History

Fact Explanation
Chronic pain Entrapment of sensory nerves as they leave the spinal cord through the spinal foramina, causes radicular pain. Lumbar stenosis is due to the narrowing of the spinal canal and a reduction of the diameter of the intervertebral foramina. This may occur due to degenerative disorders of intervertebral joints, nucleus pulposus hernia, thickening of flavum ligaments, degenerative spondylolysthesis or even a congenital narrowing. Other causes may be inflammation, tuberculosis of the spine, spinal cord tumor or metastatic deposits. Distribution of the radicular pain, is dependent on the sensory level of the spinal cord affected, and is commonly bilateral. [1,2,3]
Neurogenic claudication This is the commonest presenting symptom in the elderly. Neurogenic intermittent claudication occurs because the lumbar lordosis increases in the standing position. This causes worsening stenosis of the spinal canal causing a compression myelopathy of the cauda equina nerves. In addition it has been postulated that compression of the microvasculature of the lumbar nerve roots, also contributes to neurogenic claudication. [2.4]
Limb weakness Depending on the nerve root that is compressed as it exits from the spinal foramina, there can be varying presentations of lower limb weakness. Weakness is of a upper motor spastic type, is due to compressive myelopathy of the cord. Alternatively lower motor flaccid paralysis may occur if the compression occurs as the nerve exits through a spinal foramen. [3]
Lower limb anesthesia Distribution of limb or perineal anesthesia depends on the level of the compressive myelopathy. Saddle anesthesia is a result of cauda equina syndrome. [3]
More common among the elderly Commonly seen in the elderly and middle aged population. Due to the degenerative etiology of the condition there is compression of the cauda equina nerve roots by thickened posterior vertebral elements, facet joints, marginal osteophytes or soft tissue structures such as the ligamentum flavum or herniated discs. [4]
Bladder and bowel symptoms Due to compression of the cauda equina nerves, a neuropathic bladder can result causing urinary retention and reduced anal tone resulting in bowel incontinence. [4,5]
Congenital causes Congenital spinal stenosis can occur with diseases that affect the growth of bones, eg;- Achondroplasia. [6]
History of heavy manual work There is an increased risk of lumbar spinal stenosis in those who have engaged in long term heavy manual work, eg:- coal miners. This is believed to speed up disc degeneration and osteophyte formation. [7]
References
  1. TRUSZCZYńSKA A, TRUSZCZYńSKI O, RąPAłA K, GMITRZYKOWSKA E, TRANOWSKI A. Postural stability disorders in rural patients with lumbar spinal stenosis. Ann Agric Environ Med [online] 2014, 21(1):179-82 [viewed 25 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24738520
  2. KOBAYASHI S. Pathophysiology, diagnosis and treatment of intermittent claudication in patients with lumbar canal stenosis World J Orthop [online] , 5(2):134-145 [viewed 25 May 2014] Available from: doi:10.5312/wjo.v5.i2.134
  3. HIRABAYASHI HIROKI, TAKAHASHI JUN, HASHIDATE HIROYUKI, OGIHARA NOBUHIDE, TASHIRO ATSUTOSHI, MISAWA HIROMICHI, EBARA SOHEI, MITSUI KATSUHIRO, WAKABAYASHI SHINJI, KATO HIROYUKI. Characteristics of L3 nerve root radiculopathy. Surgical Neurology [online] 2009 July, 72(1):36-40 [viewed 26 May 2014] Available from: doi:10.1016/j.surneu.2008.08.073
  4. ALVAREZ JA, HARDY RH JR. Lumbar spine stenosis: a common cause of back and leg pain. Am Fam Physician [online] 1998 Apr 15, 57(8):1825-34, 1839-40 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9575322
  5. FAIRBANK J, HASHIMOTO R, DAILEY A, PATEL AA, DETTORI JR. Does patient history and physical examination predict MRI proven cauda equina syndrome? Evid Based Spine Care J [online] 2011 Nov, 2(4):27-33 [viewed 26 May 2014] Available from: doi:10.1055/s-0031-1274754
  6. SAITO K, MIYAKOSHI N, HONGO M, KASUKAWA Y, ISHIKAWA Y, SHIMADA Y. Congenital lumbar spinal stenosis with ossification of the ligamentum flavum in achondroplasia: a case report. J Med Case Rep [online] 2014 Mar 5, 8(1):88 [viewed 25 May 2014] Available from: doi:10.1186/1752-1947-8-88
  7. SZPALSKI M, GUNZBURG R. Lumbar spinal stenosis in the elderly: an overview Eur Spine J [online] 2003 Oct, 12(Suppl 2):S170-S175 [viewed 26 May 2014] Available from: doi:10.1007/s00586-003-0612-1

