Dr. Cadogan is Professor, Adjunct Series, University of California, Los Angeles, School of Nursing, Los Angeles, California.
The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to Mary P. Cadogan, DrPH, RN, GNP-BC, Professor, Adjunct Series, University of California, Los Angeles, School of Nursing, Factor 5-952, Box 956919, Los Angeles, CA 90095-6919; e-mail: email@example.com.
Mr. A. is a 79-year-old man who is seen at a geriatric health screening event at his local senior center. When he is evaluated, Mr. A. confides to the nurse that he has been worried lately because of back and leg pain that seem to be getting worse and requiring him to rest several times when he walks even short distances. As a result, his ability to perform his usual activities has decreased, and he feels he is losing his independence.
During the performance-based evaluation of his gait and balance, Mr. A. was noted to have difficulty rising from his chair and reported moderate lower back pain (score of 6 on a 0-to-10 pain scale) that radiated to his buttocks and thighs when he stood up. The pain increased to a level of 8 and extended down his legs when he started to walk, and he requested that the evaluation be discontinued. He leaned forward on a walker that was nearby and commented that his pain improved (to level 4) when he leaned forward. He reported that he has had low back pain “on and off” for years. A few years ago, he was evaluated by his family physician who took x-rays of his lower back and told Mr. A. that he had arthritis in his spine for which acetaminophen was recommended. Mr. A. was referred to the geriatric clinic for additional evaluation where several important findings were noted.
Mr. A. described his pain in more detail, indicating that it begins in his back and usually travels bilaterally to his buttocks and thighs, and often into his calves. It rarely occurs when he is sitting and often starts when he stands up straight, then worsens after he starts walking. The worst pain occurs when he tries to walk down stairs. He noticed that his pain improves when he wheels a grocery cart in the supermarket, but then when he tries to carry his groceries to the car, his pain returns. Recently, he tried using his son’s stationary bicycle for exercise and was surprised that he was able to pedal without pain. He stated that his only medical problems are “borderline high blood pressure,” arthritis, and an episode of gout 15 years ago.
On physical assessment of his back, he had no obvious spinal abnormalities and no specific areas of tenderness or muscle spasm. Spinal range of motion was normal for flexion, moderately decreased for lateral bending, and significantly decreased for spinal extension, which was associated with moderate to severe thigh pain. Strength and sensation in both lower extremities were intact and straight-leg-raising tests were negative. Lower extremity skin color, turgor, and temperature were normal, and all pulses were strong and equal. He had normal plantar reflexes bilaterally. However, he was noted to have a wide-based gait, decreased vibration in his feet bilaterally, and slightly decreased ankle reflexes. He had an abnormal Romberg’s test (Khasnis & Gokula, 2003) result, manifested by losing his balance when he stood with his eyes closed.
Based predominantly on the classic report of his pain, some characteristic assessment findings, and the absence of specific vascular and neurological signs, Mr. A. was informed there was a high likelihood that his pain and associated functional limitations were due to lumbar spinal stenosis (LSS). The diagnosis was confirmed with magnetic resonance imaging (MRI) of his spine.
What Causes Lumbar Spinal Stenosis?
Several factors contribute to the development of LSS, and in many individuals, these factors co-exist. LSS is most often caused by degeneration in the disks, the ligaments, or the facet joints (Katz & Harris, 2008). The process of degeneration is thought to start in the intervertebral disk where biochemical changes, such as cell death and loss of proteoglycan and water content, lead to progressive disk bulging and collapse (Butler, Trafimow, Andersson, McNeill, & Huckman, 1990). With disc degeneration, the height of the intervertebral space decreases, leading to narrowing of the lateral recess and intervertebral foramina, which exerts increased stress on the facet joints (Siebert et al., 2009). This, in turn, can cause degeneration of the joint cartilage, joint hypertrophy, and formation of osteophytes. In addition, the reduced height of the spinal segment leads to thickening and loosening of the ligamentum flavum (i.e., ligament that forms the posterior wall of the spinal canal), causing it to form creases and fold inward to the spinal canal, exerting pressure on the spinal dura (Djurasovic, Glassman, Carreon, & Dimar, 2010). Together, these degenerative and hypertrophic changes contribute to the characteristic trefoil (triangular)-shaped narrowing of the central canal (central stenosis) and can cause compression of nerve roots in the lateral recess and intervertebral foramina (lateral stenosis).
