Stenosis HPI_PMR Clinics

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Spinal stenosis: history and physicalexamination

Santhosh A. Thomas, DO*Back and Neck Center, Cleveland Clinic Foundation, Westlake Family Health Center,

30033 Clemens Road, Westlake, OH 44145, USAMedical Spine Fellowship, Cleveland Clinic Foundation, Cleveland, OH, USA

Department of Physical Medicine and Rehabilitation,

Case Western Reserve University School of Medicine, 10900 Euclid Avenue,

Cleveland, OH 44106, USA

Spinal stenosis is a ubiquitous condition that affects both men and

women [1]. Symptomatic spinal stenosis is most commonly seen in the mid-

dle-aged and elderly population; however, younger patients may also pre-

sent with signs and symptoms of spinal stenosis. Men are noted to have agreater preponderance of spinal stenosis at an earlier age, but more women

than men are affected after the age of 55 years.

Spinal stenosis can be categorized broadly as congenital or acquired spi-

nal stenosis (Table 1). Congenital or developmental spinal stenosis was orig-

inally described in children by Sarpyener and later in adults by a dutch

surgeon, Verbiest [25,27]. Spinal stenosis, in general, is defined as narrowing

of the vertebral canal, lateral recess, intervertebral foramen, or any combi-

nation thereof causing compression of neural elements. The central and lat-

eral canal of the spinal column can be compromised for various reasons.Segmental instability resulting from abnormal segmental motion may lead

to degenerative zygapophysial joints [2]. Central canal stenosis may result

from ligamentum flavum buckling or hypertrophy, buckling of the posterior

longitudinal ligament, degenerative or herniated discs, zygapophysial joint

hypertrophy, or spondylolisthesis. Lateral stenosis may be caused by con-

genitally short and thick pedicles, disc bulging or herniation, zygapophysial

joint hypertrophy or osteophytes [35]. Imaging studies are commonly abnor-

mal even in asymptomatic individuals [6,7]. The anteroposterior (AP) diam-

eter of the spinal canal varies in symptomatic patients, which overlaps

* Medical Director, Back and Neck Center, Cleveland Clinic Foundation, Westlake FHC,

30033 Clemens Road, Westlake, Ohio 44145.

E-mail address: [email protected]

1047-9651/03/$ see front matter 2003, Elsevier Science (USA). All rights reserved.

PII: S 1 0 4 7 - 9 6 5 1 ( 0 2 ) 0 0 0 4 9 - 9

Phys Med Rehabil Clin N Am

14 (2003) 2939


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greatly with asymptomatic patients [23,24,26,28,29]. Therefore, the clinical

and functional evaluation must guide decision making for management.

History

Many entities may mimic lumbar spinal stenosis (Table 2). A comprehen-

sive history will yield valuable information to differentiate these entities. A

systematic approach to history taking should be followed to minimize any

omission of crucial questioning. To assess pain, the mnemonic OPQRST

(for onset, pain-provoking factors, quality of pain, referral or radiation of

pain, severity, time frame) can be useful during the evaluation (Table 3).

Red-flag symptoms must be assessed (Table 4). If such symptoms arepresent, further diagnostic workup is immediately warranted.

Hall [8] has described the findings in individuals with lumbar spinal

stenosis (Table 5). Patients commonly present with an insidious history of

back pain, with gradual onset of radiating pain into the buttocks and

extremities. Neurogenic claudication (or pseudoclaudication) is the most

common presenting symptom, characterized by bilateral pain or weakness

Table 1

Classification of spinal stenosis

Congenital or developmental stenosisIdiopathic (hereditary)

Achondroplastic

Acquired stenosis

Degenerative

Combined congenital and degenerative stenosis

Spondylolytic/spondylolisthetic

Iatrogenic

Postlaminectomy

Postfusion

PostchemonucleolysisPosttraumatic

Metabolic

Pagets disease

Fluorosis

Modified from Arnoldi CC, Brodsky AE, Cauchoix J, et al. Lumbar spinal stenosis and

nerve root entrapment: syndromes, definition and classification. Clin Orthop 1976:115:45.

