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Spinal Stenosis

For further information, see CMDT Part 41-03: Spine Problems

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

  • Differential diagnosis

    • Claudication (arterial insufficiency)

    • Disk herniation

    • Lumbar facet joint degenerative arthritis

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

Diagnosis

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

eTable 41–1.Spine: back examination.
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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. Crossover 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. Crossover pain, where sciatica symptoms occur down the opposite leg during a straight leg raise, usually indicates a large disk herniation.

Treatment

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

  • Facet joint corticosteroid injections can also reduce pain symptoms

  • Epidural corticosteroid injections

    • Have been shown to provide immediate improvements in pain and function for patients with radiculopathy

    • However, the benefits are small and only short term

    • Consequently, there is limited evidence to recommend epidural corticosteroids for spinal stenosis

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