NASS循证临床指南：退行性腰椎管狭窄的诊断和治疗(2011版)

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Degenerative Spinal Stenosis| NASS Clinical Guidelines

Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care

Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis

NASS Evidence-Based Clinical Guidelines CommitteeD. Scott Kreiner, MD Committee Co-Chair, Natural History Co-Chair William O. Shaffer, MD Committee Co-Chair, Natural History Co-Chair Jamie Baisden, MD Outcome Measures Chair Thomas Gilbert, MD Diagnosis/Imaging Chair Jeffrey Summers, MD Medical/Interventional Treatment Chair John Toton, MD Surgical Treatment Chair Steven Hwang, MD Richard Mendel, MD Charles Reitman, MD

This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution

Introduction/Guideline Methodology

Degenerative Spinal Stenosis| NASS Clinical Guidelines

Financial Statement This clinical guideline was developed and funded in its entirety by the North American Spine Society (NASS). All particiJamie L. Baisden Thomas J. Gilbert Steven W. Hwang D. Scott Kreiner Richard C. Mendel Charles A. Reitman William O. Shaffer Nothing to disclose. Scientific Advisory Board: Steady State Imaging (Financial, option on 20,000 shares); Other Office: Medical Director (Financial, option on 20,000 shares ). Nothing to disclose. Nothing to disclose. Nothing to disclose. Nothing to disclose.

pating authors have disclosed potential conflicts of interest consistent with NASS’ disclosure policy. Disclosures are listed below:

Consulting: DePuy Spine (Financial, Level B consulting, iliolumbar module 12/09 and none since, Paid directly to institution/employer); Trips/Travel: Synthes (Financial, ProDisc C course. I paid for travel, lodging, meals and car rental. Training at no cost); Relationships Outside the One Year Requirement: DePuy Spine (Upcoming Committee Meeting[Cervical Epidural Work Group], 01/2007, Royalties, Level C for sacropelvic module). Board of Directors: First Choice Insurance Group (Financial, I am the Pain Management representative to the Board. There is a Level A remuneration for each Board meeting attended during weekdays. In the past year, I have been paid Level A), International Spine Intervention Society (ISIS) (Nonfinancial, I am on the ISIS Board of Directors. I also serve as Treasurer. Travel expenses (airfare, hotel and parking) are provided when traveling to a Board meeting (official business only)). Nothing to disclose.

Jeffrey T. Summers

John F. Toton

________________________________________ Range Key: Level A.$100 to$1,000 Level B.$1,001 to$10,000 Level C.$10,001 to$25,000 Level

D.$25,001 to$50,000 Level E.$50,001 to$100,000 Level F.$100,001 to$500,000 Level G.$500,001 to$1M Level H.$1,000,001 to$2.5M Level I. Greater than$2.5M

Comments Comments regarding the guideline may be submitted to the North American Spine Society and will be considered in development of future revisions of the work.

North American Spine Society Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis Copyright© 2011 North American Spine Society 7075 Veterans Boulevard Burr Ridge, IL 60527 USA 630.230.3600 ISBN 1-929988-29-XThis clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution

Degenerative Spinal Stenosis| NASS Clinical Guidelines

Table of ContentsI.Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 II. III. IV. Guideline Development Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Natural History of Spinal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8A.Diagnosis/Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 B. Outcome Measures for Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 C. Medical/Interventional Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 D. Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Recommendations for Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis . . . . 12

V.Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71A. B. C. D.

Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Levels of Evidence for Primary Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Grades of Recommendations for Summaries or Reviews of Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Linking Levels of Evidence to Grades of Recommendation . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . 74

VI.References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

A technical report, including the literature search parameters and evidentiary tables developed by the authors, can be accessed at /Documents/2011StenosisTechReport.pdf

Introduction/Guideline Methodology

IntroductIon

/GuIdelIne

MethodoloGy4Degenerative Spinal Stenosis | NASS Clinical GuidelinesI. Introduction Objectiveoutlines treatment options for adult patients with a diagnosis of

The objective of the North American Spine Society (NASS) Clin-degenerative lumbar spinal stenosis.

ical Guideline for the Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis is to provide evidence-based recom-THIS GUIDELINE DOES NOT REPRESENT A “STAN-mendations to address key clinical questions surrounding the DARD OF CARE,” nor is it intended as a fixed treatment pro-diagnosis and treatment of degenerative lumbar spinal steno-tocol. It is anticipated that there will be patients who will require sis. The guideline is intended to reflect contemporary treatment less or more treatment than the average. It is also acknowledged concepts for symptomatic degenerative lumbar spinal stenosis as that in atypical cases, treatment falling outside this guideline reflected in the highest quality clinical literature available on this will sometimes be necessary. This guideline should not be seen subject as of July 2010. The goals of the guideline recommenda-as prescribing the type, frequency or duration of intervention. tions are to assist in delivering optimum, efficacious treatment Treatment should be based on the individual patient’s need and and functional recovery from this spinal disorder.doctor’s professional judgment and experience. This document is designed to function as a guideline and should not be used as Scope, Purpose and Intended Userthe sole reason for denial of treatment and services. This guide-This document was developed by the North American Spine So-line is not intended to expand or restrict a health care provider’s ciety Evidence-based Guideline Development Committee as an scope of practice or to supersede applicable ethical standards or educational tool to assist practitioners who treat patients with provisions of law.

degenerative lumbar spinal stenosis. The goal is to provide a tool that assists practitioners in improving the quality and efficiency Patient Population

of care delivered to patients with degenerative lumbar spinal The patient population for this guideline encompasses adults (18 stenosis. The NASS Cyears or older) with a chief complaint of neurogenic claudication Treatment of Degenerative Lumbar Spinal Stenosis provides a linical Guideline for the Diagnosis and without associated spondylolisthesis. Furthermore, the nature of definition and explanation of the natural history of degenerative the pain and associated patient characteristics (eg, age) should lumbar spinal stenosis, outlines a reasonable evaluation of pa-be more typical of a diagnosis of spinal stenosis than herniated tients suspected to have degenerative lumbar spinal stenosis and disc.

This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason-ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the phy-sician and patient in light of all circumstances presented by the patient and the needs and resources particular to he locality or institution

Degenerative Spinal Stenosis | NASS Clinical Guidelines5II. Guideline Development Methodology

Through objective evaluation of the evidence and transparency cate the strength of the recommendations made in the guideline in the process of making recommendations, it is NASS’ goal to based on the quality of the literature. develop evidence-based clinical practice guidelines for the diag-nosis and treatment of adult patients with various spinal condi-Grades of Recommendation: tions. These guidelines are developed for educational purposes A: Good evidence (Level I studies with consistent findings) to assist practitioners in their clinical decision-making process-for or against recommending intervention.es. It is anticipated that where evidence is very strong in support of recommendations, these recommendations will be operation-B: Fair evidence (Level II or III studies with consistent find-alized into performance measures. ings) for or against recommending intervention.Multidisciplinary CollaborationWith the goal of ensuring the best possible care for adult patients suffering with spinal disorders, NASS is committed to multidis-ciplinary involvement in the process of guideline and perfor-mance measure development. To this end, NASS has ensured that representatives from medical, interventional and surgical spine specialties have participated in the development and re-view of all NASS guidelines. To ensure broad-based representa-tion, NASS has invited and welcomes input from other societies and specialties C: Poor quality evidence (Level IV or V studies) for or against recommending intervention.I: Insufficient or conflicting evidence not allowing a recom-mendation for or against intervention.Levels of evidence have very specific criteria and are assigned to studies prior to developing rec-ommendations. Recommenda-tions are then graded based upon the level of evidence. To better un-derstand how levels of evidence inform the grades of recom-mendation and the standard nomencla-ture used within the rec-ommendations see Appendix D. Evidence Analysis Training of All NASS

Guideline DevelopersGuideline recommendations are written utilizing a standard language that indicates the strength of the recommendation. “A” recommendations indicate a test or intervention is “recom-mended”; “B” recommendations “suggest” a test or intervention and “C” recommendations indicate a test or in-tervention “may be considered” or “is an option.” “I” or “Insufficient Evidence” statements clearly indicate that “there is insufficient evidence to make a recommendation for or against” a test or in-tervention. Work group consensus statements clearly state that “in the ab-sence of reliable evidence, it is the work group’s opinion that” a test or intervention may be appropriate. The levels of evidence and grades of recommendation imple-mented in this guideline have also been adopted by the Journal of Bone and Joint Surgery, the American Academy of Orthopae-Disclosure of Potential Conflicts of Interestdic Surgeons, Clinical Orthopaedics and Related Research, the All participants involved in guideline development have dis-journal Spine and the Pediatric Orthopaedic Society of North closed potential conflicts of interest to their colleagues and their America. potential conflicts have been documented in this guideline. Par-In evaluating studies as to levels of evidence for this guideline, ticipants have been asked to update their disclosures regularly the study design was interpreted as establishing only a potential throughout the guideline development process.level of evidence. As an example, a therapeutic study designed as a randomized controlled trial would be considered a poten- tial Level I study. The study would then be further analyzed as Levels of Evidence and Grades of Recom-to how well the study design was implemented and significant mendationshort comings in the execution of the study would be used to NASS has adopted standardized levels of evidence (Appendix B) downgrade the levels of evidence for the study’s con-clusions. In and grades of recommendation (Appendix C) to assist practitio-the example cited previously, reasons to downgrade the results of ners in easily understanding the strength of the evidence and a potential Level I randomized controlled trial to a Level II study recommendations within the guidelines. The levels of evidence would include, among other possibilities: an under-powered range from Level I (high quality randomized controlled trial) to study (patient sample too small, variance too high), inadequate Level V (expert consensus). Grades of recommendation indi-randomization or masking of the group assignments and lack of validated outcome measures. NASS has initiated, in conjunction with the University of Al-berta’s Centre for Health Evidence, an online training program geared toward educating guideline developers about evidence analysis and guideline development. All participants in guide-line development for NASS have completed the training prior to participating in the guideline development program at NASS. This training includes a series of readings and exercises, or in-teractivities, to prepare guideline developers for systematically evaluating literature and developing evidence-based guidelines. The online course takes approximately 15-30 hours to complete and participants have been awarded CME credit upon comple-tion of the course.

