Classically, lumbar spinal stenosis presents as pain exacerbated by prolonged ambulation, standing, and with lumbar extension, and is relieved by forward flexion and rest. Neurogenic claudication is an important feature of lumbar spinal stenosis. Symptoms are typically bilateral, but usually asymmetric. Low back pain, numbness, and tingling are present in a majority of patients. Numbness and tingling in lumbar spinal stenosis typically involve the entire leg and rarely affect only a single nerve root distribution.[8] Approximately 43 percent of the patients experience weakness. Patients may also report walking upstairs being easier than walking downstairs, as the back is forward flexed with stairs climbing. If patients present with new-onset bowel or bladder dysfunction, saddle anesthesia, bilateral lower extremity weakness, and/or increased lower extremity, the patient may have developed cauda equina or conus medullaris syndromes. 

A thorough physical examination is necessary for patients with suspected lumbar spinal stenosis. Pain with passive and active lumbar extension can be elicited. Although patients can have superimposed lumbar radiculopathy, one should keep in mind that neurologic examinations on patients with lumbar spinal stenosis are typically normal. Only 10 percent of patients would present with a positive straight leg raise test.[9] Pedal pulses should also be checked during the physical exam as vascular claudication can present similarly. 

As mentioned previously, there is no consensus on the definition of lumbar spinal stenosis diagnostic criteria. However, in evaluating low back pain, neuroimaging is indicated when there are new-onset symptoms and suspicion of lumbosacral radiculopathy or spinal stenosis. In patients without suspicion of infection, metastasis, or postoperative spine symptoms, non-contrast MRI of the lumbosacral spine is the modality of choice for lumbar spinal stenosis, and CT myelography is an option when MRI is contraindicated.[10] Many authors use an intraspinal canal area of less than 76 mm^2and 100 mm^2 for severe and moderate stenosis, respectively. Anteroposterior spinal canal diameters of less than 10 mm are also frequently used for the diagnosis of lumbar spinal stenosis. One must note that lumbar spinal stenosis is a common incidental radiological finding, especially in patients over 60 years old, and there is also a lack of correlation between the severity of the imaging studies versus the symptom severity reported by patients. MRI or CT myelography with axial loading may be a useful adjunct to routine imaging.

Electromyography and nerve conduction studies (EMG) are also used to aid the diagnosis of diagnosis, as this distinguishes polyneuropathy, radiculopathy, or other peripheral nerve disorders from lumbar spinal stenosis.[11] EMG exams are often normal in patients with lumbar spinal stenosis.

Management for lumbar spinal stenosis aims at reducing symptoms and improving functional status. Conservative treatment is the first-line treatment for this condition. Conservative treatment options include physical therapy, oral anti-inflammatory medications, and epidural steroid injections. Although there is no standardized physical therapy regimen, many therapists focus on stretching and strengthening the core muscles, which can lead to correction of posture and improved symptoms.[12] Although there are short-term benefits, lumbar epidural steroid injections have not shown to have long-term improvement of pain and disability in lumbar spinal stenosis patients, and there is no statistical difference between epidural injections with anesthetics alone versus a mixture of anesthetics with corticosteroids.[13] Lumbar corsets may also be trialed for temporary relief of pain.[14]

Barring emergencies such as cauda equina syndrome, surgical management for lumbar spinal stenosis is usually elective, as the goal of treatment is to improve function, rather than preventing neurologic impairment. The most frequently performed surgical procedure is a laminectomy. A randomized trial has shown that there is a greater improvement of symptoms in patients undergoing laminectomy compared to the non-surgical group; however, the symptom improvement between the surgical and non-surgical groups diminishes over time.[15] Laminectomy with fusion is typically reserved for patients with concurrent spondylolisthesis to provide further stability. A less invasive approach is interspinous spacer implantation; this procedure is appropriate for patients with intermittent claudication symptoms without spondylolisthesis.

Differential diagnoses for lumbar spinal stenosis include, but not limited to:

• Peripheral vascular disease (vascular claudication)
• Cauda equina syndrome
• Nonspecific low back pain
• Degenerative disc disease, spondylosis
• Malignancy
• Infection
• Radiculopathy
• Distal polyneuropathy
• Osteoarthritis
• Inflammatory arthritis
• Spinal cord vascular malformations
• Tethered cord syndrome

Lumbar spinal stenosis is a significant cause of pain and disability, and approximately half the patients have involvement of other spinal segments over time; however, it typically follows a benign course. In one cohort study, 30% of patients electing to manage lumbar spinal stenosis with non-surgical procedures eventually requested for surgical management, and approximately 19% of patients who had an initial surgery eventually underwent a repeat surgery.[16]

Lumbar spinal stenosis is a common disease process in the outpatient setting. These patients have symptoms such as leg pain and low back pain. The cause of this condition is most likely secondary to chronic wear-and-tear damages to the vertebral column. Despite the fact that imaging studies can show there is indeed lumbar spinal stenosis, the patient's may or may not have corresponding symptoms. Because there is no evidence to demonstrate the superiority of surgical versus non-surgical treatments of lumbar spinal stenosis, it is essential to take an interprofessional approach.[3] [Level 1]

Primary physicians must recognize the patient's presentation; the care of the patient must include coordinated effort with physical medicine and rehabilitation, pain management, orthopedist, and/or neurosurgeons (if there is a neurosurgical emergency). Physical therapists must also have involvement as physical therapy is the mainstay in the conservative treatment of this condition. In patients who need to undergo surgical treatment, the nursing staff (including orthopedic specialty nurses) must be aware of the patient's medical status. In short, the care of patients suffering from lumbar spinal stenosis requires an interprofessional team-based cooperative model.