Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis: A Randomized Clinical Trial

Effect of Acupuncture on Neurogenic Claudication Among Patients With Degenerative Lumbar Spinal Stenosis : A Randomized Clinical Trial

BACKGROUND

Acupuncture may improve degenerative lumbar spinal stenosis (DLSS), but evidence is insufficient.

OBJECTIVE

To investigate the effect of acupuncture for DLSS.

DESIGN

Multicenter randomized clinical trial. (ClinicalTrials.gov: NCT03784729).

SETTING

5 hospitals in China.

PARTICIPANTS

Patients with DLSS and predominantly neurogenic claudication pain symptoms.

INTERVENTION

18 sessions of acupuncture or sham acupuncture (SA) over 6 weeks, with 24-week follow-up after treatment.

MEASUREMENTS

The primary outcome was change from baseline in the modified Roland-Morris Disability Questionnaire ([RMDQ] score range, 0 to 24; minimal clinically important difference [MCID], 2 to 3). Secondary outcomes were the proportion of participants achieving minimal (30% reduction from baseline) and substantial (50% reduction from baseline) clinically meaningful improvement per the modified RMDQ.

RESULTS

A total of 196 participants (98 in each group) were enrolled. The mean modified RMDQ score was 12.6 (95% CI, 11.8 to 13.4) in the acupuncture group and 12.7 (CI, 12.0 to 13.3) in the SA group at baseline, and decreased to 8.1 (CI, 7.1 to 9.1) and 9.5 (CI, 8.6 to 10.4) at 6 weeks, with an adjusted difference in mean change of -1.3 (CI, -2.6 to -0.03; P = 0.044), indicating a 43.3% greater improvement compared with SA. The between-group difference in the proportion of participants achieving minimal and substantial clinically meaningful improvement was 16.0% (CI, 1.6% to 30.4%) and 12.6% (CI, -1.0% to 26.2%) at 6 weeks. Three cases of treatment-related adverse events were reported in the acupuncture group, and 3 were reported in the SA group. All events were mild and transient.

LIMITATION

The SA could produce physiologic effects.

CONCLUSION

Acupuncture may relieve pain-specific disability among patients with DLSS and predominantly neurogenic claudication pain symptoms, although the difference with SA did not reach MCID. The effects may last 24 weeks after 6-week treatment.

PRIMARY FUNDING SOURCE

2019 National Administration of Traditional Chinese Medicine "Project of building evidence-based practice capacity for TCM-Project BEBPC-TCM" (NO. 2019XZZX-ZJ).

Pain-related single nucleotide polymorphisms: association with lumbar spinal stenosis patient experience and non-surgical treatment outcomes

PURPOSE

Lumbar spinal stenosis (LSS) is common in our aging population resulting in pain and functional impairment. Recent advances in pain research have identified several single nucleotide polymorphisms (SNP) associated with inter-individual symptom and treatment response. The goal of the current study was to investigate the association of SNPs in Neuropeptide Y (NPY) and Catechol-O-methyltransferase (COMT) with pain, function, and treatment outcomes in Lumbar spinal stenosis (LSS) patients receiving non-surgical treatments.

METHODS

An exploratory observational biomarker study was performed ancillary to a previously published clinical trial evaluating three different non-surgical treatments for LSS. Saliva samples were obtained for single nucleotide polymorphism genotyping and blood samples were collected for NPY protein. Data on pain and function collected as part of the clinical trial at baseline, 2 and 6 months were examined for association with known polymorphisms in NPY and COMT.

RESULTS

Subjects with the NPY rs16147 TT genotype exhibited higher baseline symptom severity but also a higher likelihood of responding to non-surgical treatments. Subjects with the COMT rs4680 GG genotype also exhibited higher baseline symptom severity but did not demonstrate greater response to treatment.

CONCLUSIONS

NPY rs16147 and COMT rs4680 are important potential biomarkers associated with pain and function. NPY genotype may be useful in predicting response to non-surgical treatments in older adults with LSS.

Healthcare burden changes by restricted physical activities in lumbar spinal stenosis and spondylolisthesis: a retrospective large cohort study during the COVID-19 pandemic

BACKGROUND

Lumbar spinal stenosis (LSS) and spondylolisthesis (SPL) are characterized as degenerative spinal pathologies and share considerable similarities. However, opinions vary on whether to recommend exercise or restrict it for these diseases. Few studies have objectively compared the effects of daily physical activity on LSS and SPL because it is impossible to restrict activities ethnically and practically. We investigated the effect of restricting physical activity due to social distancing (SoD) on LSS and SPL, focusing on the aspect of healthcare burden changes during the pandemic period.

METHODS

We included first-visit patients diagnosed exclusively with LSS and SPL in 2017 and followed them up for two years before and after the implementation of the SoD policy. As controls, patients who first visited in 2015 and were followed for four years without SoD were analyzed. The common data model was employed to analyze each patient's diagnostic codes and treatments. Hospital visits and medical costs were analyzed by regression discontinuity in time to control for temporal effects on dependent variables.

RESULTS

Among 33,484 patients, 2,615 with LSS and 446 with SPL were included. A significant decrease in hospital visits was observed in the LSS (difference, -3.94 times/month·100 patients; p = 0.023) and SPL (difference, -3.44 times/month·100 patients; p = 0.026) groups after SoD. This decrease was not observed in the data from the control group. Concerning medical costs, the LSS group showed a statistically significant reduction in median copayment (difference, -$45/month·patient; p < 0.001) after SoD, whereas a significant change was not observed in the SPL group (difference, -$19/month·patient; p = 0.160).

CONCLUSION

Restricted physical activity during the SoD period decreased the healthcare burden for patients with LSS or, conversely, it did not significantly affect patients with SPL. Under circumstances of physical inactivity, patients with LSS may underrate their symptoms, while maintaining an appropriate activity level may be beneficial for patients with SPL.

The chiropractors' dilemma in caring for older patients with musculoskeletal complaints: Collaborate, integrate, coexist, or separate?

The world's elderly population is growing at a rapid pace. This has led to an increase in demand on the health and welfare systems due to age-related disorders, with musculoskeletal complaints driving the need for rehabilitation services. However, there are concerns about health services' ability to meet this demand. While chiropractic care is gaining recognition for its benefits in treating older adults with musculoskeletal disorders, there is limited scientific literature on chiropractors' role and experiences in this area. To bridge this gap, we interviewed 21 chiropractors in Great Britain, the Netherlands, Norway, and Sweden. Inductive qualitative content analysis was used to analyse the interviews, and despite differences in integration and regulation between the countries, several common facilitators and barriers in caring for and managing older patients with musculoskeletal complaints emerged. While participants expressed optimism about future collaborations with other healthcare professionals and the integration of chiropractic into national healthcare systems, they also highlighted significant concerns regarding the existing healthcare infrastructure. The participants also felt that chiropractors, with their non-surgical and holistic approach, were well-positioned to be the primary point of contact for older patients. However, there were some common barriers, such as the affordability of care, limited integration of chiropractic, and the need to prioritise musculoskeletal complaints within public healthcare. Our findings suggest that chiropractors experience their clinical competencies as an underutilised resource in the available healthcare systems and that they could contribute to and potentially reduce the escalating burden of musculoskeletal complaints and associated costs among older patients. Additionally, our findings highlight the desire among the participants to foster collaboration among healthcare professionals and integrate chiropractic into the national public healthcare system. Integrating chiropractors as allied health professionals was also perceived to improve coordinated, patient-centred healthcare for older adults.