Examination

Fact Explanation
Loss of lumbar lordosis A postural disorder often follow lumbar spinal stenosis. A diminished lumbar lordosis and sagittal deviation, usually contralateral to the pain is seen. An extended lumbar posture future diminishes the spinal canal diameter which worsens the symptoms by direct compression of nerve roots or vascular compression compromises blood supply to the spinal cord. [1,2]
Forward flexed gait Also referred to as the 'shopping cart' sign. The patient's pain improves as he/she is flexed forward. During flexion the stenotic lumbar spine stretches the ligamentum flavum and enlarges the neural foramina, relieving lower extremity symptoms. [3]
Absent Straight Leg Raise Test (SLRT) This sign is usually absent in lumbar spinal stenosis, therefore it is an important negative finding as it excludes acute disc herniation as a differential. [4]
Lower limb weakness Flaccid lower limb weakness is seen generally as the caudal nerve roots are compressed. Rarely spastic type weakness can be seen if the compressive myelopathy damages the descending tracts. [4]
Lower limb reflexes Lower limb reflexes are generally normal or reduced due to compression of the caudal lower motor neurons. However if there is descending tract involvement reflexes may be exaggerated. [4]
Neurogenic claudication Commonly bilateral (rarely unilateral), radiating pain that worsens with lumbar extension and alleviates with flexion of the spine, which makes climbing stairs, riding a bicycle etc. less disabling. Radiation is from the buttocks to the thigh and the lower leg. Pain is absent when seated and arises only during prolonged standing or walking.[5,6]
Cerebellar signs Presence of cerebellar signs such as a wide based gait or a positive Romberg's test indicate compressive myelopathy of proprioceptive and cerebellar tracts. [5.6]
References
  1. TRUSZCZYńSKA A, TRUSZCZYńSKI O, RąPAłA K, GMITRZYKOWSKA E, TRANOWSKI A. Postural stability disorders in rural patients with lumbar spinal stenosis. Ann Agric Environ Med [online] 2014, 21(1):179-82 [viewed 25 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24738520
  2. NADEAU M, ROSAS-ARELLANO MP, GURR KR, BAILEY SI, TAYLOR DC, GREWAL R, LAWLOR DK, BAILEY CS. The reliability of differentiating neurogenic claudication from vascular claudication based on symptomatic presentation Can J Surg [online] 2013 Dec, 56(6):372-377 [viewed 25 May 2014] Available from: doi:10.1503/cjs.016512
  3. GAZZERI R, GALARZA M, ALFIERI A. Controversies about Interspinous Process Devices in the Treatment of Degenerative Lumbar Spine Diseases: Past, Present, and Future Biomed Res Int [online] 2014:975052 [viewed 25 May 2014] Available from: doi:10.1155/2014/975052
  4. ALVAREZ JA, HARDY RH JR. Lumbar spine stenosis: a common cause of back and leg pain. Am Fam Physician [online] 1998 Apr 15, 57(8):1825-34, 1839-40 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9575322
  5. KATZ JEFFREY N., HARRIS MITCHEL B.. Lumbar Spinal Stenosis. N Engl J Med [online] 2008 February, 358(8):818-825 [viewed 27 May 2014] Available from: doi:10.1056/NEJMcp0708097
  6. SURI P, RAINVILLE J, KALICHMAN L, KATZ JN. Does this older adult with lower extremity pain have the clinical syndrome of lumbar spinal stenosis? JAMA [online] 2010 Dec 15, 304(23):2628-36 [viewed 27 May 2014] Available from: doi:10.1001/jama.2010.1833

