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  • Review Article
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Lumbar spinal stenosis: syndrome, diagnostics and treatment

Nature Reviews Neurology volume 5, pages 392–403 (2009)Cite this article

Abstract

Lumbar spinal stenosis (LSS) comprises narrowing of the spinal canal with subsequent neural compression, and is frequently associated with symptoms of neurogenic claudication. To establish a diagnosis of LSS, clinical history, physical examination results and radiological changes all need to be considered. Patients who exhibit mild to moderate symptoms of LSS should undergo multimodal conservative treatment, such as patient education, pain medication, delordosing physiotherapy and epidural injections. In patients with severe symptoms, surgery is indicated if conservative treatment proves ineffective after 3–6 months. Clinically relevant motor deficits or symptoms of cauda equina syndrome remain absolute indications for surgery. The first randomized, prospective studies have provided class I–II evidence that supports a more rapid and profound decline of LSS symptoms after decompressive surgery than with conservative therapy. In the absence of a valid paraclinical diagnostic marker, however, more evidence-based data are needed to identify those patients for whom the benefit of surgery would outweigh the risk of developing complications. In this Review, we briefly survey the underlying pathophysiology and clinical appearance of LSS, and explore the available diagnostic and therapeutic options, with particular emphasis on neuroradiological findings and outcome predictors.

Key Points

  • A patient's medical history and clinical symptoms are more-decisive factors than radiological observations in confirming a diagnosis of lumbar spinal stenosis (LSS)

  • Patients with mild to moderate symptoms of LSS should be treated with conservative therapies, including delordosing measures, and epidural injections and other pharmacological measures

  • In cases of severe symptomatic LSS, surgery is indicated if conservative therapy proves ineffective after 3–6 months

  • Class I evidence-based recommendations cannot be made for any conservative or surgical therapy in relation to mid-term and long-term patient outcomes

  • Future mid-term and long-term studies should identify subgroups of patients who are more likely to benefit from surgery than from conservative treatment

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Figure 1: Pathoanatomical illustration of LSS.
Figure 2: Processes involved in neurogenic claudication development in lumbar spinal stenosis.
Figure 3: Spinal alterations in a patient with monosegmental LSS at L4–5.
Figure 4: Spinal alterations in a patient with multisegmental LSS.
Figure 5: Multisegmental disc degeneration revealed by CT myelography.
Figure 6: Conventional myelography in a patient with a posterior lumbal intervertebral fusion and positional back pain.
Figure 7: Proposed treatment algorithm for symptomatic LSS.

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Acknowledgements

E. Siebert and H. Prüss contributed equally to this article. J. M. Schwab receives support from the Berlin–Brandenburg Center for Regenerative Therapies, NeuroCure (together with K. M. Einhäupl), the Wings for Life Spinal Cord Research Foundation (Travelgrant) and the International Foundation for Research in Paraplegia. Charles P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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  1. J. M. Schwab, Department of Neurology and Experimental Neurology, Spinal Cord Injury Research, Charité School of Medicine, Humboldt University, Campus Mitte, Charitéplatz 1, D-10117 Berlin, Germany jan.schwab@charite.de

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  1. Department of Neuroradiology, Charité School of Medicine, Humboldt University, Berlin, Germany

    Eberhard Siebert & Randolf Klingebiel

  2. Department of Neurology and Experimental Neurology, Humboldt University, Berlin, Germany

    Harald Prüss, Karl M. Einhäupl & Jan M. Schwab

  3. Wings for Life Spinal Cord Research Foundation, Salzburg, Austria

    Vieri Failli

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Siebert, E., Prüss, H., Klingebiel, R. et al. Lumbar spinal stenosis: syndrome, diagnostics and treatment. Nat Rev Neurol 5, 392–403 (2009). https://doi.org/10.1038/nrneurol.2009.90

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