IntroductIon

/GuIdelIne

MethodoloGy6Degenerative Spinal Stenosis | NASS Clinical Guidelinesin answering different questions within this guideline. How In addition, a number of studies were reviewed several times and (3) rep-resent the current best research evidence available. a given question was asked might influence how a study was NASS maintains a search history in Endnote, for future use or evaluated and interpreted as to its level of evidence in answer-reference.ing that particular question. For example, a randomized control Step 5: Review of Search Results/Identification of trial reviewed to evaluate the differences between the outcomes Literature to Reviewof surgically treated versus untreated patients with lumbar spinal stenosis might be a well designed and implemented Level I ther-Work group members reviewed all abstracts yielded from the

apeutic study. This same study, however, might be classified as literature search and identified the literature they will review giving Level II prognostic evidence if the data for the untreated in order to address the clinical questions, in accordance with controls were extracted and evaluated prognostically. the Literature Search Protocol. Members have identified the best research evidence available to answer the targeted clinical questions. That is, if Level I, II and or III literature is available to Guideline Development Processanswer specific questions, the work group was not required to Step 1: Identification of Clinical Questionsreview Level IV or V studies.

Trained guideline participants were asked to submit a list of clin-ical questions that the guideline should address. The lists were Step 6: Evidence Analysis

compiled into a master list, which was then circulated to each Members have independently developed evidentiary tables sum-member with a request that they independently rank the ques-marizing study conclusions, identifying strengths and weakness-tions in order of importance for consideration in the guideline. es and assigning levels of evidence. In order to systematically The most highly ranked questions, as determined by the partici-control for potential biases, at least two work group members pants, served to focus the guideline.have reviewed each article selected and independently assigned levels of evidence to the literature using the NASS levels of evi-Step 2: Identification of Work Groupsdence. Any discrepancies in scoring have been addressed by two Multidisciplinary teams were assigned to work groups and as-or more reviewers. The consensus level (the level upon which signed specific clinical questions to address. Because NASS is two-thirds of reviewers were in agreement) was then assigned comprised of surgical, medical and interventional specialists, it to the article.

is imperative to the guideline development process that a cross-As a final step in the evidence analysis process, members section of NASS membership is represented on each group. This have identified and documented gaps in the evidence to educate also helps to ensure that the potential for inadvertent biases in guideline readers about where evidence is lacking and help guide evaluating the literature and formulating recommendations is further needed research by NASS and other societies.minimized. Step 7: Formulation of Evidence-Based

Step 3: Identification of Search Terms and ParametersRecommendations and Incorporation of Expert One of the most crucial elements of evidence analysis to support Consensus

development of recommendations for appropriate clinical care Work groups held webcasts to discuss the evidence-based an-is the comprehensive literature search. Thorough assessment of swers to the clinical questions, the grades of recommendations the literature is the basis for the review of existing evidence and and the incorporation of expert consensus. Expert consensus the formulation of evidence-based recommendations. In order has been incorporated only where Level I-IV evidence is insuf-to ensure a thorough literature search, NASS has instituted a Lit-ficient and the work group has deemed that a recommendation erature Search Protocol (Appendix E) which has been followed is warranted. Transparency in the incorporation of consensus is to identify literature for evaluation in guideline development. In crucial, and all consensus-based recommendations made in this keeping with the Literature Search Protocol, work group mem-guideline very clearly indicate that Level I-IV evi-dence is insuf-bers have identified appropriate search terms and parameters to ficient to support a recommendation and that the recommenda-direct the literature search.tion is based only on expert consensus.

and databases searched, are documented in the technical report Specific search strategies, including search terms, parameters Consensus Development Process

that accompanies this guideline.Voting on guideline recommendations was conducted using a modification of the nominal group technique in which each Step 4: Completion of the Literature Searchwork group member independently and anonymously ranked Once each work group identified search terms/parameters, the a recommendation on a scale ranging from 1 (“extremely inap-literature search was implemented by a medical/research librar-propriate”) to 9 (“extremely appropriate”). C

ian, consistent with the Literature Search Protocol. tained when at least 80% of work group members ranked the onsensus was ob-Following these protocols ensures that NASS recommenda-recommendation as 7, 8 or 9. When the 80% threshold was not tions (1) are based on a thorough review of relevant literature; attained, up to three rounds of discussion and voting were held

(2) are truly based on a uniform, comprehensive search strategy; to resolve disagreements. If disagreements were not resolved af-ter these rounds, no rec-ommendation was adopted.

Degenerative Spinal Stenosis | NASS Clinical Guidelines7After the recommendations were established, work group mem-in performance measure develop-ment (eg, the AMA Physician’s bers developed the guideline content, addressing the literature Consortium for Performance Improvement) to identify those which supports the recommendations. rec-ommendations rigorous enough for measure development. All relevant medical specialties involved in the guideline devel-Step 8: Submission of the Draft Guidelines for Review/opment and at the Consortium will be invited to collaborate in Commentthe development of evidence-based performance measures re-Guidelines were submitted to the full Evidence-Based Guideline lated to spine care.Development Committee and the Research Council Director for review and comment. Revisions to recommendations were con-Step 12: Review and Revision Process sidered for incorporation only when substantiated by a prepon-The guideline recommendations will be reviewed every three derance of appropriate level evidence. years by an EBM-trained multidiscipli-nary team and revised as appropriate based on a thorough review and assessment of rel-Step 9: Submission for Board Approvalevant literature published since the development of this version Once any evidence-based revisions were incorporated, the drafts of the guideline. were prepared for NASS Board review and approval. Edits and revisions to recommendations and any other content were con-Use of Acronymssidered for incorporation only when substantiated by a prepon-Throughout the guideline, readers will see many acronyms with derance of appropriate level evidence.which they may not be familiar. A glossary of acronyms is avail-able in Appendix A. Step 10: Submission for Publication and National

Guideline Clearinghouse (NGC) InclusionNomenclature for Medical/Interventional TreatmentFollowing NASS Board approval, the guidelines have been slat-Throughout the guideline, readers will see that what has tradi-ed for publication and submitted for inclusion in the National tionally been referred to as “nonoper-ative,” “nonsurgical” or Guidelines Clearinghouse (NGC). No revisions were made at “conservative” care is now referred to as “medical/interventional this point in the process, but comments have been and will be care.” The term medical/interventional is meant to encompass saved for the next iteration. pharmacological treatment, physical therapy, exercise therapy, manipulative therapy, modalities, various types of external stim-Step 11: Identification and Development of ulators and injections.Performance Measures The recommendations will be reviewed by a group experienced

atural

istory of spiNal

steNosis8Degenerative Spinal Stenosis | NASS Clinical GuidelinesIII. Definition and Natural History of Degenerative Lumbar Spinal Stenosis

Degenerative lumbar spinal stenosis describes a condition in which there is diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes in the spinal canal. When symptomatic, this causes a variable clinical syndrome of gluteal and/or lower extremity pain and/or fatigue which may occur with or without back pain. Symptomatic lumbar spinal stenosis has certain characteristic provoc-ative and palliative features. Provocative features include upright exercise such as walking or positionally-induced neurogenic claudication. Palliative features commonly include symptomatic relief with forward flexion, sitting and/or recumbency. Work Group Consensus StatementIn order to perform a systematic review of the literature regard-ing the natural history of patients with lumbar stenosis, the above Pharmacology for studies published between January 2006 and definition of lumbar stenosis was developed by consensus fol-February 2010.

lowing a global review of the literature and definitive texts, and used as the standard for comparison of treatment groups. It is criteria because they did not adequate-ly present data about the All identified studies failed to meet the guideline’s inclusion important to understand this is an anatomic definitionthat when natural history of degenerative lumbar spinal stenosis. These symptomatic has characteristic clinical features. In order for a studies did not report results of untreated control patients, thus study to be considered relevant to the discussion, the patient limiting the validity of the papers’ conclusions concerning natu-population was required to be symptomatic, with characteris-ral history. This includes works that have been frequently cited tic clinical features described above, and to have confirmatory as so-called natural history studies but are, in fact, reports of the imaging demonstrating diminished space in the lumbar spinal results of one or more medical/interventional treat-ment mea-canal. The Levels of Evidence for Primary Research Questions sures.

grading scale provided by each article with a relevant patient population. The (Appendix B) was used to rate the level of evidence minimal medical/interventional treat-ment as being representa-The 2007 version of this guideline considered patients with diagnosis of lumbar stenosis was examined for its utility as a tive of the natural course of the disease. It was the determination prognostic factor. The central question asked was: “What hap-of the 2010 work group that any treatment may affect the natural pens to patients with symptomatic lumbar stenosis who do not history of the condition; therefore, the studies cited in 2007 sup-porting natural history of spinal stenosis would be more appro-receive treatment?”priately in-cluded in the medical/interventional treatment sec-tion of the guideline rather than be considered de facto controls. lumbar spinal stenosis, the work group performed a compre-To address the natural history of symptomatic degenerative

hensive literature search and analysis. The group reviewed the group was unable to definitively an-swer the question posed re-Because of the limitations of the available literature, the work 2007 version of the guideline which included 33 references from lated to the natural history of degenerative lumbar spinal ste-1966-2006, along with an additional 21 articles which were se-nosis. In lieu of an evidence-based answer, the work group did lected from a search of MEDLINE (PubMed), Cochrane Regis-reach consensus on the following statements addressing natural ter of Controlled Trials, Web of Science and EMBASE Drugs & history.

Degenerative Spinal Stenosis | NASS Clinical Guidelines9In the absence of reliable evidence, it is the work group’s opinion that the

natural history of patients with clinically mild to moderately symptomatic

degenerative lumbar stenosis can be favorable in about one-third to one-

half of patients.

Work Group Consensus Statement

Based on evaluation of studies that contained varying and often relatively minimal or simple inter-ventions, it appears that the natural history of mild to moderate degenerative lumbar steno-sis may be favorable for 33-50% of patients. It is the consensus of the work group that some of the medical treatments utilized in the studies reviewed likely did not significantly alter the symp-tomatic course of the disease.

In the absence of reliable evidence, it is the work group’s opinion that in

patients with mild or moderately symptomatic degenerative lumbar steno-

sis, rapid or catastrophic neurologic decline is rare.

