In terms of location of the pain, most patients with stenosis do not actually use the word pain. They describe a "grabbing" or "weak" or "buckling" sensation in their lower extremities. In central canal stenosis, the symptoms are generally noted bilaterally and fairly symmetrically, but not in a specific distribution. This contrasts with discogenic disease where the distribution is usually monoradicular. In lateral or foraminal stenosis, the symptoms may conform to a fairly specific dermatomal distribution. Unlike discogenic disease, activities involving extension which narrows the foramina and spinal canal, are associated with increased symptoms. Symptoms are worse with walking, then standing, then lying; sitting is often asymptomatic and will relieve symptoms. This is in direct contrast to discogenic disease. Valsalva maneuvers should not affect symptoms in pure stenosis. Flexion relieves symptoms as mentioned; therefore, bicycling and long car rides are often well tolerated. While walking, patients often describe relief with squatting, stooping, leaning on a walker or a cart, or improvement in symptoms when going uphill. Occasional patients with underlying congestive heart failure describe lower extremity symptoms when lying in bed at night, felt to be due to central pooling of interstitial fluids. This combination of mild underlying congestive heart failure and lumbar stenosis has been termed "vespers curse." It should be clear from the above description that in lumbar spinal stenosis, especially in central stenosis, symptoms are much more obscure than in discogenic radiculopathy. Symptoms are predominantly sensory and may include vague dysesthesias, coldness, a vague sense of weakness or "giving way". Regardless of their description, however, they limit the patient’s ability to walk. This limitation of ability to walk due to lower extremity symptoms has been termed pseudoclaudication for neurogenic claudication. It is only late in the course of stenosis that actual weakness or numbness or bowell/bladder symptoms will develop.

Spondylolisthesis

Spondylolisthesis comes in two broad varieties: congenital and developmental (degenerative). Congenital spondylolisthesis most often presents with symptoms in late childhood or adolescence, much younger than patients with discogenic disease would normally present. It is normally seen in athletic children, especially those involved in gymnastics, dance, martial arts, and crew. Other activities involving significant lumbar extension/rotation place the patient at increased risk since stresses of greater degree are borne by the pars interarticularis. Most cases involve the L5-S1 level. Only the minority of these people have radicular symptoms. In patients who present with this problem, the dermatomal distribution is almost always L5 or S1. Symptoms are worsened by extension. The condition is felt to create radiculopathy only when instability and stenosis have combined to put pressure upon the L5 or S1 nerve root.

In degenerative spondylolisthesis, the pain is usually unilateral. It is the result of foraminal stenosis in all likelihood. The age of onset is approximately 40. This condition is seen six times as often in males. L4-5 is most commonly involved. It is fairly infrequent for the patient to complain of bilateral pseudoclaudication, but monoradicular pseudoclaudication at the L5 root is fairly common. The incidence increases with age. This is again described in contrast with discogenic disease.

Tumors

It should be noted that multiple types of primary and metastatic tumors can cause radiculopathy or polyradiculopathy. One should be suspicious when the pain is constant, unrelated to position, awakens the patient, or persists beyond a month despite treatment. Obviously, associated constitutional symptoms should raise antennae. These include weight loss, anorexia, dry cough, change of bowel or bladder habits, or a smoking history. Among primary tumors, multiple myeloma is the most common. There are no specific identity characteristics for one tumor versus another. Neurological complaints including sphincter disturbances are not uncommon. In metastatic tumors, the patient often has a prior history of cancer. Any patient with a prior history of cancer who develops back pain should be considered a candidate for metastatic disease until proven otherwise. The most common metastatic tumors are bronchogenic (lung), breast, prostatic, and renal. Unfortunately, these patients can present with symptoms similar to disc disease, starting with mild local back pain and progressing to severe radicular complaints. Sudden deterioration of neurological function in these patients may suggest an ischemic insult and carry a worse prognosis. In any case, these patients must be sent for diagnostic testing in a much more urgent basis.