Author
Dr. Mark Adrian (biography, no disclosures)
What care gaps or frequently asked questions I have noticed
Degenerative lumbar spinal stenosis is a radiological finding consisting of narrowing of the spinal canal. It occurs in older adults and if symptomatic, can result in pseudoclaudication (numbness, pain, and weakness) of the lower extremities.1 Although the diagnosis is often straightforward, atypical presentations are common as are competing diagnoses. The treatment options are variable and are dependent on the patient’s goals, clinical presentation, and imaging findings.
Data that answers these questions or gaps
Degenerative changes of the spine (disc bulges, hypertrophy(enlargement) of the facet joints, and ligamentum flavum buckling) can result in narrowing of the spinal canal and compression of the spinal nerve roots, cauda equina, spinal veins, and arteries. Patients experiencing symptomatic stenosis can present with a spectrum of symptoms, ranging from minor to disabling symptoms associated with neurological deficits. Degenerative changes of the spine however are ubiquitous in older adults and the degree of stenosis on spinal imaging (even if severe) does not reliably correlate with the presence of symptoms or degree of symptoms.2
Hip arthritis, vascular disorders, and peripheral nerve dysfunction are common in the older adult and can mimic symptoms of stenosis. Non-specific lower back pain is common in general population and spinal canal narrowing is common in asymptomatic older adults. Care therefore must be taken to distinguish the source of the symptoms (Tables 1 and 2).
What I recommend (practice tips)
- Distinguish the source of the symptoms. A detailed history and physical are required to establish the diagnosis and rule out competing disorders.
- The cardinal historical features of symptomatic stenosis are varying degrees of lower extremity symptoms of pain, heaviness, numbness, or stiffness that are triggered by walking (or standing) and relieved by sitting or forward flexed posture (shopping cart sign).
- Peripheral neuropathies generally present with non-positional burning symptoms in a stocking distribution.
- Physical examination is usually benign in patients with stenosis, but evaluation of the hips, distal pulses, and reflexes is necessary to rule out competing disorders.
Table 1. Symptoms and causes
PSEUDOCLAUDICATION VASCULAR CLAUDICATION Symptoms progress from back/buttock, distally to the lower extremities Symptoms progress from ankle/calf to proximally Variable limitation of walking distance (posture dependent) Consistent limitation of walking distance Climbing downstairs more symptomatic the upstairs Climbing upstairs more symptomatic than downstairs Cycling/stationary bike generally well tolerated Cycling/stationary bike exacerbate symptoms
Table 2. Signs and symptoms suggesting hip joint-mediated pain
HIP JOINT-MEDIATED PAIN Pain with pivoting Pain with transitioning (getting in and out of the car or off the sofa) Pain with crossing legs or putting on shoes or socks Limp Painful and limited hip internal rotation on physical exam
- Cross-sectional imaging (MRI or CT) is required to establish the diagnosis. Although MRI and CT scans provide complementary information, MRI defines the soft tissues, thecal sac, and nerve roots better than a CT scan. If contra-indicated or not available, a CT scan (from the L2 level to the sacrum) is usually satisfactory. Symptomatic stenosis is positional and MRI and CTs are static investigations, performed supine. To better evaluate for a dynamic spinal deformity that may be contributing to the stenosis, standing spinal x-rays (AP and Lateral) are also recommended, in addition to cross-sectional imaging.
- In the majority of cases, symptomatic spinal stenosis is a stable (or slowly progressive) condition that can be managed conservatively. Exercises that place the patient in a flexed position should be encouraged (e.g., cycling, skating, cross-country skiing, walking with walking poles, or rolling walker) and are generally tolerated. Exercise should be encouraged to maintain and optimize fitness and function. Instruction in a home exercise program by a physiotherapist in balance, postural exercises (particularly addressing thoracic kyphosis), and hip flexor and hamstring stretching can optimize the spinal biomechanics and potentially “open up” the spinal canal.
- In some patients with radicular pain, gabapentin can be helpful.3
- Epidural steroid injections (ESI) performed in a hospital setting or facility that uses imaging guidance can provide short-term help (3–6 months) in many patients.4 The degree and duration of the response to epidural injections however are unpredictable. If effective, ESIs can safely be organized on a recurring basis.
- Referral for a surgical opinion is indicated in patients who are severely disabled with advanced spinal stenosis on imaging, or in the rare cases of rapid progression with neurological deficits, or the development of bowel or bladder dysfunction (cauda equina syndrome).5
References
- Jensen RK, Jensen TS, Koes B, Hartvigsen J. Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis. Eur Spine J. 2020;29(9):2143-2163. doi:10.1007/s00586-020-06339-1 (View with CPSBC or UBC)
- Kreiner DS, Shaffer WO, Baisden JL, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J. 2013;13(7):734-743. doi:10.1016/j.spinee.2012.11.059 (View)
- Yaksi A, Ozgönenel L, Ozgönenel B. The efficiency of gabapentin therapy in patients with lumbar spinal stenosis. Spine (Phila Pa 1976). 2007;32(9):939-942. doi:10.1097/01.brs.0000261029.29170.e6 (View with CPSBC or with UBC)
- Cohen SP, Greuber E, Vought K, Lissin D. Safety of Epidural Steroid Injections for Lumbosacral Radicular Pain: Unmet Medical Need. Clin J Pain. 2021;37(9):707-717. doi:10.1097/AJP.0000000000000963 (View)
- Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med. 2008;358(8):794-810. doi:10.1056/NEJMoa0707136 (View)
Resources
- PathwaysBC Lumbar Spinal Stenosis (LSS) Algorithm – Non malignant non infectious (SSCBC)
- PathwaysBC Back – Spinal Stenosis Pain Treatment Options – Medication, Surgery, Steroids (Option Grid)
Should we call it Neurogenic claudication rather than pseudoclaudication?
If the true definition of claudication is applied -pain in muscles due to lack of oxygen as result of reduced blood flow- then pseudoclaudication is probably the correct term, not neurogenic claudication which is the term I would have used
previous to reading the practice tip article..
Might be useful to consider duration of symptoms prior to decisions to refer for imagining or surgical consult
One part of the physical examination which is not discussed here is the SIFFT test where the levels of the posterior superior iliac spines (PSISs) are compared to assess for displaced sacroiliac (SI) joints. X-rays, CT scans and MRIs are unable to visualize these highly irregular joints whose displacement is the most likely cause of “nonspecific” low back pain the source of 90% of such pain. The 2 minute corrective exercise to replace a displaced SI joint provides immediate relief to 90% of those who perform it. Check it out at: Bertrand H, Reeves KD, Mattu R, et al. Self-Treatment of Chronic Low Back Pain Based on a Rapid and Objective Sacroiliac Asymmetry Test: A Pilot Study. Cureus. 2021 Nov 11;13(11):e19483. doi: 10.7759/cureus.19483. PMID: 34912624; PMCID: PMC8665897.
I agree that radiologic stenosis does not always correlate well with clinical disability. However, when the patient says that a year ago they could stand without leaning forward or walk without stopping & sitting for, say, 20 minutes, whereas they now have to lean on the counter/ shopping trolley or sit down to relieve increasing weakness in their legs and pain after 5 minutes, this is significant & disabling progression. When associated with moderate or severe central and/or foraminal stenosis, particularly if it is most marked at one spinal level, a surgical opinion is needed. Demographics dictate that this will be an area of significant growth in neurosurgical practice.
The pole walking and walker use is a gift..thank you