Lumbar Spinal Stenosis:​

Diagnosis and Management

Charles W. Webb, DO;​Kenneth Aguirre, MD;​and Peter H. Seidenberg, MD
Louisiana State University Health Science Center School of Medicine, Shreveport, Louisiana

Lumbar spinal stenosis is a clinical syndrome that affects more than 200,000 people in the United States annually. It is a com-
mon 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 diag-
nostic 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. (Am Fam Physician.
2024;​109(4):​350-359. Copyright © 2024 American Academy of Family Physicians.)

Up to 90% of the U.S. population will experience signif- unsuccessful or the patient has rapidly progressive neuro-
icant low back pain (i.e., pain requiring the patient to seek logic symptoms.12-14
medical care or miss work) in their lifetime.1-3 Low back
pain becomes chronic in up to 23% of patients and recurs Pathophysiology
within one year in up to 80%.2,4 Lumbar spinal stenosis is Low back pain is pain that extends from the 12th rib to
a common cause of chronic low back pain, particularly in the iliac crest.4 Lumbar spinal stenosis is a common
people older than 50 years, and is a progressive degenerative cause of chronic low back pain, particularly in older peo-
condition of the intervertebral disk, ligamentum flavum, ple, and can be acquired or congenital. The most com-
and facet joints secondary to aging. It causes a narrowing mon is acquired, which results from changes initiated by
in the spaces encompassing the neurovascular structures of degeneration of the intervertebral disk during aging. The
the spine, leading to the characteristic clinical syndrome of degeneration and atrophy of the lumbar stabilizing mus-
buttock and bilateral lower extremity pain that may include culature, in combination with repeated daily microtrau-
the lower back.3 The pain typically worsens with walking or mas from normal wear and tear, lead to degenerative disk
standing and improves with sitting or leaning forward.5-8 collapse. 2,5 This collapse is also thought to be secondary
Figure 1 shows normal spinal anatomy.3 to an imbalance between the catabolic and anabolic pro-
A diagnosis of lumbar spinal stenosis is confirmed with cesses within the disk, causing extracellular matrix degen-
radiographic findings of narrowing or stenosis of the eration, neoinnervation, and neovascularization, resulting
lumbar spinal canal or lateral recesses, differentiating it in disk bulging.15
from other similarly presenting causes of low back pain The collapse of the disk space destabilizes the anterior
(Table 14,9). Because of a lack of evidence to determine the column, which shifts the axial center of weight to the facet
best therapy, initial management includes conservative joints, interspinous ligament, and ligamentum flavum. This
methods such as oral medications, physical therapy, core leads to joint hypertrophy and osteophyte formation, which
strengthening, and injection therapy.6,10,11 Surgical man- causes narrowing of the lateral recesses, neuroforamen, or
agement can be considered if nonsurgical treatment is central canal. When this stress becomes significant, it can
cause degenerative spondylolisthesis (anterior displacement
CME This clinical content conforms to AAFP criteria for CME. of a vertebral segment) with or without spondylolysis (defect
See CME Quiz on page 305. in the pars interarticularis), which can contribute to lum-
Author disclosure:​ No relevant financial relationships. bar spinal stenosis.9,12 Table 2 lists the causes of central and
foraminal lumbar spinal stenosis.2,5,12

350 American
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 LUMBAR SPINAL STENOSIS
SORT:​KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating Comments
Magnetic resonance imaging is the study of choice for diagnosing C Expert opinion
lumbar spinal stenosis.6,10,11,23-27,35

Nonoperative treatment should be initiated as first-line therapy B There were no clear differences between
in patients with lumbar spinal stenosis, in the absence of findings interventions in the short term, and there was
warranting urgent surgical evaluation.6,20-26,34 considerable crossover bias in all studies

Nonsteroidal anti-inflammatory drugs should be considered first- B Meta-analysis of randomized trials and system-
line treatment in patients with chronic low back pain. 25-27 atic reviews on low back pain, including but not
limited to lumbar spinal stenosis

