Lumbar Spinal Stenosis (LSS) Care Pathway

4. Differential Diagnosis Requiring Medical Attention

 

Note: Musculoskeletal peripheral neuropathies or hip pathologies do not necessarily require referral to a medical provider, unlike other conditions in this section.

​

Red Flags: Immediate Referral to Emergency Care:

​

1. Cauda Equina Syndrome

• Pain Location: Severe low back pain.

• Signs/Symptoms/Red Flags: Saddle anesthesia, bowel overflow incontinence, bladder retention or overflow incontinence, bilateral progressive radicular signs.

• Physical and Neurological Examination: Decreased perianal sensation, decreased anal sphincter tone, progressive lower extremity weakness.

• Action: Immediate referral to emergency care.

 

2. Spinal Infection (osteomyelitis, discitis, epidural abscess)

• Pain Location: Localized severe back pain.

• Signs/Symptoms/Red Flags: Systemic (fever, chills, fatigue), localized pain, swelling, redness, immunosuppression, recent infection or surgery, TB (tuberculosis) history, IV drug use, poor living conditions.

• Physical and Neurological Examination: Tenderness over the affected area, possible erythema and warmth, possible neurological deficits.

• Action: Immediate referral to emergency care.

​

3. Traumatic Spinal Fracture

• Pain Location: Localized pain in the mid or lower back.

• Signs/Symptoms/Red Flags: Sudden onset of severe pain following severe trauma.

• Physical and Neurological Examination: Point tenderness.

• Action: Immediate referral to emergency care.

​

Refer to Medical Provider:

 

1. Non-traumatic Spinal Fracture

• Pain Location: Severe, progressive, localized back pain, often with radiation to the chest or abdomen.

• Signs/Symptoms: Sudden onset of severe pain following minor trauma or spontaneous in osteoporotic patients, corticosteroid use, female sex, older age (>60), history of spinal fracture or cancer.

• Physical and Neurological Examination: Point tenderness over the affected vertebra, kyphosis in severe cases.

• Action: Referral to appropriate medical provider.

 

2. Spinal Malignancy

• Pain Location: Localized pain in the mid or lower back.

• Signs/Symptoms: History of cancer; persistent pain, worse at night, not relieved by rest, constitutional symptoms (night sweats, unexplained weight loss, fatigue, fever).

• Physical and Neurological Examination: Localized tenderness, possible neurological deficits.

• Action: Referral to appropriate medical provider.

​​

3. Inflammatory Arthritides

1. Spondyloarthropathies (e.g., Ankylosing Spondylitis, Psoriatic Arthritis, Reactive Arthritis):

• Pain Location: Lower back, may radiate to buttocks and thighs.

• Signs/Symptoms: Morning stiffness > 1 hour, pain improves with activity, pain worse at night or at rest, presence of other inflammatory signs (e.g., uveitis, psoriasis), systematic symptoms (fatigue, weight loss, fever).

• Physical and Neurological Examination: Possible reduced spinal mobility, positive Schober’s test, tenderness over joints.

• Action: Referral to appropriate medical provider.

​

2. Rheumatoid Arthritis

• Pain Location: Diffuse joint pain, may include the lower back.

• Signs/Symptoms: Symmetrical joint pain, morning stiffness > 1 hour, systemic symptoms (fatigue, weight loss, fever).

• Physical and Neurological Examination: Joint swelling, tenderness, and deformity.

• Action: Referral to appropriate medical provider.

​

3. Systematic Lupus Erythematosus (SLE)

• Pain Location: May include lower back and other joints.

• Signs/Symptoms: Joint pain and swelling, fatigue, butterfly-shaped rash on the face, photosensitivity, systemic symptoms (fatigue, weight loss, fever).

• Physical and Neurological Examination: Joint tenderness and swelling, skin rashes, signs of organ involvement such as kidney issues or pleuritis.

• Action: Referral to appropriate medical provider.

​

4. Referred Pain (from abdominal/pelvic visceral conditions)

(e.g., aortic aneurysm, endometriosis, kidney stones, pancreatitis)

• Pain Location: Varies depending on the condition, often radiating to the back.

• Signs/Symptoms: Specific to the underlying condition, may include abdominal pain, gastrointestinal symptoms, urinary symptoms, systemic symptoms (e.g., fever, chills, weight loss).

