Focused examination for lumbar spinal stenosis including neurogenic claudication assessment, provocative tests, and differentiation from vascular claudication.
Lumbar stenosis examination focuses on identifying neurogenic claudication and differentiating it from vascular claudication. Examiners expect you to understand the posture-dependent nature of symptoms, perform the stoop test, and recognize that examination at rest is often normal.
High-Yield Exam Summary
Definition: Narrowing of the spinal canal, lateral recess, or neural foramina causing compression of neural elements.
Types:
Causes:
Why Posture Matters:
The "Shopping Cart Sign" (Trolley Sign):
Similarly, patients can often cycle (flexed) with no symptoms but cannot walk the same duration.
Classic Pattern:
Symptoms:
History Questions:
| feature | neurogenic | vascular |
|---|---|---|
| Character | Pain, numbness, heaviness, weakness | Cramping, aching pain |
| Location | Back, buttocks, thighs, legs (often bilateral) | Calves (usually), thighs |
| Onset | Varies with posture as well as distance | Consistent distance |
| Relief | Sitting, flexion, takes minutes | Standing rest, quick relief (less than 5 min) |
| Cycling | Usually fine (flexed) | Also causes symptoms (exercise) |
| Uphill vs Downhill | Downhill worse (extension) | Uphill worse (more effort) |
| Pulses | Normal | Reduced or absent |
| Skin | Normal | Thin, shiny, hairless |
Quick Differentiation:
Neurogenic: Can cycle but can't walk (posture-dependent)
Vascular: Can't cycle OR walk (exercise-dependent)
Neurogenic: Needs to sit for relief
Vascular: Just stopping relieves symptoms
Key Point: Examination is Often Normal at Rest!
This is a hallmark of lumbar stenosis - symptoms are dynamic and position-dependent.
What to Assess:
Reproduce and relieve neurogenic claudication
Symptoms relieved by flexion, can continue walking in stooped posture
Neurogenic claudication - flexion opens spinal canal
Ability to detect true positives
Ability to exclude false positives
Provoke stenosis symptoms
Reproduction of leg symptoms with extension
Lumbar stenosis - extension narrows canal
Ability to detect true positives
Ability to exclude false positives
Differentiate neurogenic from vascular claudication
Can walk further on inclined treadmill (flexed posture)
Neurogenic claudication (not vascular)
Ability to detect true positives
Ability to exclude false positives
Motor:
Sensory:
Reflexes:
Straight Leg Raise:
Exercise-Induced Deficit:
Clinical Tip: Examining patient immediately after walking (when symptomatic) may reveal neurological findings not present at rest.
Essential - Must Check:
Compare Sides:
Other Signs of PVD:
Mixed Picture: Patients may have BOTH stenosis and vascular disease (elderly population).
Degenerative Spondylolisthesis:
Assessment:
Grade on X-ray/MRI:
| condition | slr | rest | posture | pulses |
|---|---|---|---|---|
| Lumbar Stenosis | Negative | Usually normal | Flexion helps | Normal |
| Disc Herniation | Positive | Abnormal | Variable | Normal |
| Vascular Claudication | Negative | Normal | Any rest helps | Reduced |
| Hip OA | Negative | Groin pain, reduced ROM | N/A | Normal |
| Peripheral Neuropathy | Negative | Glove/stocking | No effect | Normal |
Walking Distance:
Functional Impact:
Neurological Status:
Treatment Threshold:
"72-year-old woman with 2-year history of bilateral leg heaviness and numbness when walking, relieved by sitting."
High-Yield Exam Summary