Differential Diagnoses

Fact Explanation
Ankylosing spondylitis Causes an inflammatory type of back pain that is associated with stiffness. Age of onset is in the 30-40 age group, being more common among males. On examination there is marked reduction in spinal mobility and will yield a positive modified Schober test. May have extra articular features such as red eye and inflammatory bowel disease. [1]
Scoliosis Idiopathic scoliosis will be apparent on examination, in addition these patients will have limited forward flexibility. [2]
Peripheral vascular disease Classically develops in the calf or buttock region, may be accompanied by impotence, amaurosis fugax, ischemic strokes etc. Examination will reveal absent peripheral pulses while doppler ultrasound will confirm this arterial insufficiency. [3]
Acute disc herniation Causes predominantly leg dominant pain below the gluteal fold, that is due to direct irritation of a spinal nerve root. [4] Often an acute event , may have been precipitated by lifting a heavy load. Straight Leg Raising Test (SLRT) will be positive. [5]
Lumbar vertebral fracture Compression fractures of lumbar vertebrae also present with symptoms of cauda equina syndrome. Healing of clinically silent fractures causes canal stenosis and subsequent root impingement. [5]
Mechanical lower back pain Neurological signs are absent and pain is made worse with movement. For patients where the pain presumably arises from the facet, disc or sacroiliac joint, in the absence of neurological signs minimal intervention is indicated. [6]
References
  1. BOSSLET K, LüBEN G, STARK M, SEDLACEK HH. Characterization of an individual specific small cell lung carcinoma associated antigen. Behring Inst Mitt [online] 1985 Dec:133-8 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2421709
  2. KAO FC, LAI PL, CHANG CH, TSAI TT, FU TS, NIU CC, CHEN LH, CHEN WJ. Influence of lumbar curvature and rotation on forward flexibility in idiopathic scoliosis. Biomed J [online] 2014 Mar-Apr, 37(2):78-83 [viewed 26 May 2014] Available from: doi:10.4103/2319-4170.113182
  3. NADEAU M, ROSAS-ARELLANO MP, GURR KR, BAILEY SI, TAYLOR DC, GREWAL R, LAWLOR DK, BAILEY CS. The reliability of differentiating neurogenic claudication from vascular claudication based on symptomatic presentation Can J Surg [online] 2013 Dec, 56(6):372-377 [viewed 25 May 2014] Available from: doi:10.1503/cjs.016512
  4. HALL H. Effective Spine Triage: Patterns of Pain Ochsner J [online] 2014, 14(1):88-95 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963059
  5. ALVAREZ JA, HARDY RH JR. Lumbar spine stenosis: a common cause of back and leg pain. Am Fam Physician [online] 1998 Apr 15, 57(8):1825-34, 1839-40 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9575322
  6. MAAS ET, JUCH JN, GROENEWEG JG, OSTELO RW, KOES BW, VERHAGEN AP, VAN RAAMT M, WILLE F, HUYGEN FJ, VAN TULDER MW. Cost-effectiveness of minimal interventional procedures for chronic mechanical low back pain: design of four randomised controlled trials with an economic evaluation. BMC Musculoskelet Disord [online] 2012 Dec 28:260 [viewed 26 May 2014] Available from: doi:10.1186/1471-2474-13-260

