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Key Features

  • Pain is usually worse with back extension and relieved by sitting

  • Occurs in older patients (aged 50 years or older)

  • May present with neurogenic claudication symptoms with walking

Clinical Findings

  • Osteoarthritis in the lumbar spine can cause narrowing of the spinal canal

  • A large disk herniation can also cause stenosis and compression of neural structures or the spinal artery, resulting in "claudication" symptoms with ambulation

  • Pain that worsens with extension

  • Reproducible single or bilateral leg symptoms that are worse after walking several minutes and that are relieved by sitting (termed "neurogenic claudication")

  • Patients often exhibit limited extension of the lumbar spine, which may reproduce the symptoms radiating down the legs

Diagnosis

  • Thorough neurovascular examination is recommended (eTable 41–1)

  • Differential diagnosis

    • Claudication (arterial insufficiency)

    • Disk herniation

    • Lumbar facet joint degenerative arthritis

    • Sacroiliitis (eg, ankylosing spondylitis, epidural abscess or tumor, piriformis syndrome)

eTable 41–1.Spine: back examination.

Treatment

  • Flexion-based exercises demonstrated by a physical therapist can help relieve symptoms

  • Epidural or facet joint corticosteroid injections can also reduce pain symptoms

  • However, patients who received epidural steroids had less improvement at 4 years among all patients with spinal stenosis and were associated with longer duration of surgery and longer hospital stay

  • Surgical treatment options include

    • Spinal decompression

    • Nerve root decompression

    • Spinal fusion

  • Some evidence suggests that instrumentation (adding surgical hardware to a ...

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