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Lumbar Spinal Stenosis: Diagnosis and Management

Charles W. Webb, DO
Kenneth Aguirre, MD
Peter H. Seidenberg, MD

American Family Physician. 2024;109(4):350-359.

Author disclosure: No relevant financial relationships.

Lumbar spinal stenosis is a clinical syndrome that affects more than 200,000 people in the United States annually. It is a common cause of chronic insidious low back pain, especially in older patient populations (mean age = 64 years). Lumbar spinal stenosis is a degenerative condition of the spine leading to narrowing in the spaces around the neurovascular bundles and the classic symptom of low back pain that radiates to the buttocks and lower extremities bilaterally. It is typically a progressive waxing and waning process that may deteriorate over years. The pain is typically burning or cramping, which worsens with standing and walking and improves with bending forward or sitting. Magnetic resonance imaging is the recommended diagnostic test because it allows cross-sectional measurement of the spinal canal. Options for nonsurgical management include physical therapy, exercise programs, spinal injections with and without corticosteroids, chiropractic treatment, osteopathic manipulation, acupuncture, and lifestyle modifications; however, few of these treatments have high-quality randomized trials demonstrating effectiveness. Surgery may be considered if nonsurgical management is ineffective.

Up to 90% of the U.S. population will experience significant low back pain (i.e., pain requiring the patient to seek medical care or miss work) in their lifetime.1–3 Low back pain becomes chronic in up to 23% of patients and recurs within one year in up to 80%.2,4 Lumbar spinal stenosis is a common cause of chronic low back pain, particularly in people older than 50 years, and is a progressive degenerative condition of the intervertebral disk, ligamentum flavum, and facet joints secondary to aging. It causes a narrowing in the spaces encompassing the neurovascular structures of the spine, leading to the characteristic clinical syndrome of buttock and bilateral lower extremity pain that may include the lower back.3 The pain typically worsens with walking or standing and improves with sitting or leaning forward.5–8 Figure 1 shows normal spinal anatomy.3

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Magnetic resonance imaging is the study of choice for diagnosing lumbar spinal stenosis.6,10,11,23–27,35 C Expert opinion
Nonoperative treatment should be initiated as first-line therapy in patients with lumbar spinal stenosis, in the absence of findings warranting urgent surgical evaluation.6,20–26,34 B There were no clear differences between interventions in the short term, and there was considerable crossover bias in all studies
Nonsteroidal anti-inflammatory drugs should be considered first-line treatment in patients with chronic low back pain.25–27 B Meta-analysis of randomized trials and systematic reviews on low back pain, including but not limited to lumbar spinal stenosis
Epidural corticosteroid injections can be considered for short-term treatment of lumbar spinal stenosis.33,34 B Two RCTs demonstrated modest results for pain and function at up to 3 weeks
Decompression surgery may improve short- and long-term function and pain in patients with lumbar spinal stenosis but is associated with a risk of complications.6,38–40,43 B Meta-analysis of RCTs, RCTs with consistent findings, and cohort studies demonstrating modest results; however, there was significant crossover between the surgical and nonsurgical groups
Bracing with a lumbosacral orthosis may decrease pain and increase walking distance in patients with lumbar spinal stenosis.35 C Consensus of observational studies

RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

CHARLES W. WEBB, DO, FAAFP, FAMSSM, is director of the Division of Sports Medicine, director of the Primary Care Sports Medicine Fellowship, and an associate professor in the Department of Family Medicine at Louisiana State University Health Shreveport School of Medicine.

KENNETH AGUIRRE, MD, CAQSM, is associate program director of the Sports Medicine Fellowship and an assistant professor in the Department of Family Medicine at Louisiana State University Health Shreveport School of Medicine.

PETER H. SEIDENBERG, MD, MOL, FAAFP, FACSM, is a professor in and chair of the Department of Family Medicine at Louisiana State University Health Shreveport School of Medicine.

Address correspondence to Charles W. Webb, DO, Louisiana State University Health Shreveport School of Medicine, 1501 Kings Hwy., P.O. Box 33932, Shreveport, LA 71130 (charles.webb@lsuhs.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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