Snapshot A 56-year-old man presents to his primary care physician for back pain. His back pain is worsened when he is walking up a hill or remaining in the standing position for long periods of time. His symptoms improve with sitting or leaning forward. He denies any bowel or bladder incontinence but occasionally experiences lower extremity numbness. An MRI of the lumbar spine demonstrates central canal narrowing. Introduction Definition narrowing of the central canal, lateral recess, or neural foramen Etiology Spondylosis or degenerative arthritis (most common) Progressive disc degeneration leads to disc protrusion and/or disc height loss Ligamentum flavum hypertrophy Facet joint arthropathy and osteophyte Congenital (e.g., achondroplasia) Pathogenesis mechanical compression of the lumbar spinal cord can result in nerve ischemia in the extended position, there is further narrowing of the lumbar spine, resulting in neurogenic claudication login to view 1 more bullet Presentation Symptoms neurogenic claudication (hallmark) pain with walking or maintaining an erect position that improves with leaning forward or sitting lower extremitiy weakness lower extremity sensory changes Physical exam neurological exam is typically normal Imaging MRI lumbar spine indication imaging study of choice in patients with findings concerning for lumbar spinal stenosis login to view 1 more bullet findings central canal stenosis lateral recess or foramen compression ligamentum flavum hypertrophy Differential Peripheral vascular disease distinguishing factors typically experience tightness and cramping claudication does not improve with flexion of the spine (e.g., walking with a shopping cart) back pain improves with lying flat immediately login to view 1 more bullet Peripheral neuropathy distinguishing factors sensory changes will be present whether with or without activity Lumbar disc herniation Treatment Medical analgesics indication login to view 2 more bullets medications login to view 2 more bullets Operative surgical decompression indication login to view 1 more bullet Complications Cauda equina syndrome Neurogenic bladder Neuropathic arthropathy