Lumbar Central Spinal Stenosis
Overview
Central stenosis refers to a narrowing of the spinal canal around the thecal sac containing the cauda equina1.
Causes
Central spinal stenosis of the lumbar spine can be caused by facet joint arthrosis and hypertrophy, thickening and bulging of the LF, bulging of the IVD, and spondylolisthesis1
Paget Disease
Paget Disease (osteitis Deformans) is an osteometabolic disorder where accelerated skeletal remodeling results in growth and deformities in bones, which can lead to lumbar spinal stenosis1.
Positional preferences
Lumbar extension and ipsilateral side bending (to a lesser degree) result in functional narrowing of the canal1.
Patients with Lumbar stenosis will tend to prefer the sitting position rather than sitting with forward leaning, lying down, or standing1.
Relief
A common example of positional relief for lumbar spinal stenosis patients is to go into spinal flexion by leaning on a shopping cart1.
Imaging
Examination
ROM
Mobility
Patients generally present with reduced flexibility or shortening of the hip flexors, specifically the iliopsoas and rectus femoris1. The length of these muscles can be measured using the Thomas Test. Oppositely, hip extensor muscles, specifically the Gluteus Maximus and the Hamstring group are generally lengthened1.
Tests
Special Tests
Slump Test
Straight Leg Raise (SLR)
The SLR is generally negative in patients with spinal stenosis1.
Bilateral Straight Leg Raise (bSLR)
DDX
| Vascular Claudication | Neurogenic Claudication | Lumbar Central stenosis |
|---|---|---|
| Pain is usually bilateral | Pain is usually bilateral but may be unilateral | Usually bilateral |
| Occurs in foot, leg, thigh, hip, or buttocks | Occurs in back, buttocks, thighs, leg, and feet | Occurs in back, buttocks, thighs, legs, and feet |
| Unaffected by spine position | Decreased in flexion, and increased with flexion and walking | Pain is decreased in spinal flexion and increased with extension and walking |
| Pain is aggravated with physical exertion, but relieved within 1-5min of rest | Pain is relieved with recumbency | Pain is relieved with prolonged rest, but may persist hours after resting |
| Pain is aggravated when walking uphill | Pain is relieved when walking uphill | |
| No burning or dysesthesia | Burning and dysesthesia from back to buttocks and legs | Burning and numbness in lower extremities |
| Decreased/absent pulses in lower extremity | Normal pulse | Normal pulse |
| Color and skin changes in feet (cold, numb, dry, or scaly skin) Poor nail and hair growth |
Normal skin nutrition | Normal skin nutrition |
| Ages 40-60+ y/o | 40-60+ y/o | peaks in 70 year olds and primarily in men |
Peripheral Artery Disease
PAD shares similarities with LSS since both include leg pain and generally occur in patients over 50 years in age1.
Intermittent Claudication
Intermittent claudication (IC) of vasculature surrounding the spinal cord can create symptoms similar to central lumbar stenosis. The best way to differentiate between Intermitting Claudication and lumbar central stenosis is to examine when symptoms onset and symptom correlation with exertion. In early stages, IC will be most aggravated when walking uphill or riding a bike whereas lumbar spinal stenosis will primarily have pain when walking downhill1. Furthermore, IC patients will report symptoms after riding a bike, whereas lumbar central stenosis can ride a bike for long distances without significant symptoms1.
Peripheral Vascular Disease (PVD)
Peripheral Vascular Disease (PVD) is a pathology with distal symptoms of pain, numbness, and tingling which cause it to be frequently confused with lumbar spinal stenosis. The most apparent difference between PVD and Lumbar central stenosis is the response to pain to exertion or spine position1. Lumbar central stenosis will be relieved by trunk flexion and aggravated by trunk extension, but PVD will not be relieved or aggravated by either position1.