• Physical and Neurological Examination: Abdominal or pelvic tenderness, palpable mass, and other specific signs related to the condition (e.g., Murphy's sign for kidney stones, Cullen's sign for pancreatitis).

• Action: Referral to appropriate medical provider/emergency care.

​

5. Intermittent Vascular Claudication due to Peripheral Arterial Disease​

• Pain Location: Bilateral leg pain.

• Signs/Symptoms: Bilateral leg pain that worsens with walking/exercise but does not get immediate relief with flexion (negative shopping cart sign). Leg pains are relieved with rest.

• Physical and Neurological Examination: Decreased or absent dorsalis pedis pulse, presence of audible bruits, skin atrophy, ulcers, hair loss, and/or abnormal ankle-brachial index < 0.90.

• Action: Referral to appropriate medical provider.

​

6. Cervical Spondylotic Myelopathy

(e.g., aortic aneurysm, endometriosis, kidney stones, pancreatitis)

• Pain Location: Neck pain with upper and lower extremity symptoms.

• Signs/Symptoms: Hand clumsiness, weakness in arms/hands, trouble with walking/balance, wide-based gait.

• Physical and Neurological Examination: Hyporeflexia at lesion, hyperreflexia below the lesion, reduced sensation, flaccid or spastic weakness, upper motor neuron signs (e.g., positive Hoffman’s, Inverted Supinator Sign, Babinski).

• Action: Referral to appropriate medical provider.

​

7. Non-Musculoskeletal Peripheral Neuropathy

(e.g., diabetic neuropathy, Guillain-Barré syndrome, nutritional deficiencies such as vitamin B12)

• Pain Location: Burning, tingling, or numbness in the feet and legs distally and bilaterally.

• Signs/Symptoms: Stocking-like distribution of sensory loss, muscle weakness.

• Physical and Neurological Examination: Reduced sensation (including vibration), absent reflexes, muscle weakness, balance difficulty.

• Action: Referral to appropriate medical provider.

​

8. Musculoskeletal Peripheral Neuropathy

(e.g., meralgia paresthetica, tarsal tunnel syndrome, peroneal nerve entrapment)

• Pain Location: Burning, tingling, or numbness in the feet and legs distally.

• Signs/Symptoms: Follows peripheral nerve distribution, typically unilateral.

• Physical and Neurological Examination: Reduced sensation, absent reflexes, muscle weakness, balance difficulty.

• Action: Appropriate conservative management. Does not necessarily require referral to a medical provider.

​

9. Lumbar Radiculopathy or Radicular Pain due to Lumbar Disc Herniation

• Pain Location: Unilateral leg pain with or without low back pain.

• Signs/Symptoms: Leg pain, paresthesia, or weakness. Leg pain aggravated with flexion or all movements. Not relieved with sitting down.

• Physical and Neurological Examination: Possible sensory deficits, weakness, or reflex loss. Provocation tests such as the straight leg raise are positive.

• Action: Appropriate conservative management. Does not necessarily require referral to a medical provider unless there are significant or progressive neurological deficits, severe unresponsive pain, or other complicating factors that may require further medical intervention or surgical consultation.

​

10. Lumbar Radiculopathy or Radicular Pain due to Spondylolisthesis

• Pain Location: Unilateral leg pain with or without low back pain.

• Signs/Symptoms: Leg pain, paresthesia, or weakness. Pain is often aggravated by extension-based movements (e.g., walking, standing) and may be relieved with flexion or rest.

• Physical and Neurological Examination: Possible sensory deficits, weakness, or reflex loss. Provocation tests may reproduce symptoms, and a step-off deformity may be palpated over the affected vertebrae.

• Action: Appropriate conservative management. Referral to a medical provider may be necessary if there are significant or progressive neurological deficits, severe unresponsive pain, or if the spondylolisthesis is unstable or severe, potentially requiring surgical consultation.

​

11. Musculoskeletal Hip Pathology

(e.g., symptomatic hip osteoarthritis, greater trochanteric pain syndrome)

• Pain Location: Hip or buttock pain.

• Signs/Symptoms: Hip or buttock pain that may refer into the anterior or posterior thigh or groin.

• Physical and Neurological Examination: Pain is reproduced during hip examination, limping gait, possible Trendelenburg sign.

• Action: Does not necessarily require referral to a medical provider.