Diagnosis and Treatment of Low Back Pain: Synopsis of the 2021 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline

ABSTRACT

Low back pain is a significant issue in the US Department of Veterans Affairs and Department of Defense populations as well as the general US population at large. This type of pain can be distressing to those who experience its effects, leading patients to seek relief of their symptoms. In 2022, leadership within the US Department of Veterans Affairs and US Department of Defense approved a joint clinical practice guideline for the management of low back pain. The guideline provides evidence-based recommendations for assessing and managing low back pain. Development of the guideline included a systematic evidence review, which was guided by 12 key questions. A multidisciplinary team, which included clinical stakeholders, reviewed the evidence that was retrieved and developed 39 recommendations using the Grading of Recommendations Assessment, Development, and Evaluation system. The scope of the clinical practice guideline is broad; however, the authors have focused on key recommendations that are important for clinicians in the evaluation and nonoperative treatment of low back pain, including pharmacologic therapies and both noninvasive and invasive nonpharmacologic treatments.

Spinal manipulation and electrical dry needling as an adjunct to conventional physical therapy in patients with lumbar spinal stenosis: a multi-center randomized clinical trial

BACKGROUND CONTEXT

Nonoperative management of lumbar spinal stenosis (LSS) includes activity modification, medication, injections, and physical therapy. Conventional physical therapy includes a multimodal approach of exercise, manual therapy, and electro-thermal modalities. There is a paucity of evidence supporting the use of spinal manipulation and dry needling as an adjunct to conventional physical therapy in patients with LSS.

PURPOSE

This study aimed to determine the effects of adding thrust spinal manipulation and electrical dry needling to conventional physical therapy in patients with LSS.

STUDY DESIGN/SETTING

Randomized, single-blinded, multi-center, parallel-group clinical trial.

PATIENT SAMPLE

One hundred twenty-eight (n=128) patients with LSS from 12 outpatient clinics in 8 states were recruited over a 34-month period.

OUTCOME MEASURES

The primary outcomes included the Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI). Secondary outcomes included the Roland Morris Disability Index (RMDI), Global Rating of Change (GROC), and medication intake. Follow-up assessments were taken at 2 weeks, 6 weeks, and 3 months.

METHODS

Patients were randomized to receive either spinal manipulation, electrical dry needling, and conventional physical therapy (MEDNCPT group, n=65) or conventional physical therapy alone (CPT group, n=63).

RESULTS

At 3 months, the MEDNCPT group experienced greater reductions in overall low back, buttock, and leg pain (NPRS: F=5.658; p=.002) and related-disability (ODI: F=9.921; p<.001; RMDI: F=7.263; p<.001) compared to the CPT group. Effect sizes were small at 2 and 6 weeks, and medium at 3 months for the NPRS, ODI, and RMDI. At 3 months, significantly (p=.003) more patients in the MEDNCPT group reported a successful outcome (GROC≥+5) than the CPT group.

CONCLUSION

Patients with LSS who received electrical dry needling and spinal manipulation in addition to impairment-based exercise, manual therapy and electro-thermal modalities experienced greater improvements in low back, buttock and leg pain and related-disability than those receiving exercise, manual therapy, and electro-thermal modalities alone at 3 months, but not at the 2 or 6 week follow-up.

Exercise treatments for lumbar spinal stenosis: A systematic review and intervention component analysis of randomised controlled trials

OBJECTIVE

To analyse the components used in exercise interventions for people with symptoms of neurogenic claudication due to lumbar spinal stenosis and identify components associated with successful interventions.

DATA SOURCES

Eligible papers published up to April 2023 from MEDLINE, EMBASE, CINAHL, PEDro, CENTRAL, Web of Science, and trial registry websites.

REVIEW METHODS

Literature searches were performed by an Information Specialist. We searched for randomised trials evaluating exercise interventions for people with neurogenic claudication symptoms (the primary symptom of lumbar spinal stenosis). Two authors independently performed study selection, data extraction, and quality assessments using the Cochrane Risk of Bias tool Version 2 and the TIDieR checklist for intervention reporting. Details of intervention components were extracted, tabulated, and synthesised using an intervention component analysis approach.

RESULTS

We found thirteen trials reporting 23 exercise interventions delivered to 1440 participants. These featured 60 different components. Most exercise interventions included supervision and flexion-based exercises. Balance exercises were rarely included. Exercise components featured more frequently in successful interventions included stretches, strength or trunk muscle exercises, fitness exercises, especially cycling, and psychologically informed approaches. Interpretation is limited by low study numbers and heterogeneity. No conclusions could be drawn about exercise supervision or dose.

DISCUSSION

Exercise interventions for people with neurogenic claudication typically feature multiple components. Common features such as supervision, lumbar flexion, and aerobic fitness exercises and also less common features such as stretches, strengthening exercises, and psychologically informed approaches warrant consideration for inclusion when designing and optimising exercise interventions for people with lumbar spinal stenosis.

Trends in Chiropractic Care and Physical Rehabilitation Use Among Adults with Low Back Pain in the United States, 2002 to 2018

BACKGROUND

While nonpharmacologic treatments are increasingly endorsed as first-line therapy for low back pain (LBP) in clinical practice guidelines, it is unclear if use of these treatments is increasing or equitable.

OBJECTIVE

Examine national trends in chiropractic care and physical rehabilitation (occupational/physical therapy (OT/PT)) use among adults with LBP.

DESIGN/SETTING

Serial cross-sectional analysis of the National Health Interview Survey, 2002 to 2018.

PARTICIPANTS

146,087 adults reporting LBP in prior 3 months.

METHODS

We evaluated the association of survey year with chiropractic care or OT/PT use in prior 12 months. Logistic regression with multilevel linear splines was used to determine if chiropractic care or OT/PT use increased after the introduction of clinical guidelines. We also examined trends in use by age, sex, race, and ethnicity. When trends were similar over time, we present differences by these demographic characteristics as unadjusted ORs using data from all respondents.

RESULTS

Between 2002 and 2018, less than one-third of adults with LBP reported use of either chiropractic care or OT/PT. Rates did not change until 2016 when uptake increased with the introduction of clinical guidelines (2016-2018 vs 2002-2015, OR = 1.15; 95% CI: 1.10-1.19). Trends did not differ significantly by sex, race, or ethnicity (p for interactions > 0.05). Racial and ethnic disparities in chiropractic care or OT/PT use were identified and persisted over time. For example, compared to non-Hispanic adults, either chiropractic care or OT/PT use was lower among Hispanic adults (combined OR = 0.62, 95% CI: 0.65-0.73). By contrast, compared to White adults, Black adults had similar OT/PT use (OR = 0.98; 95% CI: 0.94-1.03) but lower for chiropractic care use (OR = 0.50; 95% CI: 0.47-0.53).

CONCLUSIONS

Although use of chiropractic care or OT/PT for LBP increased after the introduction of clinical guidelines in 2016, only about a third of US adults with LBP reported using these services between 2016 and 2018 and disparities in use have not improved.

1. Lumbosacral radicular pain

INTRODUCTION

Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%.

METHODS

The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized.

RESULTS

Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers.

CONCLUSIONS

The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.

Novel approach of ultrasound-guided lateral recess block for a patient with lateral recess stenosis: A case report

BACKGROUND

Ultrasound guide technology, which can provide real-time visualization of the needle tip and tissues and avoid many adverse events, is widely used in minimally invasive therapy. However, the studies on ultrasound-guided Lateral recess block (LRB) are limited, this is probably because there is no recognized standard method for ultrasound scanning. This study aimed to evaluate the effect of ultrasound-guided LRB in patients with lateral recess stenosis (LRS).

CASE SUMMARY

A 65-year-old patient complained of low back pain accompanied occasionally by pain and numbness in the left lower limb. Physical examination showed tenderness on the spinous process and paraspinal muscles from L1 to S1, extensor hallucis longus and tibialis anterior weakness (muscle strength: 4-), and a positive straight leg raising test in the left lower limb (60°). Magnetic resonance imaging showed L4-L5 disc degeneration with left LRS and nerve root entrapment. Subsequently, the patient was diagnosed with LRS. This patient was treated with a novel ultrasound-guided LRB approach. The patient's symptoms significantly improved without any complications at 1 wk postoperatively and at the 3-month follow-up.

