Lumbar spinal stenosis associated with peripheral arterial
disease: a prospective multicenter observational study
Kazuhide Uesugi•Miho Sekiguchi•Shin-ichi Kikuchi•Masahiro Kanayama•
Kazuhisa Takahashi•Kazuhiro Chiba•Minoru Doita•Yasumitsu Toribatake•
Hiroshi Matsuo•Kazuo Yonenobu•Yukihiro Matsuyama•Shin-ichi Konno
Received: 5 June 2012/Accepted: 12 August 2012/Published online: 28 September 2012
? The Author(s) 2012. This article is published with open access at Springerlink.com
symptom of both lumbar spinal stenosis (LSS) and
peripheral arterial disease (PAD) in middle-aged and
elderly people. However, the prevalence and clinical
characteristics of LSS with PAD (LSSPAD) have not been
investigated in a multicenter study. The aim of this study
was to investigate the prevalence and clinical characteris-
tics of LSS associated with PAD.
570 patients diagnosed with LSS using a clinical
diagnostic support tool and MRI at 64 facilities were
enrolled. We evaluated each patient’s medical history,
physical findings, ankle brachial index, Japanese Ortho-
paedic Association Back Pain Evaluation Questionnaire
(JOABPEQ) score, and the Short Form 36 (SF-36) score.
Intermittent claudication isacommon
Statistical analyses were performed to compare LSSPAD
patients and LSS patients without PAD using the t test,
Mann–Whitney’s U test, and multivariate recurrence anal-
ysis. p values of \0.05 were considered statistically
The LSSPAD group comprised 38 patients (6.7 %);
20 (3.5 %) had pre-diagnosised PAD while 18 (3.2 %) had
undetected PAD. The clinical characteristics of these patients
were advanced age, diabetes, and a history of ischemic heart
448 (78.6 %) of those patients were followed up at three -
months after enrollment. Pain in buttocks and legs improved
less in the LSSPAD group than in the LSS group (p\0.05).
Improvements in the ‘‘general health’’ score in SF-36 were
K. Uesugi ? M. Sekiguchi (&) ? S. Kikuchi ? S. Konno
Department of Orthopaedic Surgery,
Fukushima Medical University School of Medicine,
1-Hikarigaoka, Fukushima, Fukushima 960-1295, Japan
Spine Center, Hakodate Central General Hospital,
Department of Orthopedic Surgery,
Graduate School of Medicine, Chiba University,
Department of Orthopedic Surgery,
Keio University, Tokyo, Japan
Department of Orthopedic Surgery,
Kobe University, Kobe, Japan
Department of Orthopedic Surgery,
Koseiren Takaoka Hospital, Takaoka City, Japan
Matsuo Vascular Ultrasound Laboratory,
Matsuo Clinic, Osaka, Japan
Department of Orthopedic Surgery,
Osaka Minami Medical Center, Osaka, Japan
Department of Orthopedic Surgery, Hamamatsu University
School of Medicine, Hamamatsu, Japan
J Orthop Sci (2012) 17:673–681
cerebrovascular disorder and ischemic heart disease were
associated with LSSPAD. Because LSSPAD patients show
less improvement in QOL than patients with LSS but
without PAD do, clinicians should consider the coexistence
of PAD in LSS patients.
Advanced age, diabetes, and a history of
Lumbar spinal stenosis
extremity symptoms [1, 2], including neurogenic inter-
mittent claudication as a typical symptom . On the other
hand, vascular intermittent claudication is also a typical
symptom of peripheral arterial disease (PAD) [4, 5]. Since
there is overlap in the ages at which patients develop LSS
and PAD, it is important to differentiate the claudication
caused by these two different pathologies.
PAD refers to a circulatory disorder caused by stenosis
or occlusion of the artery by arteriosclerosis or vasculitis. It
encompasses conditions such as arteriosclerosis obliterans
(ASO), Buerger’s disease, and acute arterial obstruction.
