eMedicine Specialties > Physical Medicine and Rehabilitation > Lumbar Spine Disorders

Spinal Stenosis and Neurogenic Claudication: Differential Diagnoses & Workup

Author: Michael B Furman, MD, MS, Physiatrist, Interventional Spine Care Specialist, Electrodiagnostics, Orthopedic and Spine Specialists
Coauthor(s): Kirk M Puttlitz, MD, Consulting Staff, Pain Management and Physical Medicine, Arizona Neurological Institute; Robert Pannullo, MD, Interventional Spinal Care Fellow, Department of Physical Medicine and Rehabilitation, KDV Orthopaedics and Rehabilitation Ltd; Jeremy Simon, MD, Attending Physician, Department of Physical Medicine, The Rothman Institute
Contributor Information and Disclosures

Updated: Jun 16, 2009

Differential Diagnoses

Achilles Tendon Injuries and Tendonitis
Neoplastic Lumbosacral Plexopathy
Cancer and Rehabilitation
Osteoarthritis
Chronic Pain Syndrome
Osteoporosis (Primary)
Diabetic Lumbosacral Plexopathy
Osteoporosis (Secondary)
Diabetic Neuropathy
Piriformis Syndrome
Fibromyalgia
Radiation-Induced Lumbosacral Plexopathy
Lumbar Compression Fracture
Rheumatoid Arthritis
Lumbar Degenerative Disk Disease
Scheuermann Disease
Lumbar Facet Arthropathy
Spondylolisthesis
Lumbar Spondylolysis and Spondylolisthesis
Trochanteric Bursitis
Mechanical Low Back Pain
Myofascial Pain

Other Problems to Be Considered

Rheumatologic

Ankylosing spondylitis/spondyloarthropathy
Diffuse idiopathic skeletal hyperostosis (DISH)

Infectious

Epidural, subdural, intradural abscess
Diskitis
Pott's Disease

Metabolic

Osteomalacia
Parathyroid disease
Vitamin B-12 or folic acid deficiency

Traumatic

Lumbar strain

Developmental/Congenital

Scoliosis

Vascular

Peripheral vascular disease (with vascular claudication)
Abdominal aortic dissection

Psychogenic

Conversion disorder
Malingering

Workup

Laboratory Studies

  • Lab studies are not necessary to support the diagnosis of lumbar spinal stenosis.

Imaging Studies

  • Plain radiography
    • Nonspecific plain radiographic findings possibly implicating lumbar spinal stenosis (LSS) include the following:
      • Disk space narrowing
      • Facet hypertrophy and arthrosis
      • Spondylosis
      • Degenerative scoliosis and spondylolisthesis
      • Osteochondrosis
      • Transitional segmentation
      • Spinous process settling
      • Shortened interpedicular distance
    • Interpedicular distance, considered subnormal if less than 18 mm, commonly increases from upper to lower lumbar segments.
    • Some sources define pure absolute central canal stenosis as a mid-sagittal canal diameter of less than or equal to 10 mm, pure relative at 10-12 mm, and mixed as a combination thereof. Mid-sagittal canal diameter less than 15 mm and transverse diameter less than 20 mm usually are considered abnormal.
    • Posterior disk height of 4 mm or less and foraminal height of 15 mm or less may suggest foraminal stenosis; nevertheless, clinical correlation is required. No convincing correlation has been found between clinical symptoms and radiologic findings in a study of 100 symptomatic patients with LSS. Similarly, no correlation has been shown between physical function and radiologic findings.
  • Computed tomography (CT) scanning
    • CT scan provides excellent central canal, lateral recess, and neuroforaminal visualization (see image below and Image 5). Additionally, CT scan offers contrasts between intervertebral disk, ligamentum flavum, and thecal sac. Unfortunately, CT scan, like magnetic resonance imaging (MRI), yields a high false-positive rate (35.4% when correlated with surgically proven LSS).
    • Parasagittal reconstructed CT scan findings suggesting stenosis include posterolateral vertebral body or facet osteophytosis extending into the foramen.


Axial lumbar computed tomography (CT) scan demons...

Axial lumbar computed tomography (CT) scan demonstrates marked right-sided spinal canal stenosis (black arrow) resulting from advanced right-sided facet hypertrophy. Note the vacuum disk sign within the intervertebral disc (yellow double arrow). The vacuum disk sign is further indication of degenerative changes and spinal instability.

