Back (Lumbar)
Lumbar Spinal Stenosis
요추 척추관 협착증
Narrowed spinal canal compressing the cauda equina, causing neurogenic claudication
- How common
- Common in Elderly
- Typical age
- Ages 60+
What is it?
Degenerative changes (osteophytes, ligamentum flavum hypertrophy, disc bulging) narrow the spinal canal, compressing the cauda equina. Walking increases neural demand, precipitating ischemic claudication.
Commonly affected: L3-L4, L4-L5 most common levels
How it develops
- Degenerative ChangesDisc height loss, facet joint arthropathy develop over decades
- Ligament & Osteophyte HypertrophyLigamentum flavum buckles into canal; osteophytes encroach posteriorly
- Canal NarrowingCentral or lateral recess stenosis compresses cauda equina
- Neurogenic IschemiaWalking increases neural metabolic demand, triggering ischemic claudication
Symptoms
- Neurogenic ClaudicationBilateral leg pain/weakness with walking; must stop and rest or sit
- Relief with Flexion/SittingSymptoms rapidly relieved by sitting, squatting, or lumbar flexion
- Bilateral Leg NumbnessBilateral lower extremity paresthesias, worse with extension
- Positive Bicycle SignCan ride bicycle (flexion posture) — helps differentiate from vascular claudication
- Bladder Dysfunction (Severe)Urinary retention or incontinence in severe cauda equina compression
How it is examined
- Extension ProvocationStanding and lumbar extension reproduce leg symptoms
- Walking Provocation TestHave patient walk until symptoms appear; rapid relief with sitting
- Variable Neurological ExamNeuro deficits may appear only after walking (post-exercise exam)
Imaging
X-ray shows degenerative changes, osteophytes, disc space narrowing, and sometimes spondylolisthesis.
- Multiple osteophytes
- Disc space narrowing
- Facet arthropathy
- Possible degenerative spondylolisthesis
MRI is gold standard — shows ligamentum flavum hypertrophy, loss of CSF around cauda equina, and canal diameter.
- LF hypertrophy
- Thecal sac compression (trefoil sign)
- Foraminal stenosis
- Central or lateral recess stenosis
Non-surgical care
- Flexion Exercises + PTLumbar flexion exercises (Williams), cycling — opens canal diameter
- NSAIDs + Neuropathic AgentsNSAIDs for pain; gabapentin/pregabalin for neurogenic symptoms
- Epidural Steroid InjectionsProvides temporary relief; good bridge to surgery or PT
- Walking Aids + Posture AidsShopping cart (shopping cart sign) or cane helps maintain flexion posture
Conservative options are generally tried first. Medications listed here can have side effects — discuss them with your prescriber.
When surgery is considered
Severe functional limitation, progressive neurological deficit, failed 3–6 months conservative care
Procedures that may be discussed
- Laminectomy (decompression)
- Foraminotomy
- Decompression + fusion if unstable
Outlook
Surgery achieves 80%+ improvement. Conservative care stabilizes but rarely reverses symptoms.