CONCLUSION

This is the first report on the LRS treatment with ultrasound-guided LRB from the contralateral spinous process along the inner side of the articular process by out-plane technique. Further studies are expected to investigate the efficacy and safety of ultrasound-guided LRB for patients with LRS.

The clinical effect of unilateral decompressive laminectomy plus fusion with unilateral biportal endoscopic technique for single level lumbar spinal stenosis

PURPOSE

This study aimed to compare and analyze the effectiveness of unilateral biportal endoscopic (UBE) decompressive laminectomy plus fusion and microscope-assisted open decompressive laminectomy plus fusion.

METHODS

A total of 143 patients with lumbar spinal stenosis were enrolled in this study between March 2020 and February 2021 with a minimum 2 years follow-up visit to our hospital. Sixty-five patients underwent the unilateral biportal endoscopic technique and were assigned to the UBE group, and the remaining 78 patients with microscope assistant were assigned to the Microscope group. The baseline characteristics, clinical outcomes, and radiological data were retrospectively collected and analyzed, as well as Clinical outcomes, radiological data and complications.

RESULTS

There were no significant differences between the two groups in terms of baseline characteristics (P > 0.05). The UBE group was demonstrated to be significantly superior in CRP, drainage, blood loss, treatment cost and Hospital stay than the Microscope group (P < 0.05), whereas a significant longer operation time was observed (P < 0.05). The VAS-B, ODI, and JOA-L scores of the UBE group at 1 year follow-up were significantly greater than those of the Microscope group (P < 0.05). Regarding radiological data, there were no significant differences in the section area of the spinal canal and fusion grade between the two groups (P > 0.05).

CONCLUSION

In view of the satisfactory clinical outcomes of patients and notable decompression at the stenosed segment, UBE is a feasible, minimally invasive technique for single level lumbar canal stenosis.

Interlaminar Endoscopic Lumbar Discectomy Versus Microscopic Lumbar Discectomy: A Preliminary Analysis of L5-S1 Lumbar Disc Herniation Outcomes in Prospective Randomized Controlled Trials

OBJECTIVE

A preliminary report from a single institution, noninferiority, prospective randomized controlled trial is conducted to determine the effectiveness of interlaminar endoscopic lumbar discectomy (IELD) versus microscopic lumbar discectomy (MLD) for the treatment of L5-S1 lumbar disc herniation (LDH).

METHODS

This prospective, noncrossover, randomized controlled trials was conducted at a single neurosurgical center. Patients with symptomatic radiculopathy or intermittent neurogenic claudication caused by LDH were enrolled from July 2016 to July 2021. The study compared the effectiveness of microscopic and full-endoscopic discectomy procedures. Outcome measures included visual analogue scale (VAS) scores for back and leg pain, Oswestry Disability Index scores, radiologic measurements, endurance time of walking, and satisfaction rate.

RESULTS

Of 37 assessed patients, both IELD and MLD groups demonstrated significant improvements in VAS scores for pain over time, with no significant difference between them. For secondary outcomes, the IELD group had a shorter hospital stay and reduced blood loss but a longer operation time than the MLD group. Radiographic evaluations showed no change compared to preoperative data. Patient satisfaction and recovery rates were slightly higher for the MLD group, but both groups were comparable in most evaluations, with complications being minimal.

CONCLUSION

The IELD was noninferior in improving the intensity of back and leg pain and functional disability, compared to the MLD. Additionally, the IELD showed no difference in clinical outcomes for patients in terms of radiographic results and patient satisfaction rates. The results of this research preliminarily demonstrate that the IELD could be considered an effective alternative to MLD for L5-S1 central or paracentral LDH.

Clinical Results of 10-mm Endoscopic Minimally Invasive Interlaminar Decompression in the Treatment of Lumbar Spinal Stenosis with Degenerative Lumbar Scoliosis and Simple Lumbar Spinal Stenosis

Purpose

The number of patients with lumbar spinal stenosis (LSS) with degenerative lumbar scoliosis (DLS) is gradually increasing as the population ages. The purpose of this study was to evaluate the clinical outcomes of 10-mm endoscopic minimally invasive interlaminar decompression for LSS with DLS and simple LSS.

Material and Methods

The clinical data of 175 consecutive elderly patients with LSS were retrospectively analyzed. They were divided into LSS group and LSS with DLS group based on whether they were accompanied by DLS. Patient demographics, perioperative indicators, and clinical outcomes were recorded. Lumbar spine stability was assessed by imaging data. Meanwhile, visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, and the modified Macnab criteria were used to assess clinical outcomes.

Results

There were 129 patients in the LSS group and 46 patients in the LSS with DLS group. Both groups had similar VAS and ODI scores preoperatively, and both were significantly lower postoperatively (P < 0.05). However, patients combined with DLS showed higher VAS scores for low back pain at 3 months and 1 year postoperatively (P < 0.05). In addition, postoperative LL and PI-LL were significantly improved in both groups (P < 0.05). However, patients in LSS with DLS group showed higher PT, PI and PI-LL before and after surgery. According to the modified Macnab criteria, the excellent and good rates were 92.25% and 89.13% in the LSS group and LSS with DLS group at the last follow-up, respectively.

Conclusion

10-mm endoscopic minimally invasive interlaminar decompression for LSS with or without DLS has shown satisfactory clinical outcomes. However, patients with DLS may have higher residual low back pain after surgery.

Presentation, Diagnosis, and Management of Lower Back Pain Associated with Spinal Stenosis: A Narrative Review

Lower back pain (LBP) is an extremely common symptom experienced by people of all ages and is also one of the most frequent causes of disability worldwide. This article aims to review the presentation, diagnosis, and management of lower back pain associated with spinal stenosis. The paper we prepared was classified as a "literature narrative review." Nonetheless, when searching for manuscripts included in our work and reviewing them critically, we concentrated on the keywords: "lower back pain", "lumbar spine stenosis", "diagnostic", "rehabilitation", "neurosurgery", "spine", and "elderly". The incidence of chronic lower back pain (CLBP) increases linearly starting with the third decade of life until 60 years old, and it more often affects women. The course of non-specific LBP above all depends on factors not connected with the spine, which include psychological, behavioral, and social factors, determined by the way the condition is perceived by the patient the environment. Lumbar spine stenosis (LSS) is an age-related process of degeneration of the intervertebral discs, ligamentum flavum, and facet joints, which results in narrowing of the space around the neurovascular structures of the spine. Diagnosis of spinal pain syndromes includes radiography (RTG), computed tomography (CT), and magnetic resonance imaging (MRI). Based on the results of imaging studies, neurological examination, and the severity of the disease, treatment can consist of analgesics and rehabilitation, or, when conservative methods are insufficient, surgical treatment is indicated.

Effects of Resistance Training on Pain Control and Physical Function in Older Adults With Low Back Pain: A Systematic Review With Meta-analysis

BACKGROUND AND PURPOSE

Low back pain (LBP) has a high prevalence in older adults and is associated with elevated health care costs. This systematic review and meta-analysis examines the effects of progressive resistance training (PRT) interventions on physical function (PF) and pain control in community-dwelling older adults with chronic LBP.

