Lumbar Spinal Stenosis

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This article relates to degenerative lumbar spinal stenosis, rather than congenital lumbar spinal stenosis. Degenerative lumbar stenosis first starts with disc height loss, that then results in bulging of the anulus fibrosus and ligamentum flavum into the spinal canal. These changes alter the loading of the facet joints, which leads to facet joint osteophytosis. The anteroposterior diameter of the canal is reduced by the bulging annulus anteriorly, and the hypertrophic facet joints posteriorly. Typically, the L4-L5 level is maximally constricted in the condition.

History

The cluster of Cook are features on history to determine the probability of lumbar spinal stenosis.[1] The features on history are 1) bilateral symptoms; 2) leg pain more than back pain; 3) pain during walking/standing; 4) pain relief upon sitting; and 5) age>48 years. Having no findings has a sensitivity of 96%, with a negative likelihood ratio of 0.19. Having four of five findings has a sensitivity of 6%, and specificity of 98%, with a positive likelihood ratio of 4.6. Three of five findings had a higher sensitivity, but a lower LR+ of 2.5.

Clinical Assessment

Diagnostic value of the history and physical examination.[2]
Test Name LR+ LR- Sens Spec Kappa
Wide-based gait 14 0.6 43% 97%
Urinary disturbance 7.0 0.9 14% 98%
No pain when seated 6.6 0.6 46% 93%
Improvement when bending forward 6.5 0.5 52% 92%
Numbness of perineal region 5.0 1.0 5% 99%
Abnormal Romberg test 4.3 0.7 39% 91%
Neurogenic claudication 3.7 0.2 82% 78%
Symptoms improve when seated 3.1 0.6 52% 83%
Vibration deficit 1st metatarsal head 2.8 0.6 53% 81%
Pinprick deficit foot or calf 2.5 0.7 47% 81%
Age > 65 yrs 2.5 0.3 77% 69%
Weakness 2.1 0.7 47% 78%
Absent Achilles reflex 2.1 0.7 46% 78%
Bilateral plantar numbness 2.1 0.8 27% 87%
Severe lower-extremity pain 2.0 0.5 65% 67%
Thigh pain w/ 30 sec lumbar extension 1.6 0.7 51% 69%
Pain below knees 1.5 0.7 56% 63%
Numbness 1.5 0.6 63% 59%
Poor balance 1.5 0.6 70% 53%
No pain with flexion 1.4 0.5 79% 44%
Pain below buttocks 1.3 0.4 88% 34%
Worse when walking 1.0 1.0 71% 30%

Resources

Lumbar Spinal Stenosis - JAMA Rational Clinical Examination 2010

References

  1. โ†‘ Cook et al.. The clinical value of a cluster of patient history and observational findings as a diagnostic support tool for lumbar spine stenosis. Physiotherapy research international : the journal for researchers and clinicians in physical therapy 2011. 16:170-8. PMID: 21077266. DOI.
  2. โ†‘ Katz et al.. Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination. Arthritis and rheumatism 1995. 38:1236-41. PMID: 7575718. DOI.

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