What non-surgical management strategies should be considered for patients with lumbar spinal stenosis who have mild to moderate symptoms?

For patients with lumbar spinal stenosis presenting with mild to moderate symptoms, non-surgical management strategies should focus on conservative approaches including tailored advice and information to support self-management, encouragement to remain active, and participation in exercise programmes.

Specifically, patients should be provided with information about the nature of their condition and encouraged to continue with normal activities to maintain function and mobility. Group exercise programmes that may include biomechanical, aerobic, mind–body, or combined approaches should be considered within the NHS, taking into account the patient's specific needs, preferences, and capabilities.

Manual therapy such as spinal manipulation, mobilisation, or soft tissue techniques (e.g., massage) can be considered but only as part of a treatment package that includes exercise, with or without psychological therapy.

Psychological therapies using a cognitive behavioural approach may also be considered as part of a combined physical and psychological programme, especially if there are significant psychosocial obstacles to recovery or if previous treatments have not been effective.

Pharmacological management should be cautious: oral NSAIDs may be considered at the lowest effective dose for the shortest period, taking into account individual risk factors. Opioids, gabapentinoids, antidepressants, and spinal injections are not recommended for managing low back pain or sciatica related to spinal stenosis.

Imaging is not routinely recommended unless it is likely to change management, and belts, corsets, foot orthotics, traction, acupuncture, and electrotherapies are not advised.

Return-to-work or normal daily activities should be promoted and facilitated as part of the management plan.

In summary, the key non-surgical strategies are:

• Tailored advice and information to support self-management and encourage activity
• Exercise programmes adapted to patient needs
• Manual therapy as part of a package including exercise
• Psychological therapies combined with physical treatment if indicated
• Careful use of oral NSAIDs if appropriate
• Promotion of return to work or normal activities

These approaches align with NICE guideline NG59 on low back pain and sciatica in over 16s: assessment and management ¹.