your actual symptoms, not just what the imaging shows.

A study by Brinjikji and colleagues analyzed imaging from people without pain. They found moderate stenosis in 7.5% of individuals aged 50-59 who had no symptoms.² This means that seeing a narrowing on an image does not necessarily mean you will have problems.

The gap between anatomy and symptoms

This discrepancy between imaging and clinical presentation is explained by several factors. Firstly, the degree of compression needed to cause symptoms varies enormously from person to person. Some people tolerate significant narrowing without developing problems, while others become symptomatic with mild stenosis.

Secondly, an MRI captures a static moment in time. It shows the anatomy at rest but doesn't reveal the dynamics of the spinal canal during neck movements. The canal can narrow further in extension or widen in flexion. These dynamic changes are not visible on a standard MRI.

Finally, the spinal cord has a certain capacity for adaptation. It can tolerate gradual and progressive compression better than sudden compression. This is why two people with the same degree of stenosis on an MRI can have completely different clinical presentations.

Treatment decisions should be based on your function and symptoms, not just what the MRI shows. Severe narrowing without symptoms generally does not require active treatment, while moderate stenosis with progressive myelopathy may require surgical intervention.

How does physiotherapy help depending on the type of symptoms?

For radiculopathy, physiotherapy is often the primary treatment with a good success rate. It includes cervical mobilization, strengthening, home exercises, and postural education. For myelopathy, it maintains function but cannot decompress the spinal cord.

For cervical radiculopathy

Physiotherapy is often the primary treatment. Studies show that 75 to 90% of cases respond favorably to conservative treatment.¹ Your physiotherapist will work on:

• Mobilization of the cervical joints
• Nerve release techniques
• Strengthening the stabilizing muscles of the neck
• Posture and ergonomics
• Exercises to do at home

Cervical mobilizations aim to restore normal movement of the neck joints. When joints become stiff, they can increase compression on nerve roots. By restoring mobility, nerve irritation can often be reduced.

Nerve release techniques, sometimes called "nerve gliding" or "neural mobilization," help the nerve slide more freely within its tunnel. These gentle exercises can reduce nerve adherence to surrounding tissues and decrease symptoms like numbness and tingling.

Strengthening the deep neck muscles improves cervical stability. Stronger muscles can better control movements and reduce excessive micro-movements that can worsen compression. This strengthening must be gradual and carefully dosed to avoid increasing symptoms.

For asymptomatic stenosis

If you have stenosis visible on imaging but no symptoms, physiotherapy can help maintain cervical mobility and muscle strength. This approach can contribute to preventing the onset of symptoms.

For mild myelopathy

Physical therapy can help maintain function, but it cannot decompress the spinal cord. In these cases, medical monitoring is essential. If symptoms progress, surgery may become necessary.

When myelopathy is mild and stable, physiotherapy can optimize your current function. Balance exercises can improve your walking stability. Fine motor coordination exercises can maintain your manual dexterity. Overall strengthening can compensate for certain weaknesses.

However, it's important to understand the limits of physiotherapy in this context. It cannot widen the spinal canal or remove pressure on the spinal cord. Its role is to maintain your function and monitor the progression. If your symptoms worsen despite physiotherapy, a prompt medical consultation is necessary to re-evaluate the need for surgical intervention.

When does surgery become necessary?

Surgery is recommended for progressive myelopathy with worsening neurological signs. For radiculopathy without myelopathy, it is considered after 3-6 months of failed conservative treatment. Surgery stops the progression but does not always reverse deficits.

Indications according to clinical guidelines

Surgery is generally not necessary for asymptomatic stenosis or radiculopathy that responds well to conservative treatment.

Realistic goals of surgery

Surgery can stop the progression of myelopathy and often improve symptoms. However, it doesn't always restore full function.³ This is why early intervention is 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.

Early intervention, before permanent damage occurs, generally offers better results. Once the spinal cord has sustained significant damage, complete recovery becomes less likely. Long-term neurological deficits can become irreversible.

Studies show that the majority of patients who undergo surgery for myelopathy stop deteriorating, and many experience an improvement in their function.³ However, the extent of improvement varies considerably depending on the initial severity and how long symptoms were present before surgery.

What is the prognosis based on your type of symptoms?

The prognosis varies depending on the presentation. Asymptomatic stenosis has an excellent prognosis. Radiculopathy often improves favorably with conservative treatment. Mild myelopathy can remain stable. Progressive myelopathy benefits from early surgery.

Ready to have your condition evaluated?

Our physical therapists at Physioactif can assess your symptoms and develop a personalized plan. We offer effective treatments for radiculopathy. If signs of myelopathy are present, we will quickly refer you to the appropriate care.

Cervical stenosis can seem concerning, but remember that many people live very well with this condition. Don't wait for your symptoms to worsen before seeking advice. A complete evaluation will help determine the best plan for your situation.

To make an appointment, visit our cervical pain page or contact the Physioactif clinic nearest you.

References

1. Thoomes EJ, Scholten-Peeters W, Koes B, Falla D, Verhagen AP. The effectiveness of conservative treatment for patients with cervical radiculopathy: a systematic review. Clin J Pain. 2013 Dec;29(12):1073-86.

1. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6.

1. Fehlings MG, Tetreault LA, Riew KD, et al. A Clinical Practice Guideline for the Management of Patients With Degenerative Cervical Myelopathy. Global Spine J. 2017 Sep;7(3 Suppl):70S-83S.

1. Nouri A, Tetreault L, Singh A, Karadimas SK, Fehlings MG. Degenerative Cervical Myelopathy: Epidemiology, Genetics, and Pathogenesis. Spine. 2015 Jun 15;40(12):E675-93.