Progression of PAD increases the risk of severe vascular
events and even death [6–8]. Early diagnosis and treatment
of PAD can improve the hemodynamics of the lower
extremities and reduce the risk of fatal or nonfatal car-
diovascular events [4, 5]. LSS patients with PAD have
been reported ; so, when diagnosing LSS, it is important
to bear in mind that concurrent PAD is possible. The
prevalence of LSS associated with PAD remains unclear
because there have been no large-scale epidemiological
studies on this issue. One likely reason for this is that there
are no established diagnostic criteria for LSS, based on an
international consensus. The Japanese Society for Spine
Surgery and Related Research, therefore, developed a
diagnosis support tool for LSS (sensitivity of 92.8 %,
specificity of 72.0 % ). Large-scale epidemiological
studies of LSS can be executed using this tool.
The measurement of the ankle brachial index (ABI) is
recommended for the diagnosis of PAD . The ABI is the
ratio of the arm systolic blood pressure (at the brachial
artery) to the ankle systolic blood pressure (at the posterior
tibial artery or dorsalis pedis artery) . Highly sensitive
and specific diagnosis of PAD is possible using the ABI,
comparable to that obtained using angiography or Doppler
examination [4, 5, 7, 8, 11–14]. Patients with a resting ABI
of below 0.9 may have arterial stenosis that affects
hemodynamics . In recent years, instruments that auto-
matically measure the ABI have been developed. Using
such automatic ABI devices, reliable data can be easily and
quickly obtained [6, 16, 17].
As society ages, it is thought that the number of patients
with both PAD and LSS will increase. However, the
prevalence of PAD in cases of LSS, and the clinical
characteristics of such patients, remain unclear. Thus, the
aims of the present study were to determine the prevalence
of PAD in LSS patients, to clarify the clinical character-
istics of patients with concurrent LSS and PAD, and to
clarify the treatment course for these patients.
This study was approved by the ethics committees of the
participating research institutions. Written informed con-
sent was obtained from all patients.
This study was a prospective multicenter observational
study, conducted under the guidance of the Japanese Soci-
ety for Spine Surgery and Related Research. The research
team consisted of LSSPAD project members. The survey
was conducted in 64 hospitals nationwide, all of which had
attending spinal surgeons. The recruitment period was
one year from October 1, 2008 to September 30, 2009.
The survey subjects were LSS patients who visited and were
examined at the participating hospitals during the survey
period. The clinical diagnosis support tool  for LSS was
used to identify patients with LSS (Table 1). Patients were
Table 1 Scoring scheme used for the diagnostic support tool for LSS
Absence of diabetes mellitus
Intermittent claudication (?)3
Worse when standing for a while2
Symptoms improve on bending forward3
Symptoms induced by having patients bend forward-1
Symptoms induced by having patients bend backward1
Ankle brachial index (ABI) C0.93
Absence or low response of achilles tendon reflex1
Straight leg raising test positive-2
Patients with a total score of C7 were considered to have LSS
674K. Uesugi et al.
diagnosedwith LSSby aspine specialistif(a) they achieved
a total score of C7 with the LSS diagnosis support tool, and
(b) their neurological findings were consistent with spinal
canal stenosisfound via MRIatthat particular lumbar spinal
level. Patients with impaired consciousness, serious com-
plications (heart failure, kidney failure, liver failure, respi-
ratory failure), or psychiatric diseases or symptoms were
myelopathy, had a history of lumbar spine surgery, or were
attending for a second opinion were also excluded. To avoid
bias among the hospitals, the number of patients enrolled at
each hospital was limited to 10.
Investigations at baseline
At the time of enrollment, the patients were interviewed
individually to obtain their medical histories. They were
claudication, exacerbation of symptoms when standing up,
and improvement of symptoms when bending forward
(lumbar flexion). The severity of symptoms was evaluated
pain, buttock or lower extremity pain, and buttock or lower
extremity numbness. In physical examinations, we recorded
flexion, whether the Achilles tendon reflex was diminished,
Patients were also asked if they had any comorbidities such
as hypertension, diabetes mellitus, dyslipidemia, hyperuri-
cemia and cerebrovascular disorders (stroke, cerebral hem-
orrhage, or transient cerebral ischemic attack), ischemic
heart disease (myocardial infarction, angina pectoris, or
coronary revascularization), arrhythmia, and carotid artery
disease. Lifestyle questions included history of alcohol
intake and smoking. Patients who drank routinely were
who were current or past smokers were considered to have a
history of smoking. Patients underwent hematological tests.