METHODS

A meta-analysis applying the quality effect method was performed by calculating the effect sizes (ESs) using the Cohen d with a 95% CI. A subgroup analysis was performed according to the participant and intervention characteristics. The statistical significance of differences between subgroups was calculated using a Z-test. Study bias was estimated using the version 2 of the Cochrane risk of bias tool for randomized trials (RoB 2.0) and quality of evidence (Qi) index. Small study effect/publication bias was estimated using the Doi plot and Luis Furuya-Kanamori (LFK) index. The systematic search was conducted in major databases for clinical trials published between January 1, 1990, and January 9, 2021. The inclusion criteria were articles that (1) were peer-reviewed; (2) had participants' mean age of more than 60 years; (3) studied PRT interventions; (4) had participants with LBP; (5) measured LBP or PF outcomes; (6) measured PF in terms of functionality; (7) were randomized controlled trials; (8) and non-randomized controlled trials. The exclusion criteria were (1) articles not written in English, (2) nonexperimental studies, and (3) repeated publications.

RESULTS AND DISCUSSION

Twenty-one studies were included (n = 1661). Clear improvements were found in PF (ES = 0.32 [95% CI, 0.05-0.58]; I2 = 75.1%; P < .001), but results on LBP decrease were inconclusive (ES = 0.24 [95% CI, -0.05 to 1.10]; I2 = 75.7%; P < .001). The overall evidence of this aggregated data meta-analysis of clinical trials is level C+. Main limitations are the use of aggregated data and the large heterogeneity between studies.

CONCLUSIONS

The Qi of this meta-analysis is level I (C+). We concluded that PRT interventions are useful for PF improvement in older adults with generalized LBP, LBP not arising from lumbar spinal stenosis, and having body mass index less than 27. In older adults with LBP not arising from lumbar spine stenosis, PRT interventions also decrease LBP. Interventions should have a frequency of at least 3 sessions per week. In addition, at a lower level of evidence IV (C+), we recommend that interventions with a duration of more than 12 weeks should be considered, whenever possible.

Management of lumbar spinal stenosis: a systematic review and meta-analysis of rehabilitation, surgical, injection, and medication interventions

BACKGROUND

Lumbar spinal stenosis (LSS) has a substantial impact on mobility, autonomy, and quality of life. Previous reviews have demonstrated inconsistent results and/or have not delineated between specific nonsurgical interventions.

OBJECTIVE

The purpose of this systematic review is to assess the effectiveness of interventions in the management of LSS.

METHODS

Eligible studies were randomized controlled trials (RCTs) or prospective studies, included patients with LSS, assessed the effectiveness of any interventions (rehabilitation, surgical, injection, medication), included at least two intervention groups, and included at least one measure of pain, disability, ambulation assessment, or LSS-specific symptoms. Eighty-five articles met inclusion criteria. Meta-analyses were conducted across outcomes. Effect sizes were calculated using Hedge's g and reported descriptively. Formal grading of evidence was conducted.

RESULTS

Meta-analysis comparing rehabilitation to no treatment/placebo demonstrated significant effects on pain favoring rehabilitation (mean difference, MD -1.63; 95% CI: -2.68, -0.57; I² = 71%; p = .002). All other comparisons to no treatment/placebo revealed nonsignificant findings. The level of evidence ranged from very low to high for rehabilitation and medication versus no treatment/placebo for pain, disability, ambulation ability, and LSS symptoms.

CONCLUSIONS

Although the findings of this review are inconclusive regarding superiority of interventions, this accentuates the value of multimodal patient-centered care in the management of patients with LSS.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication

BACKGROUND

The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine.

METHODS

The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members.

RESULTS

Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided.

CONCLUSIONS

The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.

Effectiveness of a 6-week specific rehabilitation program combining education and exercises on walking capacity in patients with lumbar spinal stenosis with neurogenic claudication: a randomized controlled clinical trial protocol

BACKGROUND

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is a leading cause of disability which is intimately related to a decrease in walking capacity. Walking limitation has negative physical and mental impacts on patients. Recent guidelines recommend the use of conservative treatment options such as exercises before considering surgery. Unfortunately, dedicated healthcare resources for the conservative management of patients with LSS causing NC are uncommon. Thus, it is important to develop accessible and specific rehabilitation programs aimed at improving patients' self-management, especially with regard to walking capacity. The aim of this study is to evaluate the effectiveness of a 6-week specific rehabilitation program combining education and exercises on walking capacity in patients with LSS causing NC.

METHODS/DESIGN

This is a prospective randomized controlled parallel-group clinical trial. Sixty-six patients with LSS causing NC will be recruited from identified clinics and local advertisements. The intervention group will receive standardized education and specific exercises while the control group will only receive a standardized education. The program in both groups will last for 6 weeks with 5 evaluation time points (baseline, week 2, week 4, week 6, and week 12). The primary outcome will be walking capacity measured with the Self-Paced Walking Test, and the secondary outcomes will be back and leg pain intensity, LSS-related disability, self-efficacy, level of physical activity, anxiety, depression, gait pattern characteristics, balance, and global perceived change.

DISCUSSION

This study will assess the effectiveness of a 6-week specific rehabilitation program combining education and exercises on walking capacity in patients with LSS causing NC. By measuring objective gait pattern characteristics, the study will also provide new information about the impact of NC on gait pattern that could eventually improve the evaluation and the management of LSS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05513326 . Registered on August 22, 2022.

Multilevel Decompression Surgery for Degenerative Lumbar Spinal Canal Stenosis Is Similarly Effective With Single-level Decompression Surgery

STUDY DESIGN

Retrospective case series.

OBJECTIVE

The purpose of this study was to investigate the outcome of multilevel posterior decompression surgery for degenerative lumbar spinal stenosis compared with single-level surgery.

SUMMARY OF BACKGROUND DATA

The clinical outcomes of multilevel decompression surgery are still controversial because previous studies have not been designed to randomize or adjust the patient background.

MATERIALS AND METHODS

A retrospective review of prospectively collected data from 659 surgically treated lumbar spinal stenosis patients with a minimum 2-year follow-up was performed. Among them, we compared baseline and 2-year postoperative patient-reported outcomes (PROs) including the Visual Analog Scale and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire scores of 122 patients who underwent three or more levels of surgery (M group) and 304 patients who underwent single-level surgery (S group). Further analyses were performed of 116 paired patients from both groups who were propensity score matched by age and baseline PROs.

RESULTS

The number of perioperative complications including extradural hematoma, surgical site infection, and spinal fluid leakage [M vs. S: 10 (8%) vs. 19 (6%), P =0.47], and frequency of revision surgery [5 (4%) vs. 23 (8%), P =0.10] were similar between the two groups. In the analysis of propensity score-matched patients, there were comparable improvements in the Visual Analog Scale score for lower back pain (2.6 vs. 2.4, P =0.55), buttock-leg pain (3.1 vs. 3.4, P =0.48), and buttock-leg numbness (2.9 vs. 2.9, P =0.77) in both groups. There were also similar improvements in the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire scores including lower back pain, lumbar function, walking ability, and mental health domains, except for the social life function domain (20.7±26.5 vs. 28.0±27.5, P =0.04).

CONCLUSIONS

Despite the longer surgical time and a larger volume of estimated blood loss, multilevel decompression surgery showed similar improvement to that of single-level surgery in terms of recovery of PROs and frequency of revision surgery. Multilevel decompression surgery provides good clinical outcomes with acceptable complication and revision rates when selecting appropriate patient and spinal levels.

Treatment-based classification for low back pain: systematic review with meta-analysis

OBJECTIVE

To systematically review the effects of treatment-based classification (TBC) in patients with specific and nonspecific acute, subacute and chronic low back pain.

METHODS

The following databases were searched: MEDLINE, EMBASE, PsycINFO, Global Health, CENTRAL, Web of Science, CINAHL, SPORTDiscus, PEDro and WHO from inception up to December 2021. We used the PEDro scale, the TIDieR checklist and the GRADE approach to evaluate the risk of bias, quality on reporting and the certainty of the evidence, respectively.

