How does moderate to severe spinal canal stenosis typically present with back pain?

From the Guidelines

Moderate to severe spinal canal stenosis typically presents with back pain that worsens with standing or walking and improves with sitting or leaning forward, characterized by neurogenic claudication with pain, numbness, tingling, or weakness in the legs. Patients often experience symptoms that develop with walking and are relieved by rest in a flexed position, with pain radiating down one or both legs, and commonly report having to sit down after walking short distances due to increasing discomfort 1. Many patients adopt a stooped forward posture when walking to relieve symptoms by increasing the canal diameter. Physical examination may reveal diminished reflexes, sensory changes in the legs, and occasionally weakness. Unlike vascular claudication, symptoms from spinal stenosis can also occur with prolonged standing without walking. Morning stiffness is common, and patients may report that activities requiring extension of the spine (like reaching overhead or walking downhill) worsen their symptoms. This presentation occurs because narrowing of the spinal canal compresses neural elements, with symptoms worsening in positions that further decrease the canal diameter, such as extension of the spine.

Some key points to consider in the presentation of moderate to severe spinal canal stenosis include:

• Neurogenic claudication is a hallmark symptom, characterized by pain, numbness, tingling, or weakness in the legs that develops with walking and is relieved by rest in a flexed position 1.
• Patients may exhibit a stooped forward posture when walking to relieve symptoms by increasing the canal diameter 1.
• Physical examination may reveal diminished reflexes, sensory changes in the legs, and occasionally weakness 1.
• Symptoms can occur with prolonged standing without walking, distinguishing it from vascular claudication 1.
• Morning stiffness is common, and activities requiring extension of the spine can worsen symptoms 1.

It is essential to evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with MRI (preferred) or CT only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) 1.

From the Research

Presentation of Moderate to Severe Canal Stenosis

• Moderate to severe spinal canal stenosis typically presents with back pain, as well as pain in the buttocks or lower extremities, with or without back pain 2.
• The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency 2.
• The diagnosis can generally be made based on a clinical history of back and lower extremity pain that is provoked by lumbar extension, relieved by lumbar flexion, and confirmed with cross-sectional imaging, such as computed tomography or magnetic resonance imaging (MRI) 3.

Symptoms and Characteristics

• Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain, associated with reduced space available for the neural and vascular elements of the lumbar spine 2.
• The resulting claudication or leg pain is actually vascular in origin, caused by the mechanical compression of nerve roots, which cannot receive the necessary blood supply 4.
• Symptoms may include leg pain or leg weakness, and the characteristic claudication leg pain presents in a fashion similar to the claudication symptoms seen with peripheral vascular disease 4.

Treatment and Management

• Nonoperative treatment includes activity modification, oral medications to diminish pain, and physical therapy 3.
• Surgery appears effective in carefully selected patients with back, buttock, and lower extremity pain who do not improve with conservative management 3.
• Decompressive laminectomy improved symptoms more than nonoperative therapy in a randomized trial of 94 participants with symptomatic and radiographic degenerative lumbar spinal stenosis 3.
• Percutaneous adhesiolysis and hypertonic saline neurolysis may be an effective management strategy in patients with chronic function-limiting low back and lower extremity pain with central spinal stenosis after failure of conservative management and fluoroscopically directed epidural injections 5.