Quality of life (QOL) was evaluated using the Japanese
Orthopaedic Association Back Pain Evaluation Question-
naire (JOABPEQ)  and Short Form 36 (SF-36) .
The JOABPEQ consists of five subscales and the SF-36
consists of eight subscales. With both tests, a higher score
means better maintenance of QOL.
A follow-up survey was conducted three months after
enrollment. This survey included symptoms, physical
findings, the type of treatment for LSS (conservative or
surgical therapies), and QOL (JOABPEQ and SF-36).
Definition of PAD
PAD was diagnosed by ankle brachial pressure index
(ABI). Systolic blood pressure was measured with the
patient in a supine position using either BP203RPE III
(OMRON Co. Ltd., Tokyo, Japan) or VaSeraTMVS-1500E
(Fukuda Denshi, Tokyo, Japan). ABI was calculated by
dividing the systolic blood pressure of the ankle arteries by
the systolic blood pressure of the brachial artery. At the
time of enrollment, patients who had already been diag-
nosed with PAD or patients with ABI B0.9 in either leg
were diagnosed with PAD [4, 5].
Patients with coexisting PAD and LSS were designated the
‘‘LSSPAD group,’’ and those with LSS but no PAD were
denoted the ‘‘LSS group.’’ Using the LSS group as con-
trols, an analysis was conducted to identify the character-
istics of the LSSPAD group.
To evaluate the clinical characteristics at the time of
enrollment, we analysed and compared (using the t test, v2
LSS diagnosis using support tool
Order imaging studies
Measurement of ABI
Prevalence estimation of PAD
Characteristics of LSS patient with PAD
Evaluation of symptoms (VAS)
Evaluation of QOL ( JOABPEQ, SF-36)
Drop out ( n = 122)
Baseline analysis ( n = 570)
Investigation of therapy for LSS
Evaluation of symptoms ( VAS)
Evaluation of QOL ( JOABPEQ, SF-36)
Three - months analysis ( n = 448)
Fig. 1 Registration protocol
Lumbar stenosis multicenter study 675
test, Mann–Whitney U test, and multivariate logistic
regression analysis) the two groups. p values of less than
0.05 were considered significant.
In the survey performed three months after enrollment,
the v2test or Fisher’s exact test were used to investigate
differences in symptoms, physical examination findings,
and types of treatment for LSS (conservative or surgical
therapies). A multiple regression analysis adjusted for age,
sex, comorbidities, medical history, and the type of treat-
ment for LSS was performed to evaluate the improvement
in the symptoms, JOABPEQ, and SF-36. SPSS for Win-
dows (version 16.0; SPSS Inc., Chicago, IL, USA) was
used for statistical analysis. Data are presented as propor-
tions and means (±SD).
Description of the sample
A total of 570 LSS patients were enrolled (Fig. 1): 303 men
and 267 women, with a mean age of 71 ± 8.0 years.
Among the 570 LSS patients, 38 (6.7 %) had PAD
(LSSPAD group). Of the 38 patients in the LSSPAD group,
20 (3.5 %) had already been diagnosed with PAD prior to
enrollment in this study. The remaining 18 patients (3.2 %)
had an ABI B0.9 and were diagnosed with PAD after
enrollment in this study.
Characteristics of the LSS and LSSPAD patients
at baseline and in the survey at three months
The LSSPAD group was significantly older than the LSS
group: 75 ± 6.3 years versus 71 ± 8.0 years (p\0.01)
(Table 2). Men constituted 71.1 % of the LSSPAD group,
a significantly higher percentage than in the LSS group
(51.9 %) (p\0.01). VAS scores for numbness in the
buttocks or lower extremities were significantly smaller in
the LSSPAD group than in the LSS group (p\0.01).
Of the 570 registered patients, 448 completed the fol-
low-up survey at three months—a follow-up rate of
78.6 %. Of these 448 patients, 30 (6.7 %) belonged to the
LSSPAD group. The mean age was 75 ± 6.6 years in the
LSSPAD group and 70 ± 8.3 years in the LSS group; the
mean age was significantly higher in the LSSPAD group
(p\0.01) (Table 2). No significant difference in the
clinical or physical findings for the LSSPAD and LSS
groups was observed.