Investigations - for Diagnosis

Fact Explanation
X-Ray lumbar spine Imaging of the lumbar spine is only indicated if lower back pain is accompanied by a neurological deficit or fails to resolve with conservative therapy. X Ray evaluation of the lumbar spine is the first line investigation but is by no means diagnostic, as it will may only show degenerative changes of the lumbar vertebrae such as osteophytes. [1,2]
CT myelogram Myelography is considered the gold standard in the diagnosis of lumbar stenosis. Intra thecal contrast is used to delineate the spinal cord and a saggital spinal canal diameter of less than 10 mm is considered to be absolute stenosis, while less than 12 mm is relative stenosis. Degenerative changes of the vertebrae and discs can also be visualized. [2,3]
MRI In recent times, MRI has become the popular modality of investigation as it eliminates the need for invasive intra thecal contrast and radiation exposure associated with a CT myelogram.[2]
Needle electromyography Useful in determining the multi radicular involvement in cauda equina syndrome, that can occur due to degenerative lumbar spinal stenosis. [2]
Nerve conduction studies Useful in the exclusion of other potential causes such as inflammatory or demyelineating neuropathy. [2]
References
  1. KALFF R, EWALD C, WASCHKE A, GOBISCH L, HOPF C. Degenerative lumbar spinal stenosis in older people: current treatment options. Dtsch Arztebl Int [online] 2013 Sep, 110(37):613-23; quiz 624 [viewed 26 May 2014] Available from: doi:10.3238/arztebl.2013.0613
  2. ALVAREZ JA, HARDY RH JR. Lumbar spine stenosis: a common cause of back and leg pain. Am Fam Physician [online] 1998 Apr 15, 57(8):1825-34, 1839-40 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9575322
  3. DABIRé H, BAJJOU R, CHAOUCHE-TEYARA K, FOURNIER B, DE NANTEUIL G, LAUBIE M, SAFAR M, SCHMITT H. S14063: a new potent 5-HT1A receptor antagonist devoid of beta-adrenoceptor blocking properties. Eur J Pharmacol [online] 1991 Oct 15, 203(2):323-4 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1686862

Management - General Measures

Fact Explanation
Lifestyle modification Conservative measures such as therapeutic exercises contributes to clinical recovery, improvements in ADL(activities of daily living) and a reduction in pain. [1]
Physical therapy Patients with mild to moderate lumbar spinal stenosis will benefit from physical therapy. This can include: exercise, and a progressive body-weight supported treadmill program. Exercises should be targeted at improving the strength of the abdominal muscles as this prevents excessive lumbar extension. [2,3]
Pharmacological management of pain Aimed at providing symptomatic relief from chronic lower back pain. Administration of pharmacological agents should be guided by the WHO analgesic ladder. First line therapy is with NSAIDs, they must be used judiciously and if necessary combined with a Proton Pump Inhibitor (PPI) to prevent gastric ulcers. Alternatively COXIBS can be administered, if there are no cardiovascular risk factors. Oral opioids (such as codeine and tramadol) can be considered for patients with moderate to severe pain, if the pain is causes functional impairment/ impacts quality of life (QOL). Worsening or poorly controlled pain indicates the need for surgical management. [4]
Epidural steroid injection (ESI) Epidural steroid injections (ESI) are used in tackling spinal pain. Intra laminar steroids are combined with local anesthetic agents (such as lidocaine, bupivacaine) and best results are achieved when the injection is made at the point of maximal stenosis. There is some evidence that it is also effective in post laminectomy syndrome while providing short to medium term relief in lumbar stenosis. [5,6,7]
References
  1. KIM ER, KANG MH, KIM YG, OH JS. Effects of a Home Exercise Program on the Self-report Disability Index and Gait Parameters in Patients with Lumbar Spinal Stenosis J Phys Ther Sci [online] 2014 Feb, 26(2):305-307 [viewed 25 May 2014] Available from: doi:10.1589/jpts.26.305
  2. WHITMAN JM, FLYNN TW, CHILDS JD, WAINNER RS, GILL HE, RYDER MG, GARBER MB, BENNETT AC, FRITZ JM. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine (Phila Pa 1976) [online] 2006 Oct 15, 31(22):2541-9 [viewed 25 May 2014] Available from: doi:10.1097/01.brs.0000241136.98159.8c
  3. KATZ JEFFREY N., HARRIS MITCHEL B.. Lumbar Spinal Stenosis. N Engl J Med [online] 2008 February, 358(8):818-825 [viewed 27 May 2014] Available from: doi:10.1056/NEJMcp0708097
  4. ABDULLA A, ADAMS N, BONE M, ELLIOTT AM, GAFFIN J, JONES D, KNAGGS R, MARTIN D, SAMPSON L, SCHOFIELD P, BRITISH GERIATRIC SOCIETY. Guidance on the management of pain in older people. Age Ageing [online] 2013 Mar:i1-57 [viewed 26 May 2014] Available from: doi:10.1093/ageing/afs200
  5. ABDI S, DATTA S, TRESCOT AM, SCHULTZ DM, ADLAKA R, ATLURI SL, SMITH HS, MANCHIKANTI L. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician [online] 2007 Jan, 10(1):185-212 [viewed 25 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17256030
  6. BOSWELL MV, SHAH RV, EVERETT CR, SEHGAL N, MCKENZIE BROWN AM, ABDI S, BOWMAN RC 2ND, DEER TR, DATTA S, COLSON JD, SPILLANE WF, SMITH HS, LUCAS LF, BURTON AW, CHOPRA P, STAATS PS, WASSERMAN RA, MANCHIKANTI L. Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines. Pain Physician [online] 2005 Jan, 8(1):1-47 [viewed 25 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16850041
  7. MILBURN J, FREEMAN J, STEVEN A, ALTMEYER W, KAY D. Interlaminar Epidural Steroid Injection for Degenerative Lumbar Spinal Canal Stenosis: Does the Intervertebral Level of Performance Matter? Ochsner J [online] 2014, 14(1):62-66 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963054

