Foraminal stenosis (cervical, lumbar): What to do?

foraminal stenosis

Foraminal stenosis is the narrowing of the intervertebral foramen located between 2 vertebrae superimposed. It is a frequent cause of vertebral pain (cervical pain, lumbago, etc.), although its presence is not always synonymous with pathology.

What is foraminal stenosis, and what causes it? Should we be worried about this diagnosis? How to treat it? This article serves as a guide if ever your doctor gives you this diagnosis.

Definition and anatomy (reminder)

Before discussing foraminal stenosis, it is worth reviewing some basic anatomy to help you better understand this condition.

La spine is separated into vertebrae cervical, dorsal and lumbar. The vertebrae are notably connected together by the intervertebral disc and facet joints. Between each vertebrate, there is an opening called the intervertebral foramen. These allow the nerve roots originating from the spinal cord to pass through the opening to go to various parts of the body, and provide sensory and motor function there.

In foraminal stenosis, the opening formed by the intervertebral foramen is reduced for one reason or another (which we will see later). As there are nerves passing through this foramen, a narrowing at this level can cause nerve irritation and other problems leading to neck pain, back pain, radiculopathy, etc.

Types of foraminal stenosis

Foraminal stenosis can occur anywhere along the spine :

Cervical foraminal stenosis: It occurs at the level of the cervical spine. It is quite common, mainly because the neck is one of the most mobile segments of the body. This element, in addition to the role of support for the head, makes the cervical vertebrae potentially the site of pathology leading to the narrowing of the intervertebral foramina.

Dorsal (thoracic) foraminal stenosis: She touches the dorsal column. This is the least likely type of foraminal stenosis. When it occurs, it can affect the shoulders and rib cage.

Lumbar foraminal stenosis: This is another common type of foramen stenosis. As it must support the weight of the body, the lumbar spine is frequently the site of pathology that can cause narrowing of the interverbal foramina of the lumbar vertebrae.

Causes

It is important to mention that natural aging can lead to the development of foraminal stenosis. Indeed, the wear and tear of everyday life on the vertebrae regularly causes degenerative changes (such as osteophytes or osteoarthritis), and narrowing of the intervertebral foramina in a significant percentage of the population.

Besides normal aging, certain injuries can predispose to foraminal stenosis, especially in younger people. A disc pathology can for example exert pressure on the level of the foramen and cause nervous irritation of the corresponding nerves.

Here is a list of spine-related conditions that can cause foraminal stenosis:

Symptoms and diagnosis

One can imagine that a foraminal stenosis automatically generates vertebral pain. However, this is far from being the case, and many people have foraminal stenosis without feeling the slightest symptoms. This is probably due to the tremendous adaptability of the human body, and the fact that the stenosis does not cause inflammation or nerve compression.

Nevertheless, it is usually neck or lumbar pain that prompts people to seek medical attention. This pain may be accompanied bynumbness or tingling of the arms (cervical origin) or legs (lumbar origin).

If foraminal stenosis is suspected, the doctor will typically start with a physical exam where they will assess movement, strength, reflexes, and other elements of the neurological exam. This will also make it possible to assess the impact of pain on daily and professional activities.

To clarify the diagnosis, the doctor will order tests formedical imaging. These possibly include:

  • An X-ray to observe the alignment of the vertebrae, the presence of osteophytes, the narrowing of the intervertebral foramina, etc.
  • Magnetic resonance imaging (MRI) to detect soft tissue damage, such as ligaments, discs, etc.
  • A CT scan similar to x-ray but showing more detail
  • Electromyography (EMG) to check nerve integrity, and explain whether symptoms radiating to the limbs come from nerve damage or not.
  • A bone scan to detect certain conditions such as a fracture, infection, tumor, etc.

When foraminal stenosis is detected on imaging, it is often assigned a grade corresponding to the level of narrowing of the intervertebral foramen.

  • Grade 0: no foraminal stenosis
  • Grade 1 = mild stenosis with no evidence of nerve root damage
  • Grade 2 = moderate stenosis without nerve root irritation
  • Grade 3 = severe foraminal stenosis with nerve root irritation

Treatment

Depending on the cause and severity of symptoms, treatment will be tailored to each individual with foraminal stenosis.

