Lumbar spinal stenosis (LSS) is a frequent cause of chronic low back and lower extremity pain in older patients. Symptomatic LSS typically is described as neurogenic claudication consisting of pain, weakness, numbness, and/or fatigue arising in the back and radiating into the buttock, thigh, or lower leg. The diagnosis is complicated by lack of reliable clinical or x-ray criteria. North American Spine Society guidelines recommend magnetic resonance imaging study without contrast to confirm anatomic narrowing of the spinal canal or nerve root impingement. Conservative management options include exercise and drug therapy. Epidural injections can be considered for temporary symptom management. No studies show greater effectiveness of surgical intervention over conservative management in patients with mild to moderate symptoms. Progressive symptoms, emergence of frank neurologic deficit, or findings consistent with cauda equina syndrome are indications to pursue surgical evaluation. Decompression surgery without fusion typically is recommended in the absence of spondylolisthesis or other spinal instability. Active rehabilitation is likely more effective than usual care for improvement in functional status within 12 months postoperatively without adverse events. Approximately one-third to one-half of patients with mild to moderate LSS symptoms may have a favorable prognosis.