Diagnosis And Treatment Of Degenerative Lumbar Spinal Stenosis

Degenerative lumbar spinal stenosis describes a condition in which there is diminished space available for the neural and vascular elements in the lumbar spine secondary to degenerative changes in the spinal canal. When symp- tomatic, this causes a variable clinical syndrome of gluteal and/or lower extremity pain and/or fatigue that may occur with or without back pain. Symptomatic lumbar spinal stenosis has certain characteristic provocative and palliative features. Provocative features include upright exercise such as walking or positionally induced neurogenic claudication. Palliative features commonly include symptomatic relief with forward flexion, sitting, and/or recumbency. (, )

In the absence of reliable evidence, it is the work group’s opinion that the natural history of patients with clinically mild to moderately symptomatic degenerative lumbar steno- sis can be favorable in about one-third to one-half of patients. (, )

In the absence of reliable evidence, it is the work group’s opinion that in patients with mild or moderately symptom- atic degenerative lumbar stenosis, rapid or catastrophic neurologic decline is rare.

In the absence of reliable evidence, it is the work group’s opinion that information in the literature is insufficient to define the natural history of clinically or radiographically severe degenerative lumbar stenosis.

The diagnosis of lumbar spinal stenosis may be considered 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. Patients whose pain is not made worse with walking have a low likelihood of stenosis.

There is insufficient evidence to make a recommendation for or against the use of self-administered questionnaires to improve accuracy of the diagnosis of spinal stenosis.

There is insufficient evidence to make a recommendation for or against certain physical findings for the diagnosis of degenerative lumbar spinal stenosis including an abnormal Romberg test, thigh pain exacerbated with extension, sen- sorimotor deficits, leg cramps, and abnormal Achilles tendon reflexes.

There is insufficient evidence to make a recommendation for or against the diagnostic reliability of patient-reported dominance of lower extremity pain and low back pain. (Insufficient)

In patients with history and physical examination findings consistent with degenerative lumbar spinal stenosis, magnetic resonance imaging (MRI) is suggested as the most appropriate noninvasive test to confirm the presence of anatomic narrowing of the spinal canal or the presence of nerve root impingement.

In patients with history and physical examination findings consistent with degenerative lumbar spinal stenosis for whom MRI is either contraindicated or inconclusive, computed tomography (CT) myelography is suggested as the most appropriate test to confirm the presence of anatomic narrowing of the spinal canal or the presence of nerve root impingement. (B: Suggested)

In patients with history and physical examination findings consistent with degenerative lumbar spinal stenosis for whom MRI and CT myelography are contraindicated, inconclusive, or inappropriate, CT is the preferred test to confirm the presence of anatomic narrowing of the spinal canal or the presence of nerve root impingement.

MRI or CT with axial loading is suggested as a useful adjunct to routine imaging in patients who have clinical signs and symptoms of lumbar spinal stenosis, a dural sac area of less than 110 mm² at one or more levels, and suspected but not verified central or lateral stenosis on routine unloaded MRI or CT. (B: Suggested)

It is suggested that readers use well-defined, articulated, and validated criteria for anatomic canal narrowing on MRI, computed tomography myelography (CTM), and CT to improve interobserver and intraobserver reliability.

There is insufficient evidence to make a recommendation for or against a correlation between clinical symptoms or function with the presence of anatomic narrowing of the spinal canal on MRI, CTM, or CT.

In the absence of reliable evidence, it is the work group’s opinion that imaging studies be considered as a first-line diagnostic test in the diagnosis of degenerative lumbar spinal stenosis. (, )

Electromyographic paraspinal mapping is suggested to confirm the diagnosis of degenerative lumbar spinal stenosis in patients with mild or moderate symptoms and radiographic evidence of stenosis.

There is insufficient evidence to make a recommendation for or against the use of F wave, H reflex, motor-evoked potential, motor nerve conduction studies, somatosensoryevoked potentials, dermatomal sensory–evoked potentials, and lower extremity electromyelography (EMG) in the confirmation of lumbar spinal stenosis. These studies may be used to help identify other comorbidities. (Insufficient, )

There is insufficient evidence to make a recommendation for or against the use of pharmacological treatment in the management of spinal stenosis. (Insufficient, )

There is insufficient evidence to make a recommendation for or against the use of physical therapy or exercise as stand-alone treatments for degenerative lumbar spinal stenosis. (Insufficient)

In the absence of reliable evidence, it is the work group’s opinion that a limited course of active physical therapy is an option for patients with lumbar spinal stenosis. (, )

There is insufficient evidence to make a recommendation for or against spinal manipulation for the treatment of lumbar spinal stenosis. (Insufficient)

Contrast-enhanced fluoroscopy is recommended to guide epidural steroid injections to improve the accuracy of medication delivery. (A: Recommended)

Interlaminar epidural steroid injections are suggested to provide short-term (2 weeks to 6 months) symptom relief in patients with neurogenic claudication or radiculopathy. There is, however, conflicting evidence concerning longterm (21.5–24 months) efficacy. (B: Suggested)

A multiple injection regimen of radiographically guided transforaminal epidural steroid injection or caudal injections is suggested to produce medium-term (3–36 months) relief of pain in patients with radiculopathy or neurogenic intermittent claudication from lumbar spinal stenosis. (C: Optional)

The use of a lumbosacral corset is suggested to increase walking distance and decrease pain in patients with lumbar spinal stenosis. There is no evidence that results are sustained once the brace is removed. (B: Suggested)

There is insufficient evidence to make a recommendation for or against traction, electrical stimulation, or transcutaneous electrical stimulation for the treatment of patients with lumbar spinal stenosis.

There is insufficient evidence to make a recommendation for or against acupuncture in for the treatment of patients with lumbar spinal stenosis. (Insufficient)

Medical/interventional treatment may be considered to provide long-term (2–10 years) improvement in patients with degenerative lumbar spinal stenosis and has been shown to improve outcomes in a large percentage of patients.

Decompressive surgery is suggested to improve outcomes in patients with moderate to severe symptoms of lumbar spinal stenosis. (B: Suggested)

Medical/interventional treatment may be considered for patients with moderate symptoms of lumbar spinal stenosis.

In the absence of evidence for or against any specific treatment, it is the work group’s recommendation that medical/interventional treatment be considered for patients with mild symptoms of lumbar spinal stenosis.

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There is insufficient evidence at this time to make a recommendation for or against the placement of an interspinous process spacing device in patients with lumbar spinal stenosis.

Decompression alone is suggested for patients with leg predominant symptoms without instability. (B: Suggested)

Surgical treatment may be considered to provide longterm (4+ years) improvement in patients with degenerative lumbar spinal stenosis and has been shown to improve outcomes in a large percentage of patients. (C: Optional)

Surgical decompression may be considered in patients aged 75 years or older with lumbar spinal stenosis. (C: Optional)