Table 2 Characteristics of the LSS and LSSPAD patients at baseline and in the survey at three months
Mean (SD) or N (%)?
Baseline Outcome at three months
(n = 38)
(n = 532)
(n = 30)
(n = 418)
Age (%)75 (6.3)71 (8.0)
75 (6.6)70 (8.3)
0.02Males (%)27 (71.1) 276 (51.9)22 (73.3) 212 (50.7)
Support tool 11.5 (2.1)13.2 (2.1)8.5 (4.0) 9.0 (3.8)0.76
ABI B 0.935 (92.1)–––
Presence of Intermittent claudication (%)36 (100) 483 (92.9)0.1616 (57.1) 163 (40.3)0.08
Worse when standing for a while (%)35 (94.6)469 (90.2)0.5613 (44.8)159 (39.4)0.56
Symptoms improve on bending forward (%)31 (83.8)401 (77.1)0.3511 (37.9) 141 (34.9)0.74
Lower back pain (VAS) 47.9 (29.9) 49.3 (28.6)0.77 39.0 (31.2)32.4 (27.2)0.22
Buttock or lower extremity pain (VAS) 53.6 (27.0)60.1 (28.4)0.18
42.4 (28.4)33.9 (31.3)0.16
Buttock or lower extremity numbness (VAS) 42.3 (32.1)56.4 (29.9)38.5 (31.1)36.3 (30.8)0.71
Physical examination (%)
Symptoms induced by having patients bend forward1 (2.7)20 (3.8)1.001 (3.4)16 (4.0)1.00
Symptoms induced by having patients bend backward20 (54.1) 278 (53.5)0.948 (27.6) 104 (25.9)0.84
Absence or low response of Achilles tendon reflex30 (81.1) 349 (67.1)0.0819 (65.5) 256 (63.4)0.82
Straight leg raising test positive0 (0)28 (5.4)0.25 1 (3.6)5 (1.2)0.31
VAS visual analog scale (scale 0–100 mm)
?The total numbers for some items do not add up to the total number in the top row because of missing information
676K. Uesugi et al.
Background of patients at baseline
With respect to comorbidities, there was a significantly
higher prevalence of diabetes mellitus in the LSSPAD
group than in the LSS group (p\0.01) (Table 3). No
significant differences were seen between the LSSPAD
group and the LSS group in the prevalence of hypertension,
dyslipidemia, or hyperuricemia. Regarding the medical
history, the LSSPAD group had significantly higher rates
of cerebrovascular disorder, ischemic heart disease, and
arrhythmia when compared with the LSS group. No sig-
nificant differences were seen between the LSSPAD group
and LSS group in terms of history of alcohol intake or
smoking. The LSSPAD group had significantly elevated
levels of creatinine compared with the LSS group
(p\0.05) (Table 3). No significant difference was seen
between the two groups in any other items in the hema-
Multivariate logistic analysis
From the above results, diabetes mellitus, history of cere-
brovascular disorder, ischemic heart disease, arrhythmia,
high serum creatinine level, and mild numbness in the
buttocks or lower extremities were extracted as character-
istics of LSS patients with PAD. These extracted factors
were then adjusted individually by age and sex (model 1).
After this adjustment, factors characteristic to the LSSPAD
group (p\0.05) were diabetes mellitus, history of cere-
brovascular disorder, ischemic heart disease, and mild
numbness in the buttocks or lower extremities. A multi-
variate logistic regression analysis with a forced entry
method was conducted for these factors, including age and
sex (model 2).
As a result of multivariate analysis, no sex differences
were seen between two groups. The LSSPAD group had a
significantly higher proportion of older people, a higher
prevalence of diabetes mellitus, and a more frequent his-
tory of cerebrovascular disorder or ischemic heart disease
than the LSS group (p\0.05) (Table 4). In addition, the
average VAS of numbness in the buttocks or lower
extremities was significantly smaller in the LSSPAD group
than in the LSS group (p\0.05).
Evaluation of QOL
No significant difference was observed between the
LSSPAD group and the LSS group in the JOABPEQ and
SF-36 scores at baseline (Table 5).
In the JOABPEQ and SF-36 scores at three months after
physical, and general health (GH) were significantly lower in
the LSSPAD group than in the LSS group (p\0.05).