Management - Specific Treatments

Fact Explanation
Laminectomy Laminectomy effectively decompresses the spinal canal. However, the post op complications are greater if more level are compressed. Severe stenosis may necessitate removal of parts of vertebral bones. Commonly encountered post op complications are: dural tears with cerebrospinal fluid leaks and risk of meningitis, nerve root damage and postoperative spinal instability. [1]
Laminoplasty This technique is more commonly carried out for cervical spinal stenosis. It is used in some centers for decompression of the nerve roots by osteoplastic enlargement of the lumbar spinal canal, while maintaining spinal stability. This avoids spinal instability a complication encountered in the older laminectomy technique. [2]
Implantation of interspinous distraction device Interspinous implantable devices made of titanium, polyetheretherketone and elastomeric compounds have recently become popular as an alternative to decompressive surgery. This is due to advantages such as being performed under local anesthesia, preservation of bone and soft tissue, reduced risk of epidural scarring and cerebrospinal fluid leakage, a shorter hospital stay and a faster rehabilitation period. [1,3]
Post operative physical therapy Poor outcomes following decompressive surgery is likely to be due to physical deconditioning due to the inactivity precipitated by the back pain. This maybe further exacerbated by a long post op period, without physical activity. Physical therapy should be aimed at strengthening the active stabilizing mechanism of the spine i.e. the abdominal muscles. [4]
References
  1. ALVAREZ JA, HARDY RH JR. Lumbar spine stenosis: a common cause of back and leg pain. Am Fam Physician [online] 1998 Apr 15, 57(8):1825-34, 1839-40 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9575322
  2. SANGWAN SS, KUNDU ZS, WALECHA P, SIWACH RC, KAMBOJ P, SINGH R. Degenerative lumbar spinal stenosis--results of expansive laminoplasty Int Orthop [online] 2008 Dec, 32(6):805-808 [viewed 26 May 2014] Available from: doi:10.1007/s00264-007-0415-9
  3. GAZZERI R, GALARZA M, ALFIERI A. Controversies about Interspinous Process Devices in the Treatment of Degenerative Lumbar Spine Diseases: Past, Present, and Future Biomed Res Int [online] 2014:975052 [viewed 25 May 2014] Available from: doi:10.1155/2014/975052
  4. MANNION AF, DENZLER R, DVORAK J, MüNTENER M, GROB D. A randomised controlled trial of post-operative rehabilitation after surgical decompression of the lumbar spine Eur Spine J [online] 2007 Aug, 16(8):1101-1117 [viewed 26 May 2014] Available from: doi:10.1007/s00586-007-0399-6