Lumbar Spinal Stenosis

This tool provides information to facilitate the management of lumbar spinal stenosis leading to neurogenic claudication.

Focused examination

1. Patient History 

  • Assess level of concern for major structural or other pathologies. If required, refer to an appropriate healthcare provider.

  • Identify and assess other conditions and co-morbidities. Manage using appropriate care pathways.

  • Address prognostic factors that may delay recovery.

Major structural or other pathologies may be suspected with certain signs and symptoms (red flags):

  • Cancer (history of cancer, unexplained weight loss, nocturnal pain, age >50), vertebral infection (fever, intravenous drug use, recent infection), cauda equina syndrome (urinary retention, motor deficits at multiple levels, fecal incontinence, saddle anesthesia), osteoporotic fractures (history of osteoporosis, use of corticosteroid, older age), ankylosing spondylitis (morning stiffness, improvement with exercise, alternative buttock pain, awakening due to back pain during the second part of the night, younger age), inflammatory arthritis (morning stiffness, swelling in multiple joints)

Examples of other conditions/co-morbidities:

  • Physical conditions: neck pain, headache

  • Psychological conditions: depression, anxiety

  • Co-morbidities: diabetes, heart disease

Examples of prognostic factors that may delay recovery:

  • Symptoms of depression or anxiety, passive coping strategies, job dissatisfaction, high self-reported disability levels, disputed compensation claims, somatization

2. Physical Examination

  • Assess levels of concern regarding major structural or other pathologies​.

  • Assess for neurological signs.

  • Assess walking capacity using distance, time and/or steps.

3. Management 

  • Offer information on nature, management, and the course of lumbar spinal stenosis. See patient handouts for more information to provide to patients.

  • Discuss the range of effective interventions with the patient and, together, a therapeutic intervention.

Patient Handouts

CCGI_LSS_patient handout_ENG.jpg
CCGI_LSS_patient handout_FR.jpg
 

Management lumbar spinal stenosis leading to neurogenic claudication with or without low back pain

 

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and any one of the following therapeutic interventions*:

  • Consider non-pharmacological multimodal careᶧ including the combination of:

    • education and advice, manual therapy and home-based exercise; or

    • post-operative rehabilitation beginning at 12 weeks after surgery (supervised exercise and/or educational materials encouraging activity) and cognitive behavioural therapy (CBT).  Exercises may include spinal mobilization, strengthening of spinal deep muscles, stretching of lower limb and low back, functional exercise, and walking. Education may involve ergonomic advice.  

  • Consider serotonin-norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs)​

  • Consider needle acupuncture

  • Do not offer NSAIDs, Methylcobalamin, Paracetamol (acetaminophen), Calcitonin, opioids, muscle relaxants, Pregabalin, Gabapentin, epidural steroidal injections

*All recommendations are conditional (weak) based on the GRADE assessment. Interventions are recommended if they were supported by high or moderate quality evidence.
ᶧMultimodal care: treatment involving at least two distinct therapeutic modalities, provided by one or more health care disciplines.

Care Pathway for the management of

lumbar spinal stenosis

(click here for French version)

4. Reevaluation and Discharge

  •  Reassess the patient at every visit to determine if: (1) additional care is necessary; (2) the condition is worsening; or (3) the patient has recovered.

  • Monitor for any emerging factors for delayed recovery.

5. Referrals and Collaboration

  • Refer the patient to an appropriate healthcare provider for further evaluation at any time during their care if they develop worsening symptoms and new physical or psychological symptoms​.