Work Group Consensus Statement

The literature evaluated for the degenerative lumbar spinal stenosis guideline project included numerous reports describ-ing the clinical course of patients with mild to moderate spinal stenosis. None of these reports described rapid or catastrophic neurologic decline in patients identified with mild or moderate lumbar spinal stenosis. While anecdotal experience may indi-cate the possibility of such a decline, evidence suggests that the occurrence of such a decline is exceedingly rare.

In the absence of reliable evidence, it is the work group’s opinion that

information in the literature is insufficient to define the natural history of

clinically or radiographically severe degenerative lumbar stenosis.

Work Group Consensus Statement

It should be noted that all the series reviewed excluded patients with severe neurological compromise (or loss or dysfunction) who were regarded as candidates for surgery; therefore, no con-cluions can be drawn about this patient population.

The work group identified the following potential studies, which could generate meaningful evidence to assist in further defining the natural history of degenerative lumbar spinal stenosis.

Recommendation #1: A prospective study of patients with symptomatic degenerative lumbar spinal stenosis without treatment, notwithstanding non-prescription analgesics, would provide Level I evidence regard-ing the natural history of this disorder. Unfortunately, at this time, following symptomatic patients long-term with no inter-vention is unlikely to occur.

Recommendation #2: A systematic study reviewing patients with untreated symptom-atic degenerative lumbar spinal stenosis would provide evidence regarding the natural history of the disease in this patient popu-lation. Future Directions for ResearchNatural History Bibliography 1. 2. 3. 4. 5. 6. Amundsen T, Weber H, Nordal HJ, Magnaes B, Abdelnoor M, Lilleas F. Lumbar spinal stenosis: conservative or surgi-cal management?: A prospective 10-year study. Spine. Jun 1 2000;25(11):1424-1435; discussion 1435-1426.Anderson PA, Tribus CB, Kitchel SH. Treatment of neurogenic claudication by interspinous decompression: application of the X STOP device in patients with lumbar degenerative spondylo-listhesis. J Neurosurg Spine. Jun 2006;4(6):463-471.Athiviraham A, Yen D. Is spinal stenosis better treated surgically or nonsurgically? Clin Orthop Relat Res. May 2007;458:90-93.Atlas SJ, Delitto A. Spinal stenosis: surgical versus nonsurgical treatment. Clin Orthop Relat Res. Feb 2006;443:198-207.Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgi-cal management of lumbar spinal stenosis. Spine. Aug 1 1996;21(15):1787-1794; discussion 1794-1785.Atlas SJ, Deyo RA, Keller RB, et al. The Maine Lumbar Spine Study, Part II. 1-year outcomes of surgical and nonsurgical management of sciatica. Spine. Aug 1 1996;21(15):1777-1786.This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason-ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the phy-sician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or Natural History of spiNal steNosis

atural

istory of spiNal

steNosis10Degenerative Spinal Stenosis | NASS Clinical Guidelines7. Atlas SJ, Keller RB, Robson D, Deyo RA, Singer DE. Surgical and nonsurgical management of lumbar spinal stenosis: four-year outcomes from the maine lumbar spine study. 26. spinal stenosis. Johnsson KE, Rosen I, Uden A. The natural course of lumbar Clin Orthop Relat Res. Jun 1992(279):82-86.8. 2000;25(5):556-562.Spine. Mar 1 Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term 27. spinal stenosis. Johnsson KE, Uden A, Rosen I. The effect of decompression on Acta Orthop Scand Suppl. 1993;251:67-68.outcomes of surgical and nonsurgical management of lumbar the natural course of spinal stenosis. A comparison of surgically spinal stenosis: 8 to 10 year results from the maine lumbar spine 9. study. 28. treated and untreated patients. Keller RB, Atlas SJ, Singer DE, et al. The Maine Lumbar Spine. Jun 1991;16(6):615-619.Atlas SJ, Tosteson TD, Hanscom B, et al. What is different about Spine. Apr 15 2005;30(8):936-943.Spine Study, Part I. Background and concepts. worker’s compensation patients? - Socioeconomic predictors of baseline disability status among patients with lumbar radicu-29. 1996;21(15):1769-1776.Spine. Aug 1 Koc Z, Ozcakir S, Sivrioglu K, Gurbet A, Kucukoglu S. Ef-10. lopathy. fectiveness of physical therapy and epidural steroid injec-Bederman SS, Kreder HJ, Weller I, Finkelstein JA, Ford MH, Spine. Aug 2007;32(18):2019-2026.tions in lumbar spinal stenosis. Y30. 2009;34(10):985-989.Spine (Phila Pa 1976). May 1 tive lumbar spine: a population-based study of surgeon factors, ee AJM. The who, what and when of surgery for the degenera-Kondrashov DG, Hannibal M, Hsu KY, Zucherman JF. Inter-surgical procedures, recent trends and reoperation rates. spinous process decompression with the X-STOP device for 11. Surg.Can J lumbar spinal stenosis: a 4-year follow-up study. Benoist M. The natural history of lumbar degenerative spinal Aug 2009;52(4):283-290.31. Tech. J Spinal Disord 12. stenosis. Lin SI, Lin RM, Huang LWJul 2006;19(5):323-327.generative lumbar spinal stenosis. . Disability in patients with de-Birkmeyer NJ, Weinstein JN, Tosteson AN, et al. Design of the Joint Bone Spine. Oct 2002;69(5):450-457.Spine Patient outcomes Research Trial (SPORT). 2002;27(12):1361-1372.Spine. Jun 15 32. 2006;87(9):1250-1256.Arch Phys Med Rehab. Sep Malmivaara A, Slatis P13. Brussee Poperative treatment for lumbar spinal stenosis? A randomized , Heliovaara M, et al. Surgical or non-rated evaluation of outcome of the implantation of interspinous , Hauth J, Donk RD, Verbeek AL, Bartels RH. Self-process distraction (X-Stop) for neurogenic claudication. 33. controlled trial. Manchikanti L, Cash KA, McManus CD, Pampati VSpine (Phila Pa 1976). Jan 1 2007;32(1):1-8.Spine J. Eur Preliminary Results of a Randomized, Equivalence Trial of Fluo-, Abdi S. 14. Chang Y, Singer DE, Wu YA, Keller RB, Atlas SJ. The effect of Feb 2008;17(2):200-203.roscopic Caudal Epidural Injections in Managing Chronic Low surgical and nonsurgical treatment on longitudinal outcomes Back Pain: Part 4 - Spinal Stenosis.

of lumbar spinal stenosis over 10 years. 2005;53(5):785-792.J Am Geriatr Soc. May 34. 2008;11(6):833-848.Pain Physician. Nov-Dec

Mariconda M, Fava R, Gatto A, Longo C, Milano C. Unilateral

15. Cummins J, Lurie JD, Tosteson TD, et al. Descriptive epidemi-laminectomy for bilateral decompression of lumbar spinal

ology and prior healthcare utilization of patients in The Spine stenosis: a prospective comparative study with conservatively Patient Outcomes Research Trial’s (SPORT) three observational cohorts: disc herniation, spinal stenosis, and degenerative spon-35. treated patients. Matsudaira K, Yamazaki T, Seichi A, et al. Spinal stenosis in J Spinal Disord Tech. Feb 2002;15(1):39-46.dylolisthesis.grade I degenerative lumbar spondylolisthesis: a compara-

16. Elkayam O, Avrahami E, Yaron M. The lack of prognostic Spine. Apr 1 2006;31(7):806-814.tive study of outcomes following laminoplasty and laminec-

value of computerized tomography imaging examinations in tomy with instrumented spinal fusion.

patients with chronic non-progressive back pain. 1996;16(1):19-21.Rheumatol Int. 36. 2005;10(3):270-276.J Orthop Sci. May

Murphy DR, Hurwitz EL, Gregory AA, Clary R. A non-surgical

17. Eskola A, Pohjolainen T, Alaranta H, Soini J, Tallroth K, Slati-approach to the management of lumbar spinal stenosis: a pro-

sCalcitonin treatment in lumbar spinal stenosis: a randomized, spective observational cohort study.

placebo-controlled, double-blind, cross-over study with one-year follow-up. 37. 2006;7:16.BMC Musculoskelet Disord.

Ogikubo O, Forsberg L, Hansson T. The relationship between

18. Fritz JM, Erhard RE, Vignovic M. A nonsurgical treatment ap-Calcif Tissue Int. May 1992;50(5):400-403.the cross-sectional area of the cauda equina and the preopera-

proach for patients with lumbar spinal stenosis. tive symptoms in central lumbar spinal stenosis.

1997;77(9):962-973.Phys Ther. Sep 2007;32(13):1423-1428.Spine. Jun

19. Gibson JN, Grant IC, Waddell G. The Cochrane review of 38. Onel D, Sari H, Donmez C. Lumbar spinal stenosis: clinical/

surgery for lumbar disc prolapse and degenerative lumbar spon-radiologic therapeutic evaluation in 145 patients. Conservative dylosis. treatment or surgical intervention? Spine. Feb 1993;18(2):291-

20. Gibson JN, Waddell G, Grant IC. Surgery for degen-Spine. Sep 1 1999;24(17):1820-1832.

erative lumbar spondylosis. Cochrane Database Syst Rev. 39. 298.Podichetty VK, Segal AM, Lieber M, Mazanec DJ. Effectiveness 2000(3):CD001352.of salmon calcitonin nasal spray in the treatment of lumbar

21. Haig AJ, Tong HC, Yamakawa KSJ, et al. Predictors of pain and canal stenosis: a double-blind, randomized, placebo-controlled,

function in persons with spinal stenosis, low back pain, and no back pain. 40. parallel group trial. Roland M, Morris RA. A study of the natural history of back Spine. Nov 1 2004;29(21):2343-2349.

22. Herno A, Airaksinen O, Saari T, Luukkonen M. Lumbar spinal Spine. Dec 2006;31(25):2950-2957.pain. Part 1: Development of reliable and sensitive measure of

stenosis: a matched-pair study of operated and non-operated patients. 41. disability in low-back pain. Sengupta DK, Herkowitz HN. Degenerative spondylolisthe-Spine. 1983;8(2):141-144.

