see illustration on page 71), in the channel through which the nerve exits the spinal canal (foraminal stenosis). Therefore there are 25 possible sites at which the nerves to your legs can be entrapped by spinal stenosis, in your low back alone!
More often than not, by the time you develop symptoms from spinal stenosis, the nerves are being squeezed at more than one site at the same time. I will explain how we determine exactly where the pain is coming from later in this chapter.
The classic symptoms of spinal stenosis — aching in the legs with walking that is relieved by rest (neurogenic claudication) — can be confused with the symptoms caused by poor circulation in your legs (vascular claudication). If you have poor blood circulation in your legs, walking may cause aching in your legs that is relieved by rest, very similar to the symptoms seen with spinal stenosis, but with some important differences. When the muscles in your legs do not get enough oxygen because of poor circulation, they produce lactic acid with activity. Lactic acid produces cramping pain in the muscles (see figure page 74).
How do I know my pain is from spinal stenosis and not from poor circulation?
There are some subtle differences in symptoms between the pain from spinal stenosis and poor circulation. Pain from spinal stenosis usually begins in the low back and radiates into the leg(s) and is relieved by sitting or bending over; both maneuvers open up the spinal canal, thus relieving the pressure on the nerves. Patients are frequently confused by the symptoms of spinal stenosis because their walking is limited by leg pain but they are still able to bicycle, dance, or lean on a shopping cart and get around without pain. All of these postures allow the person to bend forward enough to open up the spinal canal, relieving the pressure on their spinal nerves. When you see someone who is having difficulty walking because of spinal stenosis, they usually walk in a characteristic bent-forward position. Patients with spinal stenosis will tell you that they have good days when they can walk unlimited distances and bad days when their walking is very limited.
The symptoms of poor circulation to the legs start as a cramping sensation in the calves and radiate proximally upward into the whole leg. The pain is not relieved by bending forward. The symptoms progress with physical activity as the lactic acid in the oxygen-starved muscles builds up. The person experiencing these symptoms would rather stand than sit for relief because blood flow to the legs is stronger while standing than sitting. They cannot walk, bicycle, dance, or take part in any physical activity without developing muscle pain. The symptoms of vascular claudication are the same every day.
Spinal stenosis and poor circulation to the legs is more common after the age of 60 and can occur simultaneously, so it is possible to have symptoms of both conditions at the same time. I have seen patients who could clearly describe to me the symptoms of both. I can advise these folks which symptom is coming from which condition, and then determine from them which pain they more urgently want to be relieved of. Most people can tolerate vascular claudication better than neurogenic claudication and want their spinal stenosis fixed first. However, your PCP should refer you to a vascular surgeon to help you decide whether to pursue surgery for vascular claudicaton.
How is the pain from spinal stenosis different from a herniated disc?
Sciatic leg pain from a herniated disc can sometimes be confused with pain from spinal stenosis. It is important to distinguish which condition the symptoms stem from because herniated discs will usually shrink with time and the pain will resolve on its own, whereas the symptoms from spinal stenosis may gradually become worse over time and eventually require surgery for relief. Disc herniations, as you will recall from Chapter 5 , produce pain by compressing, stretching, and
More often than not, by the time you develop symptoms from spinal stenosis, the nerves are being squeezed at more than one site at the same time. I will explain how we determine exactly where the pain is coming from later in this chapter.
The classic symptoms of spinal stenosis — aching in the legs with walking that is relieved by rest (neurogenic claudication) — can be confused with the symptoms caused by poor circulation in your legs (vascular claudication). If you have poor blood circulation in your legs, walking may cause aching in your legs that is relieved by rest, very similar to the symptoms seen with spinal stenosis, but with some important differences. When the muscles in your legs do not get enough oxygen because of poor circulation, they produce lactic acid with activity. Lactic acid produces cramping pain in the muscles (see figure page 74).
How do I know my pain is from spinal stenosis and not from poor circulation?
There are some subtle differences in symptoms between the pain from spinal stenosis and poor circulation. Pain from spinal stenosis usually begins in the low back and radiates into the leg(s) and is relieved by sitting or bending over; both maneuvers open up the spinal canal, thus relieving the pressure on the nerves. Patients are frequently confused by the symptoms of spinal stenosis because their walking is limited by leg pain but they are still able to bicycle, dance, or lean on a shopping cart and get around without pain. All of these postures allow the person to bend forward enough to open up the spinal canal, relieving the pressure on their spinal nerves. When you see someone who is having difficulty walking because of spinal stenosis, they usually walk in a characteristic bent-forward position. Patients with spinal stenosis will tell you that they have good days when they can walk unlimited distances and bad days when their walking is very limited.
The symptoms of poor circulation to the legs start as a cramping sensation in the calves and radiate proximally upward into the whole leg. The pain is not relieved by bending forward. The symptoms progress with physical activity as the lactic acid in the oxygen-starved muscles builds up. The person experiencing these symptoms would rather stand than sit for relief because blood flow to the legs is stronger while standing than sitting. They cannot walk, bicycle, dance, or take part in any physical activity without developing muscle pain. The symptoms of vascular claudication are the same every day.
Spinal stenosis and poor circulation to the legs is more common after the age of 60 and can occur simultaneously, so it is possible to have symptoms of both conditions at the same time. I have seen patients who could clearly describe to me the symptoms of both. I can advise these folks which symptom is coming from which condition, and then determine from them which pain they more urgently want to be relieved of. Most people can tolerate vascular claudication better than neurogenic claudication and want their spinal stenosis fixed first. However, your PCP should refer you to a vascular surgeon to help you decide whether to pursue surgery for vascular claudicaton.
How is the pain from spinal stenosis different from a herniated disc?
Sciatic leg pain from a herniated disc can sometimes be confused with pain from spinal stenosis. It is important to distinguish which condition the symptoms stem from because herniated discs will usually shrink with time and the pain will resolve on its own, whereas the symptoms from spinal stenosis may gradually become worse over time and eventually require surgery for relief. Disc herniations, as you will recall from Chapter 5 , produce pain by compressing, stretching, and
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