Two types of cervical spinal stenosis have been discussed in the medical literature: an acquired (ie, degenerative) type seen in middle-aged and older patients and a congenital type seen in younger, athletic patients. The normal sagittal diameter in the mid cervical spinal canal is between 17- and 18-mm. Absolute stenosis is defined as <10 mm whereas relative stenosis is <13 mm.1
Acquired cervical stenosis results from age-related degenerative disk and facet disease with associated uncinate process hypertrophy, ligamentum flavum thickening and buckling of the posterior longitudinal ligament. Congenital spinal stenosis is associated with short pedicles and bony anomalies of the lateral masses and laminae.2
Epidemiology including risk factors and primary prevention
Cervical spondylosis is a frequent finding in asymptomatic adults with more recent studies reporting prevalence rates between 14%3 and 24.2%.3 Prevalence rates approaching 81% have been reported in individuals exhibiting symptoms.3 In fact, 98% of elderly patients sampled in one study in Hong Kong showed evidence of degenerative changes on magnetic resonance imaging (MRI) in at least one level of their cervical spine.4 Risk factors for developing cervical stenosis include advancing age, female sex, obesity, participation in American football, soccer, rugby, horseback riding, as well as major trauma and dystonic cerebral palsy.5,6
Neuronal damage in cervical stenosis is mediated by both mechanical and ischemic insults to the spinal cord. Dynamic shortening of the posterior cord (ie, dorsal columns) in extension may account for early difficulties with gait, balance and proprioception. Chronic cervical spondylotic myelopathy (CSM) causes both gray and white matter demyelination creating a preponderance of upper extremity (ie, hand) symptoms. This results from the somatotopic organization of the cervical spinal cord which places the cell bodies of the ventral horn motor neurons more laterally and the lateral cortical spinal tracts more medially making them vulnerable to mechanical compression. Compressed arterioles from the anterior spinal artery contribute to cord ischemia producing secondary free radical-mediated cell injury and apoptosis.
Traumatic injuries to the intervertebral disks in younger patients can accelerate the degenerative process. Disk herniations, in particular, may contribute to early spondylosis and kyphotic angulation of the cervical spine as axial loads are shifted to the posterior elements.
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
The progression from cervical spondylosis to stenosis and ultimately CSM is variable and difficult to predict. Many patients experience a relatively benign course of disease with episodic flare-ups of axial neck pain and/or cervical radiculopathy. A prospective, long-term, cohort study of 199 patients presenting with neck pain or cervical radiculopathy and MRI evidence of cord compression without clinical myelopathy estimated that symptomatic spinal cord compression occurred in 25% within a 4 year period at a rate of 6.25% per year.7 Those patients presenting with neurologic deficits that did not spontaneously improve experienced further neurologic decline over time resulting in permanent gait and balance impairment, loss of fine motor skills and bowel or bladder dysfunction.8
Specific secondary or associated conditions and complications
Axial neck pain is the most common symptom associated with spinal stenosis seen in clinical practice.9 Approximately one third of patients with axial neck pain present with headache and more than two thirds present with shoulder pain.10 Cervical radiculopathy most commonly affects the C6 and C7 nerve roots in the nonathletic population whereas stingers and burners affecting the C5 and C6 roots are seen in collision sport athletes (ie, American football and rugby players). Spasticity, bowel/bladder dysfunction, deep venous thrombosis and decubitus ulcers are seen more frequently in immobilized patients with advanced CSM or those in postoperative recovery and inpatient rehabilitation.
Essentials of Assessment
In addition to asking questions regarding pain and numbness, the physician should query patients on subtle changes in gait, balance and loss of fine motor skills which may suggest myelopathy. Bowel and bladder dysfunction are typically late manifestations. Physicians caring for collision sport athletes need to inquire about cervical spine range of motion and tackling technique as early loss of cervical extension and shoulder depression during tackling are associated with an increased risk for cervical neuropraxia and/or nerve root and plexus injury.11,12
Cervical spine range of motion, muscle stretch reflexes and strength should be routinely tested in all patients suspected of having cervical stenosis. Spurling’s maneuver may reproduce radicular pain and/or paresthesias which may be relieved by having the patient elevate the affected arm overhead (ie, Bakody’s sign). Hoffman’s sign, if present, has been shown to positively correlate with CSM.13 A Babinski sign, ankle clonus and Lhermitte’s phenomenon should be documented, if present. Sensory ataxia secondary to posterior column dysfunction is assessed by performing a Romberg test.
