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J O U R N A L O F T H E A M E R I C A N C H I R O P R A C T I C A S S O C I A T I O N 9
f you watched the old Carol Burnet...
M A Y 2 0 0 210
Someone with a herniated disc, then, feels pain at differ-
ent times and from different types of activity ...
M A Y 2 0 0 212
Dr. Maurer says. “We’re able to
measure the spinal canal on plain-
film radiographs for con...
clusion that you’re dealing with
stenosis, the question becomes, ‘Is it
a thickened ligament, does it have to
do with a co...
M A Y 2 0 0 214
Finding the source of the stenosis
often dictates the treatment pattern.
In some cases, surgery is the fir...
the greatest effect on that.” Patients
must be informed up front that with
stenosis, they have a chronic, pro-
gressive di...
M A Y 2 0 0 216
sis. When that’s the case, they need to
be removed, as well. Basically, you’re
talking about decompressing...
The Specific Problems of Cervical Stenosis
Stenosis, like many other conditions of the spine, can develop in either the lu...
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The Stenosis Diagnosis: Multiple Factors


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The Stenosis Diagnosis: Multiple Factors

  1. 1. Focus TheStenosis Diagnosis: MultipleFactors
  2. 2. J O U R N A L O F T H E A M E R I C A N C H I R O P R A C T I C A S S O C I A T I O N 9 f you watched the old Carol Burnett Show in the 1970s, you’ll remember Tim Conway’s “little old man.” In a shaggy gray wig, the comedian shuf- fled his way through sketch after sketch. But what Conway probably didn’t realize was that his comic little-old-man gestures were a dead-on impersonation of a relatively common, and often confounding, spinal problem: lumbar spinal stenosis. “That bent-forward, shuffling stance, the tiny steps—it’s classic,” says Edward L. Maurer, DC, DACBR, and a member of the postgraduate faculty in radiology at the National University of Health Sciences. “That’s how I jok- ingly talk about it with my patients—I remind them of the Tim Conway sketches.” The term for it is “simian stance/posture,” a flexed-forward position that helps relieve pressure on the stenotic area by opening up the spinal canal when the person is walking upright. But despite Conway’s perfect mimicry, spinal stenosis—a condition with multifactorial causes as well as clinical man- ifestations—can frequently be overlooked or misdiag- nosed. “Because of its complexity of presentation, the practitioner may overlook stenosis because he’s thinking of an acute circumstance like a herniated disc or something of that nature,” says Dr. Maurer, the author of the spinal stenosis chapter in Mosby’s 1995 Advances in Chiropractic yearbook. “I’ve had numerous conversations with several neurosurgeons about this, and I’d say that the vast majori- ty of these stenosis conditions are under- or misdiagnosed probably half the time. At some point, the practitioner starts to realize that the treatment he’s been rendering for, say, a herniated or degenerative disc isn’t working. That’s when a DC considers an MRI or other studies, and real- izes that spinal stenosis is involved.” But stenosis is one of those conditions that absolutely should not be overlooked or dismissed. Indeed, although population-based studies have not been done to determine its exact prevalence, it is a relatively common condition, says Dr. Maurer. If ignored or undertreated too long, it can lead to irreversible nerve damage. The Signs of Stenosis Stenosis can be most simply defined as a narrowing or stricture of the vertebral or neural canals of the spine. “It can be due to intrinsic changes—changes in the actual structures of the canal—or extrinsic changes, meaning something new came into the canal,” says Ronald Evans, DC, FACO, a senior staff doctor of chiropractic with ICON Whole Health in Des Moines and a trustee with the Foundation for Chiropractic Education and Research (FCER). A quick check on the probability of stenosis as the source of low-back pain can be done using the patient’s age. Stenosis is often a degenerative condition, and it may exist asymptomatically for years before pain begins to set in. “We can categorize incidences of low-back pain almost exactly by the decades in which they occur. When we’re looking at someone 20 or younger, we might think of mechanical disorders of the lower back. For people in their 30s or 40s, the incidence and instances of disc syndromes often rises above all other mechanical disorders. By their 50s and 60s, the incidence of low-back pain takes on degenerative qualities, and we no longer think so much about frank disc protrusions, but stenosis as a very real possibility,” Dr. Evans says. “Stenosis, generally, is a time- dependent, time-driven event in the aging lumbar spine. It develops because of other mechanical problems or abnor- malities.” Clues should appear in the patient’s history. Conditions that might be confused with stenosis, like herniated discs, usually have a rapid and unmistakable onset. “The patient will present with dramatically acute symptoms such as muscle spasms,” says Dr. Maurer. Stenosis, however, is