• North American Spine Society (NASS). Diagnosis and treatment of degenerative lumbar spinal stenosis. Burr Ridge (IL): North American Spine Society (NASS); 2007 Jan. 262 p. [394 references]

This is the current release of the guideline.

This guideline updates a previous version: North American Spine Society (NASS). Phase III clinical guidelines for multidisciplinary spine care specialists. Spinal stenosis version 1.0. LaGrange (IL): North American Spine Society (NASS); 2002. 91 p.

The grades of recommendations (A-C, I) and levels of evidence (I-V) are defined at the end of the Major Recommendations field.

Recommendations for Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis

Diagnosis and Imaging

What are the most appropriate historical and physical findings consistent with the diagnosis of degenerative lumbar spinal stenosis?

Lumbar spinal stenosis should be considered in older patients presenting with a history of severe lower extremity pain which improves or resolves with sitting and postural abnormalities on physical examination such as a wide-based gait. Physical findings adding to this consideration include an abnormal Romberg test, thigh pain exacerbated with extension and neuromuscular deficits. Patients whose pain is not made worse with walking have a low likelihood of stenosis.

Grade of Recommendation: I (Insufficient Evidence)

What are the most appropriate diagnostic tests for degenerative lumbar spinal stenosis?

The most appropriate, noninvasive test for imaging degenerative lumbar spinal stenosis is magnetic resonance imaging (MRI).

Grade of Recommendation: B

Computed tomography (CT) myelography is a useful study in patients who have a contraindication to MRI, for whom MRI findings are inconclusive, or in patients for whom there is a poor correlation between symptoms and MRI findings.

Grade of Recommendation: B

CT is a useful noninvasive study in patients who have a contraindication to MRI, for whom MRI findings are inconclusive or for whom there is a poor correlation between symptoms and MRI findings, and in whom CT myelogram is deemed inappropriate.

Grade of Recommendation: B

It is the consensus of this work group that, in isolated lumbar stenosis, electrodiagnostic studies do little to enhance the diagnosis or treatment of lumbar stenosis compared with history, physical examination, and imaging studies. Electrodiagnostic studies are best utilized when there is concern about additional neurologic compromise, such as peripheral polyneuropathy. In addition, Molitor et al. (1993) determined that somatosensory evoked potentials were not helpful in the diagnosis of lumbar stenosis.

Outcomes Measures for Medical/Interventional and Surgical Treatment

What are the appropriate outcome measures for the treatment of spinal stenosis?

The Oswestry Disability Index (ODI) and Swiss Spinal Stenosis Questionnaire (SSS)/Zurich Claudication Questionnaire (ZCQ) outcome tools are appropriate measures for treatment of lumbar spinal stenosis.

Grade of Recommendation: B

The Maine-Seattle Back Questionnaire (MSBQ), Oxford Claudication Score (OCS), Shuttle Walking Test (SWT), and Exercise Treadmill Test (ETT) outcome tools are appropriate measures for treatment of lumbar spinal stenosis.

Grade of Recommendation: I (Insufficient Evidence)

Valid health state measurements that are selected to assess the effectiveness of treatment of lumbar spinal stenosis must be used carefully.

Grade of Recommendation: B

Medical and Interventional Treatment

Do medical/interventional treatments improve outcomes in the treatment of spinal stenosis compared to the natural history of the disease?

A systematic review of the literature yielded no studies to answer this question. An extensive review of all articles cited in the reference section found no direct comparison of active treatment (medical/interventional) to an untreated control group (natural history).

What is the role of pharmacological treatment in the management of spinal stenosis?

There is little evidence that pharmacological treatment, including intranasal calcitonin, intramuscular calcitonin, methylcobalamin, or intravenous lipoprostaglandin E(1), provides long-term benefit in patients with lumbar spinal stenosis.

Grade of Recommendation: B

There is weak evidence that intramuscular calcitonin provides some short-term benefit in patients with moderate lumbar spinal stenosis.

Grade of Recommendation: C

What is the role of physical therapy/exercise in the treatment of spinal stenosis?

A systematic review of the literature yielded insufficient evidence to draw conclusions regarding the effectiveness of physical therapy or exercises as stand-alone treatments for lumbar spinal stenosis.

Grade of Recommendation: I (Insufficient Evidence)

Use of physical therapy and exercise may be beneficial in controlling symptoms of lumbar spinal stenosis with neurogenic claudication in certain subgroups of patients.

Level of Evidence: V (Expert Consensus)

What is the role of manipulation in the treatment of spinal stenosis?

The evidence that spinal manipulation offers benefit in the treatment of lumbar spinal stenosis is insufficient.

Grade of Recommendation: I (Insufficient Evidence)

What is the role of contrast-enhanced, fluoroscopic guidance in the routine performance of epidural steroid injections for the treatment of lumbar spinal stenosis?