RESULTS

Twenty-three trials (pooled n = 2,649) met the inclusion criteria. We have identified a total of 22 comparisons and 134 estimates of treatment effects. There was a very large heterogeneity with regards to the comparison groups. Most of individual trials had low risk of bias with a mean score of 6.8 (SD = 1.3) on a 0-10 scale. The certainty of evidence for most comparisons was low, which indicates that more high quality and robust trials are needed. We were able to pool the data using a meta-analysis approach for only two comparisons (TBC versus mobility exercises in patients with acute low back pain and traction for patients with sciatica). In general, the TBC approach seems to be useful for patients with acute low back pain, sciatica and with spinal stenosis. We strongly suggest readers to carefully read our summary of findings table for further details on each comparison.

CONCLUSION

The TBC approach seems to be useful for patients with acute low back pain, sciatica and with spinal stenosis.

GOLDIC therapy in degenerative lumbar spinal stenosis: randomized, controlled trial

Aim: Comparison of the efficacy of conservative treatment methods: epidural GOLDIC serum, epidural steroid injections, manual therapy. Materials & methods: A randomized, controlled trial. Three groups, each containing 30 patients. GOLDIC or steroid injections (dexamethasone) epidural versus manual therapy. Assessment: initial assessment and 4 (T1), 12 (T2) and 24 (T3) weeks after the last intervention. Primary outcomes: Pain intensity in numeric rating scale, Oswestry disability index, Zurich claudication questionnaire, EQ-5D-5L questionnaire. Results: GOLDIC has shown the highest mean differences and number of cases with minimal important difference among groups for every primary outcome. Conclusion: GOLDIC therapy could be a new option for the nonoperative, symptomatic treatment of degenerative lumbar spinal stenosis and is not inferior to epidural steroid injections and manual therapy.

Outcome Domain and Measurement Instrument Reporting in Randomized Controlled Trials of Interventions for Lumbar Spinal Stenosis: A Systematic Review

OBJECTIVE

To describe outcome measurement instruments and outcome domains in randomized controlled trials of any interventions for lumbar spinal stenosis (LSS).

DESIGN

Systematic review.

LITERATURE SEARCH

The Cochrane Central Register of Controlled Trials (CENTRAL) and PubMed were searched from inception to May 2020.

STUDY SELECTION CRITERIA

Trials were eligible if patients were diagnosed with LSS, with or without neurogenic claudication. Trials were eligible if they used at least 1 outcome measurement instrument.

DATA SYNTHESIS

Measurement instruments used in trials were extracted and then classified into outcome domains. We described the frequency of measurement instruments and outcome domains.

RESULTS

After study screening, 29 trials were included. In total, 54 different individual outcome measurement instruments were used. The Visual Analogue Scale (59%; n = 17) and the Oswestry Disability Index (52%; n = 15) were the most frequently used outcome measurement instruments in trials; function (90%; n = 26) and pain (62%; n = 18) were the most common outcome domains.

CONCLUSION

In total, 54 different measurement instruments were used in trials of interventions for LSS. This diverse range of observations contributes to outcome instrument heterogeneity between trials and impedes the analysis of data due to lack of comparability. The most common outcome domains assessed were pain and function, which will help inform a core outcome measure set for symptomatic LSS. J Orthop Sports Phys Ther 2022;52(7):446-456. Epub: 18 May 2022. doi:10.2519/jospt.2022.10879.

Efficacy and characteristics of physiotherapy interventions in patients with lumbar spinal stenosis: a systematic review

PURPOSE

To determine the efficacy of physiotherapy approaches used in the treatment of LSS and compare their delivery characteristics.

METHODS

A systematic search was conducted using MEDLINE/PubMed, EMBASE, Scopus, PEDro, CINAHL and Web of Science databases, from inception until March 2021. Inclusion criteria were clinical diagnosis of LSS confirmed through imaging techniques, RCTs written in English comparing physiotherapy interventions among them or versus placebo or usual care without restrictions on treatment and follow-up duration, outcomes related to pain, physical function, disability and quality of life. Two independent reviewers assessed records for eligibility and methodological quality (PEDro scale) and extracted participants' characteristics, interventions details and outcome measures at each timepoint. Pooled or un-pooled findings were reported as mean difference with 95% confidence interval, depending on heterogeneity. Evidence quality was rated using the GRADE approach.

RESULTS

Twelve studies (944 patients, mean PEDro score 7.6, range 5-9) were included. Three weeks of weight-supported walking improved pain and disability, while 8 weeks of aquatic exercises improved pain and walking tolerance (very low evidence). Six weeks of cycling reduced disability compared to weight-supported walking (low evidence). Six weeks of manual therapy plus exercise was not superior to supervised exercises (low evidence), but improved pain, walking tolerance, disability and quality of life compared to home/group exercises (moderate to very low evidence). Very low evidence supported 2 weeks of electromagnetic fields, whereas TENS (low evidence) and ultrasounds (very low evidence) revealed no effects.

CONCLUSIONS

These findings may assist clinicians in delivering effective physiotherapy interventions in LSS patients.

Diagnosis and Management of Lumbar Spinal Stenosis: A Review

IMPORTANCE

Lumbar spinal stenosis is a prevalent and disabling cause of low back and leg pain in older persons, affecting an estimated 103 million persons worldwide. Most are treated nonoperatively. Approximately 600 000 surgical procedures are performed in the US each year for lumbar spinal stenosis.

OBSERVATIONS

The prevalence of the clinical syndrome of lumbar spinal stenosis in US adults is approximately 11% and increases with age. The diagnosis can generally be made based on a clinical history of back and lower extremity pain that is provoked by lumbar extension, relieved by lumbar flexion, and confirmed with cross-sectional imaging, such as computed tomography or magnetic resonance imaging (MRI). Nonoperative treatment includes activity modification such as reducing periods of standing or walking, oral medications to diminish pain such as nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy. In a series of patients with lumbar spinal stenosis followed up for up to 3 years without operative intervention, approximately one-third of patients reported improvement, approximately 50% reported no change in symptoms, and approximately 10% to 20% of patients reported that their back pain, leg pain, and walking were worse. Long-term benefits of epidural steroid injections for lumbar spinal stenosis have not been demonstrated. Surgery appears effective in carefully selected patients with back, buttock, and lower extremity pain who do not improve with conservative management. For example, in a randomized trial of 94 participants with symptomatic and radiographic degenerative lumbar spinal stenosis, decompressive laminectomy improved symptoms more than nonoperative therapy (difference, 7.8 points; 95% CI, 0.8-14.9; minimum clinically important difference, 10-12.8) on the Oswestry Disability Index (score range, 0-100). Among persons with lumbar spinal stenosis and concomitant spondylolisthesis, lumbar fusion increased symptom resolution in 1 trial (difference, 5.7 points; 95% CI, 0.1 to 11.3) on the 36-Item Short Form Health Survey physical dimension score (range, 0-100), but 2 other trials showed either no important differences between the 2 therapies or noninferiority of lumbar decompression alone compared with lumbar decompression plus spinal fusion (MCID, 2-4.9 points). In a noninferiority trial, 71.4% treated with lumbar decompression alone vs 72.9% of those receiving decompression plus fusion achieved a 30% or more reduction in Oswestry Disability Index score, consistent with the prespecified noninferiority hypothesis. Fusion is associated with greater risk of complications such as blood loss, infection, longer hospital stays, and higher costs. Thus, the precise indications for concomitant lumbar fusion in persons with lumbar spinal stenosis and spondylolisthesis remain unclear.

CONCLUSIONS AND RELEVANCE

Lumbar spinal stenosis affects approximately 103 million people worldwide and 11% of older adults in the US. First-line therapy is activity modification, analgesia, and physical therapy. Long-term benefits from epidural steroid injections have not been established. Selected patients with continued pain and activity limitation may be candidates for decompressive surgery.