more insidious. “It’s more of a gradual onset with the patient reporting low-back pain for some time, perhaps not even recognizing a precipitating incident, and then just a growing type of discomfort in the extremities. It’s not terri- bly difficult to differentiate clinically if you are alert to it,” he says. Another set of clues comes from the sources of the patient’s pain. One of the most common symptoms of spinal stenosis is neurogenic claudication: pain, numbness, tingling, weakness, or cramping in one or both legs. Usually, the pain begins in the lower back or buttocks and radiates into one or both legs. Again, that’s similar to a common case of sciatica—but stenosis patients have a unique experience. “These are the patients who will describe—classically, this is almost textbook—that leg pain is experienced on the exertion of walking or prolonged standing,” Dr. Evans says. “The typical scenario is a man or woman who goes to the shopping mall and can get all the way into the store, and do a little shopping, but then he or she has to sit down to relieve profound leg pain.” Indeed, sitting down alone doesn’t help; the patient usually will have to lean forward and sit in a flexed position to take the pain away. This contrasts with the patient who has sciatica due to a herniated disc. “They have what’s called arborization of the nerve root by the bulging disc to such a degree that only one or two analgic positions will relieve the pain,” Dr. Evans says. “They stand in an odd position that helps lessen pain. Change that position, and they’re in terrible pain. The spinal stenosis patient, con- versely, has an acceptable range of motion, and the arcs of spinal movement aren’t so acutely painful.” II
  3. 3. M A Y 2 0 0 210 Someone with a herniated disc, then, feels pain at differ- ent times and from different types of activity than some- one with stenosis. “For example, if a patient has pain when standing or walking, that suggests stenosis rather than a herniated disc. With a herniated disc, walking or standing typically reduces pain levels,” Dr. Maurer says. His chart of differential pain patterns (Fig. 1) shows the considerable differences in stenosis pain versus disc pain. Figure 1 Differential Pain Patterns __________________________________________________ Discogenic Activity Low-Back Pain Spinal Stenosis __________________________________________________ Standing/walking Decrease Increase Sitting Increase Decrease Bending Increase No change Lifting Increase No change Valsalva maneuver Increase No change Bed rest Decrease Varies __________________________________________________ Vascular disease may also cause pain, numbness, and weakness in the lower extremities; neurogenic claudication and vascular claudication have similar clinical features. The doctor of chiropractic who thinks his patient may have stenosis will want to be sure to eliminate vascular problems as a possibility. Here again, tracking pain patterns and dif- ferentiating clinical findings offer clues. Claudication caused by vascular disease most often occurs after walking a fixed distance, while patients who have spinal stenosis walk variable distances before symptoms set in. Activities like riding a bike and walking up a hill can cause pain in patients with vascular claudication, while they don’t tend to cause pain in the stenotic patient. On the other hand, standing makes pain worse for stenotic patients, while it relieves vascular claudication. (See Fig. 2) If a patient does have the kind of heavy, leaden, wooden feeling in the lower extremities signaling either neuro- genic or vascular claudication, there’s another syndrome DCs should be wary of: Leriche’s syndrome. “This is a very serious condition stemming from coarctation of the aorta (e.g., atherosclerotic stenosis). It occurs at or below the bifurcation of the abdominal aorta, and when it hap- pens, the area that the aorta serves in the lower extremi- ties no longer has good circulation. It feels just like lum- bar stenosis or nerve compression might feel,” Dr. Evans explains. The consequences of untreated Leriche’s syn- drome can be severe: it’s the precursor to an abdominal aortic aneurysm. “The DC must differentiate by looking for changes in the pulses of the femoral artery and the lower pedal arteries. That’s the big determination. If those pulses are altered, the doctor of chiropractic can assume that more of a vascular event is presenting than some- thing of neurogenic origin.” Finally, imaging techniques can fine-tune your assessment of stenosis. “One of the easiest tools to determine develop- mental or congenital stenosis with anatomical shortening or underdevelopment is plain-film radiography,” continuedFocus Figure 2 Differential Clinical Findings between Neurogenic and Vascular Claudication ___________________________________________________________________________________________ Vascular Neurogenic ___________________________________________________________________________________________ Walking distance Fixed Variable Exercise Worse Variable Relief of pain Standing Sitting-flexed Standing Relief Worse Lying flat Relief Variable Walking uphill Pain No pain Stationary bicycle Pain No pain Sensory Stocking deficits Poorly localized Type of pain Cramp, tightness Numbness, sharp, ache Pulses Absent Present Bruit Present Absent Skin Hair loss Normal Atrophy Rarely Occasionally Weakness Rarely Occasionally Back Pain Uncommon Common Spinal movement limitation Uncommon Worse with hyperextension Genitourinary Impotence Variable ______________________________________________________________________________________________
