Lumbar Spinal Stenosis

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Original Editors

Top Contributors - Donald John Auson, Astrid Lahousse, Stefanie Van De Vijver, Roxane Roosens, Kim Jackson, Pauline Bouten, George Prudden, Laure Lievens, Manisha Shrestha, Rosie Swift, Ahmed M Diab, Mariam Hashem, Lucinda hampton, Sai Kripa and Shreya Pavaskar  

Search Strategy

Databases Searched: Pubmed, Web of Knowledge, PEDro
Keywords: Low back pain, Spinal Stenosis, Physical therapy, Treatment, LSS, Management

Definition/Description

Lumbar spinal stenosis is a condition where the spinal canal (central stenosis) or one or more of the lumbar vertebral foramina (foraminal/lateral stenosis) becomes narrowed. If the narrowing is substantial, it can cause compression of the spinal cord or spinal nerves. Symptoms include low back pain, buttock pain, leg pain and numbness. These symptoms are typically aggravated by walking and relieved with rest. [1,3,12] Not all patients with spinal narrowing develop symptoms, so the term "spinal stenosis" refers to the symptoms of pain and not to the narrowing itself. [5]

Clinically Relevant Anatomy

Five lumbar vertebrae (L1-L5) make up the “lower back”. As demonstrated in the picture to the right, this is where the spine starts curving toward the abdomen.
The spinal cord is a long, thin, tubular bundle of nervous tissue and support cells that extends from the brain.
This is the main pathway for information traveling from the brain to the peripheral nervous system. The length of the spinal cord is much shorter compared to the length of the bony spinal column. The spinal cord ends in the lower thoracic spine. The nerve roots from the lumbar and sacral levels continue from the bottom of the cord like a "horse's tail" (cauda equina) and then exit the spine.
There are 33 spinal cord nerve segments in a human spinal cord, and 5 lumbar segments that form 5 pairs of lumbar nerves. [7]

Epidemiology /Etiology

Some people are born with a small spinal canal. This is called "congenital stenosis”. However, spinal canal narrowing is most often due to age-related changes that take place over time. This condition is called "acquired spinal stenosis." Spinal stenosis is most common in people over 50 years of age. [14]
Acquired forms of LSS are further classified as degenerative, spondylolisthetic, iatrogenic (postsurgical), posttraumatic, or combined. [14]

Lumbar spinal stenosis can be caused by:

• osteoarthritis
• Inflammatory spondyloarthritis
• bulging of the disc
• thickening of the vertebral ligament
• tumor
• infection
• various metabolic bone disorders that cause bone growth, such as Paget's disease  [1,12,14]
  
  

Characteristics/Clinical Presentation

Patients typically present with radicular leg pain or neurogenic claudication. Neurogenic claudication is defined as pain, paresthesia and cramping in the buttocks and legs. Symptoms, which are posture-dependent, are worsened with extension of the lumbar spine or weight-bearing postures of the spine. Symptoms are decreased with flexion (sitting or bending forward) or non-weight-bearing postures of the spine. [2,8,12,14,15,16]
Patients may feel pain, cramping, weakness or numbness in the lower back and legs. [1,12] Pain may vary from a dull ache to dysesthetic or sharp and truly radicular. Symptoms may present as unilateral, but this is less common. Symptoms of spinal stenosis often start slowly and get worse over time. Pain in the legs may become so severe that walking, even short distances, is unbearable. Frequently, patients must sit or lean forward to temporarily ease pain. [1,12,15]

Differential Diagnosis

During the differential diagnosis, red-flag symptoms must be assessed. If such symptoms are present, further diagnostic workup is immediately warranted.

• cauda equina syndrome,
• fever,
• nocturnal pain,
• use of steroids,
• gait disturbance,
• structural deformity,
• history of carcinoma,
• unexplained weight loss,
• severe pain with recumbent position,
• recent trauma with suspicious fracture,
• presence of severe or progressive neurologic deficit [2]

Other pathologies/diseases that mimic lumbar spinal stenosis:

• degenerative hip joint (examination: Patrick and scour tests)[3]
• disc herniation http://www.physio-pedia.com/Disc_Herniation
• vascular claudication
• spinal cord primary or secondary tumor
• peripheral neuropathy
• osteoarthritis of hips or knees http://www.physio-pedia.com/Hip_Osteoarthritis
• osteoporotic compression fracture [2]
• myofascial pain
• rheumatoid arthritis http://www.physio-pedia.com/Rheumatoid_Arthritis
• lumbar degenerative disk disease
• lumbar facet arthropathy
• lumbar spondylolysis, spondylolisthesis and spondylodiskitis
• mechanical low back pain http://www.physio-pedia.com/Mechanical_low_back_pain

In older patients with back or leg pain, diagnostic possibilities differ from younger patients: non-mechanical causes of back pain, such as malignacy, infection or abdominal aortic aneurysm are common in elderly patients. [12]

Diagnostic Procedures

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Outcome Measures

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Examination

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Medical Management

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Physical Therapy Management

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Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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