Lumbar Spinal Canal Stenosis (Neurogenic Claudication)

Who: Typically over 60. Gradual onset over months to years, fluctuating rather than linear.
What: Back and leg pain, heaviness or "tired legs", often bilateral, with a walking distance they can quote you in metres.
How it behaves: Aggs: walking, standing, downhill walking, lumbar extension. Eases: sitting, bending forward, leaning on a trolley, cycling, walking uphill.

The illness script in one line:

Extension closes the canal and walking loads it — so the legs give out at a repeatable distance, and the position that fixes it is flexion, not rest.

The one thing to take from this page:

"Stenosis" means three different things and the literature swaps between them mid-sentence. A radiological finding. A clinical syndrome. A diagnosis. You assess the second one.

Say what you mean by the word, before you say anything else

Hold that line all the way down the page. The pattern on this page describes number 2. Most of the imaging evidence describes number 1. They overlap far less than students expect, and that gap is the most useful thing here.

[1][2][3][4][5][6][7][8]

There is no Australian guideline for this pattern, and that is not a formatting note. The ACSQHC Low Back Pain Clinical Care Standard (2022) was read in full on 2 Sep 2026. The words "stenosis", "claudication" and "neurogenic" appear zero times — not in the eight quality statements, not in the clinician sections, not in the consumer sections. It covers "low back pain, with or without leg pain or other neurological symptoms", it names sciatica and radicular pain, and it lists its differentials as nephritis, colitis, hip osteoarthritis and aortic dissection. Stenosis is not one of them.

So split it honestly. The generic layer — assessment, psychosocial screening, when not to image, when to escalate — does sit under an Australian standard, and you should say so. The pattern-specific layer — the claudication history, the vascular differential, the walking programme, the drug list, the surgical threshold — is anchored to Bussières et al. 2021 [9], a Canadian-led international GRADE guideline. Not Australian. When your educator asks "says who?", name which half you are quoting.

Patterns > Labels. "L4/5 canal stenosis" names a measurement. Older adult, bilateral leg heaviness, walking limit in metres, eased by flexion, vessels checked names the problem you can manage this week — and it is the one you take to your educator.

Five stages, in order. On this pattern the history is not the lead-in to the diagnosis — it is the diagnostic instrument, and that is not a slogan, it is the accuracy data. A self-administered history questionnaire reached sensitivity 84% / specificity 78% in a 250-patient validation set [10]. Head to head in 3,331 consecutive low back pain patients, of whom 42.5% had stenosis, the LSS diagnosis support tool hit 91.3% / 76.0% against the NASS clinical description at 63.9% / 89.5% [11]. Nothing in section 5 comes close to those numbers.

MAIN PROBLEM

"I can't walk to the shops any more. About 200 metres and both legs go heavy and dead, and I have to sit down. Sitting fixes it in a couple of minutes. Then I can go again."

Listen for a distance and a position. The main problem in this pattern is almost never "my back hurts" — it is a walking limit and a posture that resets it. If they lead with a number in metres, you are already most of the way there.

BODY CHART

• Map P1 and P2 bilaterally. Stenosis usually gives you two columns on the body chart, not one — buttock, posterior thigh, calf, often both sides, often asymmetrically.
• Mark heaviness, deadness and "tired legs" as distinct from pain. Patients under-report these because they don't sound like a symptom.
• Mark paraesthesia and numbness separately, and mark the perineum — see section 4 before you write anything in that box.
• Back pain is often the smaller half. Leg-dominant, below the buttock, bilateral is the shape.
• Draw the other leg even when they say it's fine. Bilateral is the pattern; it is also the CES question.

BEHAVIOUR

This is where the diagnosis lives, so code it properly.

• Coding: In — intermittent, activity-dependent, position-driven. A constant (P) presentation should make you re-ask the question. Morning stiffness here is usually M (<30 min).
• Aggs: walking, standing still, downhill walking, lumbar extension, reaching up, long queues.
  Eases: sitting, bending forward, leaning on a trolley or a bench, cycling, walking uphill, going up stairs more easily than down.
• 24-hr pattern: walking-dose dependent, not clock dependent — walking distance to onset is the number.
• Night: sitting and bending forward are the Eases. Night rest pain is in the vascular screen in §4 — ask it.
• Severity: VAS 0–10 at best / at worst / right now.
• Three numbers, and they are your asterisk signs and your outcome measure:
  1. Walking distance to onset — in metres or minutes, not "a while".
  2. The position that relieves it — sitting, or flexion, or does it need both.
  3. Time to settle once they adopt it.
• Irritability, all three parts — resting symptoms + vigour of the provoking activity + time to settle. Here it sets your walking dose, not your technique choice.
• Ask the four Nadeau items explicitly, in these words: shopping trolley sign · symptoms above or below the knee · triggered by standing alone · relieved by sitting. All four present → +LR 13 for neurogenic. And the single most useful negative you own: no pain triggered by standing alone → −LR 0.05 ([12], n=53, no published confidence intervals).

