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Does This Older Adult With Lower Extremity Pain Have the Clinical Syndrome of Lumbar Spinal Stenosis?
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Does This Older Adult With Lower Extremity Pain Have the Clinical Syndrome of Lumbar Spinal Stenosis?
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>> Hello, and welcome to JAMAevidence, our monthly podcast focused on core issues in evidence-based medicine. I am David Simel, Editor of the Rational Clinical Examination at JAMA. Older patients with back pain can present with a variety of symptom complex. Joining me on the program today to talk about one of those presentations, lumbar stenosis, is Dr. Pradeep Suri, who is an associate professor and physician in the University of Washington Department of Rehabilitation Medicine, and the author of the JAMA article "Does this Older Patient with Lower Extremity Pain have the Clinical Syndrome of Lumbar Spinal Stenosis?". Welcome, Dr. Suri, and I'd like to start with asking you to describe the pathology of lumbar stenosis.
>> Certainly. First, the word stenosis means narrowing and the pathoanatomic changes of lumbar spinal stenosis refer to narrowing in either the lumbar spine central canal, the lateral recesses, or the neural foramina where the spinal nerves exit the spine. These changes of spinal canal narrowing can be appreciated generally in two ways; direct visualization of the spinal structures during surgery, or using cross-sectional imaging techniques such as MRI or CT scan. Most commonly, when people refer to anatomic or imaging detected lumbar spinal stenosis, they are talking about central canal stenosis.
Central canal stenosis can be caused by changes affecting either the anterior portion or the posterior portion of the central canal. Disk bulging or disk herniations are the most common changes associated with age that affect the anterior portion of the canal. In the posterior portion of the central canal the major contributors to stenosis are hypertrophy of the facet joints and hypertrophy or buckling of the ligamentum flavum. The spondylolisthesis, or translation of one vertebra on top another, can also contribute to spinal canal narrowing.
And most of the anatomic changes I just mentioned can also lead to stenosis in the lateral recesses or the neural foramina. >> So what is the prevalence of lumbar spinal stenosis among older adults with the symptom complex of back and leg pain? >> That answer depends on what precisely we are referring to when we say lumbar spinal stenosis, and the specific terminology is very important here. Generally speaking, there are two conditions which clinicians might be referring to when they say lumbar spinal stenosis.
There is imaging-detected lumbar spinal stenosis and there is symptomatic lumbar spinal stenosis. Imaging-detected lumbar spinal stenosis, also called radiographic lumbar spinal stenosis, refers to some degree of spinal canal narrowing on imaging studies. This is most commonly cross-sectional imaging, such as MRI, CT, or CT myelogram, but less commonly it might involve other modalities, such as conventional myelography or plain film x-rays. To answer your question with respect to imaging-detected lumbar spinal stenosis in older adults, the prevalence is very high irrespective of any lower extremity pain or back pain ranging from about 60% for older adults in their fifties to over 90% for adults in their eighties.
It's important to remember that most of these patients with imaging-detected lumbar spinal stenosis are asymptomatic with respect to the lower extremity pain symptoms that we typically think of in symptomatic lumbar spinal stenosis. And that brings us to the second condition that clinicians might be referring to when they use the term lumbar spinal stenosis, which is the clinical syndrome of lumbar spinal stenosis, what I'll refer to today as symptomatic lumbar spinal stenosis. Symptomatic lumbar spinal stenosis refers to a characteristic clinical presentation of symptoms and signs in the setting of imaging-detected lumbar spinal stenosis and, therefore, imaging-detected lumbar spinal stenosis is necessary but not sufficient to make the diagnosis of symptomatic lumbar spinal stenosis.
Symptomatic lumbar spinal stenosis generally involves lower extremity pain, paresthesias, numbness or weakness, irrespective of the presence or absence of low back pain. To answer your question with respect to the prevalence of symptomatic lumbar spinal stenosis, the best data that we have to guide us comes from the studies included in the lumbar spinal stenosis chapter from the Rational Clinical Examination. In the studies we included the prevalence was very consistent between studies, ranging between 44% to 47%, in older adults presenting for care with back and lower extremity pain.
It's important to note that this represents the prevalence in older adults presenting to care for back and leg symptoms, and not a true population-based prevalence. We don't have accurate numbers regarding the population-based prevalence of symptomatic lumbar spinal stenosis, but we do know from community-based studies that the prevalence of back and leg pain in U.S. older adults is about 12% in the general community. Extrapolating from the available data, probably less than 50% of these individuals have symptomatic lumbar spinal stenosis, and this places a rough ballpark estimate of the prevalence of symptomatic lumbar spinal stenosis in U.S. older adults at about 5% to 6% or less.
