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Tests are very important but in context.

For example, if a patient has spinal stenosis and significant back pain only with standing that would be relieved with bending forward or sitting, I would order an epidural steroid injection to temporarily “numb” the spinal canal. Pain relief may lead me to consider a decompression.

If there was buttocks and leg pain as the symptom, a selective nerve root block would help to diagnose which nerve was causing the pain.

Back pain with standing and loading of the spine might require a discogram to determine if the disc is causing pain.

Finally, if there is pain with extension (bending backwards) as well as standing, consideration of facet blocks needs to be in the discussion.

A patient with isolated disc resorption at L5-S1 with Modec changes, endplate fractures and absolutely normal discs above with the appropriate history and physical examination might not need any diagnostic testing for a surgical discussion.

Dr. Corenman

I assume that your friend’s father had cervical stenosis and not lumbar stenosis. Both can make walking difficult but cervical stenosis can lead to myelopathy (see website for description of that disorder)- compression and dysfunction of the spinal cord.

When a radiologist uses the term “mild” or “mild to moderate”, compression is in the eye of the beholder. It is difficult to know how much compression is present as every radiologist has a different set of criteria for those terms.

It is important to know if there is at least some cerebral spinal fluid (CSF) around the cord at the level of constriction. CSF is the cushioning around the cord and the more the better.

Two problems to be concerned with in the case of cervical stenosis. One is myelopathy and the other is central cord syndrome (see website for description). Normally myelopathy is a slowly developing problem with warning signs associated and can be carefully watched for occurrence of those signs.

The problem with central cord syndrome is that it occurs immediately in the face of a specific blow to the head. The spinal canal changes in volume with flexion and extension. Flexion widens the canal and extension narrows it. A fall onto the face or forehead that forces the neck to bend backwards can pinch the cord causing this cord injury.

Central cord syndrome is more prevalent in an active population. Activities such as snow skiing or boarding, mountain biking, horseback riding and even wrestling can cause this injury in a person with cervical stenosis. I see about 10-20 central cord syndromes a year in the active population and about 1-2 in the non-active population. You can see that your risk drops substantially if you have cervical stenosis and drop at risk activities.

I agree that an epidural steroid does not fix any mechanical problems and your stenosis is a mechanical problem. If however, you have symptoms from the other problems in your neck (disc tear and bulge or nerve root irritation), the epidural should yield relief.

Will the stenosis become worse? I cannot answer that question. Most patients with stenosis from a disc bulge will have further degeneration in those discs and most likely, advancement of the bulge or spur. This could make the stenosis worse. I have also seen patients who get no worse after following them for 20 years.

Shoulder dysfunction can cause neck pain but the normal pattern is pain that starts in the shoulder and radiates to the neck. I have seen a handful of patients with unilateral neck pain that originated from the shoulder.

Dr. Corenman

Let us assume that you have a degenerative L5-S1 segment and that all your other segments are normal. The L5-1 segment is now painful and a fusion will be beneficial.

More likely than not- your range of motion now is limited by pain at endpoints of motion (flexion and extension). In addition, this degenerative segment is also very limited in motion by the significant loss of disc height and wear of the facets.

What is surprising is that your motion may improve with a fusion of this segment. The loss of motion from fusion is normally minimal because of the preexisting limited motion of the degenerative segment. In addition, the reduction of pain with fusion may allow greater motion of the segments above than previously existed without the fusion.

Dr. Corenman

The MRI findings always need to be correlated with your symptoms. If you have no symptoms, the findings might not matter.

The MRI demonstrates a disc bulge or herniation at C5-6 which compresses the left spinal cord and the left C6 nerve root but there is not signal abnormality of the cord.

A C6 nerve compression on the left could cause left sided neck pain radiating into the arm down to the thumb. The pain would be worse with certain neck maneuvers such as looking up (extending the neck) or bending the head to the left side (lateral bending). Weakness could be noted in the biceps (lifting a heavy object) and the wrist extensor (weaker grip strength). Paresthesias might radiate down the left arm (pins and needles). You might also have neck pain as your primary complaint.

Dr. Corenman