Epidural corticosteroid injections can be considered for short- B Two RCTs demonstrated modest results for pain
term treatment of lumbar spinal stenosis. 33,34 and function at up to 3 weeks

Decompression surgery may improve short- and long-term B Meta-analysis of RCTs, RCTs with consistent find-
function and pain in patients with lumbar spinal stenosis but is ings, and cohort studies demonstrating modest
associated with a risk of complications.6,38-40,43 results;​however, there was significant crossover
between the surgical and nonsurgical groups

Bracing with a lumbosacral orthosis may decrease pain and C Consensus of observational studies
increase walking distance in patients with lumbar spinal stenosis. 35

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://​w ww.
aafp.org/afpsort.

History
Patients with lumbar spinal stenosis can FIGURE 1
be asymptomatic or present with signs
Cauda equina nerve roots Posterior longitudinal ligament
and symptoms ranging from vague
low back pain to bilateral leg numbness L3 vertebral body Dural tube
and weakness. Neurogenic claudica-
tion is a cluster of symptoms such as Pedicle (cut)
Lamina (cut)
cramping, burning, and tingling that
may start in the lower back and move Superior articular
process
to the buttocks, groin, and anterior Ligamentum flavum
thigh and radiate down the posterior
part of the legs, causing a perceived loss L3 nerve root

of balance.1,5,9,13 These symptoms may Facet joint

be unilateral or bilateral and are con-
sistently reproducible with the same
activity. Loss of balance associated with
© Marcia Hartsock

low back pain has a 70% sensitivity and Transverse process

53% specificity for lumbar spinal steno-
L5 spinous process
sis.9 Symptoms are typically aggravated
by walking or prolonged standing and
relieved by bending forward (i.e., shop-
Lower lumbar spine anatomy. The lower lumbar spine carries most of the
ping cart sign [Figure 2]) or sitting.5,16,17 body weight and is often affected by spinal stenosis. Intervertebral disk
Patients with low back pain combined degeneration leads to facet loading and degeneration, influencing the
with claudicating leg pain that includes attached ligamentum flavum.
bowel and bladder dysfunction, saddle Illustration by Marcia Hartsock
anesthesia, and new or worsening lower Reprinted with permission from Alvarez JA, Hardy RH Jr. Lumbar spine stenosis:​a common
extremity weakness should be referred cause of back and leg pain. Am Fam Physician. 1998;​57(8):​1826.
for urgent surgical evaluation.18

April 2024 ◆ Volume 109, Number 4 www.aafp.org/afp American Family Physician 351
 LUMBAR SPINAL STENOSIS

TABLE 1

Differential Diagnosis of Lower Extremity Pain With Low Back Pain

Diagnosis Symptoms Physical examination findings*
Chronic exertional Tightness in the calf after exercise usually asso- Induced by strenuous exercise and relieved (over time)
compartment ciated with pain;​numbness that progresses to with limb elevation
syndrome weakness and foot drop

Hip joint pain Groin or buttock pain, with or without low back Limited internal rotation;​positive FADIR test
pain;​no pain below the knee

Lumbar nerve root Radicular pain, with or without low back pain Positive result on one or more of the following:​seated
impingement straight leg raise, slump test, supine straight leg raise;​
decreased peripheral reflexes on the affected side

Lumbar spinal Low back pain, leg pain, wide-based gait, neuro- Older age, leg pain more severe than back pain;​bilateral
stenosis logic weakness symptoms are more typical;​pain is worse with standing
and walking, relieved with leaning forward or sitting

Lumbar vertebral Low back or thoracic back pain Tenderness to palpation over the injured vertebra,
fracture midline tenderness to palpation;​acute onset;​usually no
history of recent trauma;​pain worsened by all activity

Muscle strain Strains or sprains to the hip adductors or Tenderness to palpation over the specific muscle or
abductors (gluteus medius and minimus) and hip group;​pain and weakness on eccentric testing of the
flexors, with or without low back pain specific muscle group

Myofascial referred Pain in the area of involvement Pain is reproduced with palpation of trigger or pressure
pain points within the target muscles in question, usually the
gluteus medius and minimus