>> Well, what challenges do clinicians face in diagnosing lumbar spinal stenosis and differentiating it from other conditions? >> Diagnosing symptomatic lumbar spinal stenosis is challenging in the first place because there's no single diagnostic test that serves as a gold standard. Instead, the best reference standard that we have is the assessment of an expert clinician, accompanied by MRI or CT imaging studies that show lumbar spinal canal narrowing, with or without other diagnostic tests, depending on the clinical situation.
The second challenge is the similarities in clinical presentation between symptomatic lumbar spinal stenosis and several other conditions, such as peripheral arterial disease, radicular pain due to nerve root impingement, and others. It's worthwhile going over a few particularly useful clinical features for diagnosing symptomatic lumbar spinal stenosis and distinguishing it from some of these other common clinical confounders. First, vascular claudication due to peripheral arterial disease may resemble neurogenic claudication due to symptomatic lumbar spinal stenosis.
Claudication is lower extremity pain brought on by walking. Postural changes are most useful to distinguish neurogenic claudication from vascular claudication. If claudicatory lower extremity pain typically improves with lumbar flexion, such as bending forward at the waist, either when standing or walking, this suggests neurogenic claudication due to symptomatic lumbar spinal stenosis. In our chapter on lumbar spinal stenosis in the Rational Clinical Examination, a history of having improvement of symptoms when bending forward produced a large magnitude increase in the likelihood of symptomatic lumbar spinal stenosis.
Patients commonly described their symptoms improving when leaning forward on an object such as a walker, cane, or a shopping cart, and this postural change is strongly indicative of neurogenic claudication due to symptomatic lumbar spinal stenosis and should not occur with vascular claudication, unless the patient has both conditions, and that does occur from time to time. Another important clinical confounder is lumbosacral radicular pain due to nerve root impingement, often called sciatica. Classically, radicular pain due to nerve root impingement involves a history of radiating pain into the lower extremity in a dermatomal distribution and with a neuropathic character, that is a burning, tingling, shooting, or electric component to pain.
This is sometimes band-like pain or strips of pain traveling down the limb, but many patients report areas of pain in the lower extremity which aren't necessarily contiguous or connected to each other. The most useful physical examination finding for identifying radicular pain due to nerve root impingement is the straight leg raise test. A positive straight leg raise test indicates radicular pain due to nerve root impingement and decreases the likelihood of symptomatic lumbar spinal stenosis as the cause of symptoms. The straight leg raise test is most useful when positive and less useful when negative.
To perform the straight leg raise test, have the patient lie supine on the examining table. The symptomatic leg is then raised by the examiner with the knee extended, and the examiner holds the leg at the posterior calf or ankle. Do not let the patient assist while raising the leg. Try to have the patient keep the lower extremity limp when you're applying the test. Elevate the limb and have the patient report if doing so reproduces their typical leg pain or lower extremity pain symptoms. Low back pain is not pertinent, and the presence of low back pain does not indicate a positive straight leg raise test.
Instead, you're looking for reproduction of typical lower extremity pain. Classically, pain should be reproduced between 30 to 70 degrees of limb elevation. >> Which tools are most useful for diagnosing the clinical syndrome of lumbar spinal stenosis? >> So in the Rational Clinical Examination chapter on lumbar spinal stenosis, we described a risk score by Kono and colleagues. The Kono risk score was developed in Japan, and to my knowledge, is not commonly used elsewhere for clinical or research purposes.
But briefly, the Kono score is a ten-item risk score, including history and physical examination findings. In validation testing the risk score was found to have little utility when indicating a positive result but was useful in ruling out symptomatic lumbar spinal stenosis when the risk score indicated a negative result. Although risk scores are not commonly used for diagnosing symptomatic lumbar spinal stenosis, there are some individual historical features that can aid in the diagnosis. These include historical features that are useful when positive, historical features that are useful when negative, rare symptoms that are not often seen but are useful when present, and physical examination findings, but generally speaking, the history is more useful than the physical exam in diagnosing symptomatic lumbar spinal stenosis.
