Lumbar Spinal Stenosis

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada, 2018).
• Patient and contextual information: age; sex and gender when clinically relevant; preferred language and communication needs; work or school; caregiving; mobility and transportation; and activities, roles, cultural practices and community connections important to the patient.

Primary concerns

• Onset and course: gradual or sudden onset; first episode or recurrence; duration; recent trauma, illness, surgery or change in activity; previous lumbar symptoms; and whether symptoms are improving, stable, fluctuating or worsening.
• Back and leg symptom pattern: location, intensity, quality, duration and irritability of back, buttock and leg symptoms; unilateral or bilateral distribution; numbness, tingling, heaviness, cramping or weakness; standing and walking tolerance; effect of sitting, bending forward, cycling, stairs, hills and lumbar position; and time to ease after stopping.
• Neurological and gait concerns: new or progressive weakness, foot drop, falls, balance change, altered sensation, saddle or perineal sensation, bladder, bowel or sexual change, hand clumsiness, neck symptoms and change in walking pattern or confidence.
• Functioning and participation: effects on walking, standing, transfers, self-care, household tasks, work or school, caregiving, driving, sleep, recreation, physical activity, social roles, community mobility and independence; use of rest, rails, shopping carts, walking aids or mobility devices.
• Body systems review: constitutional symptoms; neurological; cardiovascular and peripheral vascular; genitourinary and gastrointestinal; musculoskeletal and bone health; immune, infectious or inflammatory; endocrine or metabolic; respiratory; skin; haematologic or bleeding; sleep; cognition; and mood symptoms that may change safety, the differential diagnosis, medication decisions or referral.
• Health and safety context: cancer or infection history; osteoporosis or fracture risk; inflammatory disease; diabetes; peripheral arterial or other cardiovascular disease; kidney, liver, gastrointestinal or respiratory conditions; neurological disease; falls; pregnancy when relevant; recent surgery, hospitalization or immobilization; and current medications and supplements, including analgesics, anticoagulants, corticosteroids and medicines that may affect balance.
• Spine, hip and lower-limb history: previous spinal diagnosis, imaging, injections or surgery; hip, knee, ankle or foot symptoms; peripheral neuropathy; lower-limb injury or surgery; and the current medical or specialist plan when available.
• Physical activity and broader health: current and preferred activity; walking environment; strength, balance and aerobic capacity; nutrition; sleep; smoking; alcohol or substance use; and readiness for health-related change without assuming these factors explain the symptoms.
• Social and access context: work or school demands and support, caregiving, income, housing, food security, transportation, discrimination, safety, social support, access to care, technology and suitable space or equipment (Public Health Agency of Canada, 2026).
• Previous care and responses: education, activity change, exercise, rehabilitation, hands-on care, walking aids, medication, injection, other medical care and culturally grounded approaches tried; benefits, adverse effects, burden and reasons care was difficult to use or continue.
• Patient perspective: understanding of LSS and imaging, concerns about damage or deterioration, priorities, preferences, cultural context, expectations, confidence, strengths, previous experiences of care and interest in medical or surgical assessment.
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant. Reassess when symptoms, walking, neurological status or general health change.

Outcome measures

• Choose a small set that reflects the patient’s goals and can be repeated. Record the walking test, footwear, gait aid, pace, posture and stopping rule so results can be compared.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Quality of life: WHOQOL-BREF or another suitable validated measure.
• LSS symptoms and walking: the Swiss Spinal Stenosis Questionnaire, also called the Zurich Claudication Questionnaire, can track symptom severity and physical functioning. A repeatable observed walking distance or time and standing or walking symptoms can be added when useful (Anderson et al., 2025).
• Individual goals and recovery: agree on patient-defined goals and how progress will be recognized. A global rating of change or recovery can support review when useful.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change safety, the working diagnosis, care or referral. Adapt positioning, pace and loading to symptoms, comfort, consent, mobility, balance and other health conditions.

