Phys Med Rehabil Clin N Am 14 (2003) 2939

Spinal stenosis: history and physical examination

Santhosh A. Thomas, DO*
Back and Neck Center, Cleveland Clinic Foundation, Westlake Family Health Center, 30033 Clemens Road, Westlake, OH 44145, USA Medical 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 aects both men and women [1]. Symptomatic spinal stenosis is most commonly seen in the middle-aged and elderly population; however, younger patients may also present with signs and symptoms of spinal stenosis. Men are noted to have a greater preponderance of spinal stenosis at an earlier age, but more women than men are aected after the age of 55 years. Spinal stenosis can be categorized broadly as congenital or acquired spinal stenosis (Table 1). Congenital or developmental spinal stenosis was originally described in children by Sarpyener and later in adults by a dutch surgeon, Verbiest [25,27]. Spinal stenosis, in general, is dened as narrowing of the vertebral canal, lateral recess, intervertebral foramen, or any combination thereof causing compression of neural elements. The central and lateral 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 avum buckling or hypertrophy, buckling of the posterior longitudinal ligament, degenerative or herniated discs, zygapophysial joint hypertrophy, or spondylolisthesis. Lateral stenosis may be caused by congenitally short and thick pedicles, disc bulging or herniation, zygapophysial joint hypertrophy or osteophytes [35]. Imaging studies are commonly abnormal even in asymptomatic individuals [6,7]. The anteroposterior (AP) diameter 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: Thomass1@ccf.org 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

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Table 1 Classication of spinal stenosis Congenital or developmental stenosis Idiopathic (hereditary) Achondroplastic Acquired stenosis Degenerative Combined congenital and degenerative stenosis Spondylolytic/spondylolisthetic Iatrogenic Postlaminectomy Postfusion Postchemonucleolysis Posttraumatic Metabolic Pagets disease Fluorosis Modied from Arnoldi CC, Brodsky AE, Cauchoix J, et al. Lumbar spinal stenosis and nerve root entrapment: syndromes, denition and classication. Clin Orthop 1976:115:45.

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 comprehensive history will yield valuable information to dierentiate 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-ag symptoms must be assessed (Table 4). If such symptoms are present, further diagnostic workup is immediately warranted. Hall [8] has described the ndings 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 2 Dierential diagnosis for spinal stenosis Disc herniation Vascular claudication Primary or secondary tumor Peripheral neuropathy Osteoarthritis of hips or knees Osteoporotic compression fracture

S.A. Thomas / Phys Med Rehabil Clin N Am 14 (2003) 2939 Table 3 OPQRST Mnemonic Onsetsudden versus insidious Painprovoking or -relieving factors Qualitysuch as sharp, burning, aching, cramping, tingling Referral or radiation Severityuse a validated pain scale Time frameduration of symptoms

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in the buttocks, thighs, and calves initiated by prolonged standing and walking and relieved by sitting or bending forward [3,8,9]. Less commonly, symptoms may be unilateral. Pain may vary from dull and aching to dysesthetic or 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 stenosis had no eect on postoperative outcome. Development of cauda equina syndrome is rarely associated with spinal stenosis 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 dierentiate between vascular and neurogenic claudication, because the treatment plans are dierent (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 4 Red-ag 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 decit

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Table 5 Symptoms and signs of lumbar spinal stenosis in 68 patients Prevalence (%) Symptom or sign Pseudoclaudication Standing discomfort Pain Numbness Weakness Bilateral Reduced peripheral pulses Site Whole limb Above-knee only Below-knee only Radicular pain only Neurologic ndings of lumbar spinal stenosis in 68 patients Ankle reex decreased or absent Knee reex decreased or absent Objective weakness Positive straight leg raising test 94 94 93 63 43 69 9 78 15 7 6 43 18 37 10

Modied 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 Med 1985;103(2):27175.

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, rst described by Van Gelderen [12], can help dierentiate the two entities. The spinal stenosis patient with neurogenic claudication should tolerate the exercise, performed in a forward exed position and with little axial load applied. Patients with vascular claudication, however, will become symptomatic as tissue hypoxia results from the added demand of the exercise exceeding the oxygen-delivering capability of the diseased vasculature [12]. Exercise treadmills have been used as a diagnostic tool for detecting 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 exed 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 performed through 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 analogue scales and numeric scales a numeric system (eg, 010 or 1100) to