Clinical Presentation and Evaluation of LSS
Due to individual anatomical differences and patterns of central and lateral degeneration, as well as the possible involvement of one or multiple vertebral segments, clinical presentations may vary. However, there are some classic signs and symptoms that are important for nurses and other health care providers to recognize. Although many individuals with LSS describe a long history of intermittent back pain, what often causes them to seek care is the onset of neurogenic claudication (sometimes referred to as pseudo-claudication). This is one of the most characteristic symptoms of LSS, which was well described by Mr. A. in the individual example. Low back, buttock, thigh, and calf discomfort—often described as a cramping, burning sensation, sometimes with associated numbness and tingling in the legs and thighs—occurs with activities that cause lumbar extension (e.g., standing, walking) and improve with lumbar flexion (e.g., leaning forward, sitting) (Genevay & Atlas, 2010).
It is important to distinguish neurogenic claudication from vascular claudication because of the different clinical implications and management approaches for each disorder. Summarizing data from several sources (Best, 2002; Djurasovic et al., 2010; Rahman, Nowak, Gelb, Poelstra, & Ludwig, 2008; Truumees, 2005), the Table provides a comparison of neurogenic and vascular claudication. Of particular note in the Table are the maneuvers that prevent or improve pain in individuals with LSS. As described by Mr. A., pain was improved with activities associated with spinal flexion and worsened with spinal extension. The cross-sectional area of the lumbar spinal canal has been found to be reduced by up to 67% during extension among those with LSS (Truumees, 2005).
Table: Comparison of Neurogenic and Vascular Claudication
Other characteristic findings in LSS were demonstrated during Mr. A.’s evaluation. Suri, Rainville, Kalichman, and Katz (2010) developed a scoring system to predict the likelihood of a diagnosis of LSS. The following items from the patient’s history are scored (point values in parentheses):
- Age (1 = 60 to 70, 2 = older than 70).
- Absence of diabetes (1).
- Neurogenic claudication (3).
- Exacerbation of symptoms when standing up (2).
- Symptom improvement when bending forward (3).
Physical examination items are:
- Symptoms induced by having patient bend forward (−1).
- Symptoms induced by patient bending backward (1).
- Good peripheral artery circulation (3).
- Abnormal Achilles tendon reflex (1).
- Straight-leg-raising test positive for reproducing pain (−2).
Scores can range from −2 to 17, and a positive score for LSS is >7. Mr. A. scored 11 points for history and 5 for physical examination, resulting in a total score of 16, indicating a high likelihood of LSS.
Mr. A.’s diagnosis was further confirmed with MRI. Because the high resolution of MRI for soft tissues allows excellent evaluation of the intervertebral disc, nerve roots, facet joints, and contents of the central spinal canal and neural foraminae, MRI is considered the most appropriate, noninvasive imaging test for LSS (Watters et al., 2008). Computed tomography (CT) may be used for those with contraindications to use of MRI.
Natural History and Clinical Management of LSS
The goals of LSS management are to decrease pain and improve physical function and quality of life (Djurasovic et al., 2010). Results from a 4-year study of the natural course of LSS (Johnsson, Rosén, & Udén, 1992) documented no change in symptoms for 70% of patients, improvement in 15%, and worsening in 15%. In the same study, walking capacity improved in 37% of patients, remained unchanged in 33%, and worsened in 30%. In general, an initial conservative approach to treatment is advised because many individuals will respond to conservative treatment alone, and for those who do not respond, more invasive approaches may be considered (Amundsen et al., 2000).
Conservative treatment begins with identifying approaches to decrease spinal compression, alleviate pain, and improve walking capacity. Physical therapy may be recommended for development of individual programs to strengthen abdominal and back muscles, improve spinal range of motion, and identify personal goals and plans for overall fitness. Addition of ultrasound to exercise therapy may lower the need for analgesic agents among LSS patients (Goren, Yildiz, Topuz, Findikoglu, & Ardic, 2010). For overweight or obese individuals, weight loss is recommended to decrease overall stress on spinal structures. Development of strategies to avoid activities that aggravate pain and other symptoms are essential. Use of an assistive device (e.g., wheeled walker) may allow individuals to walk longer distances with less pain because it allows spinal flexion.