Peripheral Pain, numbness, and tingling in the distal lower Usually caused by a systemic issue such as diabetes
neuropathy legs and feet that are not affected by posture or mellitus or thyroid dysfunction
exercise

Piriformis syndrome Pain in the buttocks and proximal lower extremity Pain does not typically radiate below the knee unless
the sciatic nerve is being compressed;​normal reflexes
and strength testing

Referred pain from Pain in the proximal lower extremity No pain below the knee;​normal reflexes and strength
facet joints or inter- testing
vertebral disks

Sacroiliac joint pain Low back pain overlying the sacroiliac joint, with Positive compression test of the sacroiliac joint;​
or without buttock pain;​often worsens with tenderness to palpation at the sacroiliac joint and pos-
sitting or rising from a seated position terosuperior iliac spine;​positive distraction test

Trochanteric pain Lateral hip and thigh pain, with tenderness to Tightness of the Iliotibial band over the greater trochan-
syndrome palpation over the greater trochanter;​low back ter (Ober test)
pain possible

Vascular Leg pain with cramping, tightness, and fatigue;​ Decreased pulses in the lower extremities common;​
claudication pain in the buttocks and lower extremity that impaired ankle-brachial indexes
worsens with activity and is relieved with rest;​not
affected by posture such as standing or sitting

Visceral referred Low back pain, lower extremity pain, or both Pain is caused by processes such as uterine fibroids,
pain secondary to pain referred from intra- or extra- ovarian cysts, Crohn disease, ulcerative colitis, pyelo-
peritoneal structures (i.e., gastrointestinal and nephritis, and other gastrointestinal and genitourinary
genitourinary structures) disorders

FADIR = flexion, adduction, and internal rotation.

*—See Table 4 for test details.
Information from references 4 and 9.

352 American Family Physician www.aafp.org/afp Volume 109, Number 4 ◆ April 2024
 LUMBAR SPINAL STENOSIS

Physical Examination
The physical examination of patients with suspected lum- TABLE 2
bar spinal stenosis includes inspection, palpation, range of
motion, strength testing, reflexes, and special tests. Inspec- Causes of Central and Foraminal Lumbar
tion assesses for evidence of previous surgeries, spina bifida, Spinal Stenosis
and scoliosis, which can cause low back pain. A gait evalu- Achondroplasia Facet osteophyte formation
ation is necessary because lumbar spinal stenosis typically Ankylosing spondylitis Foraminal disk herniation
causes pain with prolonged standing and walking and is Congenital stenosis Lateral disk herniation
characterized by a wide-based gait.4,5,19 A wide-based gait Diffuse idiopathic skeletal Postsurgical fibrosis
with a positive Romberg sign has a 40% sensitivity and 90% hyperostosis Scoliosis
specificity for lumbar spinal stenosis.12 Facet hypertrophy Synovial cyst formation
On palpation, the spine is nontender;​however, extension
usually elicits pain (thigh pain with extension of the spine has Information from references 2, 5, and 12.
a 51% sensitivity and 69% specificity for lumbar spinal steno-
sis).12 Any decrease in strength, reflexes, or sensation should
also be noted (Table 3 and Figure 3). Although there are no differentiating lumbar spinal stenosis from osteoarthritis,
specific tests or signs for lumbar spinal stenosis, several tests vascular claudication, and other spinal cord lesions.5,22
should be performed to help exclude other diagnoses (Table
41,3,5,13). Some of these tests, when combined with other find- Treatment
ings, support a diagnosis of lumbar spinal stenosis (i.e., Rom- Evidence-based recommendations for the treatment of lum-
berg sign with a wide-based gait). It is important to check bar spinal stenosis are complicated by heterogeneity of the
distal pulses and the ankle-brachial index to exclude vascular condition, a waxing and waning nature, and lack of high-
claudication. Table 5 compares the clinical characteristics of quality studies evaluating its treatment exclusively (many of
vascular and neurogenic claudication.3 The hip joint should the studies of lumbar spinal stenosis overlap with other eti-
be examined because hip pain can mimic low back pain. ologies of chronic low back pain).23 The general options are