Table 2

Differential diagnosis for spinal stenosis

Disc herniation

Vascular claudication

Primary or secondary tumor

Peripheral neuropathy

Osteoarthritis of hips or knees

Osteoporotic compression fracture

30 S.A. Thomas / Phys Med Rehabil Clin N Am 14 (2003) 2939


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in the buttocks, thighs, and calves initiated by prolonged standing and walk-

ing and relieved by sitting or bending forward [3,8,9]. Less commonly, symp-

toms may be unilateral. Pain may vary from dull and aching to dysestheticor sharp and truly radicular. Acute exacerbations followed by a return to

baseline may occur as part of the course of the disease.

The natural history of spinal stenosis has been studied and seems to be

favorable. Johnsson and colleagues [10] found that approximately 70% of

subjects studied remained unchanged after 4 years, 15% improved, and

15% worsened. In a 10-year follow-up study, Amundsen et al [11] found that

neurologic deterioration was rare and that delaying surgery for spinal steno-

sis had no effect on postoperative outcome.

Development of cauda equina syndrome is rarely associated with spinalstenosis but if present should be considered a strong indication for surgery.

Neurogenic versus vascular claudication

In the elderly population, vascular disease may complicate the clinical

picture. It is important to differentiate between vascular and neurogenic

claudication, because the treatment plans are different (Table 6). True

vascular claudication is described as cramping pain, without a sensory

component, initiated by walking and relieved by standing. Patients can often

accurately predict the distance they can ambulate before the onset of

symptoms. Vascular claudication is typically caused by atherosclerosis and

Table 3

OPQRST Mnemonic

Onsetsudden versus insidiousPainprovoking or -relieving factors

Qualitysuch as sharp, burning, aching, cramping, tingling

Referral or radiation

Severityuse a validated pain scale

Time frameduration of symptoms

Table 4

Red-flag symptoms

Cauda equina syndrome

Fever

Nocturnal pain

Use of steroids

Gait disturbance

Structural deformity

History of carcinoma

Unexplained weight loss

Severe pain with recumbent position

Recent trauma with suspicious fracture

Presence of severe or progressive neurologic deficit

31S.A. Thomas / Phys Med Rehabil Clin N Am 14 (2003) 2939


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is often accompanied by many other symptoms, including impotence in men

and dystrophic skin changes such as alopecia, nail dystrophy, foot pallor or

cyanosis, decreased or absent peripheral pulses, and arterial bruit. The

bicycle test, first described by Van Gelderen [12], can help differentiate the

two entities. The spinal stenosis patient with neurogenic claudication should

tolerate the exercise, performed in a forward flexed position and with little

axial load applied. Patients with vascular claudication, however, will be-come symptomatic as tissue hypoxia results from the added demand of the

exercise exceeding the oxygen-delivering capability of the diseased vascula-

ture [12]. Exercise treadmills have been used as a diagnostic tool for detect-

ing neurogenic claudication and functional status and to assess the response

to surgical interventions [13,14]. Walking uphill may be less provocative

than walking downhill, again as a result of the forward flexed posture taken.

Absence of pain while seated has also been found to be strongly associated

with lumbar spinal stenosis [15].

Measurement of pain intensity, sensation, and location can be performedthrough verbal rating scales, numerical scales, and visual analogue scales

(VAS). In general, four primary types of self-reporting measures for pain are

used, including visual analogue scales, pain drawings, numerical rating

scales, and verbal rating scores. Verbal rating scales use adjectives such as

aching, shooting, or burning to describe quality of pain. Visual ana-

logue scales and numeric scales a numeric system (eg, 010 or 1100) to

Table 5

Symptoms and signs of lumbar spinal stenosis in 68 patients

Prevalence (%)Symptom or sign

Pseudoclaudication 94

Standing discomfort 94

Pain 93

Numbness 63

Weakness 43

Bilateral 69

Reduced peripheral pulses 9

Site

Whole limb 78Above-knee only 15

Below-knee only 7

Radicular pain only 6

Neurologic findings of lumbar spinal stenosis in 68 patients

Ankle reflex decreased or absent 43

Knee reflex decreased or absent 18

Objective weakness 37

Positive straight leg raising test 10

Modified from Hall S, Bartleson JD, Onofrio BM, et al. Lumbar spinal stenosis. Clinical

features, diagnostic procedures, and results of surgical treatment in 68 patients. Ann Intern Med1985;103(2):27175.