If the condition is not accompanied by any pain, there is no reason to put forward a curative treatment. Simple preventive advice related to posture, physical activity and the adjustment of activities will be recommended by the health professional.

In the presence of spinal stenosis symptoms, the following modalities will relieve symptoms and improve quality of life:

Rest and adjustment of activities

In the presence of significant pain limiting daily activities, temporary rest may be recommended. On the other hand, excessive rest could increase joint stiffness, cause muscle weakness and ultimately slow healing and worsen symptoms.

With this in mind, a health professional can suggest that his patient adjust his activities so as to remain active without increasing the pain. This includes in particular the avoidance of risky movements, as well as the movements and activities to be recommended to relieve the symptoms.

heat and ice 

In general, the use of cold compresses when the pain is significant (acute phase), followed by hot compresses or a heating pillow, can help reduce inflammation and reduce muscle tension, particularly responsible for pain.

To know in detail the difference between heat and ice, see the following article.

Physiotherapy (physiotherapy)

Therapeutic exercises can be prescribed by a physiotherapist to release nerve pressure, increase flexibility and tone the muscles surrounding the spine.

Also, massages and mobilizations can help relieve symptoms, improve the quality of movement and prevent future spinal damage.

Accessories and products

In addition to the treatments mentioned above, there are several products and accessories available on the market to relieve pain related to foraminal stenosis. It should be remembered that these tools generally provide temporary relief, and should be used sparingly.

Among the products recommended by our professionals, we have for the cervical region:

And for the lumbar region:

pharmaceuticals

Different types of medications can be used to relieve pain caused by foraminal stenosis. To learn all about the role of medication in the presence of back pain, see the following article.

Infiltration

The objective of the infiltration is to reduce inflammation locally, and to relieve pain. It is usually prescribed when the previously named modalities have not brought significant relief, and the symptoms limit the activities of daily living.

To learn more about the types of infiltration possible in the presence of low back pain, see the following article. 

surgery

If conservative treatments (including infiltration) do not relieve your symptoms, the next step is to consider surgery. On the other hand, it is not indicated at all times, and the type of surgery will depend on the location of the stenosis and its cause.

Indication: When to operate a foraminal stenosis ?

foraminal stenosis severe can be an emergency, as the compressed nerve can cause loss of function or sensation in the affected limb. If conservative methods such as drugs, injections, and physical therapy (physiotherapy) have failed to relieve symptoms, a surgical intervention can be indicated.

The goal of surgery is to remove the tissue causing the compression and restore normal function. In some cases, a graft may be needed to support surrounding tissue. The surgery of the foraminal stenosis usually relieves symptoms and restores function.

What are the types of operation of the foraminal stenosis ?

A type of surgery for foraminal stenosis is the laminectomies. A laminectomies involves removing the lamina, which is the back part of the vertebrate. This type of surgery is often done to relieve pressure on the spinal cord or nerves. A laminectomy can be performed as open surgery or minimally invasive surgery. Minimally invasive surgery uses smaller incisions and special instruments.

Another type of surgery for spinal stenosis is foraminotomy. A foraminotomy involves widening the foramen, which is the opening through which the nerve root exits the spine. This type of surgery is performed to relieve pressure on the nerve root. A foraminotomy can be performed in open surgery or minimally invasive surgery. Minimally invasive surgery uses smaller incisions and special instruments.

The third type of surgery for foraminal stenosis is the decompression, which involves removing the tissue that is pinching the nerve. This may be open surgery or minimally invasive surgery, the latter using smaller incisions and more specialized tools.

Procedure of the operation of a foraminal stenosis

In the event of an operation of the foraminal stenosis, a surgeon who specializes in spine surgery will need to be involved. Surgery is generally performed only when the previously proposed drug treatment is no longer sufficient. Surgery can also be performed in cases of severe neurological damage.

