Stenosis, lumbar spine

• 724.02 Spinal stenosis, lumbar region, without neurogenic claudication
• 724.03 Spinal stenosis, lumbar region, with neurogenic claudication

• M48.06 Spinal stenosis, lumbar region
• M48.08 Spinal stenosis, sacral and sacrococcygeal region

• Pattern 4F: Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders

Description

• Common, degenerative spinal condition
• Associated with narrowing of the spinal canal (central stenosis) or foraminal canals (lateral stenosis)
• Caused by degenerative changes to intervertebral discs and facet joints
• Can result in spinal cord compression, cauda equina compression, or nerve root compression

Essentials of Diagnosis

• Can result in neurogenic claudication, with pain, cramping, paresthesias in the lower limbs aggravated by walking and relieved by sitting or flexion
• Diagnosis made by clinical examination
• Differentiation between vascular and neurologic claudication
• Reproduction of symptoms in specific postures and activities

General Considerations

• Lumbar spinal stenosis can result in spinal cord compression, loss of bowel and bladder control
• Cervical central stenosis can cause bilateral symptoms in lower extremity

Demographics

• Prevalence increases with age
• Primarily occurs people aged 65 years or older

Signs and Symptoms

• Unilateral or bilateral leg pain with lumbar stenosis
• Pain worsens with walking, relieved by sitting
• May be with or without low back pain or neck pain
• Altered sensation, motor control, reflexes in the distribution of involved nerve roots

Functional Implications

• Difficulty walking longer distances
• Difficulty with standing activities
• Possible bowel or bladder dysfunction

Possible Contributing Causes

• Postural changes
• Weakness of core musculature
• Tightness of hip flexors, external rotators, hamstrings

Differential Diagnosis

• Vascular insufficiency
• Peripheral nerve impairment
• Hip pathology with radiating pain pattern
• Osteoarthritis
• Spinal tumor
• Peripheral neuropathy
• Degenerative disk disease

Imaging

• MRI helpful in diagnosis to visualize compressed or inflamed nerve root
• X-ray/plain film radiograph helpful if osteophyte located in intervertebral foramen3
• CT scan to show herniation compressing the spinal canal/nerves
• Electrodiagnostic/nerve conduction testing can assist to determine a specific impaired nerve function
• Doppler ultrasound to examine vascular function

• Physical Examination
  • Two-stage treadmill test
  • Ankle-brachial pressure index (ABPI) to screen for peripheral artery disease
  • Quadrant test
  • Straight leg raise test
  • Crossed straight leg raise test
  • Slump test
  • Lower limb nerve tension test
  • Deep tendon reflexes
  • Upper motor neuron tests, including tone, pathological reflexes
  • Lower limb sensation testing
  • Passive physiological intervertebral mobility testing (PPIVM)
  • Postural examination
  • Muscle length tests, including hamstrings, hip flexors, calf muscles

• To hospital for imaging
• To physician for surgical consult if myelopathy suspected
  • Fusion
  • Decompression
  • Laminectomy
• To physician for imaging and medical consult if disease suspected
• To physician for ...