A wide-based gait may be observed. The development of a myelopathic hand characterized by loss of dexterity, diffuse numbness, intrinsic muscle wasting, ulnar and flexor drift (ie, a positive finger escape sign) and an inability to grasp and release objects may impair activities of daily living.14,15
In the exceedingly unlikely case of an infectious epidural mass in the cervical spine, laboratory tests such as C-reactive protein, sedimentation rate and white blood cell count may have some clinical utility.
Cervical spine radiographs are useful screening tools in patients with suspected cervical stenosis.16 Historically, the Torg-Pavlov ratio (i.e., sagittal diameter of the cervical canal: width of a mid-cervical vertebral body) has been used to quantify the degree of stenosis. A value < 0.80 is indicative of stenosis; however, this ratio has been reported to have high false-positive rates and to correlate poorly with the true diameter of the cervical canal, especially in collision sport athletes who have larger vertebral bodies.17–19 A computed tomography myelogram may be indicated in those patients with a contraindication to MRI.
Diffusion tensor imaging (DTI) is an advanced MRI technique that may be helpful in identifying early signs of cervical spinal cord pathology that may otherwise go undetected using conventional magnetic resonance techniques.20 DTI can help identify white matter tract disruption in the cervical spinal cord, as well as the orientation of accompanying glial scar. A recent prospective observational study examining the reproducibility and functional correlation of DTI showed its promise in becoming a useful tool for monitoring those patients with cervical stenosis and/or CSM who choose to pursue non-operative management strategies.21
Supplemental assessment tools
Electrodiagnostic testing may be helpful in ruling out other disease states such as carpal tunnel syndrome, peripheral polyneuropathy or motor neuron disease (ie, amyotrophic lateral sclerosis).
Early predictions of outcomes
In collision sport athletes, cervical neuropraxia resulting in a transient loss of motor and/or sensory function may last up to 36 hours. Players with underlying stenosis have an increased risk for recurrent episodes of cervical neuropraxia which may or may not result in irreversible spinal cord injury (SCI).22 In adults with asymptomatic stenosis, the presence of electromyographic abnormalities or clinical radiculopathy is associated with the development of CSM.23
For young athletes with spinal stenosis participating in American football, proper tackling technique to help decrease the risk of cervical spine injury has previously been mentioned. The question of whether a young adult with cervical stenosis should play contact sports, such as football is controversial knowing that such activity increases the risk of severe neurologic injury. In adults with advanced CSM, pain and/or neurologic dysfunction can render these individuals unemployable.
An ergonomic evaluation of a patient’s workstation can be requested by the physician to promote normal postural alignment when seated and decrease repetitive neck extension which may exacerbate symptoms.
Rehabilitation Management and Treatments
Available or current treatment guidelines
Treatment guidelines for the nonathletic population with cervical stenosis are largely based on systematic reviews of patients with nonspecific axial neck pain. No single nonoperative intervention has proven superior to another; however, supervised exercise is likely to be more beneficial than treatments which do not employ such an approach.24 In a retrospective cohort analysis of 90,000 adult patients with cervical stenosis, 92.6% were successfully treated non-operatively while 7.4% failed non-operative management and opted for anterior cervical discectomy and fusion (ACDF) surgery.25 Failure rates of non-operative therapies were higher in smokers (11%), those having cervical epidural steroid injections (CESI) (11%) and males (8%).25 Additionally, a greater percentage of patients characterized as non-operative failures utilized opioid analgesics, muscle relaxants and CESI, as well as costing double the amount of those patients characterized as non-operative successes.25
There remains no consensus regarding return-to-play (RTP) guidelines for collision sport athletes who sustain a single episode of transient cervical neuropraxia. It is generally agreed that those athletes without radiologic evidence of stenosis may RTP.22
At different disease stages
Early cervical stenosis with mild-to-moderate cord compression without edema is usually treated nonoperatively. Physical therapy along with serial neurologic examinations every 6 months ensures early myelopathic symptoms are not missed.