23. Hsu KY, Zucherman JF, Hartjen CA, et al. Quality of life of lum-Br J Neurosurg. Oct 1996;10(5):461-465.sis: review of current trends and controversies.

bar stenosis-treated patients in whom the X STOP interspinous device was implanted. 42. 2005;30(6 Suppl):S71-81.Spine. Mar 15

Shabat S, Folman Y, Leitner Y, Fredman B, Gepstein R. Failure

24. Hurri H, Slatis PJ Neurosurg Spine. Dec 2006;5(6):500-507.of conservative treatment for lumbar spinal stenosis in elderly

ment of long-term outcome 12 years after operative and conser-, Soini J, et al. Lumbar spinal stenosis: assess-

vative treatment. 43. patients. Arch Gerontol Geriatr. May-Jun 2007;44(3):235-241.Simotas AC. Nonoperative treatment for lumbar spinal stenosis.

25. Johnsson KE, Rosen I, Uden A. The natural course of lumbar J Spinal Disord. Apr 1998;11(2):110-115.44. Clin Orthop Relat Res. Mar 2001(384):153-161.Simotas AC, Dorey FJ, Hansraj KK, Cammisa F, Jr. Nonopera-This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason-ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the phy-sician and patient in light of all circumstances presented by the patient and the needs and resources particular to he locality or institution

Degenerative Spinal Stenosis | NASS Clinical Guidelinestive treatment for lumbar spinal stenosis. Clinical and out-come results and a 3-year survivorship analysis. Spine. Jan 15 2000;25(2):197-203; discussions 203-194.Tadokoro K, Miyamoto H, Sumi M, Shimomura T. The prognosis of conservative treatments for lumbar spinal ste-nosis: analysis of patients over 70 years of age. Spine. Nov 1 2005;30(21):2458-2463.Tafazal SI, Ng L, SellRandomised placebo-controlled trial on the effectiveness of nasal salmon calcitonin in the treatment of lumbar spinal stenosis. Eur Spine J. Feb 2007;16(2):207-212.Tosteson ANA, Lurie JD, Tosteson TD, et al. Surgical Treatment of Spinal Stenosis with and without Degenerative Spondylolis-thesis: Cost-Effectiveness after 2 Years. Ann Intern Med. Dec 2008;149(12):845.van Tulder MW, Koes B, Seitsalo S, Malmivaara A. Outcome of invasive treatment modalities on back pain and sciatica: an evidence-based review. Eur Spine J. Jan 2006;15 Suppl 1:S82-92.Waikakul W, Waikakul S. Methylcobalamin as an adjuvant 11medication in conservative treatment of lumbar spinal stenosis. J Med Assoc Thai. Aug 2000;83(8):825-831.Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus non-surgical treatment for lumbar degenerative spondylolisthesis. N Engl J Med. May 31 2007;356(22):2257-2270.Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical compared with nonoperative treatment for lumbar degenerative spon-dylolisthesis. four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am. Jun 2009;91(6):1295-1304.Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus non-surgical therapy for lumbar spinal stenosis. N Engl J Med. Feb 21 2008;358(8):794-810.Zucherman JF, Hsu KY, Hartjen CA, et al. A multicenter, pro-spective, randomized trial evaluating the X STOP interspinous process decompression system for the treatment of neurogenic intermittent claudication: two-year follow-up results. Spine. Jun 15 2005;30(12):1351-1358.45. 50. 51. 46. 47. 52. 53. 48. 49.

iagnosis/imaging12Degenerative Spinal Stenosis | NASS Clinical GuidelinesIV. Recommendations for Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis Assessing the evidence for diagnostic tests poses some difficul-Assessing Evidence for Diagnostic Teststies that are not seen in therapeutic studies. In the assessment curacy of a cross-sectional imaging exam is surgery. The validity of diagnostic tests, both accuracy and the effect of testing on of surgery as a gold standard for the assessment of stenosis can outcome should be considered. The accuracy of a diagnostic test be questioned, however, as findings at surgery can be subjective. refers to the ability of the examination to detect and characterize The degree or severity of central stenosis can also be difficult to pathologic processes. Accuracy is typically expressed in terms of quantify at surgery as decompression often precedes direct ex-sensitivity and specificity amination of the central canal. For these reasons, a case can be tion of patients with the target disorder who will have a positive — sensitivity referring to the propor-made to use the best available cross-sectional imaging exam as a test, and specificity to the number of people without the disease gold standard; however, this too can be problematic.who have a negative test.1negative test effectively rules out the disease. With tests that have With tests that have a high sensitivity, a ment of a diagnostic exam. The assessment of a diagnostic exam Outcome can also be used as a gold standard in the assess-a high specificity, a positive test effectively rules in the disease. in this manner is obviously confounded by the type of treatment applied, the skill of the treating physician and patient psycho-stated in terms of positive and negative predictive value, which The performance of a test in a given population can also be social variables among other factors. Outcome studies can be depends directly on the prevalence of disease in the tested popu-very useful, however, in assessing the appropriate utilization of lation.1cross-sectional imaging. For example, two Level I studies have with a high accuracy will accurately predict the presence of dis- In populations with a high prevalence of disease, a test recently been published concerning the use of Rapid MRI.4,5these studies, the value of obtaining an early MRI in the manage- In ease. Conversely, the same test result will yield a large percentage of false positives in patient populations with a low incidence of ment of patients with low back pain was assessed using various disease (such as an asymptomatic population). One of the pur-outcome measures, including pain level, patient preference, pa-poses of a history and physical examination is to increase the tient satisfaction and cost of resource use. Each of these studies prevalence of disease in patients sent for advanced testing. For showed limited, if any, benefit in obtaining an MRI early in the this reason, in our systematic review, we have attempted to iden-course of a patient’s treatment. Studies of this type were uncom-tify those symptoms or findings which have a high likelihood mon in our review, but are of obvious importance given rising

ratio for lumbar spinal stenosis health care costs.

expected in patients diagnosed with lumbar spinal stenosis, but — those symptoms or findings

not in those who do not have lumbar spinal stenosis. The use of Assessing Evidence for Diagnostic Tests these criteria should increase the prevalence of this disease in References

the population sent for cross-sectional imaging.11. Sackett DL, Straus SE, Richardson WS, Rosenberg Wputed tomography (CT) or magnetic resonance imaging (MRI) Positive com-RB. , Haynes findings in this population will have greater relevance relative to Second Edition. Edinburgh, Scotland: Churchill Livingstone; Evidence-Based Medicine: How to Practice and Teach EBM. treatment and should lead to better outcomes.2. 2000. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SWity as evidenced by a significant incidence of stenosis and other Cross-sectional imaging exams have a low intrinsic specific-mal magnetic-resonance scans of the lumbar spine in asymp-. Abnor-pathologic findings in asymptomatic populations.2,33. tomatic subjects. Wiesel SWJ Bone Joint Surg [Am]. 1990;72:403-408.of any cross-sectional examination need to be closely correlated The results study of computer-assisted tomography. 1. The incidence of , Tsourmas N, Feffer HL, Citrin CM, Patronas N. A with the clinical examination. As a result, the accuracy of a spine positive CAT scans in an asymptomatic group of patients. MRI or CT should incorporate the ability of the test to directly visualize neurologic structures and the effect of pathologic pro-4. 1984;9:549-551.Spine.

Gilbert FJ, Grant AM, Gillan MGC, et al. Low back pain: Influ-

cesses on these structures. Direct visualization of intrinsic neu-ence of early MR imaging or CT on treatment and outcome – rologic processes and neural impingement is of obvious impor-tance in determining the etiology of myelopathic and radicular 5. Multicenter randomized trial. Jarvik JG, Holingworth WRadiology. 2004. 231:343-351.symptoms. nance imaging vs radiographs for patients with low back pain: A , Martin B, et al. Rapid magnetic reso-

randomized control trial. JAMA. 2003. 289(21):2810-18.

The gold standard in the majority of the studies testing the ac-

Degenerative Spinal Stenosis | NASS Clinical Guidelines13The diagnosis of lumbar spinal stenosis may be considered in older pa-

tients presenting with a history of gluteal or lower extremity symptoms

exacerbated by walking or standing which improves or resolves with

sitting or bending forward. Patients whose pain is not made worse with walking have a low likelihood of stenosis.

