Update of 2006 Clinical Practice Guidelines for Spinal Stenosis

Today’s physicians depend on evidence from clinical studies and what are considered “best practice” approaches by experts whenever possible. When evaluating patients with degenerative lumbar spinal stenosis (DLSS or sometimes referred to as just LSS), the clinical practice guidelines of 2006 have been the “go to” document for guidance. This saves physicians from sorting through the hundreds of studies published each year in many different journals.

But now, the 2006 guidelines have been reviewed (based on published studies up to and including July 2010) and revised. In this document, members from the Degenerative Lumbar Spinal Stenosis Work Group of the North American Spine Society (NASS) provide a summary of the new guidelines. This update is now considered the most recent evidence-based clinical practice guideline (CPG) on LSS.

Sixteen questions were posed and answered in the 2006 Clinical Practice Guidelines. The questions covered topics ranging from natural history of LSS to diagnosis and treatment of this condition. All questions were reviewed and responses provided in this 2013 update. The levels of evidence were indicated for each response using grades labeled A (recommended), B (suggested), C (an option), and I (insufficient evidence to recommend for or against).

The working group also provided a consensus statement when there wasn’t enough reliable evidence to provide a guideline. This consensus statement is the opinion of the group based on all currently available evidence and expert opinion. Here is a sampling of the questions and some of the updated responses:

  • What is the best working definition of degenerative lumbar spinal stenosis (DLSS)?
  • What is the natural history of symptomatic DLSS?
  • What are the most appropriate diagnostic tests for DLSS?
  • Does medical treatment improve results (compared to the “do nothing” approach)?
  • What happens in the long-term (four to 10 years) with surgical treatment compared with conservative care?

    No grades of recommendation were available for the first two sample questions. Instead, the Working Group provided consensus statements. In the case of the definition and natural history of lumbar spinal stenosis, they described the condition as follows: 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.

    The group agreed that the natural history (what happens over time) with this condition is a picture of mild to moderate symptoms (e.g., low back, buttock, and/or leg pain, difficulty walking, fatigue). About one-third to one-half of all affected adults will get better (with or without treatment).

    Physicians cannot really rely on patient history and reports of symptoms to make an accurate diagnosis. Pain that is not made worse when walking is probably not caused by stenosis. MRIs provide the best opportunity for identifying the characteristic narrowing of the spinal canal or nerve root impingement typical of lumbar spinal stenosis. Evidence to support these statements was listed as a Grade B (suggested). Evidence regarding other types of diagnostic testing (e.g., CT scans, electrodiagnostics, electromyography, motor-evoked potential) is also reviewed and updated.

    Many treatments considered for lumbar spinal stenosis such as acupuncture, bracing, traction, electrical stimulation, and steroid injections are considered options (Grade C). But the evidence for or against each one is limited by insufficient research/evidence. The Working Group identified these areas as in need of further research in the future.

    Surgery can improve the symptoms and quality of life in carefully selected patients. The choice of surgical procedure (e.g., decompression alone, decompression with spinal fusion, fusion with or without instrumentation) is based on age and type and severity of symptoms. Patients with moderate to severe symptoms are considered most often for surgery based on current evidence (Grade B; suggested).

    Anyone who is interested in reading the full report and reviewing all the references can access this information on the North American Spine Society’s website at www.spine.org.