Using contrast-enhanced fluoroscopy to guide epidural steroid injections improves the accuracy of medication delivery.

Grade of Recommendation: A

What is the role of epidural steroid injections in the treatment of lumbar spinal stenosis?

Nonfluoroscopically-guided interlaminar epidural steroid injections can result in short term (two to three weeks) symptom relief in patients with neurogenic claudication or radiculopathy. There is, however, conflicting evidence concerning long-term efficacy.

Grade of Recommendation: B

A single radiographically-guided transforaminal epidural steroid injection can produce short term relief in patients with radiculopathy from lumbar spinal stenosis. There is, however, conflicting evidence concerning the long-term efficacy of a single injection.

Grade of Recommendation: B

A multiple injection regimen of radiographically-guided transforaminal epidural steroid injection or caudal injections can produce long-term relief of pain in patients with radiculopathy or neurogenic intermittent claudication (NIC) from lumbar spinal stenosis.

Grade of Recommendation: C

What is the role of ancillary treatments such as bracing, traction, electrical stimulation and transcutaneous electrical stimulation (TENS) in the treatment of lumbar spinal stenosis?

The use of a lumbosacral corset can 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.

Grade of Recommendation: C

A systematic review of the literature yielded insufficient evidence to address the role of traction, electrical stimulation or transcutaneous electrical stimulation in the treatment of lumbar spinal stenosis.

Grade of Recommendation: I (Insufficient Evidence)

What is the long-term result of medical/interventional management of spinal stenosis?

Of patients with mild to moderate lumbar spinal stenosis initially receiving medical/interventional treatment and followed for two to 10 years, approximately 20 to 40% will ultimately require surgical intervention. Of the patients who do not require surgical intervention, 50 to 70% will have improvement in their pain.

Grade of Recommendation: C

Surgical Treatment

Do surgical treatments improve outcomes in the treatment of lumbar spinal stenosis compared to the natural history of the disease?

In patients with severe symptoms of lumbar spinal stenosis, decompressive surgery alone is effective approximately 80% of the time.

Grade of Recommendation: C

In patients with moderate to severe symptoms of lumbar spinal stenosis, surgery is more effective than medical/interventional treatment.

Grade of Recommendation: C

In patients with mild to moderate symptoms of lumbar spinal stenosis, medical/interventional treatment is effective approximately 70% of the time.

Grade of Recommendation: C

In patients with mild to moderate symptoms of lumbar spinal stenosis placement of the X-STOP is more effective than medical/interventional treatment.

Grade of Recommendation: I (Insufficient Evidence)

What is the role of decompression in the treatment of spinal stenosis?

At long-term follow-up (8-10 years), surgical decompression in the treatment of lumbar spinal stenosis is consistently supported when compared to medical/interventional treatments.

Grade of Recommendation: B

Patients aged 75 or greater with lumbar spinal stenosis show the same benefit from lumbar decompression as younger patients aged 65-74.

Grade of Recommendation: C

Diabetic patients, 65 and older, with lumbar spinal stenosis benefit from lumbar decompression.

Grade of Recommendation: C

Does surgical decompression alone improve surgical outcomes in the treatment of spinal stenosis compared to medical/interventional treatment alone or the natural history of the disease?

In patients with severe symptoms of lumbar spinal stenosis, decompressive surgery alone is effective about 80% of the time and medical/interventional treatment alone is effective about 33% of the time.

Grade of Recommendation: C

In patients with moderate to severe symptoms of lumbar spinal stenosis, surgery is more effective than medical/interventional treatment.

Grade of Recommendation: C

In patients with mild to moderate symptoms of lumbar spinal stenosis, medical/interventional treatment is effective up to 70% of the time.

Grade of Recommendation: C

In patients with mild to moderate symptoms of lumbar spinal stenosis, placement of an interspinous process spacing device is more effective than medical/interventional treatment at two-year follow-up.

Grade of Recommendation: I (Insufficient Evidence)

Does the addition of lumbar fusion, with or without instrumentation, to surgical decompression improve surgical outcomes in the treatment of spinal stenosis compared to treatment by decompression alone?

In patients with lumbar spinal stenosis and spondylolisthesis, decompression with fusion results in better outcomes than decompression alone.

Grade of Recommendation: B

The presence of pseudarthrosis on radiographs following lumbar fusion for lumbar spinal stenosis with spondylolisthesis does not affect outcomes at two years.

Grade of Recommendation: B

The presence of pseudarthrosis on radiographs following lumbar fusion for lumbar spinal stenosis with spondylolisthesis negatively affects outcomes at greater than five-year follow-up.

Grade of Recommendation: I (Insufficient Evidence)

The addition of instrumentation to posterior fusion for treatment of spinal stenosis with spondylolisthesis increases the radiographic fusion rate.