  4. 4. M A Y 2 0 0 212 continuedFocus Dr. Maurer says. “We’re able to measure the spinal canal on plain- film radiographs for congenital or developmental stenosis by taking the measurement from the posterior margin of the vertebra to the spin- ous-lamina junction (Fig. 3). Anything less than 10 mm is steno- sis.” The normal sagittal diameter, he explains, is approximately 15 mm or more. “When you reach 12 mm, that’s a relative stenosis. At less than 10 mm, you have a frank or an absolute stenosis.” In “either-or” cases, the doctor of chiropractic will turn to MRI or CT scans. The axial views of CT or MR will permit visu- alization of any stenotic narrowing, such as from spondylosis (Fig. 4). Once stenosis is confirmed, these more sophisticated scans can also help narrow down its cause—not always an easy task. CTs and MRIs can also help the doctor of chiropractic determine exactly where the stenosis is occur- ring, a determination that plays a key role in the choice of treatment options. “With MRI and CT, it’s much easier than it used to be to determine whether it’s the spinal canal or the neural canal that’s involved,” Dr. Maurer says. “They’re side by side, and you can have clini- cal expression from either; that’s why imaging is key. If it’s in the neural canal, then it’s far more likely that you need to get into surgery more quickly because smaller things get crowded faster than in the spinal canal.” Detective Work:Tracking Down the Source of Stenosis Once the doctor of chiropractic knows to be alert for it, stenosis is not hard to diagnose. But that’s just the beginning of the detective work. “The real crux of the problem comes with regard to the numerous factors that can cause stenosis,” Dr. Maurer says. Once you’ve come to the con- Figure 3. A: Schematic demonstrating the normal sagittal measurement of the spinal canal. The measurement is taken from the posterior aspect of the vertebral body, or spondylotic intrusion, to the spinous process-laminae junction. B: Line tracing of the spinal canal size and shape in A.1 Figure 4. A: Schematic of normal C6 vertebra. Arrows indicate the normal sagittal measurement taken from the posterior vertebral margin to the spinous process-laminae junction. Note the wide lateral recesses and wide, smooth foraminal canals. B: Spondylotic changes have produced stenosis or narrowing of the vertebral canal with decrease of the sagittal diameter. The lateral recess on the left and the foraminal canals are intruded upon by osteophytic spurs of the articular facet and covertebral joints of Luschka. Note obstruction and obliteration of the foramen transversarium. C: Gross spondylotic changes of the articular facets, mostly on the right, as well as the posterior vertebral margin. Compression and stenosis of the spinal canal, foraminal canals and vascular foramen.1
  5. 5. clusion that you’re dealing with stenosis, the question becomes, ‘Is it a thickened ligament, does it have to do with a congenital or developmen- tal anomaly, degenerative changes, or does it relate to a spinal cord tumor?’” Here’s where the confounding fac- tors come in because the list of sus- pects is somewhat long. “We have to look at issues like an expanding infection abscess. We have to look at vertebral tumors, medullary tumors, extramedullary tumors, fractures of the vertebra or its components, dis- location of the vertebra, and degen- eration of the vertebral motion com- plex,” cites Dr. Evans. Something like an abscess or an infection will require blood work and clinical lab studies to diagnose, while vertebral tumors and spinal tumors will require finely tuned imaging. “A vertebral tumor is a space-occupying mass, so it presents almost exactly like a bulging disc. Medullary and extramedullary tumors are often easily confused or invisible in early stages on plain x- ray, and yet they create exactly the same compression problems neuro- logically as a bulging disc,” Dr. Evans says. “So to best rule these out, the MRI is the imaging element of choice.” J O U R N A L O F T H E A M E R I C A N C H I R O P R A C T I C A S S O C I A T I O N 13 ACA’s Five New Brochures Convey the “Art of Healthy Living” Member Non-member 1 Pack $25 $35 2 Packs $34.96 $48.95 3 Packs $45.27 $63.35 4 Packs $53.76 $75.35 5 Packs $60.65 $84.90 10 Packs $105.30 $147.50 15 Packs $147.45 $206.50 20 Packs $180 $252 More than 20 $8.75/pack $12.25/pack To order your “Art of Healthy Living” brochures today, call 800/368-3083 and request the product code below. “About Chiropractic” – AHL-AB1 “Common Problems for Everyone” – AHL-CPE2 “The Human Body” – AHL-HB3 “Chiropractic for