Taking an accurate history is important to obtain information about the progression of the symptoms and how much it affects day-to-day life. As many patients are elderly, it is important to establish the presence of other medical problems and risk factors for vascular claudication (smoking, diabetes, high blood pressure) which is the most important clinical differential diagnosis. Clinical examination is important but neurological examination is essentially normal in most cases apart from sluggish or absent ankle and knee jerks. Foot pulses should always be examined to exclude the presence of vascular stenosis.
To establish the diagnosis, MRI scan is the investigation of choice unless there are contra-indications. In this case a CT or myelogram is indicated.
Treatment and Outlook
In many mild cases, spinal claudication can be treated without surgery. Physiotherapy and reduction in weight in obese patients can improve or stabilise symptoms. Epidural injections can significantly improve the walking distance and leg pain for several months but is no longer paid for by the NHS. Painkillers usually do not work in most patients.
Surgery improves the walking distance and leg pain in the majority of patients (70-80%). Even patients in their 80s or even 90s can respond quiet dramatically to surgical decompression and become more independent and mobile. It does not, however, cure the underlying problem of wear and tear and symptoms can deteriorate some years later again.
The operation of choice is a laminectomy or intersegmental decompression. Lately, so-called interspinous spacers (for example X-stop, Wallis ligaments, In-space and others) have been developed which can also improve the stenosis by stretching the ligaments and opening the channels where the nerves leave the spine. There is no evidence that these devices are better than conventional surgery but may have some advantages in operating time. They are significantly more expansive.