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Axial lumbar computed tomography (CT) scan demons...

Axial lumbar computed tomography (CT) scan demonstrates marked right-sided spinal canal stenosis (black arrow) resulting from advanced right-sided facet hypertrophy. Note the vacuum disk sign within the intervertebral disc (yellow double arrow). The vacuum disk sign is further indication of degenerative changes and spinal instability.

  • MRI
    • MRI remains the imaging modality of choice for LSS. Fritz and colleagues maintain that MRI effectively rules LSS in or out anatomically.5,15
      • Advantages include nonionizing radiation and superior multiplanar soft-tissue visualization without osseous artifact. A trefoil-shaped central spinal canal may provoke more symptoms than a round or oval canal by depressing the lateral recess (see image below and Image 3).


Trefoil appearance characteristic of central cana...

Trefoil appearance characteristic of central canal stenosis due to a combination of zygapophysial joint and ligamentum flavum hypertrophy.

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Trefoil appearance characteristic of central cana...

Trefoil appearance characteristic of central canal stenosis due to a combination of zygapophysial joint and ligamentum flavum hypertrophy.

      • Sagittal T1-imaged adipose tissue outlines neuroforaminal nerve root segments and dorsal root ganglia. Therefore, parasagittal MRI findings suggesting foraminal stenosis include paucity of T1-weighted perineural adipose tissue surrounding the nerve root and diminished foraminal size. Unfortunately, MRI abnormalities have been documented in 20% of asymptomatic subjects.16
  • Myelography
    • This test effectively documents central canal stenosis and remains superior in evaluating lumbar disk herniation. Predictive value of myelography versus CT scan has been reported as 83% versus 72%, respectively, for lumbar disk herniation, and 93% versus 89% for LSS. Furthermore, myelography images the entire lumbar spinal canal, and enhances stenotic segments due to hyperextension during imaging; however, it may miss lateral stenosis and HNP because the dural sac terminates at the lateral mid zone, preventing contrast spread to the distal nerve root sheath.17 (See image below and Image 7.)
    • Myelography is less sensitive and specific than CT scan or MRI.18
    • Procedural complications include spinal headache, seizure, allergic reaction, and nausea.


Anterior view of a lumbar myelogram demonstrates ...

Anterior view of a lumbar myelogram demonstrates stenosis related to Paget disease. Myelography is limited because of the superimposition of multiple spinal structures that contribute to the overall pattern of stenosis.

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Anterior view of a lumbar myelogram demonstrates ...

Anterior view of a lumbar myelogram demonstrates stenosis related to Paget disease. Myelography is limited because of the superimposition of multiple spinal structures that contribute to the overall pattern of stenosis.

  • If vascular claudication is suspected, referral to an internist for a workup is indicated. This includes a serum cholesterol level, arterial Doppler studies, ankle-brachial index values, and, in some cases, arteriography.

