basic question about spinal stenosis

[Sliu238]

Stupid question. I don't quite understand how to distinguish clinically between spinal stenosis vs radiculopathy. I understand spinal stenosis refers to narrowing of the spinal canal and radiculopathy means impingement on the root. How these manifest clinically is where I get confused. I get that classically back pain with relief with forward bending/shopping cart sign point to lumbar spinal stenosis, but can't spinal canal stenosis also impinge on nerve root (e.g. at L4/5, the L5 root) and cause radiculopathy? In the latter case, would the diagnosis be spinal stenosis with with L5 radiculopathy? Put another way, when one talks about spinal stenosis (rather than neuroforaminal stenosis which is easy to understand and almost always associated with radiculopathy), is it important to specify "spinal stenosis with radiculopathy" vs "spinal stenosis without radiculopathy" (e.g. shopping cart sign)?

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[jwheezy]

i think that's when "neurogenic claudication" comes into play

 

[Espn123]

Depends where the stenosis is - central canal typically causes bilateral symptoms that are taught in the textbook. Lateral recess and Neuroforaminal stenosis often cause unilateral symptoms. This highlights the need for a higher level understanding of “spinal stenosis” and the need to look at your own MRI. All 3 regions can have claudication.

radiculopathy or radicular pain are named when you can pinpoint a nerve root affected. (I.e. spinal stenosis in the lateral recess of L4-5 affecting the transiting L5 nerve causing radicular pain)

nice topic, thanks for bringing it up. Sounds simple but likely not understood by even some experienced docs or graduating fellows

 

[painfree23]

Is there a big difference between radiculitis and radiculopathy?

 

[Laryngospasm]

If you are Dr. Abrams yes there is! Typically speaking what we usually call Radiculopathy if more often Radiculitis. Spinal stenosis is typically a blood flow issue centrally and this presents with the bilateral neurogenic claudication. This is what usually separates it from Radiculitis or opathy.

 

[Espn123]

If you are Dr. Abrams yes there is! Typically speaking what we usually call Radiculopathy if more often Radiculitis. Spinal stenosis is typically a blood flow issue centrally and this presents with the bilateral neurogenic claudication. This is what usually separates it from Radiculitis or opathy.

I would disagree with this but it’s all a matter of nomenclature

I would call lateral recess nerve impingement a form of spinal stenosis

to me, radiculopathy implies a sensory or motor deficit. Radiculitis or radicular pain means pain in that nerve root distribution without a motor or sensory deficit.

interested to see what others do...

 

[Laryngospasm]

I would disagree with this but it’s all a matter of nomenclature

I would call lateral recess nerve impingement a form of spinal stenosis

to me, radiculopathy implies a sensory or motor deficit. Radiculitis or radicular pain means pain in that nerve root distribution without a motor or sensory deficit.

interested to see what others do...

I agree with what you are saying. I could have worded things more clearly. What I mean is most people just have the nerve pain aspect without weakness or numbness but most people’s knee jerk reaction is to call that Radiculopathy. I can count on one hand the number of times I’ve seen anyone including radiology call it Radiculitis.

 

[willabeast]

Stupid question. I don't quite understand how to distinguish clinically between spinal stenosis vs radiculopathy. I understand spinal stenosis refers to narrowing of the spinal canal and radiculopathy means impingement on the root. How these manifest clinically is where I get confused. I get that classically back pain with relief with forward bending/shopping cart sign point to lumbar spinal stenosis, but can't spinal canal stenosis also impinge on nerve root (e.g. at L4/5, the L5 root) and cause radiculopathy? In the latter case, would the diagnosis be spinal stenosis with with L5 radiculopathy? Put another way, when one talks about spinal stenosis (rather than neuroforaminal stenosis which is easy to understand and almost always associated with radiculopathy), is it important to specify "spinal stenosis with radiculopathy" vs "spinal stenosis without radiculopathy" (e.g. shopping cart sign)?

The confusion is that one can have spinal stenosis as a syndrome (a collection of symptoms) and/or spinal stenosis as a radiological definition. The radiological definition is not agreed on by everyone but even if it was, a radiologist can diagnose spinal stenosis on imaging and the patient can be asymptomatic. Given that asymptomatic patients can have imaging consistent with spinal stenosis seems to me one has to go with symptoms/PE when deciding if patient has spinal stenosis. https://pubs.rsna.org/doi/full/10.1148/radiol.12111930

 

[joshmir]

I believe Radiculopathy is defined by the American academy of neurology as 2 out of 3 of the following

Reduced DTR
Weakness
Sensory loss

Neuropathic pain, dural tension not included; if those exist without at least 2 out of 3 of the aforementioned, then is radiculitis


Please Somebody, tell me if you think what I stated above is accurate or not accurate, so that I don’t continue repeating something that is not accurate

