Lumbar Spinal Stenosis (LSS) Care Pathway

Date of last update: September, 2024

7. Physical Examination

A comprehensive clinical examination should consider the biopsychosocial aspects of the patient’s condition, cultural considerations, and the necessity of obtaining informed consent. This approach is crucial for both new and existing patients, especially when they present with new complaints. Obtaining informed consent involves explicitly addressing the purpose and process of the examination, ensuring the patient understands and agrees to the procedures. Special care should be taken when contact is made in sensitive areas, prioritizing the patient’s comfort and understanding throughout the examination. Additionally, cultural awareness is essential in healthcare, as a patient's cultural background can significantly influence their perception and response to treatment. Practitioners should adapt their examination techniques and interactions to be respectful and sensitive to cultural differences, tailoring their approach to meet the specific needs and considerations of each patient.

Observation: Abnormalities, asymmetries, posture, balance, movements, facial expression, gait, walking capacity (measured by distance or time).

Range of Motion:

• Lumbar spine's active, passive, and resisted ROM in all planes (flexion, extension, lateral flexion, and rotation). Extension may reproduce signs and symptoms, while flexion may provide relief.

• Hip active, passive, and resisted ROM in all planes (flexion, extension, abduction, adduction, internal/external rotation). Reproduction of symptoms may indicate hip pathology.

• Consider regional and segmental hypomobility, hypermobility and aberrant movement patterns.

Palpation: Identify areas of tenderness in the lumbar spine and surrounding musculature.

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Neurological Examination:

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Motor Strength:

• Check for asymmetry or weakness indicating nerve root involvement:

  • L2: Hip flexors (hip flexion).

  • L3: Quadriceps (knee extension).

  • L4: Tibialis anterior (foot dorsiflexion).

  • L5: Extensor hallucis longus (big toe extension).

  • S1: Gastrocnemius (plantar flexion).

  • S2: Hamstrings (knee flexion)

• Record the clinical findings for each. E.g., L5: Extensor hallucis longus (EHL) strength: L5: EHL – L 3/5, R 5/5

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Sensory Examination: 

• Key Observations: Check for sensory deficits in lower extremities, corresponding to specific dermatomal distributions:

  • L3: Medial thigh at the knee.

  • L4: Medial side of the calf.

  • L5: Top of the foot and toes.

  • S1: Lateral side of the foot and little toe.

• Record the clinical findings for each. E.g., "Patient reports that they perceive the same for sharp, light, and vibration for L3, L4, L5, and S1." "Patient reports a loss of perception of sharp and light for S1 on the right with all other sensations intact."

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Reflexes: 

• Key Observations: Asymmetry or absence of reflexes can indicate nerve root compression or other neurological conditions

  • L4: Patellar reflex.

  • L5: Medial hamstring reflex.

  • S1: Achilles reflex.

• Record the clinical findings: E.g., L5: R 2/4, L 3+/4

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Lower Motor Neuron Signs:

• Key Observations: Muscle atrophy, fasciculations, reduced muscle tone, symmetrical loss of function. May indicate a systemic neurological condition (e.g., radiculopathy, peripheral neuropathy, ALS, spinal muscular atrophy).

• Record as: E.g., "LMN signs: Atrophy (yes/no), Fasciculations (yes/no), Muscle tone (reduced/normal), Function loss (symmetrical/asymmetrical)"

Upper Motor Neuron Signs:

• Key Observations: Increased muscle tone, hyperreflexia, pathological reflexes (e.g., Babinski sign, Clonus). May indicate conditions affecting the central nervous system (e.g., cervical spondylotic myelopathy, multiple sclerosis, stroke, spinal cord injuries).

• Record as: E.g., "UMN signs: Muscle tone (increased/normal), Hyperreflexia (yes/no), Babinski sign (positive/negative), Clonus (yes/no)"

Special/Orthopedic Tests:

Select tests to use alongside a comprehensive clinical examination; the validity and reliability of these tests vary. Record: For all tests, note the side tested, whether the test is positive or negative, and include an observational note for the responses to the test to also inform the clinical picture. E.g., SLR R(-), L(+) patient reports pain to left heel. Tests include:

Special tests helpful to differentiate LSS from a disc herniation:

1. Passive Straight Leg Raise: Positive test: exacerbates leg pain at or below 45° of hip flexion, indicating disc pathology. A negative test is seen in neurogenic claudication due to LSS

2. Slump Test: Positive test: neurological symptoms (e.g., shooting pain, numbness, or burning down leg). A negative test is seen in neurogenic claudication due to LSS.

3. Femoral Nerve Traction Test: Positive test: reproduces symptoms (e.g., pain in low back, buttock, posterior thigh). A negative test is seen in neurogenic claudication due to LSS.

Tests for lumbar spine and hip function:

1. Kemp’s Test / Quadrant Test / Extension-Rotation Test: Positive test: pain in the lumbar region or referred pain into the lower extremity. A positive test is seen in patients with LSS

2. Trendelenburg Test: Positive test: dropping/lowering of the hip region, which could indicate hip pathology.

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Tests to help differentiate neurogenic claudication from vascular claudication:

1. Foot pulses: Positive test: absent or reduced dorsalis pedis pulse or posterior tibial pulse could indicate vascular claudication.

2. Ankle Brachial Index (ABI): Positive test: ABI < 0.90 could indicate peripheral vascular disease.

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Functional tests to test balance and lower extremity strength:

1. 30 Second Sit-to-Stand Test: Evaluates lower extremity strength. If patient scores below the average for their age and sex, this indicates lower extremity weakness, which increases their risk for falls.

2. Timed Up and Go Test: Evaluates fall risk. Patients who take > 12 seconds to complete is at risk of falls.

3. 4-Stage Balance Test: Evaluates fall risk. Patients who are unable to hold the stances for at least 10 seconds are at risk of falls.

4. Berg Balance Scale: Evaluates fall risk. A score of < 45 indicates a greater risk of falls.

5. Balance Error Scoring System (BESS): Evaluates balance. Lower scores indicate better balance and less errors. 

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Advanced Diagnostics:

• Imaging (e.g., x-ray): Generally not recommended within the first six weeks unless red flags are present to avoid unnecessary radiation exposure, overdiagnosis, and costs. Currently, there is insufficient evidence that routine imaging improves patient outcomes. Discuss the benefits and risks of imaging with patients, educating them on the role of imaging and reasons for deferring it initially when applicable. Imaging used in specific contexts should be discussed through shared decision-making (e.g.,  persistent pain and functional limitations).

• Advanced Imaging (e.g., MRI, CT): Should be considered with persistent pain, functional limitations, significant neurological deficits, or when surgical intervention is being considered. These can provide detailed information to guide diagnosis and surgical management.