Lumbar Stenosis Examination

Commonly Tested

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.

Exam day cheat sheet

Lumbar Stenosis Examination Summary

Neurogenic Claudication

Leg pain/numbness with walking
Relieved by sitting or flexion
Worse with extension/standing
Can walk further with trolley (shopping cart sign)

Key Differentiators

Neurogenic: Flexion helps, extension hurts
Vascular: Pulses reduced, rest helps quickly
Neurogenic: Can cycle (flexed) but not walk

Examination Findings

Often NORMAL at rest
May have subtle neuro findings
Extension provokes symptoms
Flexion relieves symptoms

Tests

Stoop test (walk → symptoms → flex → relief)
Extension stress test
SLR often negative (not disc)
Check peripheral pulses!

Understanding Stenosis

Pathophysiology

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)

Key Concept

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

Neurogenic Claudication

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

Character

neurogenic: Pain, numbness, heaviness, weakness
vascular: Cramping, aching pain

Location

neurogenic: Back, buttocks, thighs, legs (often bilateral)
vascular: Calves (usually), thighs

Onset

neurogenic: Varies with posture as well as distance
vascular: Consistent distance

Relief

neurogenic: Sitting, flexion, takes minutes
vascular: Standing rest, quick relief (less than 5 min)

Cycling

neurogenic: Usually fine (flexed)
vascular: Also causes symptoms (exercise)

Uphill vs Downhill

neurogenic: Downhill worse (extension)
vascular: Uphill worse (more effort)

Pulses

neurogenic: Normal
vascular: Reduced or absent

Skin

neurogenic: Normal
vascular: Thin, shiny, hairless

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

Must Know

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

Resting 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)

Special test

Stoop Test (Dyck Test)

Reproduce and relieve neurogenic claudication

Technique

1Have patient walk until symptoms develop
2Note distance walked and symptoms
3Ask patient to lean forward or squat (flex spine)
4Observe if symptoms relieve
5Continue walking in flexed posture

Positive Sign

Symptoms relieved by flexion, can continue walking in stooped posture

Indicates

Neurogenic claudication - flexion opens spinal canal

Diagnostic Accuracy

Sensitivity90%

Ability to detect true positives

Specificity80%

Ability to exclude false positives

Special test

Lumbar Extension Stress Test

Provoke stenosis symptoms

Technique

1Patient stands and extends lumbar spine
2Hold for 30-60 seconds
3May add walking in extended position

Positive Sign

Reproduction of leg symptoms with extension

Indicates

Lumbar stenosis - extension narrows canal

Diagnostic Accuracy

Sensitivity75%

Ability to detect true positives

Specificity85%

Ability to exclude false positives

Special test

Two-Stage Treadmill Test (van Gelderen Bicycle Test)

Differentiate neurogenic from vascular claudication

Technique

1Stage 1: Walk on level treadmill until symptoms
2Stage 2: Walk on inclined treadmill (forces flexion)
3Compare walking distances

Positive Sign

Can walk further on inclined treadmill (flexed posture)

Indicates

Neurogenic claudication (not vascular)

Diagnostic Accuracy

Sensitivity80%

Ability to detect true positives

Specificity90%

Ability to exclude false positives

Neurological Examination

At Rest Assessment

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

Post-Exercise Assessment

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

Rule Out Vascular Disease

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

Spondylolisthesis

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

Lumbar Stenosis

slr: Negative
rest: Usually normal
posture: Flexion helps
pulses: Normal

Disc Herniation

slr: Positive
rest: Abnormal
posture: Variable
pulses: Normal

Vascular Claudication

slr: Negative
rest: Normal
posture: Any rest helps
pulses: Reduced

Hip OA

slr: Negative
rest: Groin pain, reduced ROM
posture: N/A
pulses: Normal

Peripheral Neuropathy

slr: Negative
rest: Glove/stocking
posture: No effect
pulses: Normal

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

Severity Assessment

Clinical Grading

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

Viva scenarioStandard

Presenting Your Findings

Clinical prompt

“72-year-old woman with 2-year history of bilateral leg heaviness and numbness when walking, relieved by sitting.”

Examination Sequence

Systematic Approach

History: Walking distance, posture effect, cycling ability
Observation: Standing posture (flexed?), gait pattern
Stoop test: Walk until symptoms, flex for relief
Extension test: Standing extension provokes symptoms
Neurological at rest: Power, sensation, reflexes
SLR: Usually negative
Lumbar ROM: Extension often limited
Peripheral pulses: All four levels, both sides
Post-exercise neuro: Re-examine if symptoms provoked
Spondylolisthesis check: Palpate spinous processes

Examiner Tips

Exam day cheat sheet

Scoring High in Lumbar Stenosis Examination

Do

Check peripheral pulses (essential)
Use stoop test to reproduce and relieve symptoms
Understand examination is often normal at rest
Know neurogenic vs vascular differentiation
Examine post-exercise for induced deficit

Don't

Expect positive SLR (disc herniation sign)
Forget to check for spondylolisthesis
Miss vascular disease (both can coexist)
Forget to assess walking distance
Neglect functional impact assessment