Grade of Recommendation: C

Three recent diagnostic studies have been published by the same group of authors.1-3 The initial study by Konno and Kikuchi et al1 included a retrospective sample followed by a collection of 250 prospective patients. Two subsequent studies, Konno and Hayashino et al2 and Sugioka et al3 utilized the same prospec-tive group of 468 patients to evaluate the efficacy of two separate evaluation tools. It is not known whether some of the patients from the first study comprised a segment of the study groups for the other studies. All of these studies implemented methods intended to develop a simple clinical diagnostic tool that may help physicians diagnose lumbar spinal stenosis in patients with lower leg symptoms. The first study was done in three phases.1 The initial arm was retrospective on patients with proven lumbar spinal stenosis during surgery, second was prospective in a group of patients that were eventually confirmed surgically to have lumbar spinal stenosis, and third was a prospective validation study in a pa-tient population of mixed diagnoses. The first phase evaluated 234 patients retrospectively, 137 with lumbar spinal stenosis and 97 with lumbar disc herniation, who had successful surgery and pathology confirmed at surgery. They categorized the lumbar spinal stenosis group into radicular and cauda equina “types” based on history and physical exam as well as imaging. The radicular type was also further confirmed by temporary alleviation of symptoms with steroid injection. The radicular type of stenosis presented as unilateral radicular pain following a specific dermatome or dermatomes. The cauda equina type had symptoms often bilateral with less dermatomal-specific neurogenic claudication. To this initial group of 234 pa-tients, several subjective and objective data were analyzed, and univariate analysis revealed key factors for predicting overlap-ping symptoms between the two types of lumbar spinal stenosis. Five historical findings had an odds ratio ≥ 2 or p < 0.05: age > 50, lower extremity pain or numbness, increased pain when walking, increased pain when standing, and improvement of symptoms on bending forward. No physical examination find-ing had an odds ratio ≥ 2 or p < 0.05. Another univariate analysis was done to differentiate those patients with cauda equina type lumbar spinal stenosis, and with this information a self-admin-istered, self-reported history questionnaire (SSHQ) was devel-oped consisting of 10 questions. In the next phase, the investigators administered the ques-tionnaire prospectively to 115 patients, 60 radicular type and 55 cauda equina type, whom were recruited from multiple facilities. These patients were also diagnosed with lumbar spinal stenosis by clinical exam and MRI, and later confirmed at surgery. A re-sponsible nerve root was confirmed if intermittent claudication was abolished following single nerve root infiltration. The sen-sitivity of each question on the SSHQ was calculated and com-pared between the radicular and cauda equina types. To assess the cut-off point to distinguish between the types, one point was assigned to each question on the SSHQ, and the clinical predic-tion rule was defined based on the scores. Sensitivity of each question was calculated and a predictor role defined. A scoring system was assigned that could predict radicular type lumbar spinal stenosis, cauda equina type lumbar spinal stenosis, or neither. A score of 4 points on Q1–Q4 indicated the presence of lumbar spinal stenosis; a score of 4 on Q1–Q4 and < 1 on Q5–Q10 indicat-ed the radicular type of lumbar spinal stenosis; and a score of > 1 on Q1–Q4 and > 2 on Q5–Q10 in-dicated the cauda equina type of lumbar spinal stenosis.In the last phase, 250 consecutively assigned patients with lower extremity pain and variable underlying diagnoses were prospectively enrolled, including 165 with lumbar spinal steno-sis. Diagnosis was determined by a surgeon, then confirmed by a panel of six additional expert surgeons based on clinical exam and MRI. All patients completed the SSHQ. Of the 250 patients with persistent symptoms, 217 were given the SSHQ two weeks later for test-retest reliability. The validation studies for the SSHQ in this third phase showed an area under the ROC curve of 0.797 in the derivation set and 0.782 in the validation data set. These findings indicated that the SSHQ had both internal and external validity as a diagnostic tool for lumbar spinal stenosis. The difference between tests plotted against the mean of the tests indicated no obvious relationship or bias. The intraclass correla-tion coefficient of the SSHQ score for the first and second tests was 0.85, which indicated sufficient reproducibility. One item of the κ coefficient was found to be “fair” (question 8), and all other items were rated as having a conformity of moderate or above. They concluded that this was a simple clinical diagnostic sup-port tool to help identify patients with lumbar spinal stenosis. By asking patients who presented with back and leg symptoms

iagnosis/imaging14Degenerative Spinal Stenosis | NASS Clinical Guidelinessuggestive of lumbar spinal stenosis to fill out a simple question-naire consisting of five questions on their medical history (age quartiles defined by risk scores of 2 or less, 3–4, 5–6 and 7 or and history of diabetes) and symptoms (presence or absence of more, respectively. Of the 374 patients in the derivation set, intermittent claudication, aggravation of symptoms by standing Quartile #1 showed a 17.7% (9/51) probability of lumbar spinal and relief of symptoms by forward bending) followed by a short stenosis, whereas the second, third and fourth quartiles showed clinical examination, the diagnosis of lumbar spinal stenosis 25.3% (25/99), 50.8% (62/122), and 77.5% (79/102), respectively. could be determined with a sensitivity of 93% and specificity of The likelihood ratio in Quartile #1 of the derivation set was 0.24. 72%. A more detailed questionnaire, the SSHQ, was developed Perfor-mance modeling showed an area under the ROC curve that provided a scoring system to diagnose patients with lumbar of 0.77 (Figure 2). Sensitivity and specificity at the cut-off score spinal stenosis and to further differentiate those patients with point of 5 were 0.81 and 0.58, respectively. Of the 94 patients radicular type from cauda equina type lumbar spinal stenosis. in the validation set, Quartile 1 showed a 13.3% (2/15) prob-They concluded that additional studies were needed to validate ability of lumbar spinal stenosis, whereas the second, third and this tool in primary care settings.fourth quartiles showed 47.6% (10/21), 55.2% (16/29) and 65.5% In the next study by Konno et al2(19/29), respectively. Sensitivity and specificity at the cutoffmary complaint of pain or numbness in the legs were prospec-, 468 patients with a pri-score point of 5 were 0.75 and 0.51, respectively. The likeli-hood tively evaluated. All patients underwent extensive questioning ratio in Quartile #1 of the validation set was 0.15. The authors and clinical exam. Presence of lumbar spinal stenosis was deter-concluded this self-administered questionnaire could be useful mined by two surgeons based on history, exam and MRI and any to improve the accuracy of the diagnosis of spinal ste-nosis, and discrepancies reconciled by a consensus panel of additional 10 in particular to rule out lumbar spinal stenosis.experts. Of the patients evaluated, 47% had lumbar spinal steno-sis. A univariate analysis was conducted followed by multivariate could have been more clearly defined. In the first study, their re-In critique, criteria for the diagnosis of lumbar spinal stenosis regression. Multiple variables were included as independent pre-test validation was done in 217/250 patients. This series of stud-dictors in the multivariable model with a P value less than 0.05. ies provides Level II diagnostic evidence that a self-administered An integer score derived from the beta-coefficient was assigned questionnaire can be useful to assist with providing clinical evi-to the identified risk factors with values as follows: age (60 to dence of lumbar spinal stenosis. They also discovered several key 70 - 1, > 70 - 2), absence of diabetes (1), intermittent claudica-predictors of lumbar spinal stenosis including age > 60, intermit-tion (3), exacerbation of symptoms when standing up (2), im-tent claudication, exacerbation of symptoms when standing up, provement of symptoms when bending forward (3), symptoms improvement of symptoms when bending forward, symptoms induced by having patients bend forward (minus 1), symptoms induced by having patients bend backward and abnormal Achil-induced by having patients bend backward (1), good peripheral les tendon reflexes. Diabetes, poor peripheral circulation, symp-artery circulation (3), abnormal Achilles tendon reflex (1), and toms induced by having the patient bend forward and a positive positive SLR test (minus 2). straight leg raising test were negative predictors of lumbar spinal score values were summed up to attain a total risk score for the For each patient, all applicable risk stenosis.patient. The sum of the risk scores for each patient ranged from Katz et al4–2 to 16. Performance modeling showed that the area under the and physical findings in the diagnosis of lumbar spinal stenosis. conducted a study assessing the value of historical ROC curve was 0.918; thus the model had good discriminatory The study included 93 consecutive patients evaluated in a spine power. The positivity cut-off point was defined as 7, since the center. All patients underwent a standardized history and physi-sum of the sensitivity and the specificity was the highest at that cal examination. Lumbar spinal stenosis was diagnosed in 46%

cut-off point. Given that the positivity criterion for risk score (43 of 93) of patients by expert physician assessment with at least was greater than 7, the clinical diagnostic support tool had a 80% confidence. The remaining patients had diagnoses includ-sensitivity of 92.8% and a specificity of 72.0%. The prevalence ing nonspecific musculoskeletal pain, scoliosis, spondylolisthe-of lumbar spinal stenosis increased as the risk score increased. sis and fibromyalgia. Imaging was available in 88% of patients Lumbar spinal stenosis prevalences were 6.3% in the first quar-with lumbar spinal stenosis and confirmed the diagnosis. tile (–2 to 5), 39.3% in the second quartile (6 to 8), 72.4% in the third quartile (9 to 11), 99.0% in the fourth quartile (12 to 16). nal stenosis, with a likelihood ratio (LR) greater than two, were Historical findings most strongly associated with lumbar spi-They concluded this tool could help improve the accuracy of the greater age (LR 2.5), severe lower extremity pain (LR 2.0), ab-diagnosis of spinal stenosis.sence of pain when seated (LR 6.6), and improvement of pain with sitting (LR 3.1). Symptoms worse with walking had a nega-tient population and similar methodology, but eliminated those The last study by Sugioka et al3 used the identical 468 pa-tive likelihood ratio of 0.96. Physical findings most strongly as-variables that required a physical exam, thus investigating the sociated with lumbar spinal stenosis were wide-based gait (LR efficacy of a self administered questionnaire. The patients were 14.3), abnormal Romberg test (LR 4.3), thigh pain after 30 sec-divided into derivation and validation sets. They found the key onds of lumbar extension (LR 2.5) and neuromuscular deficits determinants with their risk scores to be age (60 to 70 - 2, >70 - (LR 2.1). Independent correlates of lumbar spinal stenosis were

3), duration of symptoms longer than six months (1), symptom advanced age, wide-based gait and thigh pain with lumbar ex-improvement with forward bending (2), symptomatic aggrava-tension. The authors concluded that the history and physical ex-tion while standing up (2), symptoms improve with backward amination were useful in the diagnosis of lumbar spinal stenosis.bending (minus 2), intermit-tent claudication (1), and urinary incontinence (1). These patients were categorized into risk score standard for the diagnosis of lumbar spinal stenosis with radio-In critique, this study relies on expert opinion as the gold

graphic confirmation in just 88% of patients. These patients were

Degenerative Spinal Stenosis | NASS Clinical Guidelines15

tremity pain, absence of extremity pain when seated and/or im-provement of pain when seated as well as lower extremity pain with spinal extension greater than 30°, an abnormal Romberg test and wide-based pared to patients with other clinical diagnoses without im-aging. This comparative patient population is not well described. This study provides Level IV evidence that the diagnosis of lum-bar spinal stenosis is suggested by greater age, severe lower ex-

There is insufficient evidence to make a recommendation for or against the use of self-administered questionnaires to improve accuracy of the diagnosis of spinal stenosis.