Follow-up survey of LSS patients at three months
No significant difference was seen in the types of treatment
implemented for LSS between the LSSPAD group (con-
servative 53.3 %, surgical 46.7 %) and the LSS group
(conservative 48.1 %, surgical 51.9 %).
At three months after enrollment, all scores for symp-
toms, JOABPEQ, and SF-36 showed lower levels of
improvement in the LSSPAD group than in the LSS group
(Table 6). Based on the results of the multivariate logistic
analysis, a multiple regression analysis was conducted,
adjusting for age, sex, association of diabetes mellitus,
history of cerebrovascular disorder, history of ischemic
heart disease, and the types of treatment for LSS. The
improvement in the VAS for buttock or lower extremity
pain was significantly lower in the LSSPAD group than in
the LSS group (p\0.05) (Table 6). No significant differ-
ence in the improvement in the JOABPEQ subscales
Table 3 Background of patients in baseline
Mean (SD) or N (%)?
(n = 38)
(n = 532)
Hypertension (%)22 (59.5) 240 (45.1)0.09
Diabetes mellitus (%) 15 (40.5)103 (19.4)
Dyslipidemia (%)7 (18.9)81 (15.2)
Hyperuricemia (%)3 (8.1)17 (3.2)0.13
Cerebrovascular disease (%)8 (21.1)38 (7.1)
Ischemic heart disease (%) 15 (39.5)32 (6.0)
Arhythma (%)5 (13.2) 19 (3.6)
Drinking history (%)10 (26.3)207 (39.6)0.11
Smoking history (%)13 (34.2)161 (30.3)0.61
WBC (/mm3) 6299 (1508)6130 (1932)0.60
Hemoglobin (g/dl) 13.4 (1.7)13.5 (1.5)0.73
AST (IU/L) 24.9 (13.9)24.8 (10.4) 0.95
ALT (IU/L) 21.2 (17.6)22.4 (14.6) 0.62
BUN (mg/dl) 18.6 (6.8)16.9 (7.9) 0.18
Creatinine (mg/dl)0.95 (0.32) 0.78 (0.35)
HbA1c (%)5.9 (1.1)5.9 (3.9)
Total cholesterol (mg/dl)194.7 (32.3)200.7 (37.9)0.35
Triglyceride (mg/dl)137.7 (72.0)137.5 (75.0)0.98
LDL-C (mg/dl)112.3 (28.5)116.4 (30.9)0.44
HDL-C (mg/dl) 55.6 (15.3)58.3 (18.6)0.40
?Total numbers for some items do not add up to the total number in
the top row because of missing information
Lumbar stenosis multicenter study 677
between the LSSPAD group and the LSS group was
observed. The SF-36 score showed a significantly lower
level of improvement in GH in the LSSPAD group than in
the LSS group (p\0.05). No significant difference was
seen in the other SF-36 subscales between the LSSPAD
group and the LSS group.
This is the first nationwide multicenter survey on the
prevalence of PAD in patients with LSS in Japan. We
found that 6.7 % of the LSS patients had PAD. In other
countries, the prevalence of PAD in the general adult
population is reported to be 3–19 % [4, 5, 14, 20, 21]. It is
also reported that the risk of PAD is significantly higher in
older people and in men [12, 14, 22, 23]. In LSS patients,
similar to the general population, the risk of concurrent
PAD increases significantly with age. However, no sex
differences were recognized. Factors other than older age
and male sex that are reported to be related to PAD are
smoking, hypertension, diabetes mellitus, dyslipidemia,
coronary artery disease, and cerebral artery disease [24–
27]. We have shown that comorbidity of diabetes mellitus,
Table 4 Factors related to LSSPAD in multivariate logistic regression analysis
Model 1Model 2
Odds ratio 95 % CI
Odds ratio95 % CI
Age––– 1.061.00–1.12 0.04
Ischemic heart disease8.00 3.71–17.267.36 3.30–16.45
Creatinine 1.380.75–2.52 0.30–––
Buttock or lower extremity numbness0.990.98–1.00 0.02 0.990.97–1.000.02
Model 1: a multivariate logistic regression analysis adjusted for age and sex, model 2: a multivariate logistic regression analysis with a forced
entry method (adjusted for age, sex, diabetes mellitus, cerebrovascular disease, ischemic heart disease, and numbness)