The clinical effectiveness of a physiotherapy delivered physical and psychological group intervention for older adults with neurogenic claudication: the BOOST randomised controlled trial

Background

Neurogenic claudication (NC) is a debilitating spinal condition affecting older adults’ mobility and quality of life.

Methods

A randomized controlled trial of 438 participants evaluated the effectiveness of a physical and psychological group intervention (BOOST program) compared to physiotherapy assessment and tailored advice (best practice advice [BPA]) for older adults with NC. Participants were identified from spinal clinics (community and secondary care) and general practice records and randomized 2:1 to the BOOST program or BPA. The primary outcome was the Oswestry Disability Index (ODI) at 12 months. Data were also collected at 6 months. Other outcomes included ODI walking item, 6-minute walk test (6MWT), and falls. The primary analysis was intention-to-treat.

Results

The average age of participants was 74.9 years (standard deviation [SD] 6.0) and 57% (246/435) were female. There was no significant difference in ODI scores between treatment groups at 12 months (adjusted mean difference [MD]: −1.4 [95% confidence intervals (CI) −4.03, 1.17]), but, at 6 months, ODI scores favored the BOOST program (adjusted MD: −3.7 [95% CI −6.27, −1.06]). At 12 months, the BOOST program resulted in greater improvements in walking capacity (6MWT MD: 21.7m [95% CI 5.96, 37.38]) and ODI walking item (MD: −0.2 [95% CI −0.45, −0.01]) and reduced falls risk (odds ratio: 0.6 [95% CI 0.40, 0.98]) compared to BPA. No serious adverse events were related to either treatment.

Conclusions

The BOOST program substantially improved mobility for older adults with NC. Future iterations of the program will consider ways to improve long-term pain-related disability.

Clinical Trials Registration Number: ISRCTN12698674

Prevalence of multimorbid degenerative lumbar spinal stenosis with knee or hip osteoarthritis: a systematic review and meta-analysis

BACKGROUND

Musculoskeletal multimorbidity is common and coexisting lumbar spinal stenosis (LSS) with knee or hip osteoarthritis (OA) has been reported. The aim of this review was to report the prevalence of multimorbid degenerative LSS with knee or hip OA based on clinical and/or imaging case definitions.

METHODS

Literature searches were performed in MEDLINE, EMBASE, CENTRAL, and CINAHL up to May 2021. Studies involving adults with cross-sectional data to estimate the prevalence of co-occurring LSS with knee or hip OA were included. Study selection, data extraction, and risk of bias assessment were performed independently by two reviewers. Results were stratified according to index and comorbid condition, and by case definitions (imaging, clinical, and combined).

RESULTS

Ten studies from five countries out of 3891 citations met the inclusion criteria. Sample sizes ranged from 44 to 2,857,999 (median 230) and the mean age in the included studies range from 61 to 73 years (median 66 years). All studies were from secondary care or mixed settings. Nine studies used a combined definition of LSS and one used a clinical definition. Imaging, clinical, and combined case definitions of knee and hip OA were used. The prevalence of multimorbid LSS and knee or hip OA ranged from 0 to 54%, depending on the specified index condition and case definitions used. Six studies each provided prevalence data for index LSS and comorbid knee OA (prevalence range: 5 to 41%) and comorbid hip OA (prevalence range: 2 to 35%). Two studies provided prevalence data for index knee OA and comorbid LSS (prevalence range 17 to 54%). No studies reporting prevalence data for index hip OA and comorbid LSS were found. Few studies used comparable case definitions and all but one study were rated as high risk of bias.

CONCLUSIONS

There is evidence that multimorbid LSS with knee or hip OA occurs in people (0 to 54%), although results are based on studies with high risk of bias and surgical populations. Variability in LSS and OA case definitions limit the comparability of studies and prevalence estimates should therefore be interpreted with caution.

REVIEW REGISTRATION

PROSPERO ( CRD42020177759 ).

Non-operative treatment for lumbar spinal stenosis with neurogenic claudication: an updated systematic review

OBJECTIVES

Neurogenic claudication due to lumbar spinal stenosis (LSS) is a growing health problem in older adults. We updated our previous Cochrane review (2013) to determine the effectiveness of non-operative treatment of LSS with neurogenic claudication.

DESIGN

A systematic review.

DATA SOURCES

CENTRAL, MEDLINE, EMBASE, CINAHL and Index to Chiropractic Literature databases were searched and updated up to 22 July 2020.

ELIGIBILITY CRITERIA

We only included randomised controlled trials published in English where at least one arm provided data on non-operative treatment and included participants diagnosed with neurogenic claudication with imaging confirmed LSS.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed risk of bias using the Cochrane Risk of Bias Tool 1. Grading of Recommendations Assessment, Development and Evaluation was used for evidence synthesis.

RESULTS

Of 15 200 citations screened, 156 were assessed and 23 new trials were identified. There is moderate-quality evidence from three trials that: Manual therapy and exercise provides superior and clinically important short-term improvement in symptoms and function compared with medical care or community-based group exercise; manual therapy, education and exercise delivered using a cognitive-behavioural approach demonstrates superior and clinically important improvements in walking distance in the immediate to long term compared with self-directed home exercises and glucocorticoid plus lidocaine injection is more effective than lidocaine alone in improving statistical, but not clinically important improvements in pain and function in the short term. The remaining 20 new trials demonstrated low-quality or very low-quality evidence for all comparisons and outcomes, like the findings of our original review.

CONCLUSIONS

There is moderate-quality evidence that a multimodal approach which includes manual therapy and exercise, with or without education, is an effective treatment and that epidural steroids are not effective for the management of LSS with neurogenic claudication. All other non-operative interventions provided insufficient quality evidence to make conclusions on their effectiveness.

PROSPERO REGISTRATION NUMBER

CRD42020191860.

Feasibility of continuous epidural analgesia in patients with failed back surgery syndrome and spinal stenosis

PURPOSE

The purpose of this study was to outline the feasibility of continuous epidural analgesia in the treatment of failed back surgery syndrome (FBSS) or spinal stenosis.

METHODS

We queried our prospective collected institutional database to include all consecutive patients, who underwent continuous epidural analgesia with accompanying intensive physiotherapeutic exercise within a timeframe of 4 years. Patients suffered from FBSS or spinal stenosis; protocolled continuous epidural analgesia was planned for 4 days within the framework of an inpatient multimodal pain therapy concept. The instillation technique of the epidural catheter, the capability to attend in accompanying physiotherapy, and the peri-interventional complications were evaluated.

RESULTS

153 patients with an average age of 57.4 years (± 11.9) were enrolled in this study. 105 patients suffered from FBSS and 48 patients had spinal stenosis. Overall, 148 patients (96.7%) reported the pain reduction and were able to perform daily intensified physiotherapeutic exercise. There were no serious adverse events, neither infection nor bleeding, no cardiopulmonary complication or permanent neurological deficits. The most common side effect was neurological impairment, such as numbness, dysesthesia, or weakness of the lower limbs with complete regression after flow rate adjustment. Patients with FBSS were more likely to develop dysesthesia (p = 0.007).

CONCLUSIONS

Continuous epidural analgesia is feasible in patients with FBSS or spinal stenosis. This treatment enables extensive physiotherapeutic treatment even in patients with severe pain conditions and can be considered as an alternative to epidural injections. An increased complication rate in comparison to short-term perioperative or perinatal application was not observed.

