Neuroforaminal stenosis

Neuroforaminal Stenosis also known as neural foraminal stenosis is a condition that affects the spinal column. It is characterized by narrowing of the nerve passageways in the spine known as neural foramina.

The neural foramina are small openings located on the sides of the vertebrae through which the spinal nerves exit the spinal cord and travel to different parts of the body.

Normally nerve roots have enough room to easily pass through the foramen. However, when these openings become narrowed or constricted, they put pressure on the nerves, causing pain, numbness, weakness, or tingling in the affected area. Severe cases of neural foraminal stenosis can cause paralysis (Melancia et al, 2014).

Neuroforaminal stenosis can occur anywhere along the spine. The spinal cord is a bundle of nerves that runs down the center of the spine. These nerves then branch off of the spinal cord and innervate the arms, legs, and other body parts.

Neuroforaminal stenosis disrupts the existing nerve only at the specific level of stenosis.

Cervical foraminal stenosis:

It occurs when there is compression of the nerve roots that exit through small openings in the cervical vertebrae specifically affecting the neck area. It is a common type of foraminal stenosis since the neck is one of the most mobile parts of the spine, supporting head movements.

Thoracic foraminal stenosis:

Stenosis is located in the thoracic spine in the upper back and can affect the shoulders and ribcage. It is the least likely type of foraminal stenosis. Lumbar foraminal stenosis: It is another type of foraminal stenosis affecting the lower back area. It is the most common type of foraminal stenosis.

Neuroforaminal stenosis can be caused by a variety of factors, including degenerative changes in the spine, trauma, and certain medical conditions (Jackson et al, 2012).

Some of the most common causes of neuroforaminal stenosis include:

Degenerative changes: As we age, the discs and joints in our spine begin to deteriorate, leading to conditions such as herniated discs, spinal stenosis, and arthritis. These degenerative changes can cause the neural foramina to narrow, putting pressure on the nerves.

Trauma: Injuries to the spine, such as fractures or dislocations, can cause the neural foramina to become narrowed. This can occur as a result of a fall, car accident, or other types of trauma.

Medical conditions: Certain medical conditions, such as tumors or infections, can cause neuroforaminal stenosis. In addition, conditions such as Paget’s disease, which causes the bones to become thick and deformed, can also lead to this condition.

Age: The risk of neural foraminal stenosis increases with age. This is because normal wear and tear associated with aging can lead to narrowing. As we age, disks in the spine lose height, begin to dry out and start to bulge.
Arthritis
Heredity/genetics
Obesity
Heavy lifting or physical labour can strain the back
Poor posture
Smoking
Diabetes
Osteoporosis
Previous injuries or surgeries on the spine.

Neuroforaminal stenosis is a relatively common condition, especially among those over the age of 50. It affects men and women equally. In fact, it is estimated that up to 5% of the population over the age of 65 suffers from neuroforaminal stenosis, and that number increases to up to 20% in those over the age of 80 (Bagley et al, 2019).

The symptoms of neuroforaminal stenosis can vary depending on the severity of the condition and the location of the affected nerves. Common symptoms include pain, numbness, tingling, and weakness in the affected area, which can be in the neck, back, arms, or legs.

Muscle weakness can affect the ability to grip, lift, or perform other activities. Severe cases of neuroforaminal stenosis can cause difficulty walking or even paralysis in extreme cases.

If the stenosis is located in the cervical spine, which is the upper part of the spine that connects the skull to the rest of the body, the symptoms may include neck pain, headaches, and weakness or numbness in the arms or hands.

If the stenosis is located in the lumbar spine, which is the lower part of the spine that connects to the pelvis, the symptoms may include lower back pain, leg pain, and weakness or numbness in the legs or feet.