With regards to historical features that are useful when positive, having no pain when seated, or having improvement in pain with bending forward, or having bilateral buttock or leg pain, all result in a large increase in the likelihood of symptomatic lumbar spinal stenosis when they are present. They are highly specific over 90%, but they have modest sensitivities of about 50%. With regards to historical features that are useful when negative, claudication or pain that increases with walking results in a large decrease in the likelihood of symptomatic lumbar spinal stenosis when it is not present.
There are also rare symptoms that are useful when present. The symptom of having a burning sensation around the buttocks or perirectal area, or having intermittent priapism associated with walking, both result in a large increase in the likelihood of symptomatic lumbar spinal stenosis when present. These findings are highly specific, about 99%, but they're insensitive, with a sensitivity of only 6%. These historical features are not ones that I found to be very useful in actual clinical practice due to the low sensitivity.
Finally, physical examination features, as I mentioned, these are generally less useful than a careful history, however, pain which is worsened with lumbar flexion or with bending forward at the waist produces a decrease in the likelihood of symptomatic lumbar spinal stenosis when it is present. Another examination finding that emerged in our systematic review was having a wide-based gait. This finding resulted in a large increase in the likelihood of symptomatic lumbar spinal stenosis when present. Wide-based gait had a high specificity of 97%, but a low sensitivity of 40%.
In the clinic I found this test useful only in cases where there was clearly an absence of other factors causing a wide-based gait. >> Is there anything else you would like to tell our listeners about the clinical examination for lumbar spinal stenosis? >> Yes. First, I'd like to re-emphasize that it's important when dealing with lumbar spinal stenosis to be absolutely explicit regarding the terminology involved, and to distinguish symptomatic lumbar spinal stenosis from imaging findings of lumbar spinal stenosis.
Second, I'd like to re-emphasize one historical feature that is of limited utility in making a diagnosis of symptomatic lumbar spinal stenosis, and that is the presence or absence of low back pain. In the setting of claudication, some providers may take the presence of low back pain to somehow indicate a greater likelihood of having symptomatic lumbar spinal stenosis. I would advise against this practice, based on the fact that low back pain tends to be highly prevalent in older adults, irrespective of the presence of lower extremity pain.
In making the diagnosis of symptomatic lumbar spinal stenosis, the clinician would be better served relying on the other historical features and physical examination findings that we discussed today. >> Thank you very much, Dr. Suri. >> You're welcome.
Segment:0 .
>> Hello, and welcome to JAMAevidence, our monthly podcast focused on core issues in evidence-based medicine. I am David Simel, Editor of the Rational Clinical Examination at JAMA. Older patients with back pain can present with a variety of symptom complex. Joining me on the program today to talk about one of those presentations, lumbar stenosis, is Dr. Pradeep Suri, who is an associate professor and physician in the University of Washington Department of Rehabilitation Medicine, and the author of the JAMA article "Does this Older Patient with Lower Extremity Pain have the Clinical Syndrome of Lumbar Spinal Stenosis?". Welcome, Dr. Suri, and I'd like to start with asking you to describe the pathology of lumbar stenosis.
>> Certainly. First, the word stenosis means narrowing and the pathoanatomic changes of lumbar spinal stenosis refer to narrowing in either the lumbar spine central canal, the lateral recesses, or the neural foramina where the spinal nerves exit the spine. These changes of spinal canal narrowing can be appreciated generally in two ways; direct visualization of the spinal structures during surgery, or using cross-sectional imaging techniques such as MRI or CT scan. Most commonly, when people refer to anatomic or imaging detected lumbar spinal stenosis, they are talking about central canal stenosis.
Central canal stenosis can be caused by changes affecting either the anterior portion or the posterior portion of the central canal. Disk bulging or disk herniations are the most common changes associated with age that affect the anterior portion of the canal. In the posterior portion of the central canal the major contributors to stenosis are hypertrophy of the facet joints and hypertrophy or buckling of the ligamentum flavum. The spondylolisthesis, or translation of one vertebra on top another, can also contribute to spinal canal narrowing.
And most of the anatomic changes I just mentioned can also lead to stenosis in the lateral recesses or the neural foramina. >> So what is the prevalence of lumbar spinal stenosis among older adults with the symptom complex of back and leg pain? >> That answer depends on what precisely we are referring to when we say lumbar spinal stenosis, and the specific terminology is very important here. Generally speaking, there are two conditions which clinicians might be referring to when they say lumbar spinal stenosis.