Everyone” – AHL-CE4 “Chiropractic Techniques” – AHL-CT5 ACA. Your solutions start here. ACA’s new brochure series titled, “The Art of Healthy Living: A Consumer’s Guide to Chiropractic Care” includes helpful hints and research that every patient should know about the chiropractic profes- sion, care and treatment. And now, these five colorful, easy-to-read brochures will help patients understand why so many Americans are satisfied with the care they receive from doctors of chiropractic. “Chiropractic for Everyone” includes information about chiroprac- tic care for seniors, expectant mothers, employers and children. “About Chiropractic” answers some of the most frequently asked ques- tions about the efficacy of chiropractic and spinal manipulation. “The Human Body” brochure includes detailed information on how and why chiropractic care can work to correct disorders in the neuromuscu- loskeletal system, allowing the body to heal itself. “Common Problems and Treatments” briefly addresses the most common spinal disorders, such as headaches and carpal tunnel syndrome, and what research shows about the efficacy of chiropractic for these problems. Lastly, “Chiropractic Techniques” walks you through your first visit to a doctor of chiropractic and the unique “art” of spinal manipulation. These brochures can make a wonderful addition to your chiroprac- tic office. Want to learn more? Interested in stocking up? The flyers are packaged in packs of 20 – one topic flyer per package.
  6. 6. M A Y 2 0 0 214 Finding the source of the stenosis often dictates the treatment pattern. In some cases, surgery is the first and only option. “If you have loss of bowel and bladder function, or paresthesias that are creating serious lower-extremity pain and claudica- tion, then you want to go right to surgery—you don’t want to mess around with it. And of course, in the case of spinal cord tumors, you defi- nitely want to investigate that quick- ly,” Dr. Maurer says. Some 30 percent of cases result from grave disorders. Dr. Evans includes expanding abscesses; vertebral, medullary, and extramedullary tumors; and fractures and disloca- tions in this category. “These are all conditions with a high risk of mov- ing toward paraplegia and perma- nent radiculopathies as the disease progresses, or as the canal stenosis becomes more severe,” he says. “These are syndromes that are irre- versible, so once these symptom pic- tures are identified, practitioners have to move on to immediate inter- ventions, such as surgery.” Treatment Tactics There are three basic treatment par- adigms for spinal stenosis, says Dr. Maurer: the medical approach, which frequently involves bed rest, analgesics, local heat, and muscle relaxants; the conservative approach, using chiropractic and self-care tech- niques; and surgery. As noted, certain cases of stenosis, such as those resulting from tumors, immediately put the patient on the road to surgery. But the majority of cases of spinal stenosis—about 70 percent—are of degenerative ori- gin. These are amenable—at least to a point—to conservative manage- ment. “The average patient that comes in with lumbar stenosis is having leg pains and continuing pain and discomfort in his low back and legs. He finds an increase in pain while standing. He can’t go to the grocery store with his wife any longer. The only thing that gives relief is sitting,” Dr. Maurer says. In these cases, the medical approach may be temporarily effective, but it will not address the cause of stenosis and can only be pursued for a limit- ed time before side effects appear or symptoms worsen. Degenerative canal stenosis can be treated conser- vatively through chiropractic, but not forever. “Even spinal manipula- tion will not afford a permanent cure, but it will often delay or put off surgical intervention. If, through manipulation, you can maintain the mobility of the joints affecting the stenotic area, you can often reduce pain expression, help increase the mobility of the joint and the function at the level of involvement, and allow the patient to maintain a rea- sonable lifestyle for many years without the need for surgical inter- vention.” Without spinal manipulation, how- ever, a typical spinal stenosis patient will go to a physician and be pre- scribed painkillers. “The next thing you know, he’s in surgery in a rela- tively short period of time, maybe one to three years. With the conserv- ative process, he may go for years and never require surgery, depend- ing on the degree of involvement and pain expression,” Dr. Maurer says. Spinal stenosis patients generally respond well to soft-tissue manage- ment of the low back and any of the classic physical therapies of ultra- sound and muscle stimulation to relieve secondary muscle spasms. “They also do respond to manipula- tive care to the low back, but gener- ally manipulation of the low back is not addressing the primary disor- der,” Dr. Evans says. “These are dis- orders of infolding of the ligamen- tum flava in the vertebral elements and disorders of osteophytic forma- tion of the facet joint, so that long- lever manipulation of the low back doesn’t