Lumbar Spinal Stenosis

Aka: Lumbar Spinal Stenosis, Lumbar Canal Stenosis, Lumbar Stenosis, Cauda Equina Pseudoclaudication, Neurogenic Claudication, Pseudoclaudication

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II. Epidemiology

  1. Age typically >50 years

III. Pathophysiology

  1. Chronic degenerative condition (esp Osteoarthritis)
    1. See risk factors below for associated conditions
    2. Most commonly associated with Osteoarthritis
    3. Lumbar degenerative disc disease often precedes Lumbar Spinal Stenosis
      1. Lumbar Vertebral disks collapse and destabilize the anterior Vertebral Column
        1. Weight is offset posteriorly onto facet joints, interspinous ligament, and ligamentum flavum
      2. Facet joints hypertrophy and osteophytes form
        1. Narrows the central canal and neuroforaminal canals
      3. Degenerative Spondylolisthesis
        1. Further contributes to spinal canal stenosis
  2. Degenerative changes contributing to Lumbar Spinal Stenosis
    1. Facet joint hypertrophy
    2. Ligamentum flavum hypertrophy
    3. Vertebral degeneration
    4. Intervertebral Herniated disc
    5. Spondylolisthesis
  3. Results in narrowed spaces enclosing spinal neurovascular structures
    1. Results in the Pseudoclaudication (buttock and Lower Extremity Pain worse with walking, standing, extension)
  4. Images
    1. LumbarSpineStenosis.gif

IV. Risk Factors

  1. Osteoarthritis (most common)
  2. Congenitally narrow canal (13 mm)
  3. Fluorosis
  4. Hyperparathyroidism
  5. Paget's Disease
  6. Ankylosing Spondylitis
  7. Cushing's Disease
  8. Acromegaly
  9. Achondroplasia
  10. Postsurgical fibrosis
  11. Scoliosis

V. Symptoms: General

  1. Constant back pain (often presenting symptom)
  2. Thigh and leg stiffness

VI. Symptoms: Leg (Neurogenic Intermittent Claudication or Pseudoclaudication)

  1. Characteristics
    1. Leg Fatigue (dullness) or Leg Weakness
    2. Leg numbness, tingling or Paresthesias
    3. Bilateral Leg Pain (burning or cramping)
      1. May involve buttocks, groin and anterior thigh
      2. May spread distally into posterior lower legs and feet
      3. May be associated with a sense of balance loss (sensitive marker for Lumbar Stenosis)
  2. Provocative
    1. Worse with walking or prolonged standing
    2. Provoked by lying prone or extending Lumbar Spine
    3. Not provoked by Bicycle riding
  3. Palliative
    1. Promptly relieved with sitting or bending forward
  4. Severe symptoms: Cauda Equina Syndrome
    1. See Cauda Equina Syndrome
    2. Always ask about bowel and Bladder dysfunction, saddle Anesthesia and Foot Drop

VII. Signs

  1. Start with complete Neurologic Exam (often normal)
  2. Perform brief ambulation to elicit leg symptoms
    1. Observe for painful ambulation
    2. Observe for wide based gait
    3. Perform Romberg Test
  3. Immediately repeat Neurologic Exam after walking
    1. Lower extremity Sensory Exam changes
    2. Lower extremity Motor Exam changes
  4. Other provocative measures
    1. Lumbar Spine extension often results in thigh pain
    2. Spine is typically NON-tender to palpation
  5. Evaluation to exclude other causes
    1. Abdominal exam (evaluate for referred pain)
    2. Hip Range of Motion (esp. rotation)
      1. Evaluate for hip disorder with referred pain
    3. Lower extremity vascular exam (distal pulses)
      1. Rule-out Vascular Claudication cause
      2. Perform Ankle-Brachial Index if suspicion for Claudication

