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Lumbar spinal stenosis refers to the narrowing of the spinal canal and intervertebral foramina. This condition is primarily caused by hypertrophy of the facet joints, thickening of the ligamentum flavum, and intervertebral disc degeneration or osteoarthritis. These pathological changes reduce the space available for the nerve roots, resulting in nerve compression and symptoms of sciatica.

Patients with lumbar spinal stenosis typically experience lower back pain that improves with forward flexion, such as leaning over a shopping cart. Pain is exacerbated by spinal extension. Symptoms worsen with prolonged standing or walking and are often relieved by rest, sitting, or spinal flexion.

Diagnosis of lumbar spinal stenosis relies heavily on patient history and clinical examination. Patient history is crucial in establishing the diagnosis. The clinical presentation may overlap with that of lumbar disc herniation. Symptoms often include leg pain, weakness, cramping, a burning sensation, or a feeling of heaviness in the lower extremities.

Lumbar spinal stenosis generally presents with bilateral leg symptoms that are nonspecific. Pain may affect one or both buttocks and/or legs. In contrast, lumbar disc herniation typically causes unilateral leg pain that follows a dermatomal distribution corresponding to the affected nerve root. For example, a herniated disc at the L4-L5 level usually compresses the L5 nerve root, resulting in sensory loss over the dorsum of the foot and weakness of the extensor hallucis longus.

In lumbar spinal stenosis, symptoms may include neurogenic claudication, characterized by calf pain, heaviness, and cramping during walking. Notably, the straight leg raise test is usually negative. Conversely, this test is frequently positive in cases of lumbar disc herniation.

In every case of suspected lumbar spinal stenosis, it is essential to evaluate the vascular status of the lower extremities to rule out vascular claudication, which may coexist with neurogenic claudication. Both conditions can present with pain induced by walking.

In vascular claudication, pain typically starts in the calves and resolves upon cessation of walking. Patients often report a predictable walking distance before symptoms force them to stop. Sitting relieves both neurogenic and vascular claudication. However, standing worsens symptoms of lumbar stenosis while relieving those of vascular claudication.

Using a stationary bike may help alleviate symptoms in lumbar spinal stenosis but tends to aggravate symptoms of vascular claudication. In vascular claudication, pain usually begins distally and radiates proximally due to poor peripheral circulation. In contrast, spinal stenosis pain starts proximally and radiates distally.

In vascular claudication, patients may exhibit physical signs such as ulcers, hair loss, lower extremity edema, or skin discoloration. Additionally, symptoms of lumbar spinal stenosis may overlap with those of hip pathology, complicating the differential diagnosis and making it difficult to determine the primary source of pain.
Quizzes
1. What is the most common anatomical cause of lumbar spinal stenosis?
✔️ Hypertrophy of the facet joints
a) Vertebral body fracture
b) Disc sequestration
✔️ c) Hypertrophy of the facet joints
d) Annular tear
Explanation: Facet joint hypertrophy, along with ligamentum flavum thickening, commonly causes spinal canal narrowing.

2. What position most commonly relieves pain in patients with lumbar spinal stenosis?
✔️ Spinal flexion
a) Standing upright
b) Spinal extension
✔️ c) Spinal flexion
d) Supine
Explanation: Flexion opens the spinal canal, decreasing nerve root compression.

3. What symptom best distinguishes lumbar spinal stenosis from lumbar disc herniation?
✔️ Bilateral leg symptoms
a) Numbness in one leg
✔️ b) Bilateral leg symptoms
c) Weakness in one foot
d) Positive straight leg test
Explanation: Lumbar stenosis typically causes bilateral, nonspecific leg symptoms.

4. Neurogenic claudication is best described as:
✔️ Pain and heaviness in the calves during walking, relieved by sitting
a) Chest pain on exertion
b) Calf pain when lying down
✔️ c) Pain and heaviness in the calves during walking, relieved by sitting
d) Shooting pain down one leg
Explanation: Neurogenic claudication refers to leg symptoms from nerve compression during walking.
5. In lumbar disc herniation at L4-L5, which nerve root is affected?
✔️ L5
a) L3
b) L4
✔️ c) L5
d) S1
Explanation: The L5 nerve root exits below the L5 pedicle and is affected at L4-L5 level.
6. Which test is typically positive in lumbar disc herniation but negative in lumbar stenosis?
✔️ Straight leg raise
a) FABER test
✔️ b) Straight leg raise
c) Trendelenburg test
d) Thomas test
Explanation: A positive straight leg raise is classic for nerve root irritation from disc herniation.