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Lumbar spinal stenosis

Key sources
The following summarized guidelines for the evaluation and management of lumbar spinal stenosis are prepared by our editorial team based on guidelines from the American Society of Pain and Neuroscience (ASPN 2022), the Canadian Chiropractic Guideline Initiative (CCGI/BJC 2021), the American College of Occupational and Environmental Medicine (ACOEM 2021), the West Virginia Society for Interventional Pain Physicians (WVSIPP/ASPN 2019), the North American Spine Society (NASS 2013), the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM 2010), the American Pain Society (APS 2009), and the American Pain Society (APS/ACP 2007).


1.Screening and diagnosis

Diagnosis: as per ASPN 2022 guidelines, diagnose lumbar spinal stenosis with neurogenic claudication based on a combination of imaging findings and history.
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  • Differential diagnosis

2.Diagnostic investigations

History and physical examination: as per NASS 2013 guidelines, insufficient evidence to support the use of the following physical findings for the diagnosis of degenerative lumbar spinal stenosis: abnormal Romberg test, thigh pain exacerbated with extension, sensorimotor deficits, leg cramps, and abnormal Achilles tendon reflexes.
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  • Diagnostic imaging

  • EMG

3.Medical management

General principles: as per CCGI 2021 guidelines, consider offering initial multimodal care nonpharmacological therapies with education, advice and lifestyle changes, behavioral change techniques in conjunction with home exercise and/or rehabilitation,
and postoperative rehabilitation - a supervised program of exercises and/or educational materials encouraging activity - with CBT 12 weeks post-surgery in patients with lumbar spinal stenosis causing neurogenic claudication.

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  • Pharmacotherapy

4.Nonpharmacologic interventions

Physical therapy
Insufficient evidence to recommend for or against the use of physical therapy or exercise as stand-alone treatments in patients with degenerative lumbar spinal stenosis.
Consider offering a limited course of active physical therapy as an option in patients with lumbar spinal stenosis.

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  • Axial bracing

  • Alternative and complementary medicine

5.Therapeutic procedures

General principles
Consider offering minimally invasive treatment strategies for the management of symptomatic lumbar spinal stenosis. Consider repeating these minimally invasive procedures or continuing to more surgical treatment solutions depending on the duration and extent of relief.
Follow the described anticoagulation recommendations and ensure detection of injury by either maintaining a reactive patient or using appropriate neurological monitoring when performing spinal interventional treatments.

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  • Epidural injections

  • Intrathecal injections

  • Neurostimulation

6.Surgical interventions

Spinal decompression: as per ASPN 2022 guidelines, offer open decompression with or without fusion when the risk-benefit ratio is deemed favorable, and in the setting of rapidly progressive neurological decline.

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  • Spinal fusion

  • Percutaneous image-guided lumbar decompression

  • Interspinous spacers

7.Patient education

General counseling
Discuss the risks and benefits of surgery in patients with persistent and disabling leg pain due to spinal stenosis.
Include a specific discussion about moderate average benefits which appear to decrease over time in patients undergoing surgery in shared decision-making regarding surgery.
Insufficient evidence regarding benefits and harms of epidural corticosteroid injections in patients with spinal stenosis.