Table 5 JOABPEQ and SF-36 scores at baseline and in the survey performed at three months
Baseline Outcome at three months
LSSPAD (n = 38) LSS (n = 532)
LSSPAD (n = 30)LSS (n = 418)
Lower back pain42.1 (30.8)47.7 (33.6)0.32 60.0 (33.5)67.1 (32.0)0.26
Lumbar function64.5 (27.1)61.6 (29.5)0.57 63.3 (33.5)67.5 (28.8)0.53
Walking ability27.6 (24.8) 35.4 (27.7)0.0941.7 (27.4) 57.5 (31.1)
Social life function 34.7 (22.3)41.8 (22.2)0.0642.8 (15.5)55.3 (24.9)
Mental health43.2 (17.8)45.8 (18.3)0.38 52.0 (18.4) 53.7 (19.0)
Physical functioning42.4 (23.7) 49.0 (23.3)0.09 53.6 (21.2)61.6 (24.5)0.09
Role physical 45.9 (31.7)47.9 (28.0)0.68 42.0 (20.4)57.3 (28.1)
Bodily pain39.5 (27.1)34.8 (20.5) 0.1949.9 (20.5) 51.6 (22.6)
General health 47.3 (15.1)47.3 (17.9)1.00 44.9 (16.8)52.2 (18.3)0.04
Vitality 46.2 (22.2)47.5 (22.2)0.72 55.2 (20.1)55.9 (21.6)0.86
Social functioning54.9 (28.1)61.4 (28.7)0.18 65.9 (22.4)67.4 (26.7)0.78
Role emotional53.8 (33.2)55.8 (31.2)0.7157.5 (26.7)62.2 (30.4)0.41
Mental health54.7 (24.8)56.8 (22.5)0.5964.8 (19.0)65.9 (21.0)0.78
?Numbers for some items do not add up to the total number in the top row because of some missing information
JOABPEQ consists of 5 subscales. Higher score indicates better QOL
SF-36 consists of 8 subscales. Higher score indicates better QOL
678K. Uesugi et al.
history of cerebrovascular disorder, and history of ischemic
heart disease are characteristic of LSS patients with PAD.
Thus, older age, association of diabetes mellitus, history of
cerebrovascular disorder, and history of ischemic heart
disease may be useful for predicting PAD in LSS patients.
In the clinical setting, the pulse of the dorsalis pedis
artery and posterior tibial artery is palpated to examine the
peripheral circulation. Patients with diminished femoral
artery or posterior tibial artery pulse are at high risk for
PAD . Although congenital defects in ankle arteries are
rare (dorsalis pedis artery: 1.8 %, posterior tibial artery:
0.18 %) , it has been reported that the dorsalis pedis
artery cannot be felt in 8.1 % and the posterior tibial artery
cannot be felt in 2.9 % of all healthy people . Conse-
quently, the sensitivity of palpation of arterial pulses in the
diagnosis of PAD is low [29, 30]. Thus, the absence of
arterial pulses in the foot could lead to the overdiagnosis of
PAD. The diagnosis of PAD by ABI is noninvasive and
simple. Moreover, by setting the ABI cutoff to 0.9, it is
possible to screen PAD with high sensitivity and specific-
ity, comparable to that of angiography . In the Trans-
Atlantic Inter-Society Consensus (TASC) II treatment
guidelines for PAD, screening for PAD with the use of ABI
is recommended for all patients with lower extremity
symptoms on exertion, patients aged 50–69 with cardio-
vascular risk factors, and all patients aged C70, regardless
of risk factors . Many LSS patients with lower extremity
symptoms, including intermittent claudication [2, 10, 26],
are elderly and at risk for PAD. Therefore, when examining
LSS patients, it is important to conduct screening by ABI
to avoid overlooking coexisting PAD.
In this study, patients in the LSSPAD group had sig-
nificantly milder buttock or lower extremity numbness than
those without PAD. However, VAS is a subjective evalu-
ation, and it is difficult to use to predict PAD.
No significant differences were seen in the JOABPEQ or
SF-36 scores between the two groups at the time of enroll-
ment. Thus, it is difficult to gauge the presence of compli-
cating PAD based on patient QOL or subjective evaluations.
