Q. I am 59 and in my 34th year as a T10 complete para. Over the past year I’ve developed numbness and tingling in my fingers that gets worse after pushing up hills. Tests say it may be cervical spinal stenosis.
What is spinal stenosis and what causes it? Is it a common secondary problem in long-term SCI? How is it diagnosed and what are the options to treat it?
A. My own research and personal experience suggests that the answer to your question is yes, spinal stenosis is fairly common and can cause serious secondary complications in people with long-term SCI. For more on the subject I turned to Dr. Cristina Sadowsky, clinical director of the International Center for Spinal Cord Injury at Kennedy Krieger Institute in Baltimore, Maryland.
“Spinal stenosis is a narrowing of spaces within the spinal column and/or spinal canal and is caused by degenerative changes in discs and cartilage that naturally occur with age as well as use and overuse,” says Sadowsky. “Stenosis can be both a culprit for paralysis onset — acute SCI — and can cause serious secondary complications in people with long-term SCI.” According to Medscape.com about five out of 1,000 people over age 50 in the United States have symptomatic stenosis.
There are two types of stenosis, central and foraminal, says Sadowsky. Central spinal stenosis is a narrowing of the spinal canal — the hollow area that surrounds and protects the spinal cord — and occurs primarily in the cervical (neck) and lumbar (curve of the back) areas. This is because these are the areas of the spine that have the most movement and thus are subject to the most wear and tear. “As we get older the spinal canal suffers changes from use and overuse. There is thickening of ligaments in the spinal canal, along with degradation of the facets (the spinal joints located at the back of the spine) and the discs between vertebrae, which combine to narrow the canal around the spinal cord,” she says.
The second type of stenosis, foraminal stenosis, is the narrowing of the openings through which nerves come out of the spinal cord, resulting in “pinched nerves.” When this happens in the cervical area, it can cause tingling, loss of sensation and muscle weakness in the arms and hands. If it occurs in the lumbar area of nonparalyzed people, it can cause back and leg pain, numbness and walking difficulties like foot drop.
Aging with SCI exacerbates stenosis, especially in the cervical area. This is due to a combination of using our arms for locomotion and having our cervical spine in a state of recurrent extension by looking up at people from chair-height. This puts extra strain on the neck. In addition, lifespans for individuals with SCI are increasing, thus the likelihood of ongoing wear and tear, which can lead to spinal stenosis occurring, is high.
This makes it important to pay attention to tingling, numbness or weakness in the fingers, hands or arms, and/or neck pain. If a person with SCI notices any of these symptoms it is imperative to consult a physician, ideally a physiatrist or a neurologist, as they could be signs of stenosis at the cervical spine, or possibly another unwanted serious neurological condition such as a syrinx (see resources). In addition, any changes in bladder and bowel function, or in spasticity, should also be discussed with a physiatrist or neurologist since this could be symptomatic of stenosis or other possible complications in the lumbar area.
Diagnosing cervical stenosis starts with a careful neurological examination that could include a physical strength exam and a pin prick exam for sensation and reflexes. A nerve conduction study may be ordered to evaluate for nerve entrapments or pinched nerves, or X-rays may be used to look for areas of wear and tear on the vertebrae or narrowed disc spaces. From there a physician may choose to order an MRI or CT scan, both of which can show changes in discs, ligaments and narrowing of the spinal or lateral canal.
Treatment for spinal stenosis starts conservatively and includes nonsteroidal anti-inflammatory drugs like ibuprofen. The next step is physical therapy. Then cortisone injections to decrease inflammation, which can provide relief by allowing extra space for the nerves. The last resort is surgery, specifically decompression with or without fusion, done either through the front of the neck (anterior) or in the back of the spine (posterior).
The key takeaway is to be aware of symptoms of stenosis and see a physician if they crop up. The earlier the diagnosis, the more options you have and the best chance at resolving your symptoms.
Two SCI Perspectives
For long-term SCI perspectives on symptoms, diagnosis and treatment of stenosis I turned to Eric Stampfli, 61, in his 43rd year as a T11 para and Bill Bowness, 60, in his 42nd year as a T12-L1 para. Both Stampfli and Bowness contacted their physicians, and their diagnoses were pinpointed on MRIs. For Stampfli, narrowing of the cervical spaces at C5-6 was pinching nerves. Bowness’ diagnosis was stenosis in the disc space between C3 and C4.
When he was about 36 years post-SCI, Stampfli had successful surgery to relieve carpel tunnel, which had manifested in numbness in his middle two fingers. “Around 38 years post-injury I started to get pins-and-needles tingling starting at the wrist, and the tingling would get much worse after pushing up hills or pushing through soft dirt while gardening,” he says.
A year ago, Stampfli opted for cortisone shots in C5-6. “The procedure wasn’t too painful, sort of like a pinch or two, similar to getting stuck with an IV but in your neck,” he says. He got relief, including full return of sensation in his hands, that lasted for about four months. “Since then I’ve had two more cortisone shots with good results. The plan is to place the injections close enough to prevent symptoms returning and hopefully enable the nerves to heal.”
Unfortunately, Bowness needed more intensive treatment for his stenosis. “Eight years post injury I started getting pins-and-needles tingling in my arms and localized pain in my hands. An MRI confirmed nerve impingement around the foramen near T1,” says Bowness. “I had the impingement surgically repaired with a foraminotomy — grinding it to widen the area — which alleviated the symptoms.”
His arms and hands remained strong until 25 years post injury when he started noticing numbness and weakness in his right arm. Within a year the symptoms progressed to significant muscle weakness that became so severe that he opted for surgery. “The surgeon went in through the front of my neck, shaved off calcified bone spurs and fused C3-4 with a plate,” he says. He was in the hospital for two days and fully healed, with full return of sensation and strength, within six months.
Bowness, a world-class adaptive water and snow skier, didn’t back off competitive skiing and the symptoms returned four years after his surgery, requiring another fusion. “I’m now fused from C3 to C6, and again, am fortunate my neck and arm fully recovered. I’ve also learned my lesson. I’m slowing down a gear or two to preserve what I have left for the long haul.”
• Charcot’s Spine a Potential Long Term Complication of Spinal Fusion, newmobility.com/2016/06/charcots-spine/
• Mayo Clinic, Spinal Stenosis, mayoclinic.org/diseases-conditions/spinal-stenosis/symptoms-causes/syc-20352961
• Syrinx and Pain, newmobility.com/2011/01/paramedic-syrinx-and-pain/
• To China and Back for Syrinx Surgery, newmobility.com/2019/10/to-china-and-back-for-syrinx-surgery/