The goal of minimally invasive surgery is to widen the foramen to eliminate compression. Endoscopic spinal surgery can be performed by making a small 2-3mm incision. The surgeon will then spread the muscles of the back and will be able to observe and carry out the decompression using the Endospin.

The operation is almost always performed under general anesthesia. Although all surgical intervention involves some risks, this procedure is generally safe and effective in relieving pain and improving function.

What are the risks ?

Each time a surgical intervention is practiced, it carries risks. It is important that patients are aware of these risks before undergoing any type of procedure. The risks of surgery vary from patient to patient, depending on their history and medical condition. However, some risks are common to all patients.

These can include a risk of partial or complete paralysis, temporary or permanent sensitivity problems and an increased risk of infection. Above all surgical intervention, it is essential that patients understand the risks involved and make an informed decision to proceed with the operation.

What about natural remedies?

Like accessories and anti-back pain products, natural products and grandmother's remedies are very popular with people suffering from back pain.

Often, these remedies include anti-inflammatory properties to relieve various body pains.

On the other hand, it should be noted that most of these natural products are not scientifically proven. It is therefore important to speak to your doctor before using them, particularly to avoid any interaction with your medications.

Natural remedies that may relieve symptoms include (click on the product you are interested in for purchasing options):

Turmeric

Thanks to its antioxidant and anti-inflammatory powers very powerful, turmeric is one of the most used plants in a culinary and therapeutic context. The composition of turmeric is essentially made of essential oils, vitamins (B1, B2, B6, C, E, K) and trace elements. But it is to its composition rich in curcumin and curcuminoids that we owe them and calm skin of this spice.

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Ginger

In addition to the particular flavor it brings to cooking and its aphrodisiac properties, ginger is a root well known for its anti-inflammatory powers. THE gingerol gives it its anti-inflammatory action. It is an active component acting on the inflammatory pain related to chronic joint inflammatory diseases, including rheumatoid arthritis, lupus, rheumatic diseases, etc. It has been proven that this active element is also effective in acting on the inflammation linked to arthritis and sciatica. Ginger also has other benefits thanks to its high potassium content and its richness in trace elements (calcium, magnesium, phosphorus, sodium) and vitamins (provitamin and vitamin B9).

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Omega-3

Omega-3s are polyunsaturated fatty acids that play a very important role in the functioning of our body. They are provided by food in three natural forms: docosahexaenoic acid (DHA), alpha linolenic acid (ALA) and eicosapentaenoic acid (EPA). Beyond their action on the brain and the cardiovascular system, omega-3s prove to be very effective against inflammation. Indeed, they have the ability to act on the inflammatory mechanisms in osteoarthritis by slowing down cartilage destruction, thus they reduce the intensity of osteoarthritis pain. Since sciatica is most often linked to inflammation secondary to a herniated disc, it can also respond to omega-3s if you consume them regularly. 

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Lemon eucalyptus

Eucalyptus is a plant most often used in the form of herbal tea or essential oil. She would have anti-inflammatory effects which give it the ability to act on the bone and joint pain in general and the pain of sciatica in particular.

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wintergreen

Wintergreen is a shrub from which a very interesting essential oil is extracted. It is one of the essential oils most used in aromatherapy. This oil, extracted from the shrub of the same name, is used in massage to relieve sciatica and act like a analgesic. Indeed, it provides a heating effect thanks to its ability toactivate blood circulation locally.

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Evolution of foraminal stenosis (prognosis)

La foraminal stenosis is a progressive condition, meaning it gets worse over time. However, the rate at which it progresses varies from person to person. In some people, the narrowing of the foramen may be so slow that they remain asymptomatic (without symptoms) for years. In others, the progression can be accelerated by certain factors, such as:

  • Excessive physical activity;
  • Osteoporosis;
  • Connective tissue disorders;
  • Aging.

Moreover, the radiological evolution of a foraminal stenosis is not always proportional to the seriousness of the situation. In other words, even if the imaging shows changes in the spine, it doesn't necessarily mean the pain is going to get worse.

The symptoms of foraminal stenosis depend on the level of inflammation and nerve damage. With treatment, most people with foraminal stenosis can manage their pain and live a relatively normal life.

References

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