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Practice Clinical Updates

Lumbar spinal stenosis

BMJ 2021; 373 doi: (Published 29 June 2021) Cite this as: BMJ 2021;373:n1581
  1. Rikke Krüger Jensen, associate professor1 2,
  2. Biswadjiet S Harhangi, neurosurgeon3,
  3. Frank Huygen, professor4,
  4. Bart Koes, professor1 5
  1. 1Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
  2. 2Chiropractic Knowledge Hub, Odense, Denmark
  3. 3Department of Neurosurgery, Erasmus Medical Centre, Rotterdam, Netherlands
  4. 4Department of Anaesthesiology, Pain Medicine, Erasmus Medical Centre, Rotterdam, Netherlands
  5. 5Department of General Practice, Erasmus Medical Centre, Rotterdam, Netherlands
  1. Correspondence to RK Jensen rikkekruger{at}

What you need to know

  • Suspect lumbar spinal stenosis in people over 50 who describe leg pain or paraesthesia on walking or prolonged standing, and who are walking reduced distances as a result

  • Imaging is not required during initial assessment as the correlation between imaging findings and symptoms is poor

  • Conservative treatment, which includes supervised exercise and manual therapy, is advised as first line treatment; about 30-50% of patients with mild to moderate symptoms experience spontaneous improvement in pain and ability to walk greater distances

  • Prescribe pain medication only for a short period and after careful consideration, taking into account the important side effects, especially in older people, and the absence of good evidence for efficacy

  • Refer patients with severe symptoms, neurological deficits, or no improvement after 3-6 months of conservative treatment to a spine specialist for imaging and further intervention or surgery

Lumbar spinal stenosis (LSS) affects about 11% of the population,1 and primarily affects older adults.1 Pain in legs and difficulty walking can limit function and participation in daily activities, which can have negative psychological effects.2

Diagnosis can be challenging because of the overlap of symptoms with other conditions that cause leg or low back pain in older adults. Lumbar spinal stenosis can usually be diagnosed clinically and managed conservatively in primary care. Patients with severe symptoms may require referral for imaging and intervention. The evidence for most treatment options is limited.345 Shared decision making with patients must consider the severity of symptoms and their impact on the person’s life, risks and benefits of treatments, and individual preferences.

What causes LSS?

Degenerative changes in the spine can cause narrowing of the central spinal canal, lateral recesses, or intervertebral foramen. Changes include disc degeneration and bony or soft tissue changes, such as facet joint arthrosis and hypertrophy of the ligamentum flavum, …

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