Lumbar spinal stenosis and lumbar disc herniation are both degenerative diseases of the lumbar spine and are often confused, but there are many differences between the two diseases. For example, lumbar spinal stenosis is more likely to occur in people over 50 years of age, while lumbar disc herniation is more likely to occur in young people between the ages of 20 and 30. Patients with lumbar spinal stenosis may not experience any discomfort at rest, but if they walk or stand for a long time, they may experience radioactive pain, numbness, or weakness in the lower extremities. Patients with lumbar spinal stenosis can often ride a bicycle and push a car inside a supermarket for a long time. The radiating pain in the lower extremities of lumbar disc herniation tends to be persistent and difficult to be relieved by squatting or lying down. The clinical manifestations of the two diseases are different because their pathogenesis is different. Lumbar spinal stenosis is caused by a herniated disc, osteophytes of the synovial joint, hypertrophy of the ligamentum flavum, degenerative slippage and other factors resulting in a decrease in the diameter of the central spinal canal, lateral spinal canal or neural foramen of the lumbar spine. When walking or standing for a long time, the pressure in the spinal canal increases resulting in poor venous return and nerve root ischemia resulting in pain. At this time, if the lumbar spine is flexed, the narrowing of the spinal canal is reduced because the intervertebral disc and ligamentum flavum are “flattened” to some extent, thus reducing the symptoms. This is why patients are less likely to experience pain when riding a bicycle or pushing a cart. The pain of lumbar disc herniation is due to a number of inflammatory reactions caused by disc herniation, rupture of the annulus fibrosus, and exposure of the nucleus pulposus tissue. Neurogenic intermittent claudication in lumbar spinal stenosis needs to be differentiated from vascular intermittent claudication in arterial obstructive disease of the lower extremities. The latter may be characterized by decreased arterial pulsation and decreased skin temperature in the lower extremities and does not present with the pain on standing and relief of lumbar flexion that is characteristic of patients with lumbar spinal stenosis. The degree of lumbar spinal stenosis needs to be assessed by CT and MRI. Patients generally read the CT and MRI imaging reports carefully, but I prefer that they ask their orthopedic surgeon to interpret the condition reflected in the films. This is because, in most people over the age of 40 who have these tests, the reports will show things like “bulging disc”, “herniated disc”, “spinal stenosis”, and “dural sac compression”. The words “dural sac compression” and even “nerve root compression” will undoubtedly cause a lot of psychological stress to the patient. In fact, many imaging stenoses do not necessarily compress nerves or produce clinical symptoms. In other words, only spinal stenosis that corresponds to the patient’s clinical presentation makes sense for a diagnosis of lumbar spinal stenosis. Lumbar spinal stenosis is different from lumbar disc herniation. The latter is an inflammatory reaction due to a herniated nucleus pulposus, and the symptoms will be relieved when the inflammation subsides with anti-inflammatory treatment and time. Lumbar spinal stenosis, on the other hand, is a series of symptoms due to increased pressure in the spinal canal caused by spinal stenosis, and therefore responds to anti-inflammatory drugs and analgesics in general. You can do lumbar back exercises, because patients with lumbar spinal stenosis are more or less accompanied by some instability factors that cause symptoms, so strengthening the lumbar back muscles can delay the progress of the disease to some extent by increasing the stability of the lumbar spine. It is also possible to wear a lumbar spine support for a short period of time, not recommended to exceed 2 weeks. The natural course of lumbar spinal stenosis is that approximately one-third to one-half of patients will improve clinically and approximately 15% will have significant deterioration. The rest of the patients may be in a state of repeated fluctuations and slow progression. Are you in that group of patients? When do you choose to continue observation and conservative treatment? When do you need to consider surgery? These are the questions to think about. If your symptoms are not very severe, for example, you can walk more than 2-3 km without difficulty although you have some pain in your lower extremities, and you have not had the disease for a long time or with low frequency (1-2 times a year, or only after exertion), you belong to the first group of patients and can continue to be observed. If you can walk only 300-500 meters or less and need to rest, or if you have numbness and weakness in the lower extremities, and if conservative treatment has been ineffective for many years or is progressively aggravated, or if you even have numbness in the perineal area and have difficulty controlling your bowel movements, you should consider surgery. The above two cases are actually easy to decide, but it is difficult to choose the third case, that is, the symptoms are sometimes good and sometimes bad, and when they are good, they are not normal, and when they are bad, they are not unable to go down. Through long follow-up, we did observe a phenomenon, that is, this part of the “bad” patients with surgery and non-surgical patients 20 years later, their situation may be similar. In other words, the operated patients may improve very well for a while after surgery, but gradually problems will appear again, while the non-operated patients may have a slow decline and some improvement in the later years (this improvement is the result of severe degeneration of the lumbar spine instead of spontaneous stabilization). So how do we choose? At this point I advocate letting the patient think and choose from the perspective of his or her actual condition and his or her quality of life requirements. If you are 50-60 years old and still in good health except for this problem, or if your job requires it, or if you have more hobbies and need to have a higher quality of life, and the problems of the lumbar spine greatly affect your requirements above, then I suggest you consider surgery. After all, this surgery can greatly improve your quality of life. Although the efficacy of the surgery may be compromised after a number of years, at least it can buy you a lot of time. If you are approaching 70 years of age and still have some minor health problems such as hypertension, diabetes, etc., I would recommend that you watch closely for 1-2 years and if your lumbar spine problems are progressing and your spinal stenosis is indeed significant, I would also recommend surgery because the disease will progress and if you delay until after 75 years of age, then the symptoms may be worse and your fears about your body tolerating the surgery will not be better. If you delay until you are 75 years old, then your symptoms may get worse, and your fear that your body will tolerate the surgery worse rather than better, then it is better to have the surgery sooner rather than later, so that you have fewer problems to solve in your later years.