From the Guidelines
Spinal stenosis is diagnosed based on a combination of clinical symptoms, physical examination findings, and imaging results, with neurogenic claudication being a hallmark symptom characterized by pain, numbness, or weakness in the legs that worsens with walking or standing and improves with sitting or leaning forward. The primary clinical criteria include lower back pain that radiates to the buttocks, thighs, and legs, often described as a burning, cramping, or aching sensation 1. Patients typically report that their symptoms are relieved when bending forward, such as when pushing a shopping cart or riding a bicycle, as this position increases the spinal canal space. Other symptoms include:
- Bilateral leg weakness
- Numbness or tingling in the legs
- In severe cases, bowel or bladder dysfunction indicating cauda equina syndrome, which requires immediate medical attention Physical examination may reveal decreased lumbar extension, neurological deficits corresponding to the affected nerve roots, and a positive spine extension test where symptoms are reproduced when the patient stands and leans backward 1. These symptoms develop because narrowing of the spinal canal or neural foramina compresses the spinal cord or nerve roots, leading to inflammation and neurological symptoms. The severity and location of stenosis determine the specific symptom pattern, with central stenosis typically causing bilateral symptoms and foraminal stenosis causing more unilateral symptoms.
The diagnosis of spinal stenosis is supported by the presence of neurogenic claudication, which has a modest positive likelihood ratio of 1.2, and radiating leg pain, which has a positive likelihood ratio of 2.2 1. Changing symptoms on downhill treadmill testing are associated with a higher positive likelihood ratio of 3.1. The usefulness of pain relieved by sitting for predicting the presence of spinal stenosis ranges from poor to high. Age older than 65 years is associated with a positive likelihood ratio of 2.5 and a negative likelihood ratio of 0.33.
Psychosocial factors and emotional distress should also be assessed, as they are stronger predictors of low back pain outcomes than physical examination findings or severity and duration of pain 1. Assessment of psychosocial factors identifies patients who may have delayed recovery and could help target interventions. However, evidence is currently insufficient to recommend optimal methods for assessing psychosocial factors and emotional distress.
From the Research
Clinical Criteria for Spinal Stenosis Diagnosis
The clinical criteria for diagnosing spinal stenosis include:
- Pain and numbness in the low back, legs, and buttocks after walking or extension of the lumbar spine 2
- Symptoms relieved with flexion of the lower back 2, 3
- Burning or cramping pain that worsens with standing and walking and improves with bending forward or sitting 3
- Back and lower extremity pain provoked by lumbar extension, relieved by lumbar flexion 4
Diagnostic Tests
Diagnostic tests used to confirm the clinical diagnosis of lumbar spinal stenosis include:
- Neurological examination 5
- MRI/CT scan 3, 4, 5
- Walking test with gait observation 5
- 'Rule out' tests: foot pulses/ABI, hip examination, and test for cervical myelopathy 5
Symptom Characteristics
Symptoms of lumbar spinal stenosis are typically characterized by: