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Answer 3
  1. Order magnetic resonance imaging of the lumbosacral spine. This patient has neurogenic claudication, the classic symptom of lumbar spinal stenosis. Unlike patients with vascular claudication, the posture of patients with spinal stenosis has a significant effect on exercise tolerance. Leaning forward (as when pushing a grocery cart) decreases pain by increasing diameter of the spinal canal. Plain radiographic films are likely to show degenerative disease but are not helpful in making the diagnosis of stenosis. When the clinical context is suggestive, MRI is the most appropriate diagnostic test. With pulses that can be palpated, the patient is not likely to have vascular claudication. Bone density tests are accurate for measuring bone density, but if a fracture is suspected, the initial test should be a plain radiograph. Exercise and physical therapy have not been shown to improve the symptoms of spinal stenosis.

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