Other Tests

  • Electrodiagnosis (EDX), including needle electromyography (EMG), nerve conduction studies (NCS), and somatosensory evoked potentials (SSEP), evaluates nerve root and peripheral nerve function.
    • Needle EMG diagnoses lumbosacral radiculopathy by detecting increased insertional activity, spontaneous potentials (eg, positive waves, fibrillations, fasciculations, chronic repetitive discharges), and decreased motor unit recruitment in paraspinal and lower extremity muscles innervated by the same nerve root. The presence of polyphasic motor unit potentials helps establish long-standing disease.
      • Limitations include inability to evaluate sensory and upper motor neurons.
      • Multisegmental muscle innervation may cause false negative results by preserving motor unit function despite nerve root compromise. Such innervation may elicit multilevel abnormalities in severe lumbar spinal stenosis (LSS).
      • Johnsson and colleagues have correlated myelographic LSS severity with multisegmental EMG abnormality.19
    • NCS differentiates LSS from other confounding neuropathic conditions such as lumbosacral plexopathy, generalized peripheral neuropathy, and mononeuropathy (eg, peroneal neuropathy at the fibular head, tarsal tunnel syndrome).
      • Canal stenosis may compress the cauda equina with resulting polyradicular insults. Such multiple lumbosacral radiculopathies involve lower lumbosacral (especially S1) nerve roots, are often bilateral and asymmetric, and frequently may manifest NCS abnormalities. Such abnormalities include decreased or unelicitable posterior tibial and peroneal compound motor action potentials (CMAPs) reflecting axon loss, and unobtainable H reflexes signifying bilateral S1 compression. Sensory nerve action potentials (SNAPs) remain unaffected (unless impingement occurs distal to the dorsal root ganglion), but may not be detectable in older persons. F waves may also be absent or prolonged in persons with LSS.20
      • Wilbourn and Aminoff advocate measuring peroneal CMAP amplitude from tibialis anterior and M-wave amplitude during H-reflex testing to gauge the extent of L5 and S1 acute denervation, respectively.21
      • Overall, Wilbourn and Aminoff report variable EDX findings, including multiple, bilateral lumbosacral radiculopathies in 50% of LSS patients, with prominent chronic motor unit action potential (MUAP) changes, and fibrillations solely in distal musculature. The remaining 50% of patients demonstrate varied abnormalities, with some manifesting 2 radiculopathies commonly as a single radicular insult in each lower extremity, either symmetrically (eg, bilateral L5) or asymmetrically (eg, left S1 and right L5). Other patients display isolated L5 or S1 radiculopathy. Limited nondiagnostic findings may be elicited, including bilaterally absent H reflexes with normal lower extremity needle EMG and sural SNAPs, as well as fibrillations in a single S1-innervated limb muscle. Lastly, many patients demonstrate normal EDX tests.21
      • Diagnostically, EMG complements MRI in assessing radiculopathy. Specifically, EMG rarely presents false-positive results and carries high specificity (85%). Conversely, MRI carries high sensitivity and poor specificity (50%) and, consequently, demonstrates many false-positive asymptomatic abnormalities. Some advocate using highly specific EMG to determine whether structural abnormalities imaged on MRI carry functional and pathologic significance. Indeed, Robinson proposes that such use of needle EMG ultimately might prove helpful in avoiding costly and high-risk invasive interventions.22
    • Somatosensory evoked potentials (SSEPs) are dispatched through large dorsal column myelinated fibers that are affected earlier than smaller fibers. Peripheral nerve lesions prolong SSEP latency and duration, while nerve root and spinal cord pathology induce further morphologic alterations.
      • Keim and colleagues have documented posterior tibial abnormalities in 95%, peroneal abnormalities in 90%, and sural abnormalities in 60% of LSS patients studied.2 A high incidence of L4, L5, and S1 nerve root involvement existed, amidst a paucity of upper lumbar segment abnormality (measured by the saphenous nerve). Bilateral lower limb changes were documented in 7 of 20 patients, suggesting that bilateral lower limb SSEPs can uncover previously unsuspected lesions. SSEPs are useful intraoperatively during decompressive surgery to assist the physician in diagnosis of LSS amidst equivocal clinical and imaging studies. SSEPs also appear to be more sensitive than other EDX approaches in evaluating LSS-provoked nerve root compression.
      • Kraft contends the best EDX technique for assessing LSS is dermatomal somatosensory evoked potentials (DSEPs).23 Insidious low-grade compression from LSS causes impaired nerve conduction, which is best appreciated by DSEPs (similar to nerve conduction study [NCS] slowing in carpal tunnel syndrome). Such pathology contrasts sharply with dramatic acute-onset HNP root compression, inducing axon loss with subsequent denervation best detected by needle EMG.
      • Using CT scan and MRI comparison standards, Kraft and colleagues demonstrated 78% sensitivity and 93% predictive value with DSEPs for an anatomical study positive for LSS when using multiple root disease (MRD) criteria. When criteria of multiple root disease and single root disease (SRD) were added, the sensitivity rose to 93%, with a positive predictive value of 94%. Kraft emphasized that the DSEP electrophysiologic signature of LSS is MRD, but SRD can suggest LSS, especially amidst applicable clinical history, physical examination, and positive EMG findings.23 Conversely, Dumitru found DSEPs to be of low sensitivity when compared to needle EMG-proven radiculopathies.24

More on Spinal Stenosis and Neurogenic Claudication

Overview: Spinal Stenosis and Neurogenic Claudication
Differential Diagnoses & Workup: Spinal Stenosis and Neurogenic Claudication
Treatment & Medication: Spinal Stenosis and Neurogenic Claudication
Follow-up: Spinal Stenosis and Neurogenic Claudication
Multimedia: Spinal Stenosis and Neurogenic Claudication
References
Further Reading
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Further Reading