Grade of Recommendation : I (Insufficient Evidence)

Konno et al1 looked at the efficacy of a self-administered, self-reported history and questionnaire (SSHQ). Through multiple analyses, they developed a series of questions intended to im-prove the accuracy of the diagnosis of lumbar spinal stenosis, and also to differentiate between two types of lumbar spinal ste-nosis termed radicular type and cauda equine type. A scoring system was developed to predict the diagnostic categories. The validation studies for the SSHQ showed an area under the ROC curve of 0.797 in the derivation set and 0.782 in the validation data set. These findings indicated that the SSHQ had both inter-nal and external validity as a diagnostic tool for lumbar spinal stenosis. The difference between tests plotted against the mean of the tests indicated no obvious relationship or bias. The intra-class correlation coefficient of the SSHQ score for the first and second tests was 0.85, which indicated sufficient reproducibility. One item of the κ coefficient was found to be “fair” (question 8), and all other items were rated as having a conformity of moder-ate or above.A second study by the same group looked prospectively at 468 patients with lower extremity symptoms.3 It is not known if part of the sample included patients from the earlier study by Konno et al.1 The patients were divided into derivation and validation sets. Following regression analysis and beta-coefficient assign-ment, they found the key determinants with their risk scores to be age (60 to 70 - 2, >70 - 3), duration of symptoms longer than six months (1), symptom improvement with forward bending (2), symptomatic aggravation while standing up (2), symptoms improve with backward bending (minus 2), intermittent clau-dication (1) and urinary incontinence (1). These pa-tients were categorized into risk score quartiles defined by risk scores of 2 or less, 3–4, 5–6 and 7 or more, respectively. Of the 374 patients in the derivation set, Quartile #1 showed a 17.7% (9/51) probability of lumbar spinal stenosis, whereas the second, third and fourth quartiles showed 25.3% (25/99), 50.8% (62/122), and 77.5% (79/102), respectively. The likelihood ratio in Quartile #1 of the derivation set was 0.24. Performance modeling showed an area under the ROC curve of 0.77 (Fig. 2). Sensitivity and specificity at the cut-off score point of 5 were 0.81 and 0.58, respectively. Of the 94 patients in the validation set, Quartile 1 showed a 13.3% (2/15) probability of lumbar spinal stenosis, whereas the second, third and fourth quartiles showed 47.6% (10/21), 55.2% (16/29) and 65.5% (19/29), respectively. Sensitivity and specificity at the cutoff score point of 5 were 0.75 and 0.51, respectively. The like-lihood ratio in Quartile #1 of the validation set was 0.15. The authors concluded this self-administered questionnaire could be useful to improve the accuracy of the diagnosis of spinal stenosis, and in particular to rule out lumbar spinal stenosis.In critique, criteria for the diagnosis of lumbar spinal ste-nosis could have been more clearly defined. In the first study, their retest validation was done in 217/250 patients. This series of studies provides Level II diagnostic evidence that a self-ad-ministered questionnaire can be useful to assist with providing clinical evidence of lumbar spinal stenosis.Wai et al5 described a prospective comparative study as-sessing the test-retest reliability of a patient’s ability to describe whether their lumbar spine pain was leg or back dominant using standardized questions. Eight questions to ascertain a patient’s ability to report location of pain (back or leg domi-nant) were assessed in a self-administered questionnaire for one group of patients and by a trained interviewer in a second group. Of the 63 patients included in the study, 32 were con-secutively assigned to self-assessment and 31 were assigned to trainer interview. All questions in the interviewer adminis-tered group were significantly more reliable (p<.001) than the self-administered group. Depending upon the specific ques-tion, between 0% and 32% of patients provided a com-pletely opposite response on test-retest. The authors concluded that A patient’s ability to identify whether their pain is leg or back dominant may be unreliable and depends on which questions are asked, and also how they are asked. While the Percent question is the most reliable method to determine the domi-nant location of pain, given the variability of responses and the generally poorer reliability, it is recommended that mul-tiple methods be used to assess a patient’s dominant location of pain. They also found answers to be more consistent when questions were administered by an interview rather than self-administered.This small study provides Level II diagnostic evidence that questions during structured interview are more likely to re-sult in consistent answers than self administered questions re-garding dominance of location of leg vs. back pain. However, regardless of the question, this information can be unreliable from one point in time to another.Konno and Kikuchi et al1 and Konno and Hayashino et al2 re-ported results from two studies suggesting that a constellation of variables could contribute to the diagnosis of lumbar spinal stenosis. After evaluating 468 patients, using univariate and multiple regression analysis, several key determinants scored This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason-ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the phy-sician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or Diagnosis/imaging

iagnosis/imaging16Degenerative Spinal Stenosis | NASS Clinical GuidelinesThere is insufficient evidence to make a recommendation for or against certain physical findings for the diagnosis of degenerative lumbar spinal stenosis including an abnormal Romberg test, thigh pain exacerbated with extension, sensorimotor deficits, leg cramps and abnormal Achilles tendon reflexes. Grade of Recommendation: I (Insufficient Evidence)together were found to be predictive of lumbar spinal stenosis. Some of these determinants were physical findings, including amination were useful in the diagnosis of lumbar spinal stenosis.good peripheral artery circulation, abnormal Achilles tendon reflex and positive SLR test. standard for the diagnosis of lumbar spinal stenosis with radio-In critique, this study relies on expert opinion as the gold graphic confirmation in just 88% of patients. These patients were could have been more clearly defined. In addition, these physi-In critique, criteria for the diagnosis of lumbar spinal stenosis compared to patients with other clinical diagnoses without im-cal findings were never evaluated alone as predictors of lumbar aging. This comparative patient population is not well described. spinal stenosis, only in the context of a combined scoring system This study provides Level IV evidence that the diagnosis of lum-using several other variables additionally related to patient his-bar spinal stenosis is suggested by greater age, severe lower ex-tory and demographics. tremity pain, absence of extremity pain when seated and/or im-provement of pain when seated as well as lower extremity pain and physical findings in the diagnosis of lumbar spinal stenosis. Katz et al4 conducted a study assessing the value of historical with spinal extension greater than 30°, an abnormal Romberg The study included 93 consecutive patients evaluated in a spine test and wide-based gait.center. All patients underwent a standardized history and physi-cal examination. Lumbar spinal stenosis was diagnosed in 46% assessing the incidence of leg cramps in patients with lumbar Matsumoto et al6 described a retrospective case control study (43 of 93) of patients by expert physician assessment with at least spinal stenosis. Of the 271 patients with lumbar spinal stenosis, 80% confidence. The remaining patients had diagnoses includ-120 completed the mailed survey. These findings were compared ing nonspecific musculoskeletal pain, scoliosis, spondylolisthe-with 370 controls. The study found that 70.8% (85/120) of the ste-sis and fibromyalgia. Imaging was available in 88% of patients nosis patients and 37.2% (137/340) of the controls experienced with lumbar spinal stenosis and confirmed the diagnosis. leg cramps, with an odds radio of 4.87 after adjusting for differ-ences in comorbidities. Leg cramps occurred once or twice per nal stenosis, with a likelihood ratio (LR) greater than two, were Historical findings most strongly associated with lumbar spi-week in 34.9% of the stenosis group and once in several months greater age (LR 2.5), severe lower extremity pain (LR 2.0), ab-in 44.5% of the control group. Leg cramps disturbed the qual-sence of pain when seated (LR 6.6), and improvement of pain ity of life and they rarely improved after decompression surgery. with sitting (LR 3.1). Symptoms worse with walking had a nega-The authors concluded that leg cramps should be recognized as tive likelihood ratio of 0.96. Physical findings most strongly as-one of the symptoms of lumbar spinal stenosis which negatively sociated with lumbar spinal stenosis were wide-based gait (LR affect the patients’ quality of life. In critique, the low response 14.3), abnormal Romberg test (LR 4.3), thigh pain after 30 sec-rate may introduce bias, depending upon construct of the in-onds of lumbar extension (LR 2.5) and neuromuscular deficits terview. Patients who had cramps may have been more likely to

(LR 2.1). Independent correlates of lumbar spinal stenosis were respond to the survey. Because of these limitations, this potential advanced age, wide-based gait and thigh pain with lumbar ex-Level III study provides Level IV prognostic evidence that there tension. The authors concluded that the history and physical ex-is an increased prevalence of leg cramps in patients with spinal stenosis, and that these cramps are not alleviated by surgery.There is insufficient evidence to make a recommendation for or against

the diagnostic reliability of patient-reported dominance of lower extrem-

ity pain and low back pain.

Grade of Recommendation: I (Insufficient Evidence)

Wai et al5 described a prospective comparative study assessing the test-retest reliability of a patient’s ability to describe whether assessed in a self-administered questionnaire for one group of their lumbar spine pain was leg or back dominant using stan-patients and by a trained interviewer in a second group. Of the dardized questions. Eight questions to ascertain a patient’s 63 patients included in the study, 32 were consecutively assigned ability to report location of pain (back or leg dominant) were to self-assessment and 31 were assigned to trainer interview. All questions in the interviewer administered group were signifi-This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason-ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the phy-sician and patient in light of all circumstances presented by the patient and the needs and resources particular to he locality or institution

Degenerative Spinal Stenosis | NASS Clinical Guidelines17

cation of pain. They also found answers to be more consistent when questions were administered by an interview rather than self-administered.This small study provides Level II diagnostic evidence that questions during structured interview are more likely to result in consistent answers than self administered questions regarding dominance of location of leg versus back pain. However, regard-less of the question, this information can be unreliable from one point in time to another.cantly more reliable (p<.001) than the self-administered group. Depending upon the specific question, between 0% and 32% of patients provided a completely opposite response on test-retest. The authors concluded that a patient’s ability to identify whether their pain is leg or back dominant may be unreliable and de-pends on which questions are asked, and also how they are asked. While the percent question is the most reliable method to determine the dominant location of pain, given the variability of responses and the generally poorer reliability, it is recommended that multiple methods be used to assess a patient’s dominant lo-

Additional Diagnostic and Imaging ConsiderationsDiagnostic Papers on Clinical Diagnostic TestingThe work group for this guideline identified several reports on the use of clinical diagnostic testing in the diagnosis of lumbar spinal stenosis. These techniques generally utilize measures of walking tolerance, time for onset of pain with exercise and re-covery time. Several studies utilized treadmill or bicycle test-ing and attempted to measure the effect of posture on exercise tolerance. The utility of these tests can be limited, however, by the ability of sometimes frail elderly patients to complete test-ing. The results of several studies, such as the study by Fritz et al described below, are promising. Testing protocols are heteroge-neous, however, and many have not been critically studied. Fritz et al7 reported on the initial experience with the two-stage exercise treadmill test (ETT) in the differential diagnosis of patients with low back pain, lower extremity pain and self-reported deficits in walking tolerance. The authors hypothesized that the findings on ETT would discriminate between stenotic and nonstenotic patients. Forty-five patients with low back pain, lower extremity pain and self-reported limitations in walking tolerance were studied with MRI or CT, Oswestry Disability In-dex (ODI), Visual Analog Scale (VAS), three self-reported pos-tural variables and two-stage ETT. Based on imaging, all patients were classified as stenotic or nonstenotic (HNP, etc). The authors reported that a linear discriminant analysis us-ing time to onset of symptoms and recovery time resulted in a likelihood ratio of 14.5. Likelihood ratios on self-reported vari-ables were much lower (<2.0). The authors concluded that a two-stage treadmill test may be useful in the differential diagnosis of lumbar stenosis. In critique, it was not clearly stated whether the patients were consecutively selected and there was no con-sistently applied and agreed upon gold standard. This study pro-vides Level III diagnostic evidence that a two-stage treadmill test may be useful in the differential diagnosis of lumbar stenosis. The work group concluded that while studies are limited, clinical diagnostic testing may be useful in selected patients to differentiate neurogenic from vascular causes of claudication.The work group identified the following potential studies that might generate meaningful evidence to assist in further defining the appropriate historical and physical findings consistent with the diagnosis of lumbar spinal stenosis.