• Ongoing consent and comfort: explain each step, provide choices, ask permission before touch or exposure, and stop or modify the examination when requested.
• Immediate safety and observation: observe general appearance, posture, transfers and spontaneous movement; record vital signs when systemic or vascular concerns are present; and inspect for trauma, skin change, muscle wasting, asymmetry or another finding that changes urgency.
• Walking and gait: observe usual and, when safe, symptom-provoking walking. Record distance or time to symptom onset and stopping, distribution and intensity of symptoms, posture, gait quality, balance, aid use and recovery with sitting or flexion (Tomkins-Lane et al., 2020; Anderson et al., 2025).
• Neurological examination: assess lower-limb strength, sensation and reflexes, including relevant myotomes and dermatomes; note atrophy, foot drop, neural tension findings and symptom symmetry. Add upper motor neuron testing and upper-limb findings when myelopathy is plausible.
• Lumbar movement and symptom response: assess active movement and relevant sustained or repeated positions as tolerated. Record whether extension, standing or walking reproduces symptoms and whether sitting or flexion changes them; a response to position supports but does not establish the diagnosis.
• Balance and functional performance: select meaningful tasks such as sit-to-stand, stairs, single-leg stance, turning, carrying, work or caregiving tasks. Record quality, capacity, symptoms, confidence, aid use and falls risk.
• Vascular, hip and differential examination: assess foot pulses and skin perfusion, and add ankle-brachial pressure index through appropriate medical or vascular care when indicated. Examine the hip and screen for cervical myelopathy, peripheral neuropathy or another neurological or lower-limb source when the presentation warrants it (Tomkins-Lane et al., 2020; National Institute for Health and Care Excellence, 2020).
• Imaging and other investigations: imaging is not used to explain symptoms in isolation. MRI is the usual advanced test when confirmation is needed and the result is likely to change medical, surgical or rehabilitation decisions. Imaging and medical investigation are arranged sooner when Red Flags or progressive neurological findings are present (American College of Radiology, 2021; Zileli et al., 2020).
• Reassessment: repeat the findings and tasks needed to review progress, revisit the working presentation, identify adverse effects and decide whether further assessment, imaging or referral is appropriate.

Working clinical presentations

Use these as working clinical descriptions rather than fixed stages or definitive tissue diagnoses. They can overlap or change. Symptoms, examination findings and imaging are interpreted together.

• Neurogenic claudication presentation: buttock or leg pain, heaviness, cramping, numbness, tingling or weakness, with or without low back pain, is brought on by standing or walking and eases with sitting or lumbar flexion. Symptoms can be bilateral, asymmetric or unilateral (Zileli et al., 2020).
• Radicular pain or radiculopathy associated with lateral recess or foraminal stenosis: radicular pain is suspected to arise from a lumbar nerve root and may follow a dermatomal distribution; radiculopathy refers to objective motor, sensory or reflex impairment and may occur with or without prominent pain. Record symptom duration, irritability, functional effect and whether neurological findings are stable or progressive. Progressive motor loss changes the urgency of referral.
• Mobility, balance or deconditioning presentation: reduced walking tolerance, lower-limb strength, balance, confidence or aerobic capacity affects independence, falls risk or valued activities alongside the spinal symptoms.
• Persistent or high-impact presentation: symptoms substantially affect walking, sleep, mood, work, caregiving, community mobility or participation despite acceptable care, or broader medical, rehabilitation or specialist shared care is needed.
• Alternative or overlapping presentation: vascular claudication, hip disease, peripheral neuropathy, cervical myelopathy, another lumbar disorder or a serious condition may mimic or coexist with LSS. Revisit Red Flags and the differential when the pattern changes or findings do not fit.

Base care on the working clinical presentation, safety, symptom duration, irritability, neurological status, goals, context and response. Use adaptable options and repeat meaningful outcomes to guide change.

Education and self-management

• Understanding the presentation: explain whether current findings fit neurogenic claudication, radicular pain or radiculopathy, or an overlapping presentation; explain the imperfect link between imaging and symptoms, the variable course and the role of repeated assessment. Use imaging language that does not imply inevitable damage or decline (Zileli et al., 2020).
• Planning for daily life: pacing, task variation, brief recovery positions, route planning, suitable seating and changes to work, caregiving or home tasks can help the patient stay engaged in valued activities.