Imaging
Most patients presenting with lumbar FIGURE 2
spinal stenosis are older than 50 years;​
therefore, plain radiography of the lum-
bar spine typically reveals degenerative
changes (Figure 4). Magnetic resonance
imaging (MRI) provides the most
diagnostic information for patients
with lumbar spinal stenosis symptoms
because it allows for cross-sectional
measurement of the spinal canal2,5,20,21
(Figure 5). However, for lumbar spinal
stenosis to be diagnosed, the patient
must have clinical symptoms and
© Jennifer Fairman
@ Jennifer Fairman

radiologic confirmation of spinal ste-

nosis (central or foraminal).5,12,13,16
Computed tomography myelogra-
phy is recommended if MRI cannot be
performed (e.g., the patient has spinal
or cardiac instrumentation or other
Shopping cart sign. The shopping cart sign, or improvement in pain from
hardware that may not be MRI com- lower lumbar stenosis with leaning forward, is due to reduction of disk
pliant).9 Other testing includes elec- herniation with reduction in the normal standing lordosis of the lumbar
tromyography and nerve conduction spine.
studies. However, these are not used Illustration by Jennifer Fairman
routinely and are usually reserved for

April 2024 ◆ Volume 109, Number 4 www.aafp.org/afp American Family Physician 353
 LUMBAR SPINAL STENOSIS
TABLE 3

Summary of Nerve Roots

Nerve
root Reflex Dermatome* Myotome Function
L1 Cremasteric (male);​ Back, groin, pelvis, and inguinal canal Iliopsoas Hip flexion
Geigel (female)

L2 Patellar Back and front of the thigh starting below the canal to the Iliopsoas Hip flexion
knee

L3 Patellar Back, upper buttock, anterior thigh, knee, and medial Quadriceps Knee extension
lower leg

L4 Patellar Medial buttock, lateral thigh, medial leg, dorsum of foot, Tibialis anterior Ankle
first toe, and medial malleolus dorsiflexion

L5 Semimembranosus Buttock, posterior, lateral thigh, lateral leg, and dorsal foot Tibialis anterior Ankle
that includes the sole and the first through fourth toes dorsiflexion

S1 Achilles Buttock, posterior leg or calcaneal area, lateral malleolus, Gastrocnemius Ankle plantar
and up the fifth toe and soleus flexion

S2 Achilles Buttock, thigh, posterior leg, and genitals Gastrocnemius Ankle plantar
and soleus flexion

*—See Figure 3 for an illustration of lower extremity dermatomes.

nonoperative treatment vs. surgery. Few high-quality ran-

FIGURE 3 domized trials have investigated differentiated approaches to
nonoperative treatment, which include medications, physical
therapy, bracing, alternative/complementary medicine, and
epidural injections. Studies comparing operative vs. non-
operative therapy often poorly describe the treatment of the
T10
nonoperative group.10 Even in trials where investigators suc-
cessfully categorized the nonoperative treatment arm, the
T11
S3 L4
significant crossover between the operative and nonoperative
T12 S4 groups hampers interpretation of the results.11
L1 S5
S2 PHARMACOLOGIC
L2
S1 L5
Medications historically used to treat lumbar spinal steno-
L3 S2 sis include acetaminophen, nonsteroidal anti-inflammatory
S1
drugs (NSAIDs), muscle relaxants, opioids, neuromodu-
lators, corticosteroids, antidepressants, and calcitonin. A
Cochrane review of two randomized controlled trials (RCTs)
found that acetaminophen was not superior to placebo
L4
L5
for reducing pain and disability in the short or long term.
S2
L3 S1 L5 However, this study was not limited to lumbar spinal ste-
nosis and included low back pain of differing etiologies.24 A
meta-analysis of six trials comparing NSAIDs with placebo
had similar limitations but found significant short-term pain
© Jennifer Fairman