solve as much of the problem as the doctor of chiropractic would like it to.” The Flexion-Distraction Solution So if routine manipulation provides only temporary, symptomatic relief, what is another useful option for the stenotic patient? Dr. Evans suggests Cox flexion-distraction techniques: long-axis flexion and distraction of the lumbar spine. “The joints are unloaded in long-axis traction, and then we have slight flexion, which removes the offending extension of the low back. The patient is then given a home exercise program,” he says. “He’s often put into pelvic tilt exercises to strengthen the stomach muscles, keeping the lumbar spine flat. We put patients in a typical rest- ing position at least once a day, lying on the floor with the legs on a foot- stool or chair in a 90-90 position for 30 minutes.” But you will reach a point in many cases, says Dr. Maurer, where steno- sis progresses to a point that it’s con- tinually encroaching on the spinal structures, and flexion-distraction and other conservative management techniques reach the limit of their usefulness. Even in the best-case scenarios, Dr. Evans adds, the patient can expect only about a 50 percent recovery. “The best recovery is when we can get a reduction of, or even absence of, the leg discomfort. The back pain can only be reduced tem- porarily. When patients are up and moving around, it comes back,” he says. “But leg pain is strictly a func- tion of how inflamed the nerve roots are from stenosis, and that’s the part that the doctors of chiropractic have to be concerned with. They can have continuedFocus
  7. 7. the greatest effect on that.” Patients must be informed up front that with stenosis, they have a chronic, pro- gressive disorder: the primary cause is not going to “get better.” “A lot of this is also predicated on where Torg ratios on x-ray are. Even before beginning care, if the Torg ratios on x-ray are below 4:5, you’ve already got a losing battle. We always try, but all parties concerned know that we’re already behind the eight ball here, and the probability of suc- cess is lower and lower,” Dr. Evans says. “But we do try on behalf of the patient because surgical intervention can be problematic and some patients just aren’t good candidates.” By the time a doctor of chiropractic sees stenosis patients, many of them may be in their 60s or 70s, with co-morbid conditions like diabetes or heart dis- ease make them poor surgical candi- dates. Dr. Maurer works frequently with a number of neurosurgeons in his area. “When we reach a point in the care of a patient with stenosis where the symptoms are continuing or worsen- ing, then we’ll do an MRI and con- sult with the neurosurgeon. Between the two of us, we arrive at a conclu- sion as to whether continuing conser- vative treatment is warranted,” he says. “I have no qualms about that once we’ve reached that point.” When It’s Time for Surgery When a patient can no longer go through the basic activities of daily living without intolerable pain, when his or her walking and standing endurance continues to decline, or when major, progressive neurological deficits appear, surgery is usually the next alternative. Fortunately, since spinal stenosis usually progresses on a fairly slow timeline, it can often be put off with conservative manage- ment for quite some time, Dr. Maurer notes. “The whole idea of operating on stenosis is based on the absolute fail- ure of conservative therapy, and I mean that in all sincerity,” agrees R. Harris Russo, MD, FACS, a neu- rosurgeon in private practice in Michigan and a former faculty mem- ber of the University of Michigan’s neurosurgery department. “It’s very rare for lumbar stenosis to paralyze the patient or put him into a wheel- chair, so the operation is not really designed to protect from paralysis but to get the patient back into the work force or into activities of daily living.” He urges the doctor of chiro- practic to abide by rigid criteria when considering whether to refer a steno- sis patient for surgery: progressive loss of function, progressive pain, and inability to walk. The decision to operate, Dr. Russo says, is “probably a bigger deal than the operation itself.” Surgery, when indicated, usually involves decom- pression of the stenotic area. “You want to open up the spinal canal and decompress the neural elements,” Dr. Russo explains. The standard operation used in most spinal stenosis cases is known as a decompression laminectomy. “One removes the posterior elements, the spinous processes, the lamina, and the facet joints,” Dr. Russo says. “This is the classic approach to steno- sis—the removal of those bony struc- tures. Underneath those structures, the normal supporting ligaments— the ligamenta flavum—are often very thick, and they compound the steno- J O U R N A L O F T H E A M E R I C A N C H I R O P R A C T I C A S S O C I A T I O N 15