S.A. Thomas / Phys Med Rehabil Clin N Am 14 (2003) 2939 Table 6 Clinical dierentiation between neurogenic claudication and vascular claudication Description Quality of pain Low back pain Sensory symptoms Muscle weakness Reex changes Arterial pulses Arterial bruits Skin/dystrophic changes (cyanosis, hair loss, and so forth) Aggravating factors Relieving factors Walking uphill Walking downhill Bicycle test Neurogenic claudication Cramping Frequently Frequently Frequently Frequently Normal Absent Absent present present present present Vascular claudication Burning, cramping Absent Absent Absent Absent Decreased or absent Frequently present Frequently present

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Erect posture, ambulation extension of spine Sitting, bending forward squatting Symptoms produced later Symptoms produced earlier No symptoms provoked unless erect

Any leg exercise Rest Symptoms produced earlier Symptoms produced later Provokes symptoms

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 anatomic 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 straightening or a reversal of the normal cervical and lumbar lordotic curves. Lumbar exion increases the cross-sectional area of the vertebral canal,
Table 7 Comparison of spinal stenosis with disc herniation Description Age Onset Positional changes Sitting (exion) Extension Focal motor weakness Dural tension signs Focal muscle stretch Reex changes Stenosis Usually >50 years Insidious Better Worse Less common Less common Less common Disc herniation Usually <50 years Sudden Worse Better Common Common Common

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lateral recesses, and intervertebral foramina, and as a result patients gradually assume a kyphotic posture to minimize symptoms. Range of motion of the spine should be assessed in the sagittal, transverse, and coronal planes. Stiness and rigidity may result from degenerative 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 Phalens 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 nd which movements are comfortable or relieve symptoms for the patient. This nding may provide information to allow the patients 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 exion. 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 disease. Sensory examination should assess light touch, pinprick, and vibration. 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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Fig. 2. Dermatomes.

symptoms and should be considered in the dierential diagnosis. Motor weakness may occur in approximately one third of patients [8], with the L5 myotome most commonly aected (Table 8). Muscle stretch reexes may be decreased or normal. Hall [8] found decreased or absent Achilles reexes in 43% of patients and decreased or absent patellar reexes in 18%. If hyperactive muscle stretch reexes, pathologic reexes such as Babinskis reex, 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, rst described by Elvey [19], are associated more commonly with disc herniations. Straight leg raise is noted to be positive in 10% to 23% of patients with lumbar spinals stenosis, however [8] (J.D. Rittenberg, MD, and K.P. Botwin, MD, personal communication, 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

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Table 8 Lumbosacral dermatomes and myotomes Level L3 L4 L5 S1 Dermatome testing site Anteromedial thigh and knee Anterior and posterior medial gastrocnemius First web space Lateral aspect of foot Myotome Hip exors/adductors Knee extensors/ankle dorsiexors Extensor hallucis longus Gastrocnemius (heel raises) Muscle stretch reexes None Patellar Medial hamstring Achilles

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 potentially signicant 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

Box 1. Waddells signs (DOReST) Distraction testing Inconsistent responses noted with the same test when performed 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 ndings with motor or sensory examination; give-way weakness; dysesthesias in nondermatomal patterns Stimulation testing Unexpected pain in distant sites; pain in lumbar spine with rotation of shoulder or axial loading with pressure on the head Tenderness Localized tenderness that is does not follow a dermatomal or expected referral pattern; supercial light touch over the low back causing severe discomfort, or deep palpation causing widespread 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 crossover or excursion test, in which the patient performs a weight-bearing hip internal/external rotation with the spine neutral, is a method the author prefers 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 modied Thomas test (Fig. 4) [6] can be performed to evaluate for iliopsoas, rectus femoris, and tensor fascia lata tightness. Hamstring, adductor, and calf muscle tightness should be assessed as well. Decits in lower-extremity exibility, especially at the hip exors, may lead to postural imbalances that may further promote a lumbar lordotic posture during standing and walking (Fig. 4). Therefore, it is important to identify these decits 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 further investigation for vascular insuciency. Waddells signs, comprising the memnonic DOReST, can help identify patients with nonorganic causes of pain (see Box 1). These signs do not represent malingering but are signs of psychologic distress. Patients with evidence of nonorganic pain often have poor surgical outcomes [21,22]. If three of the ve signs are present, there is a strong probability of nonorganic pain and psychologic distress.

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

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Fig. 4. Modied Thomas test.