Physical activity, exercise and rehabilitation

• Neurogenic claudication – activity and exercise: options include symptom-guided walking or cycling, lower-limb and trunk strengthening, aerobic exercise, balance practice and repeated functional tasks. Flexion-tolerant positions or walking supports can be used when they improve tolerance; type and progression reflect capacity and response (Bussières et al., 2021; Ammendolia et al., 2022).
• Neurogenic claudication – multimodal care: education, advice or behaviour-change support can be combined with home or supervised exercise and manual therapy (Bussières et al., 2021; Ammendolia et al., 2022).
• Radicular pain or radiculopathy: use the CCG Low Back Pain Care Pathway for presentation-specific exercise, hands-on care, imaging and referral decisions, and neurological monitoring.

Hands-on and symptom-relieving care

• Hands-on care for neurogenic claudication: lumbar or hip mobilization and soft-tissue techniques can form part of multimodal care with exercise and education (Ammendolia et al., 2022).
• Acupuncture for neurogenic claudication: a time-limited trial is an option when within scope, with response tracked against agreed outcomes (Bussières et al., 2021; Chen et al., 2026).
• Symptom relief: heat, relaxation, breathing practices, massage or another acceptable comfort strategy can support sleep, movement or activity when safe. Protect skin and circulation and review whether the approach is helping the agreed goal.

Mobility and participation supports

• Walking and mobility aids: a cane, poles, walker, rollator or other mobility aid can improve safety, confidence, posture or walking tolerance. Fit, skill, environment and the effect on symptoms are reviewed.
• Home, community and work supports: occupational therapy, workplace changes, transportation support, falls-prevention services and community programs can help with independence and participation.

Psychological, social and culturally grounded support

• Coping and behaviour support: pain-coping skills, graded activity, goal setting and support for fear, mood, sleep or distress can form part of care when these match the patient’s priorities.
• Culturally grounded approaches: traditional, Indigenous, spiritual or community-based approaches identified by the patient can be integrated when safe, acceptable and within scope, with coordination across practitioners when needed.

Medication and medical shared care

• Medication review: medication decisions sit with an authorized prescriber or pharmacist. Review intended benefit, adverse effects, sedation, falls risk, kidney, liver, gastrointestinal and cardiovascular health, other medicines, polypharmacy and the patient’s priorities. Evidence for medicines used specifically for LSS-related neurogenic claudication is limited (Bussières et al., 2021).
• Specialist assessment: referral can be arranged for progressive neurological findings, persistent disabling symptoms, substantial diagnostic uncertainty or when the patient wants to discuss imaging, injection or surgical options. Emergency findings follow Red Flags (Fornari et al., 2020).

Monitoring and reassessment

• Agree on a reassessment point based on the presentation, safety, goals, care being tried, patient needs and access rather than a fixed visit schedule.
• Review the baseline outcome set, symptoms, walking and standing tolerance, functioning, participation, balance, benefits, harms and goals. Continue, adapt or stop care according to response.
• Neurological monitoring: repeat lower-limb motor, sensory, reflex and gait findings when radiculopathy is present or radicular symptoms change. Progressive weakness, worsening sensory loss, functional decline, new bilateral findings or cauda equina features follow the Red Flags and referral actions.
• Revisiting care: revisit Red Flags, the working presentation, differential diagnosis, imaging, referral or shared care when progress differs from expectations or new safety concerns emerge.

• Expected course: among adults with symptomatic LSS managed non-surgically, pain and disability may improve during the first year, while individual courses vary and progression is not inevitable. This low-certainty group evidence cannot predict an individual outcome, and imaging severity alone does not determine the outlook (McAuliffe et al., 2026; Zileli et al., 2020).
• Factors associated with a less favourable course: greater symptom and activity limitation, longer symptom duration, neurological deficits, and coexisting degenerative spondylolisthesis or scoliosis may be associated with poorer outcomes. These are group-level associations, not certain causes or individual predictions (Zileli et al., 2020).
• Radicular pain or radiculopathy: base prognosis on the suspected cause, symptom severity and neurological course, using the CCG Low Back Pain Care Pathway for presentation-specific evidence.
• Potential supports for recovery: for neurogenic claudication, feasible activity and exercise, pacing, coping skills, suitable mobility aids, supportive relationships and workplaces, care for relevant health conditions, access to rehabilitation and timely shared care may support walking, functioning and participation (Bussières et al., 2021).
• Discussing prognosis: describe uncertainty in plain language, ask what the patient wants to know, and update the outlook using goals, repeated outcomes, neurological findings and the observed response over time. Do not treat age, an imaging grade or a single score as a fixed prediction.