AKT · Musculoskeletal/Spine & backlow yield

Spinal stenosis

Degenerative narrowing of the lumbar spinal canal → neurogenic claudication

Overview

Degenerative narrowing of the lumbar spinal canal (from facet/ligamentum flavum hypertrophy, disc bulging and osteophytes) compressing the nerve roots. It causes neurogenic claudication in older adults — and its discrimination from vascular claudication and from a simple disc prolapse is the high-yield skill. The give-away is that flexion (sitting, leaning on a trolley, walking uphill) relieves it.

Recognise

Older adult with bilateral buttock/leg pain, heaviness, numbness or weakness brought on by WALKING and STANDING (extension) and relieved by SITTING/bending forward (flexion)
Walking uphill or leaning on a shopping trolley is easier than walking downhill/upright (flexion opens the canal)
Often preserved peripheral pulses (distinguishing it from vascular claudication); back pain may be mild

Red flags

Bladder/bowel dysfunction or saddle anaesthesia → exclude cauda equina (emergency MRI)
Progressive neurological deficit → earlier surgical referral

Differentials & how to tell them apart

Vascular (peripheral arterial) claudicationrelieved by STANDING STILL (not flexion), absent pulses, low ABPI — cross-ref cardiovascular

Lumbar disc prolapsedermatomal radicular pain, positive straight-leg raise, usually younger; not posture/walking-distance dependent in the claudication pattern

Cauda equina syndromebladder/bowel/saddle involvement — emergency

Investigations

MRI of the lumbar spine is the imaging of choice (shows canal narrowing); clinically distinguish neurogenic (flexion-relieved, pulses present) from vascular claudication (relieved by rest/standing still, absent pulses, ABPI low).

Management

Conservative (physiotherapy + analgesia); decompression (laminectomy) for refractory/progressive disease

1Recognise neurogenic claudication (walking/standing-induced leg symptoms relieved by FLEXION/sitting, pulses preserved) and confirm with lumbar MRI. Manage conservatively first — exercise/physiotherapy and analgesia.Gate: Distinguish from vascular claudication (relieved by standing still, absent pulses, low ABPI) — the treatments differ entirely; and exclude cauda equina if bladder/bowel/saddle symptoms appear.
2Refractory or progressive symptoms → epidural injection or surgical decompression (laminectomy).

Conservative: exercise/physiotherapy, analgesia, activity modification — first-line; many manage with conservative measures

Epidural corticosteroid injection — for symptom relief in selected patients

Surgical decompression (laminectomy) — for severe or progressive symptoms not controlled conservatively

Address comorbidity — and falls/mobility in the older patient

Key points

Older adult, bilateral leg symptoms on WALKING/STANDING relieved by SITTING/FLEXION (easier uphill/leaning on a trolley), with PRESERVED pulses = neurogenic claudication from spinal stenosis → MRI, conservative care, decompression if refractory. Vascular claudication is relieved by standing still with absent pulses.

Monitor & prognosis

Walking distance/function, neurological signs; response to conservative care.

Often stable; decompression helps refractory neurogenic claudication.

Source: NICE NG59; cross-ref cardiovascular (vascular claudication)