Snapshot A 52-year-old man complained of low back pain radiating to the left buttock, posterior thigh and lateral leg. The pain got worse when walking downhill, and was relieved when he leaned over a table on his elbows. Examination revealed normal reflexes, reduced sensation over the left lateral and posterior leg, and weak big toe dorsiflexion. Kemp's sign was positive on the left. Straight leg raise was 30degrees on the left and 90 degrees on the right. Dorsalis pedis and posterior tibial pulses were normal. Xray showed disc degeneration at the L4-L5 level and facet joint hypertrophy at that level. Introduction Narrowing of central or lateral lumbar spinal canal caused by degenerative joint disease leads to compression of nerve roots Epidemiology middle-aged or elderly Presentation Symptoms back pain and referred buttock pain neurogenic claudication pain worse with extension (walking downhill, standing upright) pain relieved with flexion at hips and bending forward (sitting, leaning over shopping cart) leg pain (often unilateral) weakness bladder disturbances recurrent UTI present in up to 10% due to autonomic sphincter dysfunction cauda equina syndrome (rare) Physical Exam Kemp sign unilateral radicular pain from foraminal stenosis made worse by extension of back Straight leg raise (nerve root tension sign) is usually negative Valsalva test does not worsen pain (pain is worse in the case of herniated disc) Differential Important to differentiate symptoms of neurogenic claudication from vascular claudication flexion improves symptoms in neurogenic claudication because this posture increases the limited area available for the neural elements in the spinal canal and foramen ff Neurogenic Claudication Vascular Claudication Postural changes Yes, extension aggravates No Walking and Stair climbing Walking downhill or down stairs aggravates (spine in extension) Walking uphill or upstairs easier (back flexed) Walking uphill or upstairs aggravates (increased metabolic demand) Walking downhill or downstairs easier (less metabolic demand) Relieving factors Bending over, sitting Standing still, stop walking Stationary bicycle (back flexed) Relieves symptoms Causes symptoms Pulses Normal Abnormal Imaging Radiographs standing AP and lateral may show disk space narrowing, osteophyte formation facet hypertrophy degenerative spondylolithesis CT myelogram will show spinal stenosis useful in patients that can not have an MRI MRI show spinal stenosis Treatment Nonoperative NSAIDS, physical therapy NSAIDS, physical therapy (abdominal muscle strengthening) weight loss and bracing steroid injections (epidural and transforaminal) for advanced symptoms Operative surgical laminectomy may achieve short term success but many patients have recurrence