What is spinal stenosis caused by the ligamentum flavum?

One of my clients just went for a MRI and was diagnosed with spinal stenosis due a hypertrophy or thickening of ligamentum flavum. As a chiropractor, we do work with cases like this as it over leads to back pain as well as numbness and tingling in the limbs. Today, we discuss what is spinal stenosis and what you should know about it.

What is spinal stenosis?

Spinal stenosis, strictly speaking, refers to the narrow of the spinal canal. It is often categorised as mild, moderate, or severe depending on the extent of the narrowing. There are various structures that can contribute to this narrow. The most common causes are bony growth from conditions such as osteoarthritis, disc herniations, and thickening of ligaments.

spinal stenosis, mri, back pain
Spinal stenosis is often diagnosed from MRI. The severity is determined by how much narrowing has occurred. For mild cases, less than narrowing is a third or less while for severe cases, there is more than two-thirds of narrowing.

Because osteoarthritis and disc herniations is associated with increasing age, most people who are diagnosed with spinal stenosis tend to be older. This does not mean young people cannot get spinal stenosis. The youngest clients we have seen with MRI-confirmed spinal stenosis and myelopathy are in their 20s. However, younger patients tend to have less symptoms and disability.

Symptoms of spinal stenosis occurs when the narrowing creates pressure on the spinal cord. The symptoms can range from pain, numbness and tingling to muscle weakness.

What causes osteoarthritis and disc herniations?

To be honest, the pathogenesis (i.e., cause) of disc herniations and osteoarthritis is unclear. It is known that osteoarthritis is associated with aging. However, contrary to popular belief, osteoarthritis has nothing to do with wear and tear. Recent research is very clear on that. The exact mechanism to how it occurs is still unknown.

disc herniation, neck pain
Disc herniation occurs when the soft, gel-like center (nucleus pulposus) of an intervertebral disc in the spine pushes through a weakened or damaged outer layer (annulus fibrosus). This can occur in the neck, upper back or low back.

The risk factors of osteoarthritis include obesity and a sedentary lifestyle. What this tells is is that osteoarthritis is potentially modifiable. Joint injury is also a contributor to the disease. Therefore, keeping good spinal health and physical conditioning to reduce risk of joint injuries can reduce osteoarthritis risk.

For disc herniation, the understanding is slightly clearer. The current consensus is that disc herniations occur due to a weakening of the annulus fibres on the outside of the disc. This weakening results in a reduction in forces to hold the nucleus pulposus in, which results in a disc herniation.

What is the ligamentum flavum?

The ligamentum flavum is a ligament that runs down the spine on the inside of your spinal canal. It is a long and thick ligament that helps to support your spine, especially when you are bending over in flexion.

It is hypothesised that with age, the ligament loses its elasticity, which leads to its thickening (i.e., hypertrophy). The thickening can be caused by proliferation of type II collagen, ossification (i.e., hardening into a bony tissue), or calcium crystal deposition.

With excessive thickening, the patency of the spinal canal can be affected.

The key to maintaining a healthy ligamentum flavum is not to avoid flexion or exercise altogether. Instead, you are looking to participate in exercises that are suitable to your current fitness, including spinal fitness, without causing unnecessary stress to your spinal ligaments.

What is the best treatment for spinal stenosis?

In the short term, the fastest symptom relief will be with medication and avoiding movements or activities that aggravate your symptom experience. Once your symptoms start to improve, the recommendation is to return to some form of exercising as soon as possible. It is important to always exercise within your capacity and to not cause any further unnecessary stress to the affected areas.

Extended rest and avoidance of physical activity is not recommended as it will lead to weakening of your muscle and joints, and even muscle atrophy. This is particularly problematic as poorer fitness will lead to a reduce capacity for activities of daily living, which ultimate lead to more stress to the spine and an increased risk of injury.

Supervised exercise with a clinical professional will allow you to exercise safely within your limits. In doing so, you are able to enjoy the benefits of exercising without worsening your current condition.

When it comes to medication, muscle relaxants and NSAIDs are the most commonly prescribed drugs in Singapore. Muscle relaxant include drugs such as Anarex, which contains paracetamol and orphenadrine. NSAIDs are available in oral form (e.g., celecoxib, diclofenac). Topical applications include plasters (Salonpas Diclofenac 1%, KefenTech) and gels such as Voltaren and Fastum.

Is spinal stenosis a serious condition?

Yes and no. Most people with spinal stenosis have mild to moderate symptoms that can be managed with conservative treatments like exercise therapy or medication (if required). Lifestyle inventions to include appropriate exercises and also avoiding activities that may aggravate it can further improve long-term success.

For those with more severe stenosis, surgery may be required. In decompressive laminectomy, the lamina (part of your vertebrae bone) is removed together with any bony outgrowth or ligaments that are compressing the spinal cord. The removal increases the patency of the spinal canal, and relieves pressure on the spinal cord. If appropriate, minimally invasive spine surgery may also be an option. In such procedures, a keyhole approach using tubular retractor and a microscope reduces the damage to the surrounding tissue resulting in faster recovery times.

It’s essential for individuals with spinal stenosis to work closely with healthcare professionals to manage their condition effectively and prevent it from worsening. Early diagnosis and appropriate treatment can help improve symptoms and quality of life.

Can I live a full life with spinal stenosis?

Yes, it is possible for you to have spinal stenosis without symptoms. The ability for you to achieve pain-free living will depend on the severity of your stenosis as well as your physical health and lifestyle.

The condition of concern when it comes to spinal stenosis is myelopathy. Myelopathy refers to an injury to the spinal cord due to compression. However, this is a very rare disease. Myelopathy affects only one in every 30,000 people. For those with stenosis? Approximately 3%. Still very low!

If you have been recently diagnosed with spinal stenosis and you are not sure what to do, do reach out to us with a copy of your imaging report. While spinal conditions and pain can seem very serious, conservative care can help for most cases.



Frustrated by the lack of results-driven and ethical chiropractic clinics in Singapore, Chiropractor Jesse Cai found Square One Active Recovery to deliver meaningful and sustainable pain solutions.

Our goal? To make our own services redundant to you.

*We do not offer temporary pain relief such as chiropractic adjustments, dry needling, or any form of soft tissue therapy.