In the follow-up survey performed 3 months after enroll-
ment, following adjustment for age, sex, comorbidities,
medical history, and whether the patient had undergone
surgery, the level of improvement in buttock or lower
extremity pain and the GH subscale in SF-36 was
Table 6 Degrees of improvement and multiple regression analysis of results obtained in the survey performed at three months
Total (n = 448)LSSPAD (n = 30)LSS (n = 418)
Lower back pain-17.0 (33.8)-9.1 (40.4)-17.6 (33.3)0.16-0.050.30
Buttock or lower extremity pain-25.8 (38.2)-9.0 (39.7)-27.0 (37.9)0.17-0.120.01
Buttock or lower extremity numbness-19.9 (36.2)-4.0 (34.2)-21.0 (36.1) 0.19-0.09 0.06
Lower back pain19.6 (37.5)15.8 (42.1)20.0 (37.2)0.080.01 0.92
Lumbar function5.5 (31.4)-1.5 (31.2)6.2 (31.2) 0.020.070.17
Walking ability22.0 (33.6)11.8 (32.7)22.9 (33.5)0.210.070.12
Social life function13.2 (26.4) 5.1 (24.4) 13.9 (26.3)0.100.09 0.08
Mental health8.1 (19.6) 6.9 (21.2)8.3 (19.4) 0.110.01 0.83
Physical functioning 12.7 (24.6)11.0 (28.2)13.0 (24.0)0.17-0.02 0.68
Role physical6.8 (29.9)-3.0 (32.5)7.7 (29.6)0.04 0.100.05
Bodily pain 15.9 (26.7)8.3 (27.4) 16.7 (26.7)0.110.070.16
General health5.0 (17.0)-1.7 (19.1) 5.8 (17.0) 0.080.110.04
Vitality 7.9 (22.4) 6.3 (22.7)8.4 (22.7)0.10 0.02 0.74
Social functioning5.6 (29.9) 5.6 (29.2)5.8 (30.0) 0.02-0.01 0.82
Role emotional 5.2 (33.7)3.2 (33.8)5.6 (33.7)0.030.040.49
Mental health 8.3 (23.1) 6.9 (23.8)8.9 (23.6) 0.070.020.74
A lower score indicates better condition
JOABPEQ consists of 5 subscales. A higher score indicates better QOL
SF-36 consists of 8 subscales. A higher score indicates better QOL
VAS visual analog scale (scale 0–100 mm)
?The numbers for some items do not add up to the total number in the top row due to missing data
Lumbar stenosis multicenter study679
significantly lower in the LSSPAD group. The patient’s
GH score. If a patient has the impression that their state of
health is gradually deteriorating, the score for GH declines
. In the LSSPAD group, buttock or lower extremity pain
was resistant to treatment, so it is thought that patients’
subjective evaluation of the treatment effect may be lower.
In this study, only about half of the LSS patients with
PAD had already been diagnosed with PAD. This means
that a large number of LSS patients with PAD had not
undergone testing or treatment for PAD. Diagnosing
coexisting PAD from claudication or patients’ subjective
evaluations is a difficult task, making ABI screening
essential in the diagnosis of PAD.
The investigation of the comorbidities and medical
histories of LSS patients with PAD in this study was cross-
sectional. Therefore, one of this study’s limitations is that
the causal relationships between comorbidities, medical
history, and coexisting PAD could not be elucidated.
Another limitation was that the type of treatment for PAD
was not investigated.
In the future, a longitudinal study with detailed classi-
fication of each patient’s background will be needed.
Factors strongly associated with PAD in LSS patients are
advanced age, association of diabetes mellitus, history of
cerebrovascular disorder, and history of ischemic heart
disease. In LSS patients with PAD, buttock or lower
extremity pain is intractable, and improvement in QOL is
difficult to achieve. When examining patients with LSS, it
is necessary to keep PAD in mind.
assistance with the statistical analysis.
The authors thank Professor Seiji Yasumura for
Conflict of interest
The authors declare that they have no conflict
Creative Commons Attribution License which permits any use, dis-
tribution, and reproduction in any medium, provided the original
author(s) and the source are credited.
This article is distributed under the terms of the
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