Spinal Stenosis
Doctor Instruction:
Your next patient is a 51-year-old woman called Rebecca, presenting with lower back pain. Please take a history and perform an appropriate examination.
Patient History:
Rebecca, a 51-year-old female, nurse
You have always been having lower back pain for the past few years, but this has been getting gradually worse. The pain is dull and intermittent. Very often, the pain can diffuse and radiate towards the buttocks, back of the thighs, and feet - when this happens, the pain feels like a burning or cramping sensation. It can be associated with weakness in both legs. The symptoms can be triggered or worsened by sitting down, standing straight and walking downhill. It goes away after a few minutes after being at rest. Bending forward improves symptoms. You tried paracetamol, which only helped a little with pain.
If you walk for more than 50 yards, you will start noticing numbness and weakness in your legs.
No previous injury/trauma. Waterworks normal. The bowels are working normally. No other abnormal sensations or weaknesses. No incontinence. No stiffness. No fever. No weight loss. No night sweats.
Ideas, Concerns, Expectations:
You think because you often have to bend your back due to work, the pain may be caused by poor posture. You are concerned because it is starting to affect your ability to work in the hospital as a nurse. You would like to see if you can get stronger painkillers and possibly have a scan of your back.
Past Medical History:
Obesity, hypercholesterolemia, acromegaly, T2DM.
No past relevant surgical history.
Drug History:
Atorvastatin, metformin NKDA.
Family History:
Father has ankylosing spondylitis.
Social History:
You work as a senior nurse in a local hospital.
You smoke around ten cigarettes daily for over ten years but don't drink alcohol.
Live with husband in a semi-detached house.
Independent.
Examination Findings:
Lower spinal tenderness on palpation at L4-5 region.
Complete motor and sensory neurological examinations are normal.
Features of acromegaly e.g. enlarged hands, feet and facial features.
Lower limb vascular examination is normal.
No cervical tenderness or restricted movement. Gait normal.
No cauda equina syndrome features.
Peripheral pulses and ABPI normal.
Differentials:
Lumbar spinal stenosis - likely to be due to degenerative changes
Osteoarthritis of the spine
To rule out cauda equina syndrome
Ankylosing spondylitis/spondylolisthesis
Rule out peripheral arterial diseases
Other causes of back pain: spinal tumour, disc herniation, trauma, fracture, and epidural abscess.
Investigations:
Imaging:
XR Lumbar spine (may show degenerative changes/spondylolisthesis)
MRI Spine. Alternatively, CT myelography/spine when MRI is not available or unsuitable.
Consider ABPI / CT angiogram to exclude peripheral arterial disease where intermittent claudications are present.
Special tests:
Consider electromyographic (EMG) walking test - increased F latency values in lumbar spinal stenosis
Consider electromyographic paraspinal mapping
Management:
Conservative:
Exercise
Weight loss if overweight
Physiotherapy e.g. exercises that minimally stress the back, such as walking, swimming, or bicycling. Exercise may also strengthen the paraspinal muscles.
NSAIDSs e.g. naproxen, celecoxib +/- PPI cover / antacids
Paracetamol
Medication for neuropathic pain e.g. amitriptyline, gabapentin, pregabalin.
Consider oral steroids for acute exacerbation of painful symptoms.
Activity modification e.g. limit heavy lifting/prolonged sitting/repetitive bending/twisting of the back.
Consider deep heat therapy with massage to relieve spasms associated with back pain
Surgical:
Consider decompression surgery +/- fusion e.g. laminectomy ( removal of the lamina from affected vertebra) followed by physiotherapy
Consider interspinous distraction procedure to reduce backward movement of the spine.
Consider epidural injections with local anaesthetic and corticosteroids under specialist guidance for short/long-term pain relief.
Viva Questions:
Explain the pathophysiology of spinal stenosis.
Spinal stenosis is the narrowing of the spinal canal, which holds the spinal cord and nerves. It's often due to age-related disc degeneration, arthritis, and thickened ligaments. This narrowing can compress the spinal cord and nerves, leading to pain, numbness, and weakness. Factors like herniated discs and inflammation worsen the compression. Treatment involves pain management, physical therapy, and sometimes surgery to relieve pressure on the nerves and spinal cord.
At what level of the spine does spinal stenosis occur most commonly?
Spinal stenosis most commonly occurs in the lumbar (lower back) region of the spine. This is because the lumbar spine bears the most weight and undergoes significant movement, which can contribute to degenerative changes over time. Lumbar spinal stenosis can result in compression of the spinal cord and nerve roots, leading to symptoms such as lower back pain, leg pain, numbness, and weakness. However, spinal stenosis can also occur in the cervical (neck) and thoracic (mid-back) regions of the spine, albeit less frequently.
What are the causes of spinal stenosis?
Degeneration of spinal structures due to aging.
Disc degeneration and herniation.
Osteoarthritis and bone spurs.
Thickened ligaments.
Congenital factors and genetics.
Injuries and trauma.
Tumors or abnormal growths.
These factors narrow the spinal canal, compressing nerves and causing stenosis symptoms.
What are the risk factors of spinal stenosis?
Age: Risk increases with aging.
Genetics: Family history matters.
Congenital: Narrow canal from birth.
Injuries: Past spine trauma or surgery.
Lifestyle: Heavy lifting, certain jobs.
Obesity: Excess weight strains spine.
Diseases: Arthritis, diabetes, etc.
Scoliosis: Abnormal spine curvature.
What are the red flag symptoms/signs of back pain?
Neurological Issues: Weakness, numbness, or tingling.
Bladder/Bowel Problems: Loss of control.
Severe Pain: Unbearable or unrelenting.
Fever: Along with back pain.
Unexplained Weight Loss: Rapid and unintended.
Cancer History: Especially if pain is new.
Night Pain: Worse at night.
Trauma: After injury or accident.
Age Over 50: New-onset pain.
Steroid Use: Especially long-term.