Neurosurgical consultation is sought when cord compression is severe or edema is seen on MRI. Even after surgery, many patients continue to complain of unsteady gait and poor balance with residual neck and/or arm pain with paresthesias, especially if a focus of abnormal signal (i.e., gliosis) was appreciated in the spinal cord preoperatively.
In later stages, patients may suffer an acute injury exacerbating their chronic stenosis causing a central cord syndrome. In such cases, inpatient rehabilitation is paramount to help them restore lost function. Neurologic injury, however, may not be reversible.
Coordination of care
Physiatrists are well trained to coordinate care for both the nonathletic and athletic patient populations with cervical stenosis. Older patients with advanced disease may require physical, occupational, and psychologic therapies depending on their impairments, as well as social work services to assist with community reintegration.
Early neurosurgical consultation for athletes sustaining a single episode of cervical neuropraxia may be prudent, especially in those players found to have underlying stenosis who wish to return to full contact play (which will be subsequently discussed).
Patient & family education
A multidisciplinary team approach to counseling both older adults and young athletes with cervical stenosis should be employed. For the athlete who wishes to return to contact sports after sustaining a cervical spine injury, meeting with coaching staff, athletic trainers, and family to educate them on the risks of SCI is now standard of care. Educating family members and allied health personnel (i.e., home health aides, visiting nurses) on fall risks in older adults with CSM at the time of physiatric consultation is essential.
Morbidity associated with cervical stenosis from loss of neurologic function increases with age. In those patients with SCI, functional recovery in the inpatient setting is documented utilizing serial Functional Independence Measure scores or the Spinal Cord Independence Measure, a 19-item questionnaire assessing self-care, respiration and sphincter management and mobility.26
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
Participation in collision sports is implicated in the development of premature cervical spondylosis, which may increase the severity, but not necessarily the frequency, of SCI. Any player sustaining an episode of transient cervical neuropraxia should be screened with an MRI scan to rule out underlying cervical stenosis. RTP decision making should then be made on an individual basis with regard to the sport played.
Older patients presenting with neck pain, loss of cervical range of motion, and subtle changes in gait, balance and fine motor skills should raise suspicion for cervical stenosis and be screened appropriately.
Cutting Edge/ Emerging and Unique Concepts and Practice
Surgical decompression is indicated in those patients with cervical stenosis who fail conservative management. Historically, the ACDF, posterior laminectomy and laminoplasty procedures have been used. In recent years, there has been growing interest in minimally invasive spinal surgeries via endoscopic approaches as a viable option in select patients with cervical stenosis. Studies have shown endoscopic techniques to be as effective as traditional decompressions27-29. Additionally, they are associated with shorter length of hospital stay, less intraoperative blood loss and quicker return to work.27–29 These new techniques, however, have steep learning curves which may deter some surgeons from implementing them into practice.30 Comparative studies are needed to assess for long-term efficacy and potential adverse effects.
The study of biomechanics in collision sports, especially as it pertains to athletes with cervical stenosis, overlaps with the work done in concussion. In vivo biomechanical data has been collected in American football players using accelerometer arrays mounted on players’ helmets to measure the location and magnitude of forces necessary to produce cervical spine and head injuries.31 This data continues to be used to improve the safety profile of protective head gear. Newer in vivo studies of American football players using instrumented helmets and video analysis has provided data that may potentially impact coaching and rule changes, as greater head impact magnitudes have been associated with longer closing distances, especially when players start in a 3-point stance.32
Gaps in the Evidence- Based Knowledge
There is still no consensus on the timing of surgical intervention in older adults with asymptomatic cervical stenosis. Some surgeons advocate for earlier spinal decompression with or without fusion to prevent a catastrophic central cord syndrome, whereas other surgeons prefer to wait until the patient is clinically myelopathic.
