Clinical presentation of symptomatic spinal canal stenosis

Symptomatic spinal canal stenosis generally presents with low back pain radiating to the buttocks and legs, and is usually bilateral. Patients can also present with leg pain alone and no back pain. Pain may be aggravated by walking or standing, and relieved by sitting or leaning forward (neurogenic claudication or pseudoclaudication); this must be distinguished from the similar symptoms of claudication due to arterial insufficiency. Radicular leg pain in a single dermatomal distribution is more suggestive of single nerve root compression (see Symptomatic lumbar disc herniation).

Progressive bilateral foot or leg weakness, reduced sensation in the ‘saddle’ area, and altered bladder or bowel function (eg urinary retention, faecal incontinence) indicate the possibility of cauda equina compression. Any indication of cauda equina compression is a spinal emergency; immediately refer the patient to an emergency department for review by a neurosurgeon or spinal surgeon. Alerting features of other serious pathologies in patients with spinal pain should also be excluded (see Serious pathologies requiring urgent management in patients with back and neck pain and their alerting features (‘red flags’)).

Note: Any indication of cauda equina compression is a spinal emergency.