Artificial Intelligence Algorithm-Based Lumbar and Spinal MRI for Evaluation of Efficacy of Chinkuei Shin Chewan Decoction on Lumbar Spinal Stenosis

The study aimed to explore the application value of lumbar Magnetic Resonance Imaging (MRI) images processed by artificial intelligence algorithms in evaluating the efficacy of chinkuei shin chewan decoction (a traditional Chinese medicine to nourish the kidney) in the treatment of lumbar spinal stenosis (LSS). Specifically, 110 LSS patients admitted to the hospital were selected as the research subjects. They were randomly divided into the control group (n = 55) and experimental group (n = 55) according to different treatment methods. The control group was treated with traditional medicine, and the experimental group additionally took chinkuei shin chewan decoction on its basis. Based on the traditional U-net algorithm, a U-net registration algorithm based on artificial intelligence was designed by introducing the information entropy theory, and the algorithm was applied to the lumbar MRI image evaluation of LSS patients. Compared with the traditional U-net algorithm, the artificial intelligence-based U-net registration algorithm had a decreased noise level (P < 0.05), the Jaccard (J) value (0.84) and the Dice value (0.93) increased significantly versus the traditional algorithm (J = 0.63, Dice = 0.81), and the characteristics of the image were more accurate. Before treatment, the Oswestry Disability Index (ODI) scores of the experimental group and the control group were 44.32 ± 6.45 and 43.32 ± 5.45, respectively. After treatment, the ODI scores of the two groups were 10.21 ± 5.05 and 17.09 ± 5.23, respectively. Both showed significant improvement, while the improvement of the experimental group was more obvious than that of the control group (P < 0.05). The overall effective rates of the two groups of patients were 96.44% and 82.47%, respectively, and the experimental group was significantly higher than the control group (P < 0.05). Under the U-net registration algorithm based on artificial intelligence, the diagnostic accuracy of lumbar MRI in the experimental group was 94.45%, significantly higher than 67.5% before the introduction of the algorithm (P < 0.05). In conclusion, chinkuei shin chewan decoction are effective for the treatment of LSS, and lumbar MRI based on the artificial intelligence U-net registration algorithm can evaluate the efficacy of LSS well and is worthy of promotion.

Pragmatic trials of pain therapies: a systematic review of methods

ABSTRACT

Pragmatic randomised clinical trials aim to directly inform clinical or health policy decision making. Here, we systematically review methods and design of pragmatic trials of pain therapies to examine methods, identify common challenges, and areas for improvement. Seven databases were searched for pragmatic randomised controlled clinical trials that assessed pain treatment in a clinical population of adults reporting pain. All screening steps and data extractions were performed twice. Data were synthesised descriptively, and correlation analyses between prespecified trial features and PRECIS-2 (PRagmatic-Explanatory Continuum Indicator Summary 2) ratings and attrition were performed. Protocol registration: PROSPERO-ID CRD42020178954. Of 57 included trials, only 21% assessed pharmacological interventions, the remainder physical, surgical, psychological, or self-management pain therapies. Three-quarters of the trials were comparative effectiveness designs, often conducted in multiple centres (median: 5; Q1/3: 1, 9.25) and with a median sample size of 234 patients at randomization (Q1/3: 135.5; 363.5). Although most trials recruited patients with chronic pain, reporting of pain duration was poor and not well described. Reporting was comprehensive for most general items, while often deficient for specific pragmatic aspects. Average ratings for pragmatism were highest for treatment adherence flexibility and clinical relevance of outcome measures. They were lowest for patient recruitment methods and extent of follow-up measurements and appointments. Current practice in pragmatic trials of pain treatments can be improved in areas such as patient recruitment and reporting of methods, analysis, and interpretation of data. These improvements will facilitate translatability to other real-world settings-the purpose of pragmatic trials.

Walking Biomechanics and Spine Loading in Patients With Symptomatic Lumbar Spinal Stenosis

Symptomatic lumbar spinal stenosis is a leading cause of pain and mobility limitation in older adults. It is clinically believed that patients with lumbar spinal stenosis adopt a flexed trunk posture or bend forward and alter their gait pattern to improve tolerance for walking. However, a biomechanical assessment of spine posture and motion during walking is broadly lacking in these patients. The purpose of this study was to evaluate lumbar spine and pelvic sagittal angles and lumbar spine compressive loads in standing and walking and to determine the effect of pain and neurogenic claudication symptoms in patients with symptomatic lumbar spinal stenosis. Seven participants with symptomatic lumbar spinal stenosis, aged 44–82, underwent a 3D opto-electronic motion analysis during standing and walking trials in asymptomatic and symptomatic states. Passive reflective marker clusters (four markers each) were attached to participants at T1, L1, and S2 levels of the spine, with additional reflective markers at other spinal levels, as well as the head, pelvis, and extremities. Whole-body motion data was collected during standing and walking trials in asymptomatic and symptomatic states. The results showed that the spine was slightly flexed during walking, but this was not affected by symptoms. Pelvic tilt was not different when symptoms were present, but suggests a possible effect of more forward tilt in both standing (p = 0.052) and walking (p = 0.075). Lumbar spine loading during symptomatic walking was increased by an average of 7% over asymptomatic walking (p = 0.001). Our results did not show increased spine flexion (adopting a trunk-flexed posture) and only indicate a trend for a small forward shift of the pelvis during both symptomatic walking and standing. This suggests that provocation of symptoms in these patients does not markedly affect their normal gait kinematics. The finding of increased spine loading with provocation of symptoms supports our hypothesis that spine loading plays a role in limiting walking function in patients with lumbar spinal stenosis, but additional work is needed to understand the biomechanical cause of this increase.

PROMIS Scores Should Not be Used in Isolation to Measure Outcomes in Lumbar Stenosis Patients

STUDY DESIGN

Retrospective cross-sectional analysis.

OBJECTIVE

The aim of this study was to establish the strength of relationship between the Patient-reported Outcomes Measurement Information System (PROMIS) Adult Depression (AD), Physical Function (PF), and Pain Interference (PI) with the Swiss Spinal Stenosis Questionnaire (SSSQ) in assessing lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

In 2009, there were >35,000 surgeries for LSS, which amounted to $1.65 billion in health care cost. By 2021, there will be >2.4 million people in the United States with symptomatic LSS. There is an increasing emphasis on patient-reported outcomes (PROs) to define value in medicine. Therefore, it would be beneficial to compare PROMIS, a universal PRO, against the SSSQ, the "criterion standard" for assessing LSS.

METHODS

Eighty-two patients with LSS completing the PROMIS and SSSQ were enrolled. Per existing institutional protocol, PROMIS AD, PF, and PI were completed at every clinic visit. Linear regression analysis was then performed to evaluate how well the SSSQ and PROMIS scores correlated to each other.

RESULTS

When linear regression was performed for pre-treatment values, the R2 value for the SSSQ PF versus PROMIS PF was 0.14 (P = 0.0008), whereas the R2 value for the SSSQ symptom severity versus PROMIS PI was 0.03 (P = 0.13). The R2 value for the combined SSSQ physical function and symptom severity versus PROMIS AD was 0.07 (P = 0.02). When post-treatment SSSQ satisfaction scores were correlated to postoperative PROMIS AD, PI, and PF scores, the R2 values for a good linear fit were 0.13, 0.25, and 0.18 respectively (P values: 0.01, 0.003, and 0.003).

CONCLUSION

Pre-treatment PROMIS scores do not adequately capture the disease-specific impact of spinal stenosis, but postoperative PROMIS scores better reflect outcomes after surgery for LSS. PROMIS scores should not be used in isolation to assess outcomes in patients with LSS.Level of Evidence: 4.

Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021

Low back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Globally, LBP is highly prevalent and a leading cause of disability. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), clinical practice guideline (CPG) for LBP. The overall objective of this update was to provide recommendations on interventions delivered by physical therapists or studied in care settings that included physical therapy providers. It also focused on synthesizing new evidence, with the purpose of making recommendations for specific nonpharmacologic treatments. J Orthop Sports Phys Ther 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304.