I think doctors who do procedures to help radic should define These things, not doctors that just diagnosed. Not knocking neurologist, but I believe that expertise in an area, especially definitions, and clinical guidelines, and decision making, should be made by the specialty societies that represents these things, not doctors that just diagnose. Not knocking neurologists, but I believe that expertise in an area, especially definitions, and clinical guidelines, and decision making, should be made by the specialty societies that represent Those who treat the condition. Because all of us no patients who have radiculitis that gets great relief from epidurals, and bemoan the guidelines that only supports epidurals for radiculopathy and not radiculitis

 

[callmeanesthesia]

I think another part of the confusion arises from the practical aspect. Definitions I’m seeing above are spot on what I’ve read and been taught as well.
However... if I diagnose my patient with lumbar radicular pain, there’s a much greater chance their insurance carrier is going to deny the MRI and/or epidural.
Regarding stenosis vs radiculopathy, I’d say a lot of it comes down to mechanical compression causing ischemia, vs inflammation and chemical sensitization. The stenosis pain therefore is activity and position dependent, whereas the inflammatory pain hurts all the time. This is an oversimplification and you will generally see these coexist to some extent, such as with a large disc herniation that is mechanically displacing the nerve root and also causing a huge inflammatory response.

 

[deleted472101]

If the pain is episodic do to position I believe it’s the stenosis if the Imaging also shows some degree.

if the pain is there more often than not regardless of position it could be radiculitis or Radiculopathy.

Also make sure you ruled out other causes of low back pain first via history and physical.

 

[Rocuronium18]

Great discussion everyone. I really like this paper - "Consensus on the clinical diagnosis of lumbar spinal stenosis: Results of an International Delphi Study" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4966995/pdf/nihms755508.pdf). It identified main factors based on history important for the diagnosis of lumbar spinal stenosis. The six top items were “leg or buttock pain while walking”, “flex forward to relieve symptoms”, “feel relief when using a shopping cart or bicycle”, “motor or sensory disturbance while walking”, “normal and symmetric foot pulses”, “lower extremity weakness” and “low back pain”.

I personally like the terminology "spinal stenosis with radiculopathy" if no neuroforaminal stenosis is identified.

 

[BloodySurgeon]

Stupid question. I don't quite understand how to distinguish clinically between spinal stenosis vs radiculopathy. I understand spinal stenosis refers to narrowing of the spinal canal and radiculopathy means impingement on the root. How these manifest clinically is where I get confused. I get that classically back pain with relief with forward bending/shopping cart sign point to lumbar spinal stenosis, but can't spinal canal stenosis also impinge on nerve root (e.g. at L4/5, the L5 root) and cause radiculopathy? In the latter case, would the diagnosis be spinal stenosis with with L5 radiculopathy? Put another way, when one talks about spinal stenosis (rather than neuroforaminal stenosis which is easy to understand and almost always associated with radiculopathy), is it important to specify "spinal stenosis with radiculopathy" vs "spinal stenosis without radiculopathy" (e.g. shopping cart sign)?

I could most likely misunderstand the question but is your question how to determine if a symptomatic patient with leg radiculopathy is originating from a central stenosis vs lateral recess vs neuroforaminal stenosis clinically without imagining?

The answer is you cant. However with imagining if you have questionable findings it would depend on the level of the radiculopathy (i.e dermatome, weakness, etc). Central effects levels below vs neuroforaminal effects the exiting level.

 

[DrSpine]

How I differentiate:

Radiculopathy can be due to nerve root impingement/irritation from a disc herniation. Most often you see it in <55; severe sudden pain, shooting down the leg. Worse with prolonged sitting. Other levels generally fine or displaying mild degenerative changes.

Spinal Stenosis is essentially crowding of the spinal canal or neuroforamen. Kind of like arthritis of the back. Degenerative changes, range of many different things from ligamentum flavum hypertrophy, multilevel weakening/flattening of the discs, spondylosis, facet changes. All of this comes together and either A) Crowds the Spinal Canal in the middle, or B) Crowds the neuroforamen. Symptoms range from dull aches, pain shooting down the leg, dull cramps, stiffness, etc. Often times can be bilateral or unilateral affecting a nerve root. Typically older patient >55 years old. Localized stenosis to the low back and no radiation down the legs is often caused by the facets. More variation caused by symptoms as you can see versus a simple radiculopathy from disc herniation.

 

[Sliu238]

Great responses. I have learned a great deal from the discussion.

Today I saw a patient h/o kyphoplasty at L2 from compression fracture, imaging showed retropulsion such that there was mild central canal stenosis at that level and may be a disc herniation at L5-S1 with mild NFS. She presented with R=L back pain w/ signs of neurogenic claudication but also had radiating pain down LLE in L5-S1 distribution. My attending asked if her primary complaint back pain or leg pain. When I answered back, attending favored pursing bilateral L2 TFESI, not Left L5-S1 TFESI.