Often, concurrent use of pain medication is required. As recommended in the most recent guidelines from the American Geriatrics Society (AGS) Panel on the Pharmacological Management of Persistent Pain in Older Persons (2009), management of chronic pain in older adults should begin with regularly dosed acetaminophen (Tylenol® and others) titrated to a level that achieves pain management. The maximum dose is 4 g daily. However, for those with hepatic insufficiency or history of alcohol abuse, acetaminophen may be contraindicated or require dose reduction. Although nonsteroidal anti-inflammatory drugs (NSAIDs) are considered a next treatment step for LSS if acetaminophen does not provide sufficient pain relief (Katz & Harris, 2008), older adults are at high risk for adverse effects related to NSAID use. According to the AGS guidelines, additional medications such as gabapentin (Neurontin®), pregabalin (Lyrica®), or duloxetine (Cymbalta®) may be added for treatment of neuropathic pain. Finally, low-dose opioids or tramadol (Ultram®) may be considered for individuals whose pain is not managed adequately with other medications.
If symptom management is not achieved with conservative approaches, more invasive interventions, such as epidural injections or surgery, may be considered. Data from the Spine Patient Outcomes Research Trial (SPORT) document greater improvement in pain and function through 4 years among those treated surgically compared with those with conservative treatment only (Weinstein et al., 2010). Results from the same trial indicate that patients with predominant leg pain (versus back pain) have greater symptom relief following surgery (Pearson et al., 2011). Risk of surgical complications may increase with age, comorbidities, history of previous hospitalization, and more complex surgical procedures for LSS (Deyo et al., 2010). Others have demonstrated that LSS surgery in patients older than 75 can be conducted safely and with similar outcomes as in younger patients (Wang, Green, Shah, Vanni, & Levi, 2003).
Summary and Nursing Considerations
As recommended, Mr. A. started a regular dosing schedule of acetaminophen and gabapentin. Following an intensive physical therapy program, he noticed marked improvement in his symptoms. Use of a wheeled walker allows him to increase walking distance without pain. He uses a stationary bicycle daily and swims twice per week to improve his overall fitness. He returned to his local senior center to thank the staff for identifying the source of his pain and other symptoms and for the interventions that have allowed him to maintain his independence.
As demonstrated in Mr. A.’s example, LSS may be associated with significant disability and impaired quality of life. LSS may be underrecognized as a source of pain and functional limitation among older adults. Careful attention to aggravating and alleviating factors during pain assessments may identify positional maneuvers associated with pain. When individuals with a known diagnosis of LSS are seen in clinical settings, care planning should include strategies such as activity modification (avoidance of excess spine extension) to minimize pain and maximize function. Particular attention should be given to patients who are unable to verbally communicate pain. Observation of pain behaviors associated with spinal extension and relieved with flexion may indicate a need for LSS-specific pain and symptom management.
- American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. (2009). Pharmacological management of persistent pain in older persons. Journal of the American Geriatrics Society, 57, 1331–1346.
- Amundsen, T., Weber, H., Nordal, H.J., Magnaes, B., Abdelnoor, M. & Lilleâs, F. (2000). Lumbar spinal stenosis: Conservative or surgical management? A prospective 10-year study. Spine, 25, 1424–1435. doi:10.1097/00007632-200006010-00016 [CrossRef]
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Comparison of Neurogenic and Vascular Claudication
|Characteristic||Neurogenic Claudication||Vascular Claudication|
|Pain location||Back, buttocks, thighs, calves; travels in a proximal to distal direction||Pain develops in calves; travels in a distal to proximal direction|
|Pain quality||Sharp or crampy, may be associated with burning, numbness, tingling||Cramping|
|Maneuvers that may precipitate or aggravate pain|
Pain occurs with standing and walking
Pain improves from flat to inclined treadmill walking
Pain is worse descending compared with ascending stairs
Pain does not occur during the bicycle testa
Pain occurs with walking
Pain equally severe with flat or inclined treadmill walking
Pain is equal ascending and descending stairs
Pain occurs during the bicycle testa
|Alleviating factors||Pain is rapidly relieved with sitting or bending forward and by lying, particularly on side||Slow relief with standing still|
|Other Distinguishing Features|
|Lower extremity pulses||Normal||Decreased or absent|
|Lower extremity skin||Normal||Pale or cyanotic, shiny, hairless|
|Impotence||Absent||May be present|
|Cauda equina syndrome symptoms (e.g., weakness in legs, numbness in anal and genital regions, disturbances in bowel or bladder function)||Rare||Absent|