VIII. Differential Diagnosis

  1. See Differential Diagnosis of Low Back Pain
  2. Vascular
    1. Vascular Claudication
    2. Chronic Exertional Compartment Syndrome
  3. Neurologic
    1. Large Central DIsc Herniation
    2. Lumbar nerve root impingement (typically unilateral)
    3. Piriformis Syndrome
    4. Peripheral Neuropathy
  4. Musculoskeletal Disorders
    1. Spondylolisthesis
      1. Degenerative lumbar Vertebra subluxation (L4-5)
    2. Lumbar Spine Trauma or Vertebral Fracture
    3. Sacroiliac Joint Dysfunction
    4. Muscle Strains (e.g. hamstrings, quadriceps, hip adductor or abductors)
    5. Hip Joint disorder
    6. Myofascial Pain
    7. Trochanteric Bursitis
  5. Mass Lesions of Spine
    1. Spine Metastases with nerve compression
    2. Conus Medullaris
    3. Cauda equina neoplasm
    4. Benign cystic spinal lesions
      1. Neurofibromatosis
      2. Ependymoma
      3. Hemangioblastoma
      4. Dermoid
      5. Epidermoid
      6. Lipoma
  6. Infectious or Inflammatory Conditions
    1. Epidural Abscess
    2. Inflammatory arachnoiditis
  7. Referred Pain (Abdomen and Pelvis)
    1. Gynecologic (e.g. Uterine Fibroids or Ovarian Cysts)
    2. Inflammatory Bowel Disease (e.g. Crohn Disease, Ulcerative Colitis)
    3. Urologic (e.g. Pyelonephritis or Ureteral Stone)
    4. Vascular (e.g. Abdominal Aortic Aneurysm)

IX. Imaging

  1. L-Spine MRI findings (preferred)
    1. Loss of epidural fat (T1 weighted images)
    2. Loss of CSF signal at dural sac (T2 weighted images)
    3. Degenerative disc disease
  2. L-Spine CT Myelogram (if MRI contraindicated)
    1. Classic "Cloverleaf" or "Trefoil" canal appearance
  3. L-Spine XRay alternative diagnosis findings
    1. Degenerative spine changes
    2. Occult Spina bifida
    3. Spondylolisthesis

X. Complications

  1. Cauda Equina Syndrome

XI. Management

  1. Neurologic deficits
    1. See Cauda Equina Syndrome
  2. Pseudoclaudication and no neurologic deficits
    1. Mild symptoms
      1. Progressive Exercise
        1. Shortterm Goal: Increase walk distance and decrease pain
      2. NSAIDs
      3. Consider Gabapentin or Duloxetine (Cymbalta)
      4. Lumbosacral Orthosis may reduce pain and increase walk distance
      5. No strong evidence for TENS, Acupuncture or Chiropractic Manipulation
      6. Anesthetic block
        1. Effects last 1 month
      7. Epidural Corticosteroids
        1. No benefit over Anesthetic block alone
        2. Fukasaki (1998) Clin J Pain 14:148-51 [PubMed]
        3. Friedly (2014) N Engl J Med 371(1):11-21 [PubMed]
    2. Moderate to severe symptoms
      1. Surgical intervention indications
        1. Time to first symptoms: 2 minutes or less
        2. Total ambulation time: 7 minutes or less
      2. Surgical decompression (or minimally invasive) with or without fusion, Laminectomy, or percutaneous spacer
        1. May relieve leg symptoms
        2. Will not relieve back pain
        3. Functional outcomes (e.g. walk distance) may be better with surgery after 1 year
        4. Surgical complications may be higher with percutaneous interspinous spacer

XII. References

  1. Alvarez (1998) Am Fam Physician 57(8): 1825-40 [PubMed]
  2. Arbit (2001) Clin Orthop, 137-43 [PubMed]
  3. Nagler (1998) Postgrad Med 103(4):69-83 [PubMed]
  4. Schonstrom (2001) Radiol Clin North Am 39(1):31-53 [PubMed]
  5. Sheehan (2001) Clin Orthop, 61-74 [PubMed]
  6. Snyder (2004) Am Fam Physician 70:517-20 [PubMed]
  7. Webb (2024) Am Fam Physician 109(4): 350-9 [PubMed]

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