Guideline 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 American College of Occupational and Environmental Medicine (ACOEM 2021), the Canadian Chiropractic Guideline Initiative (CCGI/BJC 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 2 3 4 5 6 7 8 Guidelines 1. Screening and diagnosis Diagnosis: https://web.pathway.md/diseases/recMB2e9Yp8HBdafn 1/8 6/29/23, 5:55 AM Lumbar spinal stenosis Pathway As per ASPN 2022 guidelines, diagnose lumbar spinal stenosis with neurogenic claudication based on a combination of imaging findings and history. B As per NASS 2013 guidelines, suspect the diagnosis of lumbar spinal stenosis in older patients presenting with a history of gluteal or lower extremity symptoms exacerbated by walking or standing which improves or resolves with sitting or bending forward, recognizing that patients whose pain is not made worse with walking have a low likelihood of stenosis. B Differential diagnosis: differentiate neurogenic claudication from other claudication sources. B 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. I Show 2 more As per ACP 2007 guidelines, elicit a focused medical history and perform a physical examination to categorize patients with low back pain into one of the following broad categories: nonspecific low back pain back pain potentially associated with radiculopathy or spinal stenosis back pain potentially associated with another specific spinal cause. B Diagnostic imaging: As per ASPN 2022 guidelines, obtain MRI and/or CT in the axial and sagittal planes to enhance detection of lateral recess and central canal stenosis. B Show 2 more As per NASS 2013 guidelines, consider obtaining imaging studies as first-line diagnostic strategy for the diagnosis of degenerative lumbar spinal stenosis. E Show 4 more As per ACP 2007 guidelines: Obtain diagnostic imaging and testing in patients with low back pain and severe or progressive neurologic deficits or when serious underlying conditions are suspected based on history and physical examination findings. B Obtain MRI (preferred) or CT in patients with persistent low back pain and signs or symptoms of spinal stenosis only if they are potential candidates for surgery or epidural corticosteroid injection. B Electromyography: As per NASS 2013 guidelines: Consider obtaining electromyographic paraspinal mapping to confirm the diagnosis of degenerative lumbar spinal stenosis in patients with mild or moderate symptoms and https://web.pathway.md/diseases/recMB2e9Yp8HBdafn 2/8 6/29/23, 5:55 AM Lumbar spinal stenosis Pathway radiographic evidence of stenosis. C Insufficient evidence to recommend for or against the use of F wave, H reflex, motor-evoked potential, motor nerve conduction studies, somatosensory-evoked potentials, dermatomal sensory-evoked potentials, and lower extremity electromyelography for the confirmation of lumbar spinal stenosis. Consider obtaining these studies to help identify other comorbidities. I As per AANEM 2010 guidelines, consider obtaining the following electrodiagnostic studies to aid the clinical diagnosis in patients with suspected lumbosacral radiculopathy: peripheral limb EMG C paraspinal mapping with needle EMG in lumbar radiculopathy C H-reflex in S1 radiculopathy. C Show 2 more 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, C 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. C As per WVSIPP 2019 guidelines, decide on treatment options in patients with lumbar spinal stenosis depending on the following: degree, level, and architecture of stenosis severity of symptoms failed less-invasive treatments patient comorbidities. A As per NASS 2013 guidelines: Consider offering medical/interventional treatment in patients with mild E or moderate symptoms of lumbar spinal stenosis. C Consider offering medical/interventional treatment to provide long-term (2-10 years) improvement in patients with degenerative lumbar spinal stenosis. C Pharmacotherapy: As per CCGI 2021 guidelines: Consider offering a trial of SNRIs or TCAs in patients with lumbar spinal stenosis causing neurogenic claudication. C Do not use the following pharmacological therapies in patients with lumbar spinal stenosis causing neurogenic claudication: NSAIDs, methylcobalamin, calcitonin, acetaminophen, opioids, muscle relaxants, pregabalin, D and gabapentin. D https://web.pathway.md/diseases/recMB2e9Yp8HBdafn 3/8 6/29/23, 5:55 AM Lumbar spinal stenosis Pathway As per WVSIPP 2019 guidelines, consider offering nonsteroidal anti-inflammatory medications, neuropathic pain medications (membrane-stabilizing agents), and opioids as monotherapy in patients with spinal stenosis, balancing the patient's individual risks and benefits. B As per NASS 2013 guidelines, insufficient evidence to recommend for or against the use of pharmacological treatment in the management of spinal stenosis. I 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. I Consider offering a limited course of active physical therapy as an option in patients with lumbar spinal stenosis. E Axial bracing: As per WVSIPP 2019 guidelines, consider offering axial bracing for the treatment of neurogenic claudication and spinal stenosis. Consider offering axial bracing for the treatment of neurogenic claudication related to spinal segmental motion in patients with suspected instability. C As per NASS 2013 guidelines, consider offering a lumbosacral corset to increase walking distance and decrease pain in patients with lumbar spinal stenosis. C Alternative and complementary medicine: As per CCGI 2021 guidelines, consider offering manual