RTP guidelines for athletes with underlying cervical stenosis remains controversial. Some experts believe that functional spinal stenosis (ie, a lack of cerebrospinal fluid around the spinal cord on MRI) represents an absolute contraindication to return to contact or collision sports; however, this criterion has yet to be fully evaluated in the literature.22 Others advocate for more liberal allowance to play with previously asymptomatic cervical stenosis.22
- Wolf BS, Khilnani M, Malis L. The sagittal diameter of the bony cervical spinal canal and its significance in cervical spondylosis. Journal of the Mount Sinai Hospital, New York. 1956;23(3):283-292. Accessed March 13, 2021. https://pubmed.ncbi.nlm.nih.gov/13320096/
- Miyazaki M, Takita C, Yoshiiwa T, Itonaga I, Tsumura H. Morphological analysis of the cervical pedicles, lateral masses, and laminae in developmental canal stenosis. Spine. 2010;35(24). doi:10.1097/BRS.0b013e3181e8958f
- Smith SS, Stewart ME, Davies BM, Kotter MRN. The Prevalence of Asymptomatic and Symptomatic Spinal Cord Compression on Magnetic Resonance Imaging: A Systematic Review and Meta-analysis. Global Spine Journal. Published online 2020. doi:10.1177/2192568220934496
- Wang X-R, Kwok TCY, Griffith JF, Yu BWM, Leung JCS, Wáng YXJ. Prevalence of cervical spine degenerative changes in elderly population and its weak association with aging, neck pain, and osteoporosis. Annals of Translational Medicine. 2019;7(18):486-486. doi:10.21037/atm.2019.07.80
- Kelly JC, Groarke PJ, Butler JS, Poynton AR, O’Byrne JM. The Natural History and Clinical Syndromes of Degenerative Cervical Spondylosis. Advances in Orthopedics. 2012;2012:1-5. doi:10.1155/2012/393642
- Lv Y, Tian W, Chen D, Liu Y, Wang L, Duan F. The prevalence and associated factors of symptomatic cervical Spondylosis in Chinese adults: A community-based cross-sectional study. BMC Musculoskeletal Disorders. 2018;19(1):1-12. doi:10.1186/s12891-018-2234-0
- Bednarik J, Kadanka Z, Dusek L, et al. Presymptomatic spondylotic cervical myelopathy: An updated predictive model. European Spine Journal. 2008;17(3):421-431. doi:10.1007/s00586-008-0585-1
- Edwards CC, Riew KD, Anderson PA, Hilibrand AS, Vaccaro AF. Cervical myelopathy: Current diagnostic and treatment strategies. Spine Journal. 2003;3(1):68-81. doi:10.1016/S1529-9430(02)00566-1
- Mccormack BM, Weinstein PR. Cervical spondylosis – An update. Western Journal of Medicine. 1996;165(1-2):43-51. Accessed March 13, 2021. /pmc/articles/PMC1307540/?report=abstract
- Heller JG. The syndromes of degenerative cervical disease. Orthopedic Clinics of North America. 1992;23(3):381-394. doi:10.1016/s0030-5898(20)31752-1
- Penning L. Some aspects of plain radiography of the cervical spine in chronic myelopathy. Neurology. 1962;12(8):518-519. doi:10.1212/wnl.12.8.518
- Torg JS, Guille JT, Jaffe S. Injuries to the cervical spine in American football players. Journal of Bone and Joint Surgery – Series A. 2002;84(1):112-122. doi:10.2106/00004623-200201000-00017
- Denno JJ, Meadows GR. Early diagnosis of cervical spondylotic myelopathy: A useful clinical sign. Spine. 1991;16(12):1353-1355. doi:10.1097/00007632-199112000-00001
- Ebara S, Yonenobu K, Fujiwara K, Yamashita K, Ono K. Myelopathy hand characterized by muscle wasting: A different type of myelopathy hand in patients with cervical spondylosis. Spine. 1988;13(7):785-791. doi:10.1097/00007632-198807000-00013
- Ono K, Ebara S, Fuji T, Yonenobu K, Fujiwara K, Yamashita K. Myelopathy hand. New clinical signs of cervical cord damage. Journal of Bone and Joint Surgery – Series B. 1987;69(2):215-219. doi:10.1302/0301-620x.69b2.3818752
- Côté P, Cassidy JD, Yong-Hing K, Sibley J, Loewy J. Apophysial joint degeneration, disc degeneration, and sagittal curve of the cervical spine: Can they be measured reliably on radiographs? Spine. 1997;22(8):859-864. doi:10.1097/00007632-199704150-00007