S1
relief with NSAIDs in patients with chronic low back pain.25
A more recent Cochrane review of the pharmacologic treat-
L5
S2 S1 ment of low back pain (also not specific to lumbar spinal ste-
L4 L5
nosis) found that NSAIDs, muscle relaxants, and opioids had
a small effect on pain reduction, but use of muscle relaxants
Lower extremity dermatomes.
and opioids was complicated by a significant risk of adverse
Illustration by Jennifer Fairman
effects.26 A systematic review found no clinically significant
difference in pain control between NSAIDs and opioids.27

354 American Family Physician www.aafp.org/afp Volume 109, Number 4 ◆ April 2024
 LUMBAR SPINAL STENOSIS
TABLE 4

Tests to Differentiate Lumbar Spinal Stenosis From Other Diagnoses

Test Findings Diagnosis if positive
Babinski sign Using the handle of a reflex hammer, the clinician sweeps up the plantar surface of Upper motor neuron
the patient’s foot from the heel up and over to the great toe;​upward movement or lesion
dorsiflexion of the great toe is positive

Buerger test With the patient supine, the affected leg is lifted between 15 and 30 degrees for 30 Peripheral vascular
to 60 seconds;​if pallor occurs, the test is positive for vascular insufficiency disease

Compression test of With the patient in the lateral recumbent position, the clinician places a hand on the Sacroiliac joint
the sacroiliac joint anterosuperior iliac spine and iliac crest of the patient’s upward side, then presses dysfunction
toward the floor;​a positive test elicits pain at the sacroiliac joint

Crossed straight leg The clinician raises the contralateral leg (opposite leg to the sciatic symptoms) to Nerve root impinge-
raise test 60 degrees of hip flexion while the patient is supine;​reproduction of the radicular ment at the spine
symptoms down the contralateral leg below the knee is considered a positive result
and has a 35% sensitivity and 90% specificity for nerve root impingement

Distraction test With the patient in the supine position, the clinician places their hands on the Sacroiliac joint
(squish test) anterosuperior iliac spine and produces a downward force toward the sacroiliac dysfunction
joint;​a positive test elicits pain at the sacroiliac joint

Flexion, adduction, With the patient in the supine position, the clinician takes the affected hip into full Hip impingement
and internal rotation flexion, external rotation, and full abduction to start, then as the hip extends, they syndrome, iliopsoas
test (anterior appre- also take the hip into full internal rotation and adduction;​a positive result is indicated tendonitis, or ante-
hension test) by groin pain rior labral tear

Hoffmann sign Flicking of the middle fingernail while the patient is seated elicits flexion of the Upper motor neuron
thumb and index finger lesion, usually in the
cervical spine

Kemp test The patient extends the back and rotates at the same time;​a positive test elicits pain, Lumbar spine facet
numbness, and tingling in the concerned area arthropathy

Patrick sign Reproduced leg pain with lateral rotation of the flexed knee indicates degenerative Arthritis of the hip
hip joint disease joint

Piriformis test With the patient in the lateral recombinant position and the involved side up, the Piriformis syndrome
involved hip is flexed to 60 degrees with the knee flexed;​the clinician stabilizes the
hip with one hand and pushes the knee down with the other hand;​a positive test elic-
its pain in the piriformis muscle and potentially down the thigh if sciatica is present

Seated straight leg With the patient seated and the knees and hips at 90 degrees, the clinician passively Nerve root impinge-
raise extends the knee;​if pain is elicited below the knee, the test is positive ment of the lumbar
spine, usually from a
herniated disk

Slump test The patient is seated on the table and asked to slump, chin to the chest, then the Nerve root impinge-
knee is placed passively in extension and the ankle is dorsiflexed;​if pain radiates ment of the lumbar
below the knee, the test is positive spine

Supine straight leg The leg is elevated to at least 30 to 40 degrees while the patient is supine;​per- Nerve root impinge-
raise (Lasègue sign) forming this straight leg test while dorsiflexing the foot at the same time may ment in the lumbar
elicit ipsilateral radicular pain radiating distal to the knee, suggesting nerve root spine, usually from
compression a herniated disk in a
narrowed foramen

