Spine, Neck & Back

Lumbar Spinal Stenosis

Lumbar spinal stenosis is a narrowing of the spinal canal or nerve root tunnels (foramina) in the lower back that compresses the spinal nerves and causes leg pain, heaviness, and fatigue with walking. It is among the most common spinal diagnoses in adults over 60 and a leading reason for disability in older Americans. At Maryland Orthopedic Specialists, we offer a non-operative approach (including physical therapy, activity modification, and epidural steroid injections) that allows most patients to manage their symptoms effectively and maintain an active lifestyle.

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What is lumbar spinal stenosis?

The lumbar spinal canal is bounded anteriorly by the vertebral bodies and discs, posteriorly by the facet joints and ligamentum flavum, and laterally by the pedicles. Degenerative changes over time (disc height loss, facet joint hypertrophy, ligamentum flavum thickening, and osteophyte formation) progressively reduce the space available for the cauda equina and exiting nerve roots.

Central stenosis refers to narrowing of the central canal, producing compression of multiple nerve roots of the cauda equina. Symptoms typically affect both lower extremities and are characteristically brought on by walking and standing (axial loading) and relieved by sitting or forward flexion.

Foraminal (lateral) stenosis refers to narrowing of the intervertebral foramen through which a single nerve root exits. This more often produces a unilateral radicular pattern similar to disc herniation, and it may coexist with central stenosis.

The most commonly affected levels are L4–L5 and L3–L4, reflecting the greatest degenerative burden in the lumbar spine.

Symptoms — do you recognize these?

The hallmark of lumbar spinal stenosis is **neurogenic claudication**: lower extremity symptoms (pain, heaviness, tingling, cramping, or weakness) provoked by walking or prolonged standing and relieved by sitting or lumbar flexion (leaning forward on a shopping cart, for example). This postural dependence distinguishes neurogenic claudication from vascular claudication and from lumbar disc herniation. Patients may also report:

Low back pain or buttock aching
Leg weakness with sustained activity
Numbness or tingling affecting one or both legs
Symptoms that are better riding a bicycle than walking (because cycling maintains a flexed lumbar posture)
Relief: Neurogenic — Sitting or flexion; Vascular — Standing still
Onset: Neurogenic — Walking + standing; Vascular — Walking only
Bicycle riding: Neurogenic — Well-tolerated; Vascular — Produces symptoms
Pulses: Neurogenic — Normal; Vascular — Reduced
Skin changes: Neurogenic — None; Vascular — Hair loss, pallor

Call us at (301) 515-0900. Same-day appointments available at our Bethesda and Germantown locations. Rapidly progressive weakness or bowel/bladder dysfunction requires urgent evaluation.

How we diagnose it

Clinical examination documents walking tolerance, the presence of a wide-based gait, lower extremity neurological deficits (motor strength, sensation, reflexes), and the postural nature of symptoms. The tandem gait test is a sensitive screen for neurological compromise.

Imaging:

MRI of the lumbar spine is the gold-standard imaging study, providing cross-sectional views of the thecal sac, disc-level anatomy, facet arthropathy, and ligamentum flavum thickness. MRI allows grading of central canal and foraminal stenosis severity.
Standing plain radiographs (including flexion-extension views) assess spinal alignment, disc height, and dynamic instability (spondylolisthesis).
CT myelography provides complementary information when MRI is contraindicated or when surgical planning requires detailed bony anatomy.

Vascular consultation or ankle-brachial index (ABI) testing may be ordered when vascular claudication cannot be excluded clinically, given that the two conditions can coexist in older adults.

Treatment options

Most patients with lumbar spinal stenosis manage symptoms well with non-operative care.

Physical Therapy

Flexion-based exercises open the spinal canal and are the foundation of stenosis management. Leaning slightly forward while walking or exercising takes pressure off the compressed nerves. Aquatic therapy is especially helpful for patients whose walking is significantly limited, since buoyancy reduces the load on the spine. Core stabilization training reduces the mechanical stress on the narrowed spinal segments and helps patients stay active long term.

Activity Modification

Walking with a slight forward lean, using poles or a walker, and choosing cycling over running are practical ways to reduce neurogenic claudication during daily activity. Favoring a flexed lumbar posture (which cycling naturally provides) allows patients to stay aerobically fit without aggravating symptoms. Avoiding prolonged standing and extension activities helps prevent flares.

Epidural Steroid Injection

Epidural steroid injections reduce nerve inflammation and can meaningfully improve walking tolerance during flares. They are most useful as a bridge while physical therapy progresses, giving patients enough relief to participate in rehabilitation. Effects can last months, and repeat injections can be used strategically when symptoms return.

Surgical Referral

For patients who have tried 3–6 months of conservative care and still have significant limitations, decompression surgery is very effective and is coordinated with a surgical specialist. The decision to pursue surgery is always made collaboratively between the patient and the surgical team.

Recovery & rehabilitation

The natural history of lumbar spinal stenosis is variable. Symptoms fluctuate over time, and a meaningful proportion of patients remain stable or improve without surgery. Non-operative management substantially improves function and pain in most patients. Patients who participate in regular PT, maintain core conditioning, and use injections strategically can often sustain high levels of daily activity for years. Ongoing monitoring is appropriate, particularly if neurological symptoms change.

Frequently Asked Questions

Does lumbar stenosis always get worse?

Not necessarily. Studies show that roughly 70% of patients with mild-to-moderate stenosis remain stable or improve over 4 years without surgery. Symptoms fluctuate, and non-operative management can meaningfully delay or prevent the need for surgical intervention.

How many epidural injections can I have?

Generally, up to three epidural steroid injections are recommended per 12-month period, with retreatment based on the degree of response. Your MOS physician will guide the optimal injection schedule.

Is walking harmful with stenosis?

Walking is generally encouraged within your symptom tolerance. Short, frequent walks with adequate rest breaks are preferable to prolonged forced marching. Activity modification, not rest, is key.

Can stenosis cause permanent nerve damage?

Cauda equina syndrome (bowel/bladder dysfunction from severe central compression) is a surgical emergency requiring immediate evaluation. Outside of this rare scenario, most patients do not sustain permanent nerve damage from managed lumbar stenosis.

Will a back brace help?

A lumbar flexion orthosis can reduce symptoms during high-demand activities. Its role is primarily as a symptomatic aid, not a structural correction.

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Medically reviewed by Christopher S. Raffo, MD

Last reviewed May 1, 2026

References

Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. "Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults." JAMA 2010;303(13):1259–1265. https://doi.org/10.1001/jama.2010.338
Friedly JL, Comstock BA, Turner JA, et al. "A randomized trial of epidural glucocorticoid injections for spinal stenosis." New England Journal of Medicine 2014;371(1):11–21. https://doi.org/10.1056/NEJMoa1313265
Ammendolia C, Stuber K, de Bruin LK, et al. "Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication: a systematic review." Spine 2012;37(10):E609–E616. https://doi.org/10.1097/BRS.0b013e318240d57d
Lurie J, Tomkins-Lane C. "Management of lumbar spinal stenosis." BMJ 2016;352:h6234. https://doi.org/10.1136/bmj.h6234
North American Spine Society. "Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis." Spine 2008. https://doi.org/10.1097/BRS.0b013e31817f8f30
OrthoInfo / AAOS. "Spinal Stenosis." https://orthoinfo.aaos.org/en/diseases--conditions/spinal-stenosis/