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quantify pain intensity. Pain drawings indicate symptom distributions and

can be helpful in identifying involved nerve root levels or referral patterns.By indicating symptoms that do not follow a particular physiologic or ana-

tomic pattern, use of pain drawings can also help identify patients who

embellish their symptoms [16].

Physical examination

Physical examination of patients presenting with signs and symptoms of

lumbar spinal stenosis should start simply with observation. The history and

examination are typically distinct from that of a herniated disc (Table 7).Gait and standing posture will typically be kyphotic. There may be straight-

ening or a reversal of the normal cervical and lumbar lordotic curves.

Lumbar flexion increases the cross-sectional area of the vertebral canal,

Table 7

Comparison of spinal stenosis with disc herniation

Description Stenosis Disc herniation

Age Usually >50 years Usually


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lateral recesses, and intervertebral foramina, and as a result patients gradu-

ally assume a kyphotic posture to minimize symptoms.

Range of motion of the spine should be assessed in the sagittal, trans-verse, and coronal planes. Stiffness and rigidity may result from degenera-

tive changes. The reproduction of thigh pain with 30 seconds of sustained

lumbar extension has been found to be strongly associated with lumbar

spinal stenosis [15] (Fig. 1). This test can be thought of as analogous to Pha-

lens test for carpal tunnel syndrome. Lumbar extension along with rotation

(Kemps test) may reproduce back or ipsilateral leg pain by dynamically

compromising the intervertebral foramen. As important as pain provocation

is, it is also important to find which movements are comfortable or relieve

symptoms for the patient. This finding may provide information to allow thepatients physical therapy or exercise to start in a pain-free and successful

manner. In data collected on 52 patients who went on to surgery for lumbar

spinal stenosis, 56% had pain with extension, and only 17% had pain with

lumbar flexion. Buttock tenderness over the sciatic notch was present in

44%, and paravertebral tenderness was present in 35% (J.D. Rittenberg,

MD, and K.P. Botwin, MD, personal communication, 2002). Compression

fracture caused by osteoporosis should be considered in the elderly patient

with tenderness with palpation in the midline over the spinous processes.

The neurologic examination may be completely normal early in the dis-ease. Sensory examination should assess light touch, pinprick, and vibra-

tion. Dermatomal versus stocking-pattern sensory changes should be

evaluated (Fig. 2). Peripheral neuropathy may present with similar distal

Fig. 1. Sustained lumbar extension provocation test.



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symptoms and should be considered in the differential diagnosis. Motorweakness may occur in approximately one third of patients [8], with the

L5 myotome most commonly affected (Table 8). Muscle stretch reflexes

may be decreased or normal. Hall [8] found decreased or absent Achilles

reflexes in 43% of patients and decreased or absent patellar reflexes in 18%.

If hyperactive muscle stretch reflexes, pathologic reflexes such as Babinskis

reflex, or spastic gait are present, further investigation is warranted [17,18].

Cervical or thoracic spinal stenosis may occur concomitantly with lumbar

stenosis and may cause signs and symptoms of myelopathy.

Adverse dynamic neural tension signs, first described by Elvey [19], areassociated more commonly with disc herniations. Straight leg raise is noted

to be positive in 10% to 23% of patients with lumbar spinals stenosis, how-

ever [8] (J.D. Rittenberg, MD, and K.P. Botwin, MD, personal communica-

tion, 2002). It has been proposed that loss of extensibility at one site of a

nerve may produce increased tensile loads when the peripheral nerve or the

nerve root is stretched, leading to mechanical dysfunction. Along with the

Fig. 2. Dermatomes.



