import { HighYieldBox, ExamCheatSheet, Tabs, Tab, ComparisonTable, VivaScenario, ContentSection, SpecialTestCard , MedicalImage} from '@/components/content' # Lumbar Stenosis Examination 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. ## Quick Reference One-Pager ## Understanding Stenosis **Definition:** Narrowing of the spinal canal, lateral recess, or neural foramina causing compression of neural elements. **Types:** - **Central stenosis**: Main canal narrowing - **Lateral recess stenosis**: Nerve root in lateral recess - **Foraminal stenosis**: At exit foramen **Causes:** - Degenerative (most common): Disc bulging, facet hypertrophy, ligamentum flavum thickening - Degenerative spondylolisthesis (especially L4-5) - Congenital (short pedicles) - Combined **Why Posture Matters:** - Extension narrows canal (ligamentum flavum buckles) - Flexion opens canal (stretches ligamentum flavum) - Walking = relative extension (symptoms) - Sitting/bending = flexion (relief) **The "Shopping Cart Sign" (Trolley Sign):** - Patient can walk much further leaning on a shopping cart - Flexed posture opens the spinal canal - Same patient may struggle to walk the same distance upright - Pathognomonic for neurogenic claudication Similarly, patients can often cycle (flexed) with no symptoms but cannot walk the same duration. ## Clinical Presentation **Classic Pattern:** - Leg pain, heaviness, numbness, or weakness with walking - Bilateral or alternating (not fixed dermatomal) - Symptoms worsen as walking continues - Relieved by sitting, squatting, or leaning forward - NOT immediately relieved by rest standing (unlike vascular) **Symptoms:** - May describe legs as "tired," "heavy," "burning" - Often both legs (may alternate) - Back pain is often minimal or absent - Worse walking downhill (extension) than uphill (flexion) **History Questions:** - "How far can you walk?" - "What makes you stop?" - "Does sitting relieve symptoms?" - "Can you push a trolley/cart farther?" - "Can you cycle without symptoms?" ## Neurogenic vs Vascular Claudication **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 ## Physical Examination **Key Point: Examination is Often Normal at Rest!** This is a hallmark of lumbar stenosis - symptoms are dynamic and position-dependent. **What to Assess:** - General posture (may stand flexed) - Lumbar ROM (often reduced extension) - Neurological examination (may be subtle or normal) - Peripheral pulses (must exclude vascular) ## Neurological Examination **Motor:** - May be entirely normal - Subtle weakness may be present (L4, L5, S1) - Test key myotomes (quads, EHL, gastrocnemius) **Sensory:** - Often normal or subtle - May have patchy numbness - Not strictly dermatomal (multiple levels) **Reflexes:** - Often normal - May be diminished (multi-level involvement) - Not hyperreflexic (not myelopathy - no cord in lumbar spine) **Straight Leg Raise:** - Usually NEGATIVE (not acute disc) - May be positive if superimposed radiculopathy **Exercise-Induced Deficit:** - Key feature differentiating stenosis - After walking provokes symptoms: - Weakness may appear (couldn't detect at rest) - Sensory changes may become apparent - Reflexes may diminish - Resolves with rest and flexion **Clinical Tip:** Examining patient immediately after walking (when symptomatic) may reveal neurological findings not present at rest. ## Vascular Examination **Essential - Must Check:** - Femoral pulses - Popliteal pulses - Dorsalis pedis pulses - Posterior tibial pulses **Compare Sides:** - Note any asymmetry - Grade pulses (normal, reduced, absent) **Other Signs of PVD:** - Hair loss on legs - Thin, shiny skin - Cool extremities - Delayed capillary refill - Trophic nail changes - Ulceration **Mixed Picture:** Patients may have BOTH stenosis and vascular disease (elderly population). ## Associated Conditions **Degenerative Spondylolisthesis:** - Very common at L4-5 - More common in women - Contributes to stenosis - Look for palpable step-off **Assessment:** - Palpate spinous processes - Note any step deformity - May see skin crease (chronic) **Grade on X-ray/MRI:** - Meyerding classification - Most degenerative are Grade I-II ## Differential Diagnosis ## Severity Assessment **Walking Distance:** - How far before symptoms force stopping? - Document in meters **Functional Impact:** - Household mobility only? - Limited community mobility? - Need for aids? **Neurological Status:** - Any fixed deficit? - Bladder/bowel symptoms (rare, urgent)? **Treatment Threshold:** - Walking distance less than 200m despite conservative treatment - Progressive neurological deficit - Significant quality of life impact ## Summary Presentation ## Examination Sequence 1. **History**: Walking distance, posture effect, cycling ability 2. **Observation**: Standing posture (flexed?), gait pattern 3. **Stoop test**: Walk until symptoms, flex for relief 4. **Extension test**: Standing extension provokes symptoms 5. **Neurological at rest**: Power, sensation, reflexes 6. **SLR**: Usually negative 7. **Lumbar ROM**: Extension often limited 8. **Peripheral pulses**: All four levels, both sides 9. **Post-exercise neuro**: Re-examine if symptoms provoked 10. **Spondylolisthesis check**: Palpate spinous processes ## Examiner Tips