Lumbar Spinal Stenosis

Procedure

Patient stands and performs active lumbar extension by placing hands behind the head or lower back and arching backward. Observe for symptom reproduction or relief over 30 seconds.

Positive Finding

Reproduction or worsening of leg pain, numbness, or claudication symptoms with extension; or relief of symptoms suggests stenosis

Sensitivity / Specificity

72% / 70%

Delitto et al., 1992, Physical Therapy; Kreiner et al., 2007, Spine

Interpretation

Extension typically worsens stenotic symptoms by narrowing the spinal canal further. Relief with extension may suggest flexion-biased pathology (e.g., disc herniation). Combined with flexion relief, high diagnostic value for stenosis.

Procedure

Patient stands or sits and performs active forward flexion of the lumbar spine, bending toward the toes. Assess symptom response over 30–60 seconds.

Positive Finding

Relief or elimination of leg pain, numbness, or claudication symptoms with flexion

Sensitivity / Specificity

88% / 77%

Delitto et al., 1992, Physical Therapy; Schizas et al., 2010, European Spine Journal

Interpretation

Flexion typically relieves stenotic symptoms by enlarging the spinal canal and stretching the ligamentum flavum. Relief with flexion combined with extension-induced symptoms is highly suggestive of lumbar stenosis.

Procedure

Patient walks on level ground or a treadmill at a self-selected pace and records the distance or time at which leg pain, numbness, or weakness develops. Rest in flexion (sitting or forward bending) until symptoms resolve, then repeat.

Positive Finding

Reproducible leg pain or claudication at a consistent distance; immediate relief with lumbar flexion or sitting

Sensitivity / Specificity

85% / 75%

Haig et al., 2006, Spine; Katz et al., 1995, Spine

Interpretation

Neurogenic claudication (pain with walking, relief with flexion/sitting) is a hallmark of lumbar stenosis. Reproducibility and rapid relief distinguish it from vascular claudication.

Procedure

Patient supine; examiner lifts one extended leg passively to assess the angle at which leg pain or neural symptoms occur. Repeat on contralateral side.

Positive Finding

Reproduction of leg pain or radicular symptoms below the knee; limitation of range of motion (typically <60°) due to pain

Sensitivity / Specificity

52–58% / 65–72%

Reiman et al., 2016, JOSPT; Rubinstein et al., 2015, Cochrane Database

Interpretation

SLR has limited sensitivity for stenosis but may reproduce symptoms in patients with lateral recess stenosis or foraminal involvement. Normal SLR does not rule out stenosis. More useful when positive in combination with extension-provocation signs.

Procedure

Patient lies prone with legs off the edge of the treatment table and feet unsupported. Examiner observes stability and symptoms. Patient then performs active hip/lumbar extension by lifting the legs while keeping the pelvis on the table.

Positive Finding

Reproduction of lumbar pain or radicular symptoms; visible segmental instability or loss of pain control with active hip extension

Sensitivity / Specificity

72% / 60%

Kasai et al., 2006, Spine; Saragiotto et al., 2016, Cochrane Database

Interpretation

May be positive in stenosis with coexisting segmental instability or spondylolisthesis. Less specific for pure stenosis but helps identify mechanical contributors.

Procedure

Patient sits or stands. Examiner gently applies downward axial compression through the patient's shoulders or head for 10–30 seconds, or patient performs self-compression by holding heavy objects.

Positive Finding

Reproduction or exacerbation of leg pain, claudication, or radicular symptoms

Sensitivity / Specificity

See current literature / See current literature

Interpretation

Axial loading may compress the stenotic canal and provoke symptoms. Lack of standardization limits use; less commonly employed than extension or flexion tests but may contribute to clinical reasoning.