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supine straight leg raise and the sit-slump test, the femoral stretch test,

should be performed with the patient either prone or lying on the side [19,20].

The entire functional kinetic chain should be considered as potentiallysignificant in contributing to symptoms. A screening examination of the

lower extremities should include the hip, knee, ankle, and foot. Degenerative

joint disease of the hip is commonly seen in the elderly population. Because

hip arthrosis may mimic or overlap the symptoms of stenosis at the L2-4

Table 8

Lumbosacral dermatomes and myotomes

Level Dermatome testing site Myotome Muscle stretch reflexesL3 Anteromedial thigh and knee Hip flexors/adductors None

L4 Anterior and posterior

medial gastrocnemius

Knee extensors/ankle

dorsiflexors

Patellar

L5 First web space Extensor hallucis longus Medial hamstring

S1 Lateral aspect of foot Gastrocnemius (heel raises) Achilles

Box 1. Waddells signs (DOReST)

Distraction testing

Inconsistent responses noted with the same test when per-

formed in a standard fashion and when the patients attention

is distracted (eg, seated straight leg raising without discomfort

versus radiating pain with supine straight leg raise)

Overreaction

Inappropriate verbal or facial expression, posture, contortions,

or withdrawal of limbs with touch

Regional disturbance

Nonanatomic findings with motor or sensory examination;

give-way weakness; dysesthesias in nondermatomal patterns

Stimulation testing

Unexpected pain in distant sites; pain in lumbar spine with ro-

tation of shoulder or axial loading with pressure on the head

Tenderness

Localized tenderness that is does not follow a dermatomal or

expected referral pattern; superficial light touch over the low back

causing severe discomfort, or deep palpation causing wide-

spread discomfort through the thoracic spine or sacrum or hips



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levels, provocative maneuvers and range of motion should be assessed. Hip

osteoarthritis typically causes an antalgic gait. In standing, the hip cross-

over or excursion test, in which the patient performs a weight-bearing hipinternal/external rotation with the spine neutral, is a method the author pre-

fers to assess both provocation and range of motion (Fig. 3). This test

should not elicit typical leg pain in the stenotic patient. Evaluation of range

of motion and provocative testing should also be performed in the supine

position. Pain with external or internal rotation may suggest hip-mediated

pain. The modified Thomas test (Fig. 4) [6] can be performed to evaluate for

iliopsoas, rectus femoris, and tensor fascia lata tightness. Hamstring, ad-

ductor, and calf muscle tightness should be assessed as well. Deficits in

lower-extremity flexibility, especially at the hip flexors, may lead to posturalimbalances that may further promote a lumbar lordotic posture during

standing and walking (Fig. 4). Therefore, it is important to identify these defi-

cits and subsequently to stretch tight muscles.

The skin and nails should be evaluated for dystrophic changes such as

alopecia and nail dystrophy. Decreased or absent distal pulses warrant fur-

ther investigation for vascular insufficiency.

Waddells signs, comprising the memnonic DOReST, can help identify

patients with nonorganic causes of pain (see Box 1). These signs do not rep-

resent malingering but are signs of psychologic distress. Patients with evi-dence of nonorganic pain often have poor surgical outcomes [21,22].

If three of the five signs are present, there is a strong probability of non-

organic pain and psychologic distress.

Fig. 3. Hip crossover test. (A) Right hip internal rotation. (B) Right hip external rotation.



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Summary

The history and physical examination are an essential component in theassessment of patients with lumbar spinal stenosis. The differential diagnosis

is broad, and many conditions may be ruled out with a thorough office eval-

uation. Peripheral neuropathy, arteriovascular disease, and hip arthrosis

are common entities with similar symptoms. Imaging studies provide poor

specificity. Clinical decision making should be based on a collection of data,

including the history and physical findings, functional status, imaging and

electrodiagnostic studies, and other adjunctive studies.

Acknowledgment

The author would like to acknowledge Sapna V. Thomas, MD, for her

assistance in preparation of this manuscript.

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Stenosis HPI_PMR Clinics