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Shopping Cart Sign

What Is It, What It Means, and More

Author:Lily Guo

Editors:Alyssa Haag,Emily Miao, PharmD,Kelsey LaFayette, DNP, RN

Illustrator:Jessica Reynolds, MS

Copyeditor:Sadia Zaman, MBBS, BSc


What is the shopping cart sign?

The shopping cart sign refers to the temporary relief of back pain that occurs when a person bends over as if they were leaning on a shopping cart. 

Illustration of elderly gentleman pushing a shopping cart while having back pain.

What is the significance of the shopping cart sign?

The shopping cart sign may be indicative of lumbar (i.e., lower) spinal stenosis, a very common condition in which there is a narrowing of the spaces within the spine, which can put pressure on the spinal cord and spinal nerves. The act of bending over provides relief of the pain by increasing the amount of space between the spinal cord and the vertebrae or discs that are impinging it.

Spinal stenosis is most common in the lumbar spine but can also frequently occur in the cervical (i.e., upper) spine. The shopping cart sign, however, is usually only indicative of lumbar stenosis. 

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How is the shopping cart sign assessed?

The shopping cart sign is assessed primarily following a thorough history and physical exam. Pertinent findings in the individual’s history may include lower back pain brought on by walking and exercise, and pain that is typically relieved with sitting or by maintaining a position in which the spine is flexed forward (i.e., bending over). Upon physical examination, the clinician might observe that the individual walks with a hunched posture. Pain may worsen when asking the individual to bend backwards. Lumbar spinal stenosis can also be diagnosed using imaging techniques, such as magnetic resonance imaging (MRI). 

What causes spinal stenosis?

Spinal stenosis occurs when the spinal canal is narrowed. Some individuals are born with a congenitally small spinal canal which can make them more likely to develop spinal stenosis. Other congenital causes include spinal deformity, such as scoliosis; or genetic diseases that affect bone and muscle development throughout the body (e.g., Hurler syndrome, Paget disease of bone). Individuals may also be born with inherited gene mutations that predispose them to spinal tumors, which can grow into the spinal canal and cause nerve compression and spinal stenosis. 

More commonly, spinal stenosis results from acquired conditions causing wear and tear on the spine over time. This includes a condition called osteoarthritis, a form of degenerative arthritis that commonly occurs in the lower back. Osteoarthritis of the vertebra can prompt the formation of bone spurs, which can grow into the spinal canal. Those at higher risk for osteoarthritis include those with obesity and individuals greater than 60 years old. Similarly, over time the vertebral discs, which act as shock absorbers, may also degenerate. The soft inner material of the discs (nucleus pulposus) can protrude and add pressure to the spinal cord or spinal nerves, known as a disc herniation. Disc herniations are more common in those 30 to 50 years old and those who have had trauma to their spine, such as from a motor vehicle accident. Other acquired conditions that can result in spinal stenosis include thickening of the ligaments stabilizing the spine; spinal injuries causing dislocation or fracture of the vertebrae into the spinal canal; and swelling of nearby tissue after back surgery.

What are other signs and symptoms of spinal stenosis?

Other signs and symptoms of spinal stenosis include pain or cramping in one or both legs when standing or walking for long periods of time; numbness or tingling in a foot or leg; weakness in a foot or leg; and back pain. These symptoms can worsen over time. Typically the neurologic examination is normal in those with spinal stenosis, meaning the individual does not have a loss of strength, sensation, or coordination in the trunk or lower extremities. However, more severe cases of spinal stenosis may result in a loss of bladder control or difficulty walking. Rarely, some people with spinal stenosis may not experience any symptoms at all. 

How is spinal stenosis treated?

Milder cases of spinal stenosis may be treated with minimally invasive methods. Self-directed balance and flexibility exercises and/or physical therapy have been shown to increase strength of the back muscles. Hot and cold packs and over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may also be used. 

If the pain does not resolve with conservative methods, a clinician may suggest steroid injections, which is an outpatient procedure where a local anesthetic and a steroid medication are injected directly into the epidural space to reduce pain and inflammation in and around the affected nerve roots. If the pain is debilitating or there is loss of bowel or bladder function, surgical intervention may be necessary. One surgical approach includes lumbar laminectomy, a surgical procedure where the lamina (i.e., posterior part of the vertebra) is removed to provide more space for the compressed spinal cord and/or nerve roots.

What are the most important facts to know about the shopping cart sign?

The shopping cart sign refers to the relief of back pain experienced by someone with spinal stenosis when they assume a hunched position, as if they were leaning over a shopping cart. Spinal stenosis refers to the narrowing of the spinal canal, which may be congenital or caused by osteoarthritis, disc herniation, or trauma. This results in pain in the lower back that can also radiate to the legs and feet. Individuals can also experience numbness, tingling, and weakness in the lower extremities. Severe cases of spinal stenosis can result in a loss of bladder control or an inability to walk. Treatment options may be conservative for mild cases of spinal stenosis and can include physical therapy, NSAIDs, and epidural injections. More severe cases may require surgery, including laminectomy to increase the space surrounding the affected nerves. 

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Related links

Anatomy clinical correlates: Spinal cord pathways
Spinal stenosis

Resources for research and reference

Crowell, A. (2018, March 7). The “Shopping Cart Sign” and spinal stenosis. In DISC Spine Institute. Retrieved November 29, 2021, from https://www.discspine.com/back-stories/shopping-cart-sign-spinal-stenosis/

Gleiber, M. A. (2015). Spinal stenosis: Causes, symptoms, and treatment. In Michael A. Gleiber MD, PA. Retrieved November 29, 2021, from https://www.michaelgleibermd.com/news/condition-spinal-stenosis/

Mayo Clinic. (2020, October 24). Spinal Stenosis. In Mayo Clinic. Retrieved November 29, 2021, from https://www.mayoclinic.org/diseases-conditions/spinal-stenosis/symptoms-causes/syc-20352961

Schmidt, M., Breyer, S., Löbel, U., Yarar, S., Stücker, R., Ullrich, K., Müller, I., & Muschol, N. (2016). Musculoskeletal manifestations in mucopolysaccharidosis type I (Hurler syndrome) following hematopoietic stem cell transplantation. Orphanet Journal of Rare Diseases, 11(93). DOI: 10.1186/s13023-016-0470-7

Spine Nevada. (2019). Stenosis. In Spine Nevada. Retrieved November 29, 2021, from https://spinenevada.com/spine_problems/stenosis.html

Staehler, R. (2020, October 22). Lumbar epidural steroid injections for low back pain and sciatica. In Spine. Retrieved November 29, 2021, from https://www.spine-health.com/treatment/injections/lumbar-epidural-steroid-injections-low-back-pain-and-sciatica

Tunick, J. K. (2014, April 2). Shopping cart sign. In Natural Pain Solutions. Retrieved November 29, 2021, from https://www.naturalpainsolutionsportland.com/shopping-cart-sign/