therapy (moderate-quality evidence) and acupuncture on a trial basis in patients with lumbar spinal stenosis causing neurogenic claudication. C As per NASS 2013 guidelines, insufficient evidence to recommend for or against the following options for the treatment of patients with lumbar spinal stenosis: spinal manipulation traction electrical stimulation transcutaneous electrical stimulation acupuncture. I 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. C Follow the described anticoagulation recommendations and ensure detection of injury by either maintaining a reactive patient or using appropriate neurological monitoring when performing https://web.pathway.md/diseases/recMB2e9Yp8HBdafn 4/8 6/29/23, 5:55 AM Lumbar spinal stenosis Pathway spinal interventional treatments. B Epidural injections: As per ASPN 2022 guidelines: Offer epidural corticosteroid injections in the treatment of patients with symptomatic lumbar spinal stenosis. B Consider offering repeated epidural corticosteroid injections when the patient experiences significant temporary improvement in symptoms. Be aware that the number and frequency of injections may be limited by insurance and payer rules and regulations. C Landmark trials: LESS In patients who had lumbar central spinal stenosis and moderate-to-severe leg pain and disability, corticosteroid plus lidocaine was not superior to lidocaine with respect to change in Roland-Morris Disability Questionnaire score at 6 weeks. Friedly JL et al. N Engl J Med. 2014 Jul 3. As per ACOEM 2021 guidelines: Offer epidural corticosteroid injections in selected circumstances for the treatment of acute or subacute radicular pain syndromes, typically after treatment with NSAIDs and waiting at least 3 weeks. A Avoid offering epidural corticosteroid injections for the treatment of spinal stenosis. D As per CCGI 2021 guidelines, do not offer epidural corticosteroid injection in patients with lumbar spinal stenosis causing neurogenic claudication. D As per NASS 2013 guidelines, use contrast-enhanced fluoroscopy to guide epidural corticosteroid injections to improve the accuracy of medication delivery. A Show 2 more Intrathecal injections: offer intrathecal drug delivery systems in the treatment of lumbar spinal stenosis after anatomic considerations at the index level of treatment for minimally invasive decompressive options, and if more direct methods fail or are not suitable. B Neurostimulation: consider offering spinal cord stimulation in the treatment of lumbar spinal stenosis after anatomic considerations at the index level of treatment for minimally invasive decompressive options, and if more direct methods fail or are not suitable. C 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. B https://web.pathway.md/diseases/recMB2e9Yp8HBdafn 5/8 6/29/23, 5:55 AM Lumbar spinal stenosis Pathway As per ACOEM 2021 guidelines, consider offering lumbar discectomy to speed recovery in patients with radiculopathy due to ongoing nerve root compression failing to improve significantly after 4-6 weeks and appropriate conservative therapy. C Show 2 more As per NASS 2013 guidelines, consider offering decompressive surgery to improve outcomes in patients with moderate-to-severe symptoms of lumbar spinal stenosis. C Show 3 more Spinal fusion: As per ASPN 2022 guidelines, consider offering interspinous fusion in patients with lumbar degenerative spine disease in the presence of degenerative disc disease, with symptomatic mild-to-moderate lumbar spinal stenosis, with or without instability, with a grade 2 spondylolisthesis. C As per ACOEM 2021 guidelines, do not offer lumbar fusion for the treatment of spinal stenosis. D Percutaneous image-guided lumbar decompression: consider offering percutaneous image- guided lumbar decompression for the treatment of mild-to-moderate lumbar spinal stenosis in the presence of neurogenic claudication, with grade 2 spondylolisthesis, and with a contribution of spinal narrowing with at least 2.5 mm of ligamentum flavum hypertrophy. B Interspinous spacers: As per ASPN 2022 guidelines, consider placing interspinous spacers for the treatment of symptomatic spinal stenosis at the index level with mild-to-moderate spinal stenosis, with grade 1 spondylolistheses, in the absence of dynamic instability or micro-instability represented as fluid in the facets on advanced imaging. B As per NASS 2013 guidelines, insufficient evidence to recommend for or against the placement of an interspinous process spacing device in patients with lumbar spinal stenosis. I 7. Patient education General counseling: 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 Clinical findings Symptoms Neurological exam https://web.pathway.md/diseases/recMB2e9Yp8HBdafn 6/8 6/29/23, 5:55 AM Lumbar spinal stenosis Pathway Buttock pain Absence of achilles reflex Claudication Lhermitte's phenomenon Difficulty walking Imaging findings Gait disturbance Hip pain Spondylolisthesis Leg cramping Leg pain Leg paresthesia Leg weakness Low back pain Numbness of feet Numbness of soles of feet Thigh pain Diagnostic maneuvers Abnormal Romberg's test Diagnostic procedures Queckenstedt's maneuver Studies 2014 LESS In patients who had lumbar central spinal stenosis and moderate-to-severe leg pain and disability, corticosteroid plus lidocaine was not superior to lidocaine with respect to change in Roland-Morris Disability Questionnaire score at 6 weeks. Friedly JL et al. N Engl J Med. 2014 Jul 3. References 1. Timothy R Deer, Jay S Grider, Jason E Pope et al. 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