Recommendation #1: A sufficiently powered observational study of the predictive value of historical and physical findings in patients with the lumbar spinal stenosis, as defined by this guideline, is proposed. The study should allow for a subgroup analysis of the subsets of patients with neurogenic claudication and radiculopathy.Recommendation #2: A prognostic study with long-term follow-up of up to 10 years could be performed on the cohort of spinal stenosis patients de-fined in Study #1.Recommendation #3:Recommend further research to clarify the association of gait abnormalities, posture, balance and fall risk in patients with lumbar spinal stenosis.Recommendation #4:Recommend further research on the reliability of patient-reported dominance of lower extremity pain and low back pain. This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason-ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the phy-sician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or Diagnosis/imagingFuture Directions for Research

iagnosis/imaging18Degenerative Spinal Stenosis | NASS Clinical GuidelinesHistory and Physical Exam References15. Engel K, Seidel W1. Konno S, Kikuchi S, Tanaka Yrent strategies in diagnosis: Interdisciplinary diagnostic system. . Degenerative lumbar spinal stenosis - Cur-lumbar spinal stenosis: a self-administered, self-reported history , et al. A diagnostic support tool for Deutsches Arzteblatt2. questionnaire. 16. Fritz, J.M., et al. Lumbar spinal stenosis: a review of current con-. 2008;105(47):823.Konno S, Hayashino Y, Fukuhara S. Development of a clinical BMC Musculoskelet Disord. 2007 Oct 30; 8:102.cepts in evaluation, management, and outcome measurements. diagnosis support tool to identify patients with lumbar spinal Arch Phys Med Rehabil3. stenosis. 17. Fritz JM, Delitto A, Welch WC, Erhard RE. Preliminary results . 1998;79(6):700-8.Sugioka T, Hayashino Y, Konno S, Kikuchi S, Fukuhara S. Eur Spine J. 2007;16(11):1951-7.of the use of a two-stage treadmill test as a clinical diagnostic Predictive value of self-reported patient information for the tool in the differential diagnosis of lumbar spinal stenosis. identification of lumbar spinal stenosis. 18. Spinal Disord. J 4. 237-44.Fam Pract. 2008;25(4): Genevay S, Atlas SJ. Lumbar spinal stenosis. 1997;10(5):410-6.Katz JN, Dalgas M, Stucki G, et al. Degenerative lumbar spinal 19. Rheumatolstenosis. Diagnostic value of the history and physical examina-Giles DJ, Thomas RJ, Osborn AG, et al. Lumbar spine: pretest . 2010;24(2):253-65.Best Pract Res Clin 5. tion. 20. predictability of CT findings. Wai EK, Howse K, Pollock JWArthritis Rheum. 1995; 38(9): 1236-41.Grobler, LJ. Back and leg pain in older adults. Presentation, Radiology. 1984;150(3):719-22.The reliability of determining “leg dominant pain”, Dornan H, Vexler L, Dagenais S. 21. diagnosis, and treatment. 6. 9(6):447-453.. Spine J. 2009; Haswell K, Gilmour J, Moore B. Clinical decision rules for iden-Clin Geriatr Med. 1998;14(3):543-76.Matsumoto M, Watanabe K, Tsuji T, et al. Nocturnal leg cramps: tification of low back pain patients with neurologic involvement a common complaint in patients with lumbar spinal canal steno-22. in primary care. 7. sis. Huber JF, Dabis E, Huesler J, Ruflin GB. Symptom assessment Spine. 2008;33(1):68-73.Fritz JM, Erhard RE, Delitto A, Welch WC, Nowakowski PE. Spine (Phila Pa 1976). 2009;34(5):E189-94.in lumbar stenosis/spondylolysis - patient questionnaire versus Preliminary results of the use of a two-stage treadmill test as a 23. physician chart. clinical diagnostic tool in the differential diagnosis of lumbar Iversen MD, Kale MK, Sullivan Jr JT. Pilot case control study Swiss Med Wkly. 2009;139(41-42):610-4.spinal stenosis. J Spinal Disord. 1997;10(5):410-6.of postural sway and balance performance in aging adults with degenerative lumbar spinal stenosis. History and Physical Findings Bibiolography2009;32(1):15-21.J Geriatr Phys Ther. 1. Aalto TJ, Malmivaara A, Kovacs F, et al. Preoperative predictors 24. Iversen MD, Katz JN. Examination findings and self-reported for postoperative clinical outcome in lumbar spinal stenosis: walking capacity in patients with lumbar spinal stenosis. Ther2. systematic review. Abraham PSpine (Phila Pa 1976). 2006; 31(18):E648-63.25. Jenis LG, An HS. Spine update. Lumbar foraminal stenosis. . 2001;81(7):1296-306.Phys Spine3. spinal stenosis. , Ouedraogo N, Leftheriotis G. Diagnosing lumbar Adamova B, Vohanka S, Dusek L. Differential diagnostics in JAMA. 2010;303(15):1479-1480.26. Jenis, LG, An HS, Gordin R. Foraminal stenosis of the . 2000; 25(3):389-94.patients with mild lumbar spinal stenosis: the contributions and lumbar spine: a review of 65 surgical cases. 2001;30(3):205-11.Am J Orthop. 4. limits of various tests. Amundsen T, Weber H, Lilleås F, Nordal HJ, Abdelnoor M, Eur Spine J. 2003;12(2):190-6.27. Jensen OH, Schmidt-Olsen S. A new functional test in the diag-Magnaes B. Lumbar spinal stenosis. Clinical and radiologic nostic evaluation of neurogenic intermittent claudication. RheumatolClin 5. features. Berthelot JM, Bertrand-Vasseur A, Rodet D, Maugars Y, Prost A. Spine. 1995;20(10):1178-86.28. Jönsson B, Annertz M, Sjöberg C, Strömqvist B. A prospective . 1989;8(3):363-7.Lumbar spinal stenosis: a review. and consecutive study of surgically treated lumbar spinal ste-nosis. Part I: Clinical features related to radiographic findings. 6. 315-25.Rev Rhum Engl Ed. 1997;64(5): Binder, DK, Schmidt MH, Weinstein PR. Lumbar spinal steno-29. Spine. Kato Y, Kawakami T, Kifune M, et al. Validation study of a clini-1997;22(24):2932-7.

7. sis. Cadosch D, Gautschi OPSemin Neurol. 2002;22(2):157-66.cal diagnosis support tool for lumbar spinal stenosis.

spinal stenosis - Claudicatio spinalis. Pathophysiology, clinical , Fournier JY, Hildebrandt G. Lumbar

30. Sci.Katz JN, Dalgas M, Stucki G, et al, Degenerative lumbar spinal 2009;14(6):711-8.J Orthop

8. aspects and treatment. Chad DA. Lumbar spinal stenosis. Praxis. 2008;97(23):1231-1241.stenosis. Diagnostic value of the history and physical examina-tion.

9. 18.Neurol Clin. 2007;25(2):407-

Chou R, Qaseem A, Snow V31. Katz JN, Dalgas M, Stucki G, Lipson SJ. Diagnosis of lumbar Arthritis Rheum. 1995;38(9):1236-41.

of low back pain: A joint clinical practice guideline from the , et al. Diagnosis and treatment spinal stenosis.

American college of physicians and the American pain society. 32. Katz JN, Stucki G, Lipson SJ, et al. Predictors of surgi-Rheum Dis Clin North Am. 1994. 20(2):471-83.

cal outcome in degenerative lumbar spinal stenosis.

10. Annals Intern Med.Ciric I, Mikhael MA. Lumbar spinal-lateral recess stenosis. 2007;147(7):478-491.1999;24(21):2229-33.Spine.

Konno S, Hayashino Y, Fukuhara S, et al. Development of a

11. Neurol Clin33.

Daffner SD, Wang JC. The pathophysiology and nonsurgical . 1985;3(2):417-23.clinical diagnosis support tool to identify patients with lumbar treatment of lumbar spinal stenosis. spinal stenosis. Konno S, Kikuchi S, Tanaka Y, et al. A diagnostic support tool Eur Spine J. 2007;16(11):1951-7.

12. 657-68.Instr Course Lect. 2009;58: 34.

Deen HG Jr, Zimmerman RS, Lyons MK, et al. Test-retest repro-for lumbar spinal stenosis: a self-administered, self-reported ducibility of the exercise treadmill examination in lumbar spinal history questionnaire. KortebeinLumbar spinal stenosis. BMC Musculoskelet Disord. 2007;8:102.

13. stenosis. 35.

Deyo RA, Rainville J, Kent DL. What can the history and physi-Mayo Clin Proc. 2000;75(10):1002-7.2008;358(24):2647; author reply 2647-8.N Engl J Med.

cal examination tell us about low back pain? 36. Lequesne M, Zaoui A. Misleading “hip” or buttock pain: Proximal arteritis or lumbar spinal stenosis?

