Cervical stenosis

# Cervical stenosis: understanding, recognizing, and treating narrowing of the spinal canal

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 been diagnosed with this condition, here is some important information: many people have stenosis that is visible on imaging but never develop symptoms. Treatment depends on your actual symptoms, not just what the MRI shows. At Physioactif, our physical therapists evaluate your overall condition to develop 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 that is visible on imaging but never develop 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 occurs when this diameter decreases to less than 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, see our comprehensive guide to neck pain.

What causes cervical canal narrowing?

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

Normal aging of the cervical spine

With 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 shocks and decreases their height. When the discs collapse, the vertebrae move closer together.

This narrowing alters the mechanics of the facet joints, which are the small joints located at the back of each vertebra. These joints then bear more weight than they should normally carry. 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 and tear. Osteophytes, bony growths often referred to as "parrot beaks," form at the edges of the vertebrae and joints. The body produces these structures in an attempt to stabilize the mobile segments that have become unstable.

Unfortunately, these osteophytes can invade the spinal canal space. 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, the tunnels through which the 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 bony 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 yellow ligament, 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 aggravate stenosis. Even a minor congenital malformation of the canal can predispose individuals to developing symptoms earlier. People born with a naturally narrow spinal canal have less "reserve" before the narrowing becomes symptomatic.

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

How can you recognize the symptoms of nerve compression?

Symptoms depend on the structure that is compressed. Radiculopathy causes pain and numbness in one arm. Myelopathy causes clumsiness in the hands, unsteadiness when walking, 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 the ages of 50 and 54^.

Characteristic symptoms include:

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

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

Symptoms of cervical myelopathy

Myelopathy, compression of the spinal cord, causes very different and more serious symptoms:

• Bilateral clumsiness of the hands (difficulty buttoning, change 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 proportion of adults over the age of 60 have stenosis on MRI without any symptoms.² If your MRI shows stenosis but you have no neurological symptoms, this does not mean that you will develop them.

The presence of stenosis on imaging does not predict the future onset of symptoms. Many people have stable stenosis for years without ever developing pain or weakness. This is why preventive treatment is not generally 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 future problems can help you avoid excessive worry.

What are the warning signs that require urgent medical attention?

Seek immediate medical attention if you experience: progressive weakness in your arms or legs, increasing difficulty walking, loss of balance, bladder control problems, or worsening clumsiness in your hands. These signs of myelopathy require urgent evaluation.

• Weakness that progresses week by week
• Unsteady gait or frequent stumbling
• Increasing clumsiness in precise movements
• Urinary or fecal incontinence
• Symptoms affecting both sides

These symptoms suggest compression of the spinal cord, which can worsen without treatment. Prompt consultation allows intervention before permanent damage occurs^.

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

How is cervical stenosis diagnosed?

The diagnosis combines symptom history, neurological examination, and imaging. The examination looks for signs of myelopathy: brisk reflexes, Hoffmann's sign, unsteady gait. MRI shows the narrowing but does not always predict symptoms.

The physical therapist or doctor will evaluate several factors:

Why doesn't MRI tell the whole story?

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

A study by Brinjikji and colleagues analyzed images of people without pain. They found moderate stenosis in 7.5% of people aged 50-59 who had no symptoms.² This means that seeing narrowing on an image is not a death sentence.

The discrepancy between anatomy and symptoms

This discrepancy between imaging and clinical findings can be explained by several factors. First, the degree of compression required to cause symptoms varies greatly from one person to another. Some people tolerate significant narrowing without developing problems, while others become symptomatic with mild stenosis.

Next, MRI captures a moment frozen in time. It shows static anatomy, but does not reveal the dynamics of the canal during neck movements. The canal may 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, progressive compression better than sudden compression. This is why two people with the same degree of stenosis on MRI may have completely different clinical presentations.

Treatment decisions should be based on your function and symptoms, not just on the appearance of the MRI. Severe narrowing without symptoms usually does not require active treatment, while moderate stenosis with progressive myelopathy may require surgery.

How does physical therapy help depending on the type of symptoms?

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

For cervical radiculopathy

Physical therapy is often the primary treatment. Studies show that 75 to 90% of cases respond favorably to conservative treatment.¹ The physical therapist 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 to the joints in the neck. 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 in its tunnel. These gentle exercises can reduce the nerve's adhesion to surrounding tissues and decrease symptoms of numbness and tingling.

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

For asymptomatic stenosis

If you have stenosis that is visible on imaging but no symptoms, physical therapy can help maintain cervical mobility and muscle strength. This approach can help prevent symptoms from developing.

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, physical therapy can optimize your current function. Balance exercises can improve your walking stability. Fine coordination exercises can maintain your manual dexterity. Overall strengthening can compensate for certain weaknesses.

However, it is important to understand the limitations of physical therapy in this context. It cannot widen the spinal canal or relieve pressure on the spinal cord. Its role is to maintain your function and monitor progress. If your symptoms worsen despite physical therapy, prompt medical consultation is necessary to reassess the need for surgery.

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 conservative treatment has failed. Surgery stops 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 for surgery

Surgery can halt the progression of myelopathy and often improve symptoms. However, it does not always restore function to normal.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 yields better results. Once the spinal cord has suffered significant damage, full recovery becomes less likely. Long-term neurological deficits may become irreversible.

Studies show that the majority of patients who undergo surgery for myelopathy stop deteriorating and many experience an improvement in function.³ However, the degree of improvement varies considerably depending on the initial severity and duration of symptoms prior to surgery.

What is the prognosis based on your symptoms?

The prognosis varies depending on the presentation. Asymptomatic stenosis has an excellent prognosis. Radiculopathy often responds well to conservative treatment. Mild myelopathy may remain stable. Progressive myelopathy benefits from early surgery.

Ready to have your condition assessed?

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 may seem alarming, but remember that many people live very well with this condition. Don't wait until your symptoms worsen to seek medical advice. A comprehensive evaluation will help determine the best plan for your situation.

To make an appointment, visit our neck 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.

2. 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.

3. 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.

4. 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.