1. Lumbar Stenosis

2. Normal Anatomy

3. Pathophysiology
Refers to a narrowing of the vertebral canal, lateral recesses or intervertebral forearm
Commonly caused by degenerative changes
Not all individuals with narrowing of spaces are symptomatic
Description rather than a diagnosis
Pain occurs due to diminished space around the vascular and neural structures of the lumbar spine

4. root

5. Mechanism Of Injury Insidious Traumatic Congenital/Inherited
Idiopathic (hereditary)
Achondroplastic
Short/Tbick Pedicles (in lateral stenosis)
Acquired Stenosis
Degenerative changes (Spondylosis)
Ligamentous Hypertrophy (LF or PLL)
Facet Joint Hypertrophy
Osteophyte formation
Disc protrusion
Spondylolisthesis
Infection
Foreign bodies
Traumatic
Fractures
Lumbar Instability

6. Subjective Presentation will depend on associated pathology
Insidious history of back pain
Gradual onset of radiating pain in to unilateral or bilateral buttock and extremities
Aggravated by positions that reduce space (commonly extension)
Leg cramping at night
Neurogenic Claudication (different than vascular claudication which worsens on exertion rather than with positions that reduce space)

7. Objective Presentation depends on associated pathology
Pain or limited range with movements that close space (commonly extension)
Posture may be kyphotic with reversal of lumbar and cervical curves
Possible tightness in posterior musculature of lower extremities
Possibly reduced reflexes and sensation changes – commonly originating from L5 nerve root

8. Differential Diagnosis
Cauda Equina Syndrome – immediate onward referral
Spinal vascular malformations, tumours, infections – immediate onward referral
Non-specific lower back pain (neuro claudication uncommon)
Pain originating from hip or knee joint
Peripheral neuropathy
Ateriovascular Disease (vascular claudication)

9. Special Tests Kemp’s Test for Lumbar Spine
AKA ‘Quadrant Test’ or ‘Extension Rotation Test’
Limited evidence to support diagnostic accuracy
May not be appropriate if patient is highly irritable

10. Further Investigation
CT with intrathecal myelography
MRI
EMG – limited evidence suggesting some accuracy determining symptom severity
Axial 3-dimensional image from computed tomography myelography in a patient with severe spinal stenosis. The stenotic pattern (yellow arrow) results from hypertrophic facet joints (black arrow), bulging of disc annulus (white arrow), and thickened ligamentum flavum posteriorly.

11. Sagittal T1-weighted magnetic resonance image of the spine in discitis
Sagittal T1-weighted magnetic resonance image of the spine in discitis. Note the posterior bulging of the vertebral body endplate and disc annulus into the spinal canal (black arrow). The endplates of the disc interspace enhance following an injection of gadolinium diethylenetriamine pentaacetic acid (white arrows), whereas the central abscess within the disc space remains dark (yellow arrow)

12. General Management
Analgesia
Gabapentin
Activity modification

13. Conservative Management
Manage the underlying pathology (cause/direction of compression)
Maintain function as much as possible
Address any reversible conditions: obesity, general deconditioning etc.
Pain Relief
NSAID’s, Ice, Massage
Restore Normal ROM
Thoracic, Lumbar
Restore Normal Neurodynamics
Soft tissue techniques, joint mobilisation, nerve sliders
Restore Normal Muscular Activation
Consider functional deficits VS daily requirements for each individual
Use of lumbar support (weight-belt) for symptom modification if necessary

14. Surgical Management Epidural Corticosteroid injections
Posterior Approach
Decompressive Laminectomy
Decompressive Laminectomy with fusion (for multilevel symptoms)
Anterior Approach
Discectomy
Fusion (for multilevel symptoms)