- Blackley HR, Plank LD, Robertson PA. Determining the sagittal dimensions of the canal of the cervical spine. Journal of Bone and Joint Surgery – Series B. 1999;81(1):110-112. doi:10.1302/0301-620X.81B1.9001
- Herzog RJ, Wiens JJ, Dillinghamd MF, Sontag MJ. Normal cervical spine morphometry and cervical spinal stenosis in asymptomatic professional football players: Plain film radiography, multiplanar computed tomography, and magnetic resonance imaging. Spine. 1991;16(6S):S178-S186. doi:10.1097/00007632-199106001-00001
- Odor JM, Watkins RG, Dillin WH, Dennis S, Saberi M. Incidence of cervical spinal stenosis in professional and rookie football players. The American Journal of Sports Medicine. 1990;18(5):507-509. doi:10.1177/036354659001800510
- Bosma RL, Stroman PW. Diffusion tensor imaging in the human spinal cord: Development, limitations, and clinical applications. Critical Reviews in Biomedical Engineering. 2012;40(1):1-20. doi:10.1615/CritRevBiomedEng.v40.i1.10
- Ellingson BM, Salamon N, Woodworth DC, et al. HHS Public Access. 2018;28(5):472-480. doi:10.3171/2017.7.SPINE176.Reproducibility
- Triantafillou KM, Lauerman W, Kalantar SB. Degenerative Disease of the Cervical Spine and Its Relationship to Athletes. Clinics in Sports Medicine. 2012;31(3):509-520. doi:10.1016/j.csm.2012.03.009
- Matz PG, Anderson PA, Holly LT, et al. The natural history of cervical spondylotic myelopathy. Journal of Neurosurgery: Spine. 2009;11(2):104-111. doi:10.3171/2009.1.SPINE08716
- Hurwitz EL, Carragee EJ, van der Velde G, et al. Treatment of neck pain: noninvasive interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders. Spine. 2008;33(4 SUPPL.). doi:10.1097/BRS.0b013e3181644b1d
- Davison MA, Lilly DT, Eldridge CM, Singh R, Bagley C, Adogwa O. A comparison of prolonged nonoperative management strategies in cervical stenosis patients: Successes versus failures. Journal of Clinical Neuroscience. 2020;80:63-71. doi:10.1016/j.jocn.2020.07.041
- Catz A, Itzkovich M, Agranov E, Ring H, Tamir A. SCIM – Spinal cord independence measure: A new disability scale for patients with spinal cord lesions. Spinal Cord. 1997;35(12):850-856. doi:10.1038/sj.sc.3100504
- Yuan H, Zhang X, Zhang LM, Yan YQ, Liu YK, Lewandrowski KU. Comparative study of curative effect of spinal endoscopic surgery and anterior cervical decompression for cervical spondylotic myelopathy. Journal of Spine Surgery. 2020;6(Suppl 1):S186-S196. doi:10.21037/jss.2019.11.15
- Ji-jun H, Hui-hui S, Zeng-wu S, Liang Z, Qing L, Heng-zhu Z. Posterior full-endoscopic cervical discectomy in cervical radiculopathy: A prospective cohort study. Clinical Neurology and Neurosurgery. 2020;195. doi:10.1016/j.clineuro.2020.105948
- Ahn Y, Keum HJ, Shin SH. Percutaneous Endoscopic Cervical Discectomy versus Anterior Cervical Discectomy and Fusion: A Comparative Cohort Study with a Five-Year Follow-Up. Journal of Clinical Medicine. 2020;9(2):371. doi:10.3390/jcm9020371
- Morgenstern R, Morgenstern C, Yeung AT. The Learning Curve in Foraminal Endoscopic Discectomy: Experience Needed to Achieve a 90% Success Rate. SAS Journal. 2007;1(3):100-107. doi:10.1016/S1935-9810(07)70054-3
- Broglio SP, Sosnoff JJ, Shin SH, He X, Alcaraz C, Zimmerman J. Head impacts during high school football: A biomechanical assessment. Journal of Athletic Training. 2009;44(4):342-349. doi:10.4085/1062-6050-44.4.342
- Schmidt JD, Guskiewicz KM, Mihalik JP, Blackburn JT, Siegmund GP, Marshall SW. Head impact magnitude in American high school football. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4231
Original Version of the Topic
Todd R. Lefkowitz, DO, Martin Zonenshayn, MD. Cervical stenosis. 7/11/2013.
Previous Revision(s) of the Topic
Todd R. Lefkowitz, DO, Ilana Etelzon, MD. Cervical stenosis. 8/11/2017.
Todd R. Lefkowitz, DO
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Zhi Cheng Chen, MD
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