HISTORY

Give this stage the time it deserves. On this pattern it carries more diagnostic weight than anything you will do with your hands.

• Onset gradual, over months to years. A sudden onset is a different pattern until proven otherwise.
• The trajectory, honestly asked. Getting worse, or fluctuating? Most patients say worse. Most cohorts say fluctuating — and 54% of community screen-positives were screen-negative a year later [7]. Ask them what a good month looked like.
• The walking limit over time. Was it 2 km last year and 200 m now, or has it been 200 m for five years? Rate of change is the referral question, not the distance itself.
• Konno's five history items are the fastest screen you have — each carries an OR ≥2, p<0.05 for the syndrome:

• Vascular history, taken properly, not ticked. Smoking, diabetes, ischaemic heart disease, previous stroke, hypertension, cholesterol, claudication in the family. This is a screening question in every other lumbar pattern. Here it is part of the differential (section 4).
• Previous imaging, and — more importantly — what they were told about it. Someone managing "severe spinal stenosis" in their head is managing a different problem from the one in their legs.
• Comorbid knee and hip OA. Self-reported stenosis symptoms are reported by 8–50% of primary-care knee and hip OA patients, and by 11–71% of the low back pain cohort — yet fewer than 10% of each met clinical stenosis criteria ([13], n=10,234). Symptoms are not the syndrome.

SPECIAL / SCREENING QUESTIONS

Every patient. Every time. Before you touch them. This population is older, so the base rates of the dangerous things are higher than in a young back — see section 4 for the numbers, and go there before you go to section 5.

• Cauda equina, asked directly and unhurriedly: bladder, bowel, saddle or perineal sensory change, sexual dysfunction, bilateral progressive weakness.
• Vascular claudication and PAD: calf symptoms, cold feet, non-healing wounds, rest pain at night, smoking.
• Abdominal aortic aneurysm: non-mechanical abdominal or back pain that does not answer to position.
• Malignancy, fracture, infection, inflammatory — carry over unchanged from the NSLBP page. Screen them; don't learn them twice.
• Medications, falls history, and what they've stopped doing. Sexual function and social isolation belong in this stage too — pain plus limited walking drives hopelessness, anxiety and isolation, and no guideline prompts you to ask ([14]; narrative review, framing only).

CLOSE THE SUBJECTIVE PROPERLY

Before you stand up you should be able to say, out loud: the distance, the relieving position, the settle time, whether the four Nadeau items are present, and whether the calf-plus-standing vascular pattern is there instead. That sentence is your reasoning. The objective exists to test it.

Top three, one discriminating feature each. Rule out the two dangerous ones first, then split the two that actually look alike.

And three more you should be able to name:

• Abdominal aortic aneurysm — same demographic, same risk factors. The discriminator is positional dependence: stenosis pain answers to flexion and to stopping; an aneurysm does not. Non-mechanical back or abdominal pain, a pulsatile mass, pain unrelated to walking distance → same-day medical assessment. Sudden severe or tearing pain, collapse, or a patient who looks shocked → ambulance now. This page carries no accuracy data for AAA and will not pretend to. It is a screening obligation, not a test.
• Lumbar discogenic pain — central or bilateral back pain with non-dermatomal buttock and thigh referral, dull and deep, worse with sitting and flexion, eased by standing and walking. Flexion is the aggravator, not the reliever. No walking-distance limit.
• Hip osteoarthritis — groin pain, pain on weight-bearing from the first step rather than after a distance, restricted and painful hip IR, and no relief from sitting because the problem is not in the canal. Named as a differential by the ACSQHC standard itself, common in the same age group, and it coexists constantly.

The honest bit. Nobody has measured how reliably two clinicians agree on this diagnosis. There is no κ study for lumbar spinal canal stenosis the way there is for sciatica. We know the questionnaires perform decently against a physician's diagnosis; we do not know how well two physiotherapists agree with each other. Take your ranking to your educator with the discriminator attached — "bilateral, 200 m limit, eased by flexion, calf symptoms need sitting not just standing, pedal pulses present, so I've ranked it neurogenic" is a reasoning conversation. "I think it's stenosis" isn't.