  8. 8. M A Y 2 0 0 216 sis. When that’s the case, they need to be removed, as well. Basically, you’re talking about decompressing nervous tissue that is under pressure. You do the least amount of damage and injury by doing the most effective and the shortest operation.” Dr. Russo notes that there are other surgical options, but in most cases, he advises the decompression laminecto- my. “There are other, more theoretic, ways of doing this. For example, one option is to remove the posterior ele- ments en bloc and then wire them back in.” The advantage with this type of surgery is that the patient has, to a degree, a reconstituted spinal canal; but the operation is significantly more complicated and takes a lot longer. “Some neurosurgeons do this because they’re hoping to prevent further instability developing as a result of the operation, so they attempt to reconsti- tute the normal anatomy of the spine. There’s a lot of controversy about that, and, to my mind, there really aren’t any indications for it,” Dr. Russo says. What are your patient’s odds of recovery after surgery for stenosis? Most patients have good or even excellent results, Dr. Maurer says, returning to most types of work, shopping, walking, and other daily activities with little pain. But even in the best-case scenarios, they’re not likely to be able to do everything they otherwise would. Strenuous lifting, prolonged walking or sitting, and long-distance car rides can often cause serious flareups of the old symptoms. The worse the symptoms were before surgery and the longer they persisted, the more likely it is that the postoperative results will be less than optimal. “The surgery itself, in good hands, is relatively curative,” Dr. Russo says. “What we’re really concerned about is picking stenosis up early, and pre- venting the progressive loss and pro- gressive pain, particularly because you’re dealing with an older popula- tion. In the face of heart disease and hypertension, once you lose these muscles and the ability to walk, the patient is way behind—no matter what you do in the future.” w Reference 1. Maurer EL. Practical Applied Roentgenology. 1983. continuedFocus Practice Promotion Tool Kit From sections on public and media relations to advertising in the print and broadcast media, this kit con- tains an unprecedented collection of tips and information you need to help your practice stand out in the crowd. Features include: • Advertising slicks • Tips on effective community outreach • Charts and graphs to use in presentations • Sample news releases and speeches • Patient education fact sheets • Radio public service announcements • Tips on dealing effectively with the media • A media spokesperson handbook to help you answer the “tough” questions • Background, research and other resources to help you craft your own practice promotion Order Item PPTK. ACA Member Price: $45.00 Non-Member Price: $95.00 To order, call 800/368-3083.
  9. 9. The Specific Problems of Cervical Stenosis Stenosis, like many other conditions of the spine, can develop in either the lumbar or the cervical spine. Lumbar stenosis is more common, but stenosis of the cervical spine can have far more severe consequences. “The neck is such a vital pipeline that if we have stenosis of the cervical canal, the consequences are magnified, compared to lum- bar stenosis. Everything rises on an order of magnitude as compared to the low back,” Dr. Evans says. Canal stenosis in the cervical spine can cause pain, but it can also produce a phenomenon called rhizalgia. In such cases, the patient feels pain on the same side of the body—in the arm, down the back, and into the leg. “We know, at that moment, that that patient has some space-occupying mass pressing hard enough on the neural tissue to produce arm and ipsilateral pain,” Dr. Evans says. “That can be a disc or canal stenosis. Again, in orders of magnitude, it can go from a radiculopathy to something much worse. If the ultimate consequence of stenosis can be paraplegia for lower extremities, it can be quadriplegia for cervical spine stenosis, or spinal cord stroke because of compression in the canal.” Depending on where the cervical stenosis occurs, death is a possibility. “This is where prompt advanced imaging is absolutely imperative,” Dr. Evans says. One clinical sign, in particular, immediately moves everything to the advanced imaging stage. This is Lhermitte’s sign. “When it’s positive, you assume it demonstrates myelopathy of the cervical spine, meaning that there’s something wrong with the spinal cord,” he says. “In the past, everybody had taken that to mean multiple sclerosis. It is not; it only means there is myelopathy of the cervical spine, and something is encroaching on the cervical spinal cord.” What is Lhermitte’s sign? When the patient, in a sitting position, sharply flexes the chin to the chest, he or she experiences electrical sen- sations or paresthesia into the upper extremities and/or the lower extremities. “Patients who tell me that whenever they look down at a magazine they get paresthesias into their arms and can also feel it in their toes, that’s a positive Lhermitte’s sign,” Dr. Evans says. “If I can reproduce that in the clinic, then I’m looking at getting a prompt MRI for that patient before anything else.” J O U R N A L O F T H E A M E R I C A N C H I R O P R A C T I C A S S O C I A T I O N 17