Related eMedicine topics:
Cauda Equina
Cauda Equina and Conus Medullaris Syndromes
Cauda Equina Syndrome [Emergency Medicine]
Cauda Equina Syndrome [Orthopedic Surgery]
Degenerative Disk Disease
Degenerative Lumbar Disc Disease in the Mature Athlete
Lumbar Degenerative Disk Disease
Spinal Stenosis [Neurosurgery]
Spinal Stenosis [Orthopedic Surgery]
Spinal Stenosis [Radiology]

Clinical guidelines:
Diagnosis and treatment of degenerative lumbar spinal stenosis. North American Spine Society - Medical Specialty Society.  2002 (revised 2007 Jan).  262 pages.  NGC:005896 

Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 9: fusion in patients with stenosis and spondylolisthesis. American Association of Neurological Surgeons - Medical Specialty Society
Congress of Neurological Surgeons - Professional Association.  2005 Jun.  7 pages.  NGC:005370

Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 10: fusion following decompression in patients with stenosis without spondylolisthesis. American Association of Neurological Surgeons - Medical Specialty Society
Congress of Neurological Surgeons - Professional Association.  2005 Jun.  6 pages.  NGC:005371

Clinical trials:
A Pivotal Study of a Facet Replacement System to Treat Spinal Stenosis

Dynamic Stabilization for Lumbar Spinal Stenosis With Stabilimax NZ® Dynamic Spine Stabilization System

IDE Clinical Trial Comparing Coflex vs. Fusion to Treat Lumbar Spinal Stenosis (coflex)

Investigating Superion™ In Spinal Stenosis [ISISS]

Lumbar Stenosis Outcomes Research (LUSTOR)

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Keywords

spinal stenosis, neurogenic claudication, stenosis, stenosis lumbar, lumbar spinal stenosis, laminectomy, spine surgery, disk surgery, disc surgery, foraminal stenosis, stenosis surgery, spinal stenosis surgery, spinal stenosis treatment, central stenosis, central canal stenosis, claudication, intervertebral foramen stenosis, lateral gutter stenosis, lateral recess stenosis, subarticular stenosis, subpedicular stenosis, neural compression, spinal canal narrowing, ligamentum flavum hypertrophy, facet hypertrophy of cephalad vertebra, vertebral body osteophytosis, herniated nucleus pulposus, HNP, foraminal canal stenosis, incomplete vertebral arch closure, spinal dysraphism, segmentation failure, achondroplasia, osteopetrosis

early vertebral arch ossification, osseous exostosis, shortened pedicles, thoracolumbar kyphosis, apical vertebral wedging, anterior vertebral beaking, Morquio syndrome, posterior disc protrusion, zygapophyseal joint hypertrophy, spondylolisthesis, diskectomy, discectomy, Paget disease, fluorosis, acromegaly, ankylosing spondylitis, disc desiccation, degenerative disk disease, degenerative disc disease, failed back surgery syndrome, bilateral neurogenic claudication, cauda equina microvascular ischemia, intraneural fibrosis, radiculopathy

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Contributor Information and Disclosures

Author

Michael B Furman, MD, MS, Physiatrist, Interventional Spine Care Specialist, Electrodiagnostics, Orthopedic and Spine Specialists
Michael B Furman, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, International Spine Intervention Society, North American Spine Society, Pennsylvania Medical Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: pfizer Honoraria Speaking and teaching

Coauthor(s)

Kirk M Puttlitz, MD, Consulting Staff, Pain Management and Physical Medicine, Arizona Neurological Institute
Kirk M Puttlitz, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Phi Beta Kappa
Disclosure: Nothing to disclose.

Robert Pannullo, MD, Interventional Spinal Care Fellow, Department of Physical Medicine and Rehabilitation, KDV Orthopaedics and Rehabilitation Ltd
Robert Pannullo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Phi Beta Kappa
Disclosure: Nothing to disclose.

Jeremy Simon, MD, Attending Physician, Department of Physical Medicine, The Rothman Institute
Jeremy Simon, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

J Michael Wieting, DO, MEd, Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Principles and Practices, Director of Sports Medicine, Associate Director of Physician Assistant Training Program, Department of Osteopathic Principles and Practice, Lincoln Memorial University-DeBusk College of Osteopathic Medicine
J Michael Wieting, DO, MEd is a member of the following medical societies: American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners, American College of Sports Medicine, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, and International Society of Physical and Rehabilitation Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD, Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center
Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association
Disclosure: Nothing to disclose.

 
 
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