Summary The history and physical examination are an essential component in the assessment of patients with lumbar spinal stenosis. The dierential diagnosis is broad, and many conditions may be ruled out with a thorough oce evaluation. Peripheral neuropathy, arteriovascular disease, and hip arthrosis are common entities with similar symptoms. Imaging studies provide poor specicity. Clinical decision making should be based on a collection of data, including the history and physical ndings, 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. References
[1] Kellgren JH, Lawrence JS, Bier F. Genetic factors in generalized osteo-arthrosis. Ann Rheum Dis 1963;22:23754. [2] Kirkaldy-Willis WH, Wedge JH, Yong-Hing K, et al. Pathology and pathogenesis of lumbar spondylosis and stenosis. Spine 1978;3:31928. [3] Naylor A. Factors in the development of the spinal stenosis syndrome. J Bone Joint Surg Br 1979;61(3):3069. [4] Pennal GF, Schatzker J. Stenosis of the lumbar spinal canal. Clin Neurosurg 1971;18:129. [5] Geraci MC, Alleva JT. Physical examination of the spine and its functional kinetic chain. In: Cole AJ, Hering SA, editors. The low back pain handbook. Philadelphia: Hanley and Belfus; 1997. p. 4970.

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[6] Boden SD, Davis DO, Dina TS, et al. Abnormal magnetic resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. Bone Joint Surg Am 1990; 72:4038. [7] Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med 1994;331:6973. [8] 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 Med 1985;103(2):2715. [9] Blau JN, Logue V. Intermittent claudication of the cauda equina. Lancet 1961;1:10816. [10] Johnsson K-E, Rosen I, Uden A. The natural course of lumbar spinal stenosis. Clin Orthop 1992;279:826. [11] Amundsen T, Weber H, Nordal HJ, et al. Lumbar spinal stenosis: conservative or surgical management? A prospective 10-year study. Spine 2000;25(11):142436. [12] Dyck P, Doyle JB. Bicycle test of Van Gelderen in diagnosis of intermittent cauda equina compression syndrome. J Neurosurg 1997;46:66770. [13] Deen HG, Zimmerman RS, Lyons MK, et al. Measurement of exercise tolerance on the treadmill in patients with symptomatic lumbar spinal stenosis: a useful indicator of functional status and surgical outcome. J Neurosurg 1995;83:2730. [14] Fritz JM, Erhard RE, Delitto A, et al. Preliminary results of the use of a two-stage treadmill test as a clinical diagnostic tool in the dierential diagnosis of lumbar spinal stenosis. J Spinal Disord 1997;10:4106. [15] Katz JN, Dalgas M, Stucki G, et al. Degenerative lumbar spinal stenosis: diagnostic value of the history and physical examination. Arthritis Rheum 1995;38(9):123641. [16] Hinnant DW. Psychological evaluation and testing. In: Tollison CD, Satterthwaite JR, Tollison JW, editors. Handbook of pain management. 2nd edition. Baltimore: Williams & Wilkins; 1994. p. 1836. [17] Bernhardt M, Hynes RA, Blume HW, et al. Current concepts review: cervical spondylotic myelopathy. J Bone Joint Surg Am 1993;75(1):11928. [18] Lunsford LD, Bissonette DJ, Zorub DS. Anterior surgery for cervical disc disease. Part 2: treatment of cervical spondylotic myelopathy in 32 cases. J Neurosurg 1980;53:129. [19] Elvey RL. The investigation of arm pain. In: Boyling JD, Palastanga N, editors. Grieves modern manual therapy: the vertebral column. 2nd edition. Edinburgh: Churchill Livingstone; 1994. p. 57585. [20] Butler DS. Mobilisation of the nervous system. Melbourne: Churchill Livingstone; 1991. [21] Waddell G, Bircher M, Finlayson D, et al. Symptoms and signs: physical disease or illness behaviour? BMJ 1984;289:73941. [22] Waddell G, McCulloch JA, Kummel E, et al. Nonorganic physical signs in low back pain. Spine 1980;5:11725. [23] Emery SE. Cervical spondylotic myelopathy: diagnosis and treatment. J Am Acad Orthop Surg 2001;9:37688. [24] Hamanishi C, Matukura N, Fujita M, et al. Cross-sectional area of the stenotic lumbar dural tube measured from the transverse views of magnetic resonance imaging. J Spinal Disord 1994;7:38893. [25] Sarpyener MA. Congenital stricture of the spinal canal. Journal of Bone and Joint Surgery 1945;27:709. [26] Uden A, Johnsson KE, Jonsson K, et al. Myelography in the elderly and the diagnosis of spinal stenosis. Spine 1985;10(2):1714. [27] Verbiest H. A radicular syndrome from developmental narrowing of lumbar spinal canal. J Bone Joint Surg Br 1954;36(2):2307. [28] Yamada H, Ohya M, Okada T, et al. Intermittent cauda equina compression due to narrow spinal canal. J Neurosurg 1972;37:838. [29] Arnoldi CC, Brodsky AE, Cauchoix J, et al. Lumbar spinal stenosis and nerve root entrapment: syndromes, denition and classication. Clin Orthop 1976;115:45.