Cervical foraminal stenosis. Symptoms can include:

• Neck pain
• Balance problems
• Loss of bowel or bladder control
• Trouble using your hands
• Numbness or tingling in the hand, arm, foot, or leg
• Weakness in the hand, arm, leg, or foot‌

Thoracic foraminal stenosis symptoms can include:

• Neck pain
• Weakness in the shoulder muscles
• Pain in the shoulders, arms, and hands
• Numbness or tingling in the arms and hands

Lumbar foraminal stenosis. Symptoms can include:

• Sciatica, or pain that begins in your buttock and extends down the leg, possibly into
  the foot
• Weakness in the leg or foot
• Pain in the lower back that may come and go
• Numbness or tingling in the buttock, leg, or foot
• Loss of bowel or bladder control
• Pain that worsens when you stand or walk for long periods
• Pain that gets better when you bend forward or sit

The condition is diagnosed through a combination of medical history, physical examination, and diagnostic imaging tests such as X-rays, magnetic resonance imaging (MRI), or computed tomography (CT) scans.

• X-rays show vertebrae to help identify or rule out growths, injuries, and abnormalities.
• Magnetic resonance imaging (MRI) shows damage or disease that affects the cartilage and intervertebral discs.
• Computerized tomography (CT) scans give outlines of all the structures that surround the spinal canal, showing any impacts on your nerves.
• A myelogram is a procedure that uses a dye to show the movement of fluid between individual discs in the spine. Once they inject dye, a CT or MRI is used to see pressure points affecting the nerves.‌
• Bone scans identify fractures, growths, arthritis, and infections that impact the spinal column.
• Additional diagnostic tests, such as nerve conduction studies or electromyography (EMG) may also help to determine the severity of nerve compression and related nerve damage.

Treatment for neuroforaminal stenosis will depend on the severity of the condition, the location of the stenosis, and the patient’s overall health.

Conservative treatments, such as rest, physical therapy, and pain medication, may be recommended for mild cases of neuroforaminal stenosis. Physical therapy can help improve strength and flexibility, while pain medication can help relieve discomfort.

For more severe cases, a physician may recommend more aggressive treatments, such as epidural steroid injections or surgical intervention.

Epidural steroid injections involve injecting a corticosteroid medication into the space around the spinal nerve root to reduce inflammation and relieve pain. This treatment can be effective for the temporary relief of symptoms.

Surgical intervention may be necessary if the stenosis is severe or if conservative treatments have failed to provide relief. The type of surgery will depend on the location of the stenosis and the extent of nerve compression.

Surgical options include:

Interspinous distraction device: This procedure involves implanting a device in the space between the vertebrae to widen the gap and relieve pressure on the nerves.
Foraminotomy: A surgeon removes the bone that is causing the compression to give the nerves more room.

Interventional treatments for neuroforaminal stenosis:

• Dextrose (prologtherapy) injections for neuroformaminal stenosis
• PRP (plasma rich protein) injections for neuroforaminal stenosis
• nStride injections for neuroforaminal stenosis
• Ultrasound guide facet joint injections for neuroforaminal stenosis
• Medial branch block injections for neuroforaminal stenosis
• Caudal and lumbar epidural injections for neuroforaminal stenosis

Non-interventional pain management for neuroforaminal stenosis:

Psychotherapy
Kinesiology education sessions

There are a number of things that can be done at home to help relieve the symptoms of spinal stenosis. One of the best things to do is light to moderate exercise, such as 30 minutes of walking every other day.

You can also use hot or cold compresses. The heat helps loosen up the muscles, while cold reduces inflammation. You can use a compress on either the neck, upper back, or lower back, depending on where the stenosis is located.

Practice good posture by standing up straight, sitting in a supportive chair, or sleeping on a firm mattress. When lifting heavy objects, always bend from the knees and do not put any strain on your back.

It is also important to seek medical attention promptly in order to manage your condition effectively and avoid further deterioration of your condition.

1. Melancia JL, Francisco AF, Antunes JL. Spinal stenosis. HandbClin Neurol. 2014;119:541-549.doi:10.1016/B978-0-7020-4086-3.00035-7
2. Jackson RP, McManus AC, Moore J. Lumbar spinal stenosis: treatment options for an aging population. Mo Med. 2012;109(6):466-469.
3. Bagley C, MacAllister M, Dosselman L, Moreno J, Aoun SG, El Ahmadieh TY. Current concepts and recent advances in understanding and managing lumbar spine stenosis. F1000Res.2019;8:F1000 Faculty Rev-137. Published 2019 Jan 31. doi:10.12688/f1000research.16082.1