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Lumbar spinal stenosis

What's new

Updated 2024 AAFP guidelines for the diagnosis and management of lumbar spinal stenosis.

Guidelines

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 Academy of Family Physicians (AAFP 2024), the American Society of Pain and Neuroscience (ASPN 2022), the American College of Occupational and Environmental Medicine (ACOEM 2021), the Canadian Chiropractic Guideline Initiative (CCGI/BJC 2021), the West Virginia...
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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.
B
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  • Differential diagnosis

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.
I
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  • Diagnostic imaging

  • EMG

Medical management

General principles: as per AAFP 2024 guidelines, Offer nonoperative treatment as first-line therapy in patients with lumbar spinal stenosis, in the absence of findings warranting urgent surgical evaluation.
B

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  • Pharmacotherapy

Nonpharmacologic interventions

Physical therapy
As per NASS 2013 guidelines:
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.
I
Consider offering a limited course of active physical therapy as an option in patients with lumbar spinal stenosis.
E

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  • Axial bracing

  • Alternative and complementary medicine

Therapeutic procedures

General principles
As per ASPN/WVSIPP 2019 guidelines:
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.
C
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.
B

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  • Epidural injections

  • Intrathecal injections

  • Neurostimulation

Surgical interventions

Spinal decompression: as per AAFP 2024 guidelines, Consider offering decompression surgery to improve short- and long-term function and pain in patients with lumbar spinal stenosis, taking into account the risk of associated complications.
C

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  • Spinal fusion

  • Percutaneous image-guided lumbar decompression

  • Interspinous spacers

Patient education

General counseling
As per APS 2009 guidelines:
Discuss the risks and benefits of surgery in patients with persistent and disabling leg pain due to spinal stenosis.
A
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.
I