Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 41-03: Spine Problems + Key Features Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ ++ 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 Download Section PDF Listen +++ ++ 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) ++Table Graphic Jump LocationeTable 41–1.Spine: back examination.View Table||Download (.pdf)eTable 41–1. Spine: back examination. Maneuver Description Inspection Check the patient's posture in the standing position. Assess for hyperlordosis, kyphosis, and scoliosis. Palpation Include important landmarks: spinous process, facet joints, paravertebral muscles, sacroiliac joints, and sacrum. Range of motion testing Check range of motion actively (patient performs) and passively (clinician performs) especially with flexion and extension of the spine. Rotation and lateral bending are also helpful to assess symmetric motion or any restrictions. Neurologic examination Check motor strength, reflexes and dermatomal sensation in the lower extremities. Straight leg raise test The patient lies supine and the clinician elevates the patient's leg. A positive test for sciatica pain is classically described as "electric shock"-like pain radiating down the posterior aspect of the leg from the low back. This can occur in the setting of a disk herniation or degenerative conditions causing neural foraminal stenosis. Cross-over pain, where sciatica symptoms occur down the opposite leg during a straight leg raise, usually indicates a large disk herniation. Indirect straight leg raise test The patient sits on the side of the exam table with the knees bent. The clinician extends the knee fully. A positive test for sciatica pain is classically described as "electric shock"-like pain radiating down the posterior aspect of the leg from the low back. Cross-over pain, where sciatica symptoms occur down the opposite leg during a straight leg raise, usually indicates a large disk herniation. + Treatment Download Section PDF Listen +++ ++ 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 spinal fusion) leads to a higher fusion rate, but there is no evidence that it makes any difference to clinical outcomes A Cochrane review showed surgery was not clearly better than nonsurgical treatment and had complication rates of 10–24% compared to 0% for nonoperative treatments; thus, the role of surgery for spinal stenosis is limited