Grade of Recommendation: B

Of patients with lumbar spinal stenosis meeting Posner's criteria of instability, decompression with fusion provides better outcomes than decompression alone at greater than two-year follow-up.

Grade of Recommendation: I (Insufficient Evidence)

Of patients with lumbar spinal stenosis without spondylolisthesis or instability, there is no evidence to support the addition of a fusion.

Grade of Recommendation: I (Insufficient Evidence)

What is the long-term result (four+ years) of surgical management of spinal stenosis?

The long-term results of surgical management of spinal stenosis are good or excellent in 50-79% of patients.

Grade of Recommendation: C

Definitions:

Grades of Recommendation for Summaries or Reviews of Studies

A. Good evidence (Level I Studies with consistent finding) for or against recommending intervention.

B. Fair evidence (Level II or III Studies with consistent findings) for or against recommending intervention.

C. Poor quality evidence (Level IV or V Studies) for or against recommending intervention.

I. Insufficient or conflicting evidence not allowing a recommendation for or against intervention.

Levels of Evidence for Primary Research Question¹

RCT = randomized controlled trial

1. A complete assessment of quality of individual studies requires critical appraisal of all aspects of the study design.
2. A combination of results from two or more prior studies.
3. Studies provided consistent results.
4. Study was started before the first patient enrolled.
5. Patients treated one way (e.g., cemented hip arthroplasty) compared with a group of patients treated in another way (e.g., uncemented hip arthroplasty) at the same institution.
6. The study was started after the first patient enrolled.
7. Patients identified for the study based on their outcome, called "cases" (e.g., failed total arthroplasty) are compared to those who did not have outcome, called "controls" (e.g., successful total hip arthroplasty).
8. Patients treated one way with no comparison group of patients treated in another way.

None provided

The type of evidence supporting the recommendations is specifically stated for each recommendation.

• North American Spine Society (NASS). Diagnosis and treatment of degenerative lumbar spinal stenosis. Burr Ridge (IL): North American Spine Society (NASS); 2007 Jan. 262 p. [394 references]

Not applicable: The guideline was not adapted from another source.

2002 (revised 2007 Jan)

North American Spine Society - Medical Specialty Society

North American Spine Society (NASS)

North American Spine Society (NASS) Clinical Guidelines Committee

Committee Members: William C. Watters III, MD, Committee Chair; Jamie Baisden, MD, Surgical Treatment Chair; Thomas Gilbert, MD, Diagnosis/Imaging Chair; D. Scott Kreiner, MD, Medical/Interventional Treatment Chair; Daniel Resnick, MD, Natural History Chair; Christopher Bono, MD; Gary Ghiselli, MD; Michael Heggeness, MD, PhD; Daniel Mazanec, MD; Conor O'Neill, MD; Charles Reitman, MD; William O. Shaffer, MD; Jeffrey Summers, MD; John Toton, MD

All participants involved in guideline development have disclosed potential conflicts of interest to their colleagues and their potential conflicts have been documented for future reference. They will not be published in any guideline, but kept on file for reference, if needed. Participants have been asked to update their disclosures regularly throughout the guideline development process.

This is the current release of the guideline.

This guideline updates a previous version: North American Spine Society (NASS). Phase III clinical guidelines for multidisciplinary spine care specialists. Spinal stenosis version 1.0. LaGrange (IL): North American Spine Society (NASS); 2002. 91 p.

None available

None available

This NGC summary was completed by ECRI on July 9, 2003. The information was verified by the guideline developer on November 26, 2003. This summary was updated October 25, 2004. This summary was updated on May 3, 2005 following the withdrawal of Bextra (valdecoxib) from the market and the release of heightened warnings for Celebrex (celecoxib) and other nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on June 16, 2005, following the U.S. Food and Drug Administration advisory on COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on October 3, 2005, following the U.S. Food and Drug Administration advisory on Paxil (paroxetine). This summary was updated by ECRI on December 12, 2005, following the U.S. Food and Drug Administration advisory on Paroxetine HCL - Paxil and generic paroxetine. This summary was updated by ECRI on May 31, 2006 following the U.S. Food and Drug Administration advisory on Paxil (paroxetine hydrochloride). This summary was updated by ECRI on November 16, 2006, following the FDA advisory on Lamictal (lamotrigine). This summary was updated by ECRI Institute on May 17, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Gadolinium-based contrast agents. This summary was updated by ECRI Institute on June 20, 2007 following the U.S. Food and Drug Administration (FDA) advisory on gadolinium-based contrast agents. This NGC summary was updated by ECRI Institute on November 26, 2007. The updated information was verified by the guideline developer on December 6, 2007.

Full-text guidelines can only be acquired through the North American Spine Society (NASS). Questions regarding use and reproduction should be directed to NASS, attention Belinda Duszynski, Manager of Research and Quality Improvement.