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General Considerations
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Lumbar spinal stenosis, defined as narrowing of the spinal canal with compression of the nerve roots, may be congenital or (more commonly) acquired It most frequently results from enlarging osteophytes at the facet joints, hypertrophy of the ligamentum flavum, and protrusion or bulging of intervertebral disks Lumbar spinal stenosis may produce symptoms by directly compressing nerve roots or by compressing nutrient arterioles that supply the nerve roots
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Clinical Findings
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A Symptoms and Signs
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Since age is the greatest risk factor for spinal degenerative changes, most patients with lumbar spinal stenosis are over 60 years old Patients typically complain of either leg pain or trouble walking The pain may originate in the low back but will extend below the buttock into the thigh in nearly 90% of patients In approximately 50% of patients, the pain will extend below the knee The pain is often a combination of aching and numbness, which characteristically worsens with walking The pain can also be brought on by prolonged standing Not infrequently the symptoms are bilateral Many patients are more troubled by poor balance, unsteadiness of gait, or leg weakness that develops as they walk Some describe these neuroclaudication symptoms as developing spaghetti legs or walking like a drunk sailor Because the lumbar spinal canal volume increases with back flexion and decreases with extension, some patients observe that they have fewer symptoms walking uphill than down The back and lower extremity examination in patients with lumbar spinal stenosis is often unimpressive Less than 10% have a positive straight leg raise sign, 25% have diminished deep tendon reflexes, and 60% have slight proximal weakness Walking with the patient may reveal unsteadiness, although usually the patient s perception of gait disturbance is greater than that of an observer
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B Imaging
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The diagnosis of spinal stenosis in a patient with symptoms is best confirmed by MRI
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LUMBAR SPINAL STENOSIS
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ESSENTIALS OF DIAGNOSIS
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Most patients are older than 60 years Presenting symptom is often back pain radiating to the buttocks and thighs Pain often interferes with walking and worsened by lumbar extension Back and leg pain often associated with numbness and paresthesias
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Differential Diagnosis
The onset of symptoms with standing, the location of the maximal discomfort to the thighs, and the preservation of pedal pulses help distinguish the pseudoclaudication of spinal stenosis from true claudication caused by vascular insufficiency Distinguishing spinal stenosis from disk herniation can be challenging since both conditions can produce pain radiating down the back of the leg Features that favor spinal stenosis are the gradual onset of symptoms, the marked exacerbation with walking, and the amelioration of symptoms with sitting or lumbar flexion Com-
Arthritis & Musculoskeletal Disorders
plaints of bilateral aching in the buttocks associated with stiffness may make some practitioners consider the diagnosis of polymyalgia rheumatica However, patients with lumbar spinal stenosis do not have the shoulder or neck symptoms characteristic of polymyalgia rheumatica
CMDT 2008
aggravates pain and increases fatigue Physical examination is normal except for trigger points of pain produced by palpation of various areas such as the trapezius, the medial fat pad of the knee, and the lateral epicondyle of the elbow
Treatment
Weight loss and exercises aimed at reducing lumbar lordosis, which aggravates symptoms of spinal stenosis, can help Lumbar epidural corticosteroid injections provide some immediate relief for about 50% of patients and more sustained relief for approximately 25% When disabling symptoms persist, decompressive laminectomy provides at least short-term relief in approximately 80%
Atlas SJ et al Spinal stenosis: surgical versus nonsurgical treatment Clin Orthop Relat Res 2006 Feb;443:198 207 [PMID: 16462443]
Differential Diagnosis
Fibromyalgia is a diagnosis of exclusion A detailed history and repeated physical examination can obviate the need for extensive laboratory testing Rheumatoid arthritis and systemic lupus erythematosus (SLE) present with objective physical findings or abnormalities on routine testing, including the ESR and C-reactive protein Thyroid function tests are useful, since hypothyroidism can produce a secondary fibromyalgia syndrome Polymyositis produces weakness rather than pain The diagnosis of fibromyalgia probably should be made hesitantly in a patient over age 50 and should never be invoked to explain fever, weight loss, or any other objective signs Polymyalgia rheumatica produces shoulder and pelvic girdle pain, is associated with anemia and an elevated ESR, and occurs after age 50 Hypophosphatemic states, such as oncogenic osteomalacia, should also be included in the differential diagnosis of musculoskeletal pain unassociated with physical findings In contrast to fibromyalgia, oncogenic osteomalacia usually produces pain in only a few areas and is associated with a low serum phosphate level
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