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The Rational Clinical Examination |

Does This Older Adult With Lower Extremity Pain Have the Clinical Syndrome of Lumbar Spinal Stenosis?

Pradeep Suri, MD; James Rainville, MD; Leonid Kalichman, PT, PhD; Jeffrey N. Katz, MD, MS
JAMA. 2010;304(23):2628-2636. doi:10.1001/jama.2010.1833.
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Context The clinical syndrome of lumbar spinal stenosis (LSS) is a common diagnosis in older adults presenting with lower extremity pain.

Objective To systematically review the accuracy of the clinical examination for the diagnosis of the clinical syndrome of LSS.

Data Sources MEDLINE, EMBASE, and CINAHL searches of articles published from January 1966 to September 2010.

Study Selection Studies were included if they contained adequate data on the accuracy of the history and physical examination for diagnosing the clinical syndrome of LSS, using a reference standard of expert opinion with radiographic or anatomic confirmation.

Data Extraction Two authors independently reviewed each study to determine eligibility, extract data, and appraise levels of evidence.

Data Synthesis Four studies evaluating 741 patients were identified. Among patients with lower extremity pain, the likelihood of the clinical syndrome of LSS was increased for individuals older than 70 years (likelihood ratio [LR], 2.0; 95% confidence interval [CI], 1.6-2.5), and was decreased for those younger than 60 years (LR, 0.40; 95% CI, 0.29-0.57). The most useful symptoms for increasing the likelihood of the clinical syndrome of LSS were having no pain when seated (LR, 7.4; 95% CI, 1.9-30), improvement of symptoms when bending forward (LR, 6.4; 95% CI, 4.1-9.9), the presence of bilateral buttock or leg pain (LR, 6.3; 95% CI, 3.1-13), and neurogenic claudication (LR, 3.7; 95% CI, 2.9-4.8). Absence of neurogenic claudication (LR, 0.23; 95% CI, 0.17-0.31) decreased the likelihood of the diagnosis. A wide-based gait (LR, 13; 95% CI, 1.9-95) and abnormal Romberg test result (LR, 4.2; 95% CI, 1.4-13) increased the likelihood of the clinical syndrome of LSS. A score of 7 or higher on a diagnostic support tool including history and examination findings increased the likelihood of the clinical syndrome of LSS (LR, 3.3; 95% CI, 2.7-4.0), while a score lower than 7 made the diagnosis much less likely (LR, 0.10; 95% CI, 0.06-0.16).

Conclusions The diagnosis of the clinical syndrome of LSS requires the appropriate clinical picture and radiographic findings. Absence of pain when seated and improvement of symptoms when bending forward are the most useful individual findings. Combinations of findings are most useful for identifying patients who are unlikely to have the diagnosis.

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Figure. Radiographic Features of Lumbar Spinal Stenosis
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A, left, axial T2-weighted magnetic resonance image (MRI) at the L3-L4 level; right, normal radiographic appearance of the spinal canal includes patent central canal, lateral recesses, and neural foramina. B, left, axial T2-weighted MRI at L4-L5 level; right, radiographic features seen with lumbar spinal stenosis include intervertebral disk bulging, ligamentum flavum hypertrophy, and facet joint osteorthritis. Stenosis may occur in the central canal, the lateral recess, or the neural foramina.

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