Tightness of the With the patient in the lateral recombinant position and the involved leg up, the Iliotibial band
iliotibial band over clinician passively abducts and extends the involved leg with the knee flexed at 90 syndrome
the greater trochan- degrees, then lowers the leg;​if the knee does not fall to the level of the opposite
ter (Ober sign) knee, then the iliotibial band is tight, and the test is positive

Trendelenburg test Weakness in the gluteal abductors affecting L5 to S2;​can be affected by lumbar Nerve impairment
spinal stenosis of the L5 to S2 nerve
roots

Information from references 1, 3, 5, and 13.

April 2024 ◆ Volume 109, Number 4 www.aafp.org/afp American Family Physician 355
 LUMBAR SPINAL STENOSIS

TABLE 5

Clinical Differentiation Between Neurogenic and Vascular Claudication

Clinical characteristics Neurogenic claudication Vascular claudication
Location of pain Thighs, calves, back, and rarely buttocks Buttocks or calves

Quality of pain Burning, cramping Cramping

Aggravating factors Erect posture, ambulation, extension of Any leg exercise

the spine

Relieving factors Squatting, bending forward, sitting Rest

Autonomic changes Bladder incontinence (rare) Impotence may coexist with other symptoms of
vascular claudication

Leg pulses and blood pressure Usually normal Blood pressure decreased;​pulses decreased or
absent;​bruits or murmurs may be present

Skin/trophic changes Usually absent Pallor, cyanosis, and nail dystrophy often present

Adapted with permission from Alvarez JA, Hardy RH Jr. Lumbar spine stenosis:​a common cause of back and leg pain. Am Fam Physician. 1998;​
57(8):​1825-1834.

A small RCT found that adding gabapentin to physical needed to evaluate the use of transcutaneous electrical nerve
therapy, bracing, and NSAIDs improved pain control in stimulation and manipulation (chiropractic and osteo-
patients with lumbar spinal stenosis.28 Significant adverse pathic) to treat lumbar spinal stenosis.35
effects in 40% of treated patients may limit the use of gab-
apentin.29 The antidepressant duloxetine (Cymbalta) has SURGICAL INTERVENTIONS
been shown to improve chronic low back pain compared Surgical options for the treatment of lumbar spinal stenosis
with placebo, but the studies did not include lumbar spinal include decompression, decompression with fusion, percu-
stenosis.30,31 In patients with lumbar spinal stenosis, nasal taneous implantation of an interspinous spacer device, and
calcitonin has not been shown to significantly improve pain minimally invasive lumbar decompression. Surgery is more
or function.32 Patients must weigh the risks of adverse effects effective than nonoperative therapy in improving short- and
with the potential benefits of pain relief when considering long-term pain, especially if leg symptoms are predominant;​
any medication for the treatment of lumbar spinal stenosis. however, surgery is also associated with a higher risk of com-
Two RCTs demonstrated that epidural corticosteroid plications.6,38-40 A trial demonstrated greater improvement
injections with lidocaine improve pain and function after in pain, function, and self-reported progress at 8 years with
3 weeks compared with lidocaine alone. Epidural cortico- surgery compared with nonoperative treatment. However,
steroid injections should only be considered for short-term the convergence of outcomes between the treatment groups
pain relief, and clinicians should consider epidural lidocaine after 5 years was significant, and a large loss of patients to
injections without the addition of corticosteroids.33,34 follow-up is suspected to have biased the treatment effect
calculations.41 In a more recent meta-analysis, there were no
NONPHARMACOLOGIC differences between operative and nonoperative approaches
Exercise and physical therapy are options to decrease pain in short-term functional outcomes at 6 months, and there
and improve walking distance in the short term, but there were increased complications in patients treated surgically.
is no robust evidence for these treatments.8 Bracing with a At 1 year, functional outcomes appear to be improved with
lumbosacral orthosis may decrease pain and increase walk- postsurgical intervention.6,38-40
ing distance.35 There is conflicting evidence from low-quality Studies evaluating decompression techniques could
trials on the effects of acupuncture on lumbar spinal steno- not conclude whether one technique was superior.42 In
sis.36,37 Larger studies are needed to determine whether acu- patients without spondylolisthesis or lumbar scoliosis,
puncture has promise as treatment. More studies are also fusion with decompression does not improve outcomes

