Lumbar Spinal Stenosis

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

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II. Images

  1. LumbarSpineStenosis.gif

III. See Also

  1. Cervical Spinal Stenosis

IV. Pathophysiology

  1. Predisposition with congenitally narrow canal 13 mm
  2. Degenerative condition
    1. Osteoarthritis (most common)
    2. Fluorosis
    3. Hyperparathyroidism
    4. Paget's Disease
    5. Ankylosing Spondylitis
    6. Cushing's Disease
    7. Acromegaly
  3. Resulting changes
    1. Facet joint hypertrophy
    2. Ligamentum flavum hypertrophy
    3. Vertebral degeneration
    4. Intervertebral Herniated disc
    5. Spondylolisthesis

V. Symptoms: General

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

VI. Symptoms: Leg (neurogenic Intermittent Claudication)

  1. Characteristics
    1. Leg Fatigue (dullness) or Leg Weakness
    2. Leg numbness or Paresthesias (tingling Sensation)
    3. Bilateral Leg Pain (burning or cramping)
      1. Involves buttocks and thighs
      2. Spreads distally into feet
  2. Provocative
    1. Provoked by lying prone or extending Lumbar Spine
    2. Worse with walking
    3. Not provoked by Bicycle riding
  3. Palliative
    1. Promptly relieved with sitting
  4. Severe symptoms
    1. See Cauda Equina Syndrome

VII. Signs

  1. Complete Neurologic Exam (often normal)
  2. Brief ambulation to elicit leg symptoms
  3. Immediately repeat Neurologic Exam
    1. Lower extremity Sensory Exam changes
    2. Lower extremity Motor Exam changes
  4. Lower extremity vascular exam
    1. Rule-out Vascular Claudication cause

VIII. Complications

  1. Cauda Equina Syndrome

IX. Differential Diagnosis

  1. Vascular Claudication
  2. Mass lesions of spine
    1. Conus Medullaris
    2. Cauda equina neoplasm
    3. Benign cystic spinal lesions
      1. Neurofibromatosis
      2. Ependymoma
      3. Hemangioblastoma
      4. Dermoid
      5. Epidermoid
      6. Lipoma
  3. Spine Metastases with nerve compression
  4. Large Central DIsc Herniation
  5. Spondylolisthesis
    1. Degenerative lumbar Vertebra subluxation (L4-5)
  6. Lumbar Spine Trauma or Vertebral Fracture
  7. Epidural Abscess
  8. Inflammatory arachnoiditis

X. Imaging

  1. L-Spine XRay alternative diagnosis findings
    1. Degenerative spine changes
    2. Occult Spina bifida
    3. Spondylolisthesis
  2. 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
  3. L-Spine CT
    1. Classic "Cloverleaf" or "Trefoil" canal appearance

XI. Management

  1. Neurologic deficits
    1. See Cauda Equina Syndrome
  2. Pseudoclaudication and no neurologic deficits
    1. Mild symptoms
      1. Progressive Exercise
      2. Anesthetic block
        1. Effects last 1 month
      3. 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 ro Laminectomy
        1. May relieve leg symptoms
        2. Will not relieve back pain

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]

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