There is imaging-detected lumbar spinal stenosis and there is symptomatic lumbar spinal stenosis. Imaging-detected lumbar spinal stenosis, also called radiographic lumbar spinal stenosis, refers to some degree of spinal canal narrowing on imaging studies. This is most commonly cross-sectional imaging, such as MRI, CT, or CT myelogram, but less commonly it might involve other modalities, such as conventional myelography or plain film x-rays. To answer your question with respect to imaging-detected lumbar spinal stenosis in older adults, the prevalence is very high irrespective of any lower extremity pain or back pain ranging from about 60% for older adults in their fifties to over 90% for adults in their eighties.
It's important to remember that most of these patients with imaging-detected lumbar spinal stenosis are asymptomatic with respect to the lower extremity pain symptoms that we typically think of in symptomatic lumbar spinal stenosis. And that brings us to the second condition that clinicians might be referring to when they use the term lumbar spinal stenosis, which is the clinical syndrome of lumbar spinal stenosis, what I'll refer to today as symptomatic lumbar spinal stenosis. Symptomatic lumbar spinal stenosis refers to a characteristic clinical presentation of symptoms and signs in the setting of imaging-detected lumbar spinal stenosis and, therefore, imaging-detected lumbar spinal stenosis is necessary but not sufficient to make the diagnosis of symptomatic lumbar spinal stenosis.
Symptomatic lumbar spinal stenosis generally involves lower extremity pain, paresthesias, numbness or weakness, irrespective of the presence or absence of low back pain. To answer your question with respect to the prevalence of symptomatic lumbar spinal stenosis, the best data that we have to guide us comes from the studies included in the lumbar spinal stenosis chapter from the Rational Clinical Examination. In the studies we included the prevalence was very consistent between studies, ranging between 44% to 47%, in older adults presenting for care with back and lower extremity pain.
It's important to note that this represents the prevalence in older adults presenting to care for back and leg symptoms, and not a true population-based prevalence. We don't have accurate numbers regarding the population-based prevalence of symptomatic lumbar spinal stenosis, but we do know from community-based studies that the prevalence of back and leg pain in U.S. older adults is about 12% in the general community. Extrapolating from the available data, probably less than 50% of these individuals have symptomatic lumbar spinal stenosis, and this places a rough ballpark estimate of the prevalence of symptomatic lumbar spinal stenosis in U.S. older adults at about 5% to 6% or less.
>> Well, what challenges do clinicians face in diagnosing lumbar spinal stenosis and differentiating it from other conditions? >> Diagnosing symptomatic lumbar spinal stenosis is challenging in the first place because there's no single diagnostic test that serves as a gold standard. Instead, the best reference standard that we have is the assessment of an expert clinician, accompanied by MRI or CT imaging studies that show lumbar spinal canal narrowing, with or without other diagnostic tests, depending on the clinical situation.
The second challenge is the similarities in clinical presentation between symptomatic lumbar spinal stenosis and several other conditions, such as peripheral arterial disease, radicular pain due to nerve root impingement, and others. It's worthwhile going over a few particularly useful clinical features for diagnosing symptomatic lumbar spinal stenosis and distinguishing it from some of these other common clinical confounders. First, vascular claudication due to peripheral arterial disease may resemble neurogenic claudication due to symptomatic lumbar spinal stenosis.
Claudication is lower extremity pain brought on by walking. Postural changes are most useful to distinguish neurogenic claudication from vascular claudication. If claudicatory lower extremity pain typically improves with lumbar flexion, such as bending forward at the waist, either when standing or walking, this suggests neurogenic claudication due to symptomatic lumbar spinal stenosis. In our chapter on lumbar spinal stenosis in the Rational Clinical Examination, a history of having improvement of symptoms when bending forward produced a large magnitude increase in the likelihood of symptomatic lumbar spinal stenosis.
Patients commonly described their symptoms improving when leaning forward on an object such as a walker, cane, or a shopping cart, and this postural change is strongly indicative of neurogenic claudication due to symptomatic lumbar spinal stenosis and should not occur with vascular claudication, unless the patient has both conditions, and that does occur from time to time. Another important clinical confounder is lumbosacral radicular pain due to nerve root impingement, often called sciatica. Classically, radicular pain due to nerve root impingement involves a history of radiating pain into the lower extremity in a dermatomal distribution and with a neuropathic character, that is a burning, tingling, shooting, or electric component to pain.
