pathology: neuroforaminal stenosis

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Definition

Narrowing of one or more neuroforamina (nerve exit channels from the spinal column, intervertebral foramina), which can lead to nerve root compression syndrome of the spinal nerves there, so that neuroradicular complaints, pain radiation, paraesthesia and possibly paresis result. paresis may result. This disorder usually occurs in the milder to lower cervical spine or the lower lumbar spine. CT or MRI can be used to assess the diameter of the neurofomamina and determine whether the narrowing is osseous or soft tissue. Symptoms often occur below 5 mm ap diameter of the neurofomamina. Segmental instability, for example due to multifidus dysfunction, aggravated by insufficient musculature in the transversus abdominis region, diaphragm and pelvic floor muscles increase the occurrence of symptoms. As one study shows, the transversus abdominis contracts before the intended performing muscles during all rapid movements of the trunk and arms. In the case of back pain, multifidi and transversus abdominis are not only often insufficient, but also contract too late. In addition, multifidus dysfunction often results in the conversion of type 1 fibres into type 2 fibres, which causes them to fatigue much more quickly. Segmental stabilisation (SS) is therefore of central importance here, as Wang showed in a study on intervention for lumbar back pain. However, there is still no reliable proof of effectiveness and evidence. With a prevalence of 8-25%, lumbar neuroforaminal stenoses are not only frequently present in lumbar back pain, but are also present asymptomatically and are discovered as incidental findings. Many cases, including more severe stenoses, remain asymptomatic; only around 17.5% of more severe cases become symptomatic. The incidence of foraminal stenosis increases above all from the age of 55. There are data that speak of 40% of those over 60 years of age being affected, from 80 onwards it is said to be 75%. One pathomechanism is the body’s reaction to degenerative changes in the intervertebral discs, whereby the lig. flavum or the soft tissue structures of the facet joints hypertrophy. Foraminal stenosis can be categorised into 4 grades:

  • 0: (physiological): normal fat pad around the nerve root
  • 1: (mild): missing fat pad in one dimension. Characterised as anteroposterior narrowing due to a) thickened or kinked lig. Flavum or b) superoinferior narrowing due to the intervertebral discs, due to loss of height of the intervertebral discs or due to osteophytes
  • 2: (moderate): extensive absence of the perineural fat without compression of the nerve root
  • 3: (severe): lack of perineural fat with compression of the nerve root

Cause

  1. Intervertebral disc disease with loss of height
  2. Osteoarthritis of the facet joint
  3. Spondylarthrosis with osteophytes
  4. Spondylolisthesis
  5. Osteochondrosis with spondylophytes
  6. rarely: Bone tumours, metastases
  7. Hypertrophy of the lig. flavum
  8. Back trauma due to changes or scar tissue
  9. Paget’s disease
  10. Morbus Bechterew
  11. iatrogenic: Spinal surgery (Persistent Spinal Pain Syndrome (PSPS))
  12. Cysts
  13. RA

Predisposing

  1. Degeneration of the intervertebral discs with loss of height
  2. Congenital shape anomalies
  3. Scoliosis
  4. Multifidus dysfunction

Diagnosis

  1. MRI, CT

Symptoms

  1. Pain when walking
  2. Paraesthesia, acute onset or creeping in
  3. With cervical spine manifestation: Cervicobrachialgia
  4. with lumbar spine: ischialgieforme pain
  5. Muscle weakness
  6. paraesthesia

Complications

  1. Atrophy of the nerve
  2. Disturbance of continence, micturition, defecation, erection
  3. Secondary disorders due to pain avoidance behaviour/altered movement behaviour

Therapy

  1. For paralysis or unmanageable pain, surgery: microsurgical decompression, removal of bone material, spondylodesis, spacer, spinal spreader. In the cervical spine, depending on the procedure, a significant alleviation of symptoms is achieved in 70-80% of cases with a complication rate due to injuries to the spinal cord of less than one per cent
  2. Exercise therapy, not causal, but symptom-reducing: Strengthening training for the trunk, especially targeted training for segmental stability, such as the multifidi, also the transversus abdominis, the diaphragm and the pelvic floor muscles
  3. Stretching training to reduce muscle tension in the trunk area
  4. Sport: adapted to the symptoms
  5. Nerve root infiltration (symptomatic or diagnostic)
  6. Walking training: Walking until pain occurs, then rest, then continue walking
  7. cycling, also instead of walking

DD