History and exam

Key diagnostic factors

common

presence of risk factors

Key factors include age over 40 years, previous back injury or surgery, and manual labour.

onset and duration of symptoms

Onset of symptoms is insidious and duration is from months to years.

back pain

Back pain without the symptoms of neurogenic claudication may have causes other than lumbar stenosis or may be the first symptom of degenerative changes in the lumbar spine. Investigations should be done to rule out common causes of back pain such as spinal metastatic disease, thoracolumbar fractures, and osteomyelitis of the spine.

activity-related back pain

Back pain related to activity may be a result of associated degenerative changes, spondylolisthesis, or mechanical instability.

leg pain when walking

Neurogenic claudication is the classic symptom of lumbar stenosis.

Upon walking, patients complain of pain and weakness in the thighs and calves and a sensation of numbness in the lower extremities.

Patients are forced to stop and bend over or sit down to gain relief.

stooped posture when walking

In advanced disease, patients report being able to move progressively decreasing distances and may adopt a stooped posture to maximise their function. Classically, they report the “shopping cart sign” in which they lean forwards onto a shopping trolley to flex the spine and increase the size of the spinal canal.

leg numbness or paraesthesiae

Symptoms of leg numbness and/or paraesthesiae may accompany back pain and leg pain and usually result from lateral recess or foraminal stenosis.

absence of examination findings

Neurological deficits are uncommon. Diminished ankle or knee jerk reflex might be present, but these findings are non-specific. Straight leg raising test is usually negative.

Other diagnostic factors

common

pain radiating down the leg

Pain radiating down the leg may also be caused by lateral recess or foraminal stenosis.

The L4-L5 levels are most commonly affected, and the pain radiates down the lateral aspect of the leg.

In the absence of other symptoms of lumbar stenosis, disc herniation is the most common cause of this type of pain.

uncommon

bladder or bowel dysfunction

Cauda equina syndrome may develop in patients with long-standing untreated lumbar spinal stenosis, albeit rarely; it is much more frequently associated with an acute disc herniation.

Cauda equina syndrome may manifest with bowel and/or bladder incontinence, lower extremity weakness, and saddle paraesthesiae.

muscle weakness or wasting

Severe muscle weakness or wasting is rare and is a feature of advanced disease.

If present, it is usually a consequence of co-existing nerve root compression from intervertebral disc herniation or severe lateral recess stenosis.

Risk factors

strong

age >40 years

Disease of ageing. Degenerative changes leading to stenosis develop with age. Onset of symptoms typically occurs between the ages of 40 and 70 years.[15]

previous back surgery

Lumbar laminectomy and/or fusion may lead to the development of stenosis at adjacent levels, spondylolisthesis, and/or spinal instability.[16]

previous injury

Injury to the lumbar spine may lead to premature degenerative changes, stenosis due to retropulsed fracture fragments, or post-traumatic spondylolisthesis.

achondroplasia

Associated with significant spinal stenosis over the cervical, thoracic, and lumbar regions. Surgical treatment is often necessary.

acromegaly

Untreated acromegaly is associated with development of lumbar spinal stenosis.[20] Treatment of the disorder is recommended, although surgical treatment for patients with symptomatic lumbar spinal stenosis may be necessary.

weak

manual labour

People who perform heavy-duty work may develop degenerative changes in the spine earlier in life because of increased mechanical wear of the spine and higher risk of traumatic injury.

family history of back pain

Family history of back pain may indicate idiopathic congenital spinal stenosis.

smoking

Smoking is associated with a higher risk of low back pain. The incidence of lumbar spinal stenosis and subsequent surgical intervention may be increased in cigarette smokers.[17] Successful fusion rates are lower and surgical outcomes are worse in those who smoke compared with those who do not.[18]

diabetes mellitus

Diabetes mellitus (HbA1c ≥ 6.1) has been associated with symptomatic lumbar spinal stenosis when the degree of radiographic compression is moderate.[19]

peripheral vascular occlusive disease

Lower ankle brachial indices (≤ 1.0) have been associated with symptomatic lumbar spinal stenosis when the degree of radiographic compression is moderate.[19]

Use of this content is subject to our disclaimer