14. 760-5.Jama. 1992;268(6):

Ebell MH. Diagnosing lumbar spinal stenosis. 2006;35(4 II):663-668.Presse Medicale. cian. 2009;80(10):1145.Am Fam Physi-37. Lim MR, Huang RC, Wu A, Girardi FPation of the elderly patient with an abnormal gait. , Cammisa FP Jr. Evalu-J Am Acad This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason-ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the phy-sician and patient in light of all circumstances presented by the patient and the needs and resources particular to he locality or institution

Degenerative Spinal Stenosis | NASS Clinical GuidelinesOrthop Surg. 2007;15(2):107-17.Lin SI, Lin RM, Huang LW. Disability in patients with de-generative lumbar spinal stenosis. Arch Phys Med Rehabil. 2006;87(9):1250-6.Mann NH 3rd, Brown MD, Enger I. Statistical diagnosis of lum-bar spine disorders using computerized patient pain drawings. Comput Biol Med. 1991;21(6):383-97.Matsumoto M, Watanabe K, Tsuji T, et al. Nocturnal leg cramps: a common complaint in patients with lumbar spinal canal ste-nosis. Spine (Phila Pa 1976). 2009;34(5):E189-94.McKinley W., et al. Cervical and lumbar spinal stenosis associ-ated with myelopathy and cauda equina syndrome. Topics in Spinal Cord Injury Rehabilitation. 2008;14(2):10-18.Moon ES, Kim HS, Park JO, et al. Comparison of the predic-tive value of myelography, computed tomography and MRI on the treadmill test in lumbar spinal stenosis. Yonsei Med J. 2005;46(6):806-11.Morishita Y, Hida S, Naito M, Arimizu J, Takamori Y. Neuro-genic intermittent claudication in lumbar spinal canal steno-sis: the clinical relationship between the local pressure of the intervertebral foramen and the clinical findings in lumbar spinal canal stenosis. J Spinal Disord Tech. 2009;22(2):130-4.Oniankitan O, Magnan A, Fianyo E, Mijiyawa M. Lumbar spinal stenosis in an outpatient clinic in Lome, Togo. Medecine Tropi-cale. 2007;67(3):263-266.Papadakis NC, Christakis DG, Tzagarakis GN, et al. Gait vari-ability measurements in lumbar spinal stenosis patients: Part A. Comparison with healthy subjects. Physiol Meas. 2009;30(11): 1171-1186.Pratt RK, Fairbank JC, Virr A. The reliability of the Shuttle Walking Test, the Swiss Spinal Stenosis Questionnaire, the Oxford Spinal Stenosis Score, and the Oswestry Disability Index in the assessment of patients with lumbar spinal stenosis. Spine. 2002;27(1):84-91.Roach KE, Brown MD, Albin RD, et al. The sensitivity and specificity of pain response to activity and position in categoriz-ing patients with low back pain. Phys Ther. 1997;77(7):730-8.Sato K, Kikuchi S. Clinical analysis of two-level compression of the cauda equina and the nerve roots in lumbar spinal canal stenosis. Spine. 1997;22(16):1898-903; discussion 1904.Schafer A, Hall T, Briffa K. Classification of low back-related leg pain-A proposed patho-mechanism-based approach. Manual Therapy. 2009;14(2): 222-230.Siebert E, Prüss H, Klingebiel R, et al. Lumbar spinal steno-sis: syndrome, diagnostics and treatment. Nat Rev Neurol. 2009;5(7):392-403.51. 52. 53. 54. 19Simonetti I, Pratesi C. Intermittent claudication or neurogenic claudication? “Why don’t you speak to me”? Intern Emerg Med. 2006;1(2):133; discussion 133-4.Singh K, Samartzis D, Biyani A, An HS. Lumbar spinal stenosis. J Am Acad Orthop Surg. 2008;16(3):171-6.Spivak, JM. Degenerative lumbar spinal stenosis. J Bone Joint Surg Am. 1998;80(7):1053-66.Sugioka T, Hayashino Y, Konno S, Kikuchi S, Fukuhara S. Predictive value of self-reported patient information for the identification of lumbar spinal stenosis. Fam Pract. 2008;25(4): 237-44.Tadokoro K, Miyamoto H, Sumi M, Shimomura T. The progno-sis of conservative treatments for lumbar spinal stenosis: analy-sis of patients over 70 years of age. Spine. 2005;30(21): 2458-63.Thomas SA. Spinal stenosis: history and physical examination. Phys Med Rehabil Clin N Am. 2003;14(1):29-39.Truumees E. Spinal stenosis: pathophysiology, clinical and radiologic classification. Instr Course Lect. 2005;54:287-302.van Gijn J. Lumbar spinal stenosis. N Engl J Med. 2008;358(24):2647; author reply 2647-8.Varcoe RL, Taylor CF, Annett P, Jacobsen EE, McMullin G. The conundrum of claudication. Anz J Surg. 2006;76(10):916-927.Wai EK, Howse K, Pollock JW, Dornan H, Vexler L, Dagenais S. The reliability of determining “leg dominant pain”. Spine J. 2009;9(6):447-453.Watters, WC 3rd, Bono CM, Gilbert TJ, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenera-tive lumbar spondylolisthesis. Spine J. 2009;9(7):609-614.Watters, WC 3rd, Gilbert TJ, Kreiner DS. Diagnosing lumbar spinal stenosis. JAMA. 2010;303(15):1479; author reply 1480-1.Westergaard L, Hauerberg J, Springborg JB. Outcome after sur-gical treatment for lumbar spinal stenosis: the lumbar extension test is not a predictive factor. Spine (Phila Pa 1976). 2009;34(25): E930-5.White AP, Albert TJ. Evidence-Based Treatment of Lumbar Spinal Stenosis. Semin Spine Surg. 2009;21(4):230-237.Whitehurst M, Brown LE, Eidelson SG, D’angelo A. Functional mobility performance in an elderly population with lumbar spinal stenosis. Arch Phys Med Rehabil. 2001;82(4):464-7.Williamson JB. Percutaneous stimulation of the cauda equina. A new diagnostic method in spinal stenosis. Spine. 1991;16(4):460-2.Yamashita K, Aono H, Yamasaki R. Clinical classification of patients with lumbar spinal stenosis based on their leg pain syn-drome: its correlation with 2-year surgical outcome. Spine (Phila Pa 1976). 2007;32(9):980-5.38. 39. 40. 41. 42. 55. 56. 57. 58. 59. 60. 61. 62. 63. 43. 44. 45. 46. 47. 48. 49. 50. 64. 65. 66. 67.

iagnosis/imaging20Degenerative Spinal Stenosis | NASS Clinical GuidelinesDiagnosing Spinal Stenosis with Imaging in signal-to-noise and further decreases in scan times. New Limitations and Assumptions in Magnetic Resonance sequences have been introduced, and most MRI centers now Imaging (MRI) Studiesutilize multi-echo spin echo sequences for routine PD and T2-The results of this systematic review may not apply to all MRI weighted imaging. STIR and T2 fat saturation images are also systems. In general, the studies cited in this guideline utilized frequently used and may increase the sensitivity of MRI for in-mid or high field strength MRI systems with dedicated surface flammatory, neoplastic and traumatic pathologies.coils. Their findings and the ensuing guideline’s may not apply to low field strength systems. Only one study in our series, per-included in the evidentiary tables) evaluated the application of CT technologies have also evolved. While one study (not formed by Cihangiroglu et al1helical scanning to spine imaging, no studies were identified strength systems. This study showed that the interobserver vari-, evaluated both low and high field which utilized more current 8 or 16 multidetector technologies. ability was increased with use of the low field strength system These technologies have resulted in a marked decrease in imag-and the authors recommended that a high field strength system ing times and many CT centers now routinely utilize 1 or 2 mm should be used whenever anatomic detail is necessary for surgi-sections in the evaluation of the spine. The use of thin section cal planning. Additional research studies need to be per-formed technique has decreased partial voluming artifact, has improved to evaluate the performance of low field strength MRI relative to the quality of sagittal reformations and has improved the ability high field strength MRI, state-of the-art computed tomography of CT to evaluate the integrity of lumbar fusions. The impact of (CT) and CT myelography.these technologies on overall accuracy needs to be studied.or state-of-the-art technique. MRI, and to a lesser extent CThe results of our systematic review also assume adequate been compared to a state-of-the-art CT system in routine clini-While the accuracy of a state-of-the-art MRI system has not are user-dependent. The MRI studies cited in this guideline, in T, cal imaging, the technical improvements in each modality have general, uti-lized thin (4-5 mm) sections and a combination of tended to parallel each other and the modalities remain comple-T1-, proton density and T2 pulse sequences in both the axial and mentary. MRI continues to provide superior soft tissue contrast sagittal planes. State-of-the-art protocols should utilize thin sec-with excellent visualization of soft tissue pathology, the dural sac tions and provide excellent signal-to-noise ratios with high in-interface and neural elements. CT continues to be more sensitive plane resolution. With routine indications, stacked axial sections for calcified structures and provides better visuali-zation of both should be obtained and should include at least the L5-S1, L4-5, structural integrity and bridging bone. MRI remains a nonion-L3-4 levels. Additional an-gled or stacked axial sections can be izing modality, while with CT, the dose of ionizing radiation may obtained through adjacent or more cephalad levels as indicated. be increased with routine utilization of 1 or 2 mm sections. A masked, randomized, controlled study comparing the benefits of Evolution of Imaging Technologythese two modalities would clarify the impact of these develop-Both Cments on their relative accuracy.evolve over time. In our review, early developmental studies T and MRI technology have evolved and continue to were discarded because they did not use surface coils or because development of “open” MRI systems, small contained MRI sys-The evolution of MRI technologies has also resulted in the thick (10 mm) sections were used. The studies cited above, how-tems for placement in a doctor’s “back office,ever, do not reflect more recent improvements in MRI and CT tems, and axial loading systems that simulate upright physiolog-” upright MRI sys-technologies. MRI coils, gradients and imaging sequences have ic MRI/CT imaging. Evolution is not always synonymous with continued to improve, and have resulted in further increases improved quality, however, and both the accuracy and efficacy of these new sys-tems also need to be evaluated.

In patients with history and physical examination findings consistent with

degenerative lumbar spinal stenosis, MRI is suggested as the most appro-

priate, noninvasive test to confirm the presence of anatomic narrowing of

the spinal canal or the presence of nerve root impingement.Grade of Recommendation: B

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