This is sometimes band-like pain or strips of pain traveling down the limb, but many patients report areas of pain in the lower extremity which aren't necessarily contiguous or connected to each other. The most useful physical examination finding for identifying radicular pain due to nerve root impingement is the straight leg raise test. A positive straight leg raise test indicates radicular pain due to nerve root impingement and decreases the likelihood of symptomatic lumbar spinal stenosis as the cause of symptoms. The straight leg raise test is most useful when positive and less useful when negative.
To perform the straight leg raise test, have the patient lie supine on the examining table. The symptomatic leg is then raised by the examiner with the knee extended, and the examiner holds the leg at the posterior calf or ankle. Do not let the patient assist while raising the leg. Try to have the patient keep the lower extremity limp when you're applying the test. Elevate the limb and have the patient report if doing so reproduces their typical leg pain or lower extremity pain symptoms. Low back pain is not pertinent, and the presence of low back pain does not indicate a positive straight leg raise test.
Instead, you're looking for reproduction of typical lower extremity pain. Classically, pain should be reproduced between 30 to 70 degrees of limb elevation. >> Which tools are most useful for diagnosing the clinical syndrome of lumbar spinal stenosis? >> So in the Rational Clinical Examination chapter on lumbar spinal stenosis, we described a risk score by Kono and colleagues. The Kono risk score was developed in Japan, and to my knowledge, is not commonly used elsewhere for clinical or research purposes.
But briefly, the Kono score is a ten-item risk score, including history and physical examination findings. In validation testing the risk score was found to have little utility when indicating a positive result but was useful in ruling out symptomatic lumbar spinal stenosis when the risk score indicated a negative result. Although risk scores are not commonly used for diagnosing symptomatic lumbar spinal stenosis, there are some individual historical features that can aid in the diagnosis. These include historical features that are useful when positive, historical features that are useful when negative, rare symptoms that are not often seen but are useful when present, and physical examination findings, but generally speaking, the history is more useful than the physical exam in diagnosing symptomatic lumbar spinal stenosis.
With regards to historical features that are useful when positive, having no pain when seated, or having improvement in pain with bending forward, or having bilateral buttock or leg pain, all result in a large increase in the likelihood of symptomatic lumbar spinal stenosis when they are present. They are highly specific over 90%, but they have modest sensitivities of about 50%. With regards to historical features that are useful when negative, claudication or pain that increases with walking results in a large decrease in the likelihood of symptomatic lumbar spinal stenosis when it is not present.
There are also rare symptoms that are useful when present. The symptom of having a burning sensation around the buttocks or perirectal area, or having intermittent priapism associated with walking, both result in a large increase in the likelihood of symptomatic lumbar spinal stenosis when present. These findings are highly specific, about 99%, but they're insensitive, with a sensitivity of only 6%. These historical features are not ones that I found to be very useful in actual clinical practice due to the low sensitivity.
Finally, physical examination features, as I mentioned, these are generally less useful than a careful history, however, pain which is worsened with lumbar flexion or with bending forward at the waist produces a decrease in the likelihood of symptomatic lumbar spinal stenosis when it is present. Another examination finding that emerged in our systematic review was having a wide-based gait. This finding resulted in a large increase in the likelihood of symptomatic lumbar spinal stenosis when present. Wide-based gait had a high specificity of 97%, but a low sensitivity of 40%.
In the clinic I found this test useful only in cases where there was clearly an absence of other factors causing a wide-based gait. >> Is there anything else you would like to tell our listeners about the clinical examination for lumbar spinal stenosis? >> Yes. First, I'd like to re-emphasize that it's important when dealing with lumbar spinal stenosis to be absolutely explicit regarding the terminology involved, and to distinguish symptomatic lumbar spinal stenosis from imaging findings of lumbar spinal stenosis.
Second, I'd like to re-emphasize one historical feature that is of limited utility in making a diagnosis of symptomatic lumbar spinal stenosis, and that is the presence or absence of low back pain. In the setting of claudication, some providers may take the presence of low back pain to somehow indicate a greater likelihood of having symptomatic lumbar spinal stenosis. I would advise against this practice, based on the fact that low back pain tends to be highly prevalent in older adults, irrespective of the presence of lower extremity pain.
In making the diagnosis of symptomatic lumbar spinal stenosis, the clinician would be better served relying on the other historical features and physical examination findings that we discussed today. >> Thank you very much, Dr. Suri. >> You're welcome.
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