More stupid questions:
1 - what is the procedural treatment spinal stenosis - why b/l TFESI in this case rather than interlaminar?
2 - what is the general indication/what is your algorithm to choose TFESI vs ILESI vs caudal?
3 - why is it important to distinguish if primary complaint is back (neck) vs leg (arm) - when would distinguishing this be important? Is it to distinguish axial (back > extremity pain) vs radicular (extremity > back pain)? If pt above had leg pain > back pain, would this be more consistent with radicular pain that would benefit from selective nerve root block?

 

[paindoc007]

A

Great responses. I have learned a great deal from the discussion.

Today I saw a patient h/o kyphoplasty at L2 from compression fracture, imaging showed retropulsion such that there was mild central canal stenosis at that level and may be a disc herniation at L5-S1 with mild NFS. She presented with R=L back pain w/ signs of neurogenic claudication but also had radiating pain down LLE in L5-S1 distribution. My attending asked if her primary complaint back pain or leg pain. When I answered back, attending favored pursing bilateral L2 TFESI, not Left L5-S1 TFESI.

More stupid questions:
1 - what is the procedural treatment spinal stenosis - why b/l TFESI in this case rather than interlaminar?
2 - what is the general indication/what is your algorithm to choose TFESI vs ILESI vs caudal?
3 - why is it important to distinguish if primary complaint is back (neck) vs leg (arm) - when would distinguishing this be important? Is it to distinguish axial (back > extremity pain) vs radicular (extremity > back pain)? If pt above had leg pain > back pain, would this be more consistent with radicular pain that would benefit from selective nerve root block?

Where was the back pain? Low down at the lumbosacral junction? If so, I agree with you. Start with an epidural at L5.

as far as interlam vs tfesi, just understand it’s the difference b/w anterior epidural and posterior epidural spread of steroid. Where’s the disc impacting the canal to cause stenosis? Hence, most people (this forum included) for discogenic dx with radic, people lean towards a tfesi first.

 

[callmeanesthesia]

Great responses. I have learned a great deal from the discussion.

Today I saw a patient h/o kyphoplasty at L2 from compression fracture, imaging showed retropulsion such that there was mild central canal stenosis at that level and may be a disc herniation at L5-S1 with mild NFS. She presented with R=L back pain w/ signs of neurogenic claudication but also had radiating pain down LLE in L5-S1 distribution. My attending asked if her primary complaint back pain or leg pain. When I answered back, attending favored pursing bilateral L2 TFESI, not Left L5-S1 TFESI.

More stupid questions:
1 - what is the procedural treatment spinal stenosis - why b/l TFESI in this case rather than interlaminar?
2 - what is the general indication/what is your algorithm to choose TFESI vs ILESI vs caudal?
3 - why is it important to distinguish if primary complaint is back (neck) vs leg (arm) - when would distinguishing this be important? Is it to distinguish axial (back > extremity pain) vs radicular (extremity > back pain)? If pt above had leg pain > back pain, would this be more consistent with radicular pain that would benefit from selective nerve root block?

This one’s a judgement call - there’s no clear right answer in how you pursue it or which procedure first, and there are likely multiple pain generators. If leg pain > back pain, then we are often looking more at a radicular issue (but don’t forget mimics such as meralgia paresthetica - I’ve seen a lot of patients misdiagnosed with L3 radic).
In this case though, back>leg pain could be multiple issues. If there is foraminal narrowing up higher it could be a high lumbar radicular pain, but you’d still want to see a dermatomal distribution to call that, and that’s usually going to be one side more than the other. If just the central stenosis with no foraminal or subarticular narrowing it could be that - sometimes high lumbar neurogenic claudication will not produce the leg pain we typically associate with neuro claudication. The change in shape from the fracture will put more pressure on the posterior elements and they commonly develop facet pain around the compression fracture. Lower lumbar facet arthropathy is most common in all-comers and can also cause referred pain down the back of the legs. Any one of those elements may be most appropriate to treat first.
When you say she had signs of neurogenic claudication do you mean her back hurts worse when she walks and gets better when she sits? Because that is the same pattern as facets. Or do you mean her legs get heavy, weak, and/or numb as she walks (in that case also important to look for signs of vascular claudication)

 

[avalon10]

If you are Dr. Abrams yes there is! Typically speaking what we usually call Radiculopathy if more often Radiculitis. Spinal stenosis is typically a blood flow issue centrally and this presents with the bilateral neurogenic claudication. This is what usually separates it from Radiculitis or opathy.

Spinal stenosis is a blood flow issue?!?
Anyone agree or disagree with this??

 

[painfree23]

Spinal stenosis is a blood flow issue?!?
Anyone agree or disagree with this??

Agree. Increased Blood flow needs to go to the spinal canal with increased activity but there’s no room for this blood flow, right?