Lumbar Spinal Stenosis (LSS) Care Pathway

8. Diagnostic Criteria for LSS

 

Diagnosis requires a thorough understanding of the patient's condition. It integrates patient stories; clinical findings; risk factor evaluations; and physical, psychological, social, and environmental aspects of pain.

 

A. LSS with neurogenic claudication (central stenosis)

• Definition: LSS with neurogenic claudication not due to serious underlying pathology requiring medical attention such as cauda equina syndrome, infection, tumor, or fracture and is typically amenable to conservative care (e.g., education, manual therapy, exercise).

• Prevalence: Estimated to affect approximately 10 and 40% of the general population.

• Risk Factors: Age > 70, history of trauma, genetics, comorbidities such as diabetes.

• Pain Location: Widespread lower extremity pain with or without low back pain.

• Duration: Pain is often chronic (more than 12 weeks).

• Signs/Symptoms:

  • Pain can be aching, cramping, or burning most commonly in both legs, but can be unilateral.

  • Intensity varies from mild to severe.

  • Aggravated by extension-based movements or postures such as walking or standing, and relieved with forward bending, sitting, or lying down.

  • Associated muscle stiffness or spasms.

• Clinical Phenotypes: Patients can present with pain, sensory/balance deficits, or both

  • Pain: Aching, cramping, pain, and/or burning most commonly in both legs, although it can be unilateral.

  • Sensory/Balance Deficits: Tingling, paresthesia (abnormal sensations like tingling, pricking, or numbness), numbness, and weakness most commonly in both legs. Difficulty with balance.

• Physical and Neurological Examination: Pain reproduced by provocation tests; neurological deficits may be present in cases with sensory/balance deficits

 

B. LSS with Radicular Unilateral Leg Pain (lateral recess or foraminal stenosis)

• Definition: Characterized by nerve root compression resulting in unilateral leg pain. It can be associated with LBP and is typically amenable to conservative care but may require surgical intervention if severe or progressive.

• Prevalence: Common cause of radicular pain in older adults.

• Risk Factors: Age > 50, history of lumbar disc herniation, spinal degeneration, trauma, or congenital spinal stenosis.

• Pain Location: Unilateral lower extremity pain with or without LBP.

• Duration: Pain is often chronic (more than 12 weeks) but can vary based on the severity of nerve compression.

• Signs and Symptoms: Pain following a dermatomal pattern associated with a nerve root. Aggravated by extension-type activities like walking and standing, and less influenced by changes to posture.

• Physical and Neurological Examination: Pain reproduced by physical tests (e.g., straight leg raise); possible neurological deficits (e.g., sensory deficits, weakness, altered reflexes).