356 American Family Physician www.aafp.org/afp Volume 109, Number 4 ◆ April 2024
 LUMBAR SPINAL STENOSIS

FIGURE 4 FIGURE 5

A A

Radiographs in a patient with L5 to S1 right-sided disk B

herniation. (A) Anteroposterior view. Note the verte-
bral endplate irregularities (blue arrows), the minimal Magnetic resonance imaging scan showing axial
scoliotic curve, and the loss of disk height in L4 to L5 view of the lumbar spine. (A) Central canal stenosis
and L5 to S1 (red arrows). (B) Lateral view. Note the with nerve root impingement by herniated intraver-
multilevel degenerative disk disease demonstrated tebral disk (white arrow), facet hypertrophy (yellow
by endplate abnormalities and the loss of disk height arrows), and foraminal narrowing (orange arrows).
worse at L4 to L5 and L5 to S1 (blue arrows), the mild (B) Bilateral facet hypertrophy (yellow arrows) with
to moderate facet arthropathy (red arrows), and the narrowing of the lateral recesses causing nerve root
reduction in the normal lordotic curve. impingement (orange arrows).

over decompression alone. 35,43 Meta-analyses evaluating safety, and cost-effectiveness of interspinous spacer devices
percutaneously placed interspinous spacer devices found and minimally invasive lumbar decompression.
that although there may be some benefit in patients with- Clinicians should discuss a range of nonoperative treat-
out spondylolisthesis who have extension-based neurogenic ment options with their patients and consider surgical
claudication, there are high rates of complications and reop- referrals for patients whose symptoms are refractory or
eration.44,45 Case series and cohort studies have evaluated worsen over time.
minimally invasive lumbar decompression, which appears to This article updates previous articles on this topic by Snyder, et
be successful in decreasing the patient’s length of hospitaliza- al.,48 and Alvarez and Hardy. 3
tion, blood loss, and tissue damage;​however, these findings Data Sources:​A PubMed search was completed in Clinical
must be balanced against the higher complication rates.46,47 Queries using the key terms lumbar spinal stenosis and spinal
More research is needed to determine the effectiveness, stenosis. The search included meta-analyses, randomized con-

April 2024 ◆ Volume 109, Number 4 www.aafp.org/afp American Family Physician 357
 LUMBAR SPINAL STENOSIS

trolled trials, clinical trials, and systematic reviews. The Agency 13. Will JS, Bury DC, Miller JA. Mechanical low back pain. Am Fam Physi-
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sible, studies that did not define how race or gender categories 16. Orita S, Inage K, Eguchi Y, et al. Lumbar foraminal stenosis. Eur J Orthop
were assigned were not used in our final review. Search dates:​ Surg Traumatol. 2016;​26(7):​685-693.
April 6 and 13, 2023, and February 6, 2024. 17. Genevay S, Atlas SJ. Lumbar spinal stenosis. Best Pract Res Clin Rheu-
matol. 2010;​24(2):​253-265.
18. Cook CJ, Cook CE, Reiman MP, et al. Systematic review of diagnostic
The Authors accuracy of patient history, clinical findings, and physical tests in the
diagnosis of lumbar spinal stenosis. Eur Spine J. 2020;​29(1):​93-112.
CHARLES W. WEBB, DO, FAAFP, FAMSSM, is director of the 19. Chong F, Fan W, Liu L, et al. Correlation between atrophy of the gluteus
Division of Sports Medicine, director of the Primary Care medius muscle and symptoms of lumbar spinal stenosis. World Neuro-
Sports Medicine Fellowship, and an associate professor in the surg. 2023;​172:​e177-e184.
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