CINN Medical Group Physician Blog

Good thing I don’t feel as bad as my pictures look

Part III of a series on lumbar stenosis

It sounds kind of simple, but successful treatment of back problems depends on an accurate diagnosis of the problem. Establishing an accurate diagnosis requires careful consideration of the history, physical examination, and studies like x-rays, MRI, CT, and other diagnostic studies and images. Radiologists are paid to point out every little detail that is not exactly what would be found in a normal 18 year old spine, and so x-ray and MRI reports are frequently filled with notations of stenosis here, bulges there, osteophytes all over the place, and sometimes even lions, tigers and bears (ok, so maybe the animals aren’t there, but there is a Scotty dog that we will discuss one of these days). The best approach therefore is to start with the history and physical, which means talking to the patient and examining the patient. After that is completed, the films are used to find the anatomic abnormalities that match the patient’s findings.

The problem we have been discussing actually should be known as neurogenic claudication, which means pain in the legs with walking that comes from problems with nerves (there is also something called vascular claudication, which is pain in the legs with walking that comes from clogged arteries). Patients usually have pain in the buttocks thighs, and sometimes calves with walking or standing. It gets worse the more they walk, and in fact we can tell if progress is being made with treatment by how far they can walk without pain. Unless the stenosis is very severe, the pain goes away with sitting or laying down. There is sometimes some numbness in the toes or in the areas that are painful, but usually there isn’t any weakness. This set of symptoms and findings usually make it easy to diagnose lumbar stenosis. However, sometimes patients have only back pain, rather than thigh pain, and the absence of thigh/calf pain brings up the possibility that the source of the pain is something other than pressure on the nerves.

Once the clinical (something based on the history and physical findings) diagnosis is made, the studies are examined to see if there is a finding that fits with the problem. The narrowing of the space for the nerves (stenosis) does not usually cause problems until it is moderate or severe. As long as there is even a little extra space, there isn’t pressure on the nerves. Symptoms happen when all the extra space is gone and the nerves are crowded together and compressed. Therefore, radiology reports frequently contain lots of findings that are not important and have no relavence to a patient’s problems or treatment. However, when the patient has an exam and history consistant with lumbar stenosis, and the studies reveal significant narrowing of the space for the nerves (stenosis), an accurate diagnosis has been reached, and treatment options can be considered. And that will be the topic of the next post.

Previous posts by Dr. Stadlan:

Is it just arthritis?

The shopping cart sign