Symptoms of lumbar spinal stenosis in people with knee or hip osteoarthritis or low back pain: a cross-sectional study of 10,234 participants in primary care

OBJECTIVE

The aims of this study were to evaluate: the proportion of people reporting symptoms associated with lumbar spinal stenosis (LSS) in primary care programs for knee or hip osteoarthritis (OA) or persistent low back pain (LBP) and; the prevalence of self-reported clinical LSS in these three cohorts, according to two sets of adapted criteria.

METHOD

A cross-sectional analysis of baseline data from the Good Life with osteoArthritis in Denmark primary care programs. Self-report LSS symptom questions were administered to participants with knee OA, hip OA, and persistent LBP. The prevalence of eleven LSS symptoms and clinical LSS were calculated for each cohort.

RESULTS

A total of 10,234 participants were included in the analysis. A similar proportion of participants in each cohort were female (69%), with a 6- and 7-year older mean age in the knee and hip cohorts compared to the back cohort. A greater proportion of participants with LBP reported LSS symptoms (range 11-71%) than in the hip (11-50%) and knee (8-40%) cohorts. This pattern was observed for all but one symptom. The same pattern was observed for the prevalence of clinical LSS with less than 10% of people in each cohort satisfying the clinical criteria.

CONCLUSION

Self-reported LSS symptoms are commonly reported by people treated in primary care for knee or hip OA, although not as frequently as reported by those with LBP. Despite symptoms of LSS being common, only a small proportion of people were classified as having self-reported clinical LSS.

Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on nonsurgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. Clinical outcomes evaluated included pain, disability, quality of life, and walking capacity. The target audience for this guideline includes all clinicians, and the target patient population includes adults with LSS (congenital and/or acquired, lateral recess or central canal, with or without low back pain, with or without spondylolisthesis) causing NC. The guidelines panel developed 6 recommendations based on randomized controlled trials and 5 others based on professional consensus, summarized in 3 overarching recommendations: (Grade: statements are all conditional/weak recommendations) Recommendation 1. For patients with LSS causing NC, clinicians and patients may initially select multimodal care nonpharmacological therapies with education, advice and lifestyle changes, behavioral change techniques in conjunction with home exercise, manual therapy, and/or rehabilitation (moderate-quality evidence), traditional acupuncture on a trial basis (very low-quality evidence), and postoperative rehabilitation (supervised program of exercises and/or educational materials encouraging activity) with cognitive-behavioral therapy 12 weeks postsurgery (low-quality evidence). Recommendation 2. In patients LSS causing NC, clinicians and patients may consider a trial of serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants. (very low-quality evidence). Recommendation 3. For patients LSS causing NC, we recommend against the use of the following pharmacological therapies: nonsteroidal anti-inflammatory drugs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants, pregabalin (consensus-based), gabapentin (very low-quality), and epidural steroidal injections (high-quality evidence). PERSPECTIVE: This guideline, on the basis of a systematic review of the evidence on the nonsurgical management of lumbar spine stenosis, provides recommendations developed by a multidisciplinary expert panel. Safe and effective non-surgical management of lumbar spine stenosis should be on the basis of a plan of care tailored to the individual and the type of treatment involved, and multimodal care is recommended in most situations.

Lumbar spondylolisthesis: STATE of the art on assessment and conservative treatment

INTRODUCTION

There is weak relationship between the presence of lumbar spondylolisthesis [SPL] and low back pain that is not always associated with instability, either at the involved lumbar segment or at different spinal levels. Therefore patients with lumbar symptomatic SPL can be divided into stable and unstable, based on the level of mobility during flexion and extension movements as general classifications for diagnostic and therapeutic purposes. Different opinions persist about best treatment (conservative vs. surgical) and among conservative treatments, on the type, dosage, and progression of physical therapy procedures.

PURPOSE AND IMPORTANCE TO PRACTICE

The aim of this Masterclass is to provide clinicians evidence-based indications for assessment and conservative treatment of SPL, taking into consideration some subgroups related to specific clinical presentations.

CLINICAL IMPLICATIONS

This Masterclass addresses the different phases of the assessment of a patient with SPL, including history, imaging, physical exam, and questionnaires on disability and cognitive-behavioral components. Regarding conservative treatment, self- management approaches and graded supervised training, including therapeutic relationships, information and education, are explained. Primary therapeutic procedures for pain control, recovery of the function and the mobility through therapeutic exercise, passive mobilization and antalgic techniques are suggested. Moreover, some guidance is provided on conservative treatment in specific clinical presentations (lumbar SPL with radiating pain and/or lumbar stenosis, SPL complicated by other factors, and SPL in adolescents) and the number/duration of sessions.

FUTURE RESEARCH PRIORITIES

Some steps to improve the diagnostic-therapeutic approach in SPL are to identify the best cluster of clinical tests, define different lumbar SPL subgroups, and investigate the effects of treatments based on that classification, similarly to the approach already proposed for non-specific LBP.

Responsiveness of Outcome Measures in Nonsurgical Patients with Lumbar Spinal Stenosis: A Secondary Analysis From a Randomized Controlled Trial

STUDY DESIGN

Secondary analysis from a randomized controlled trial on nonsurgical interventions for patients with lumbar spinal stenosis (LSS).

OBJECTIVE

The aim of this study was to assess the responsiveness of the Self-Paced Walking Test (SPWT), Swiss Spinal Stenosis Questionnaire (SSS), and Oswestry Disability Index (ODI) and determine their minimal clinically important differences (MCID) in nonsurgical LSS patients.

SUMMARY OF BACKGROUND DATA

Limited information is available about the responsiveness of these tests in nonsurgical LSS population.

METHODS

A total of 180 participants completed the SPWT, SSS, and ODI at baseline, 2, and 6 months. Responsiveness was assessed by distribution-based method, including effect size and standardized response mean, and anchor-based method, using the patient global index of change (PGIC) as the external anchor to distinguish responders and non-responders. Areas under the curve (AUC) were calculated along with MCIDs for "minimal" and "moderate improvement" subgroups.

RESULTS

The following values represent 2- and 6-month analyses of each outcome measure, respectively. Standard effect sizes: 0.48 and 0.50 for SPWT, -0.42 and -0.36 for SSS, and -0.29 and -0.25 for ODI. Spearman correlation coefficients between PGIC and outcomes were: 0.44 and 0.39 for SPWT, -0.53 and -0.55 for SSS, and -0.46 and -0.54 for ODI. MCIDs for the "minimal improvement" subgroup were: 375.9 and 319.3 ms for SPWT, -5.3 and -5.8 points for SSS, and -9.3 and -10.8 points for ODI. AUCs was 0.68 to 0.76. MCIDs for the "moderate improvement" subgroup were: 344.2 and 538.2 m for SPWT, -5.5 and -7.5 points for SSS, and -9.1 and -13.6 points for ODI. AUCs ranged from 0.68 to 0.76.

CONCLUSION

The SPWT, SSS, and ODI are responsive outcome measures to assess nonsurgical patients with LSS. This finding, along with the reported MCIDs, can help clinicians to monitor changes in their patients' walking and physical function over time and make clinical decisions. They also provide researchers with reference for future studies in LSS.Level of Evidence: 2.

Effectiveness of an exercise-based prehabilitation program for patients awaiting surgery for lumbar spinal stenosis: a randomized clinical trial

Lumbar spinal stenosis is the most common reason for spine surgery in older adults, but the effects of prehabilitation on perioperative outcomes among these patients have not been investigated. This study aims to evaluate the effectiveness of a preoperative exercise-based intervention program compared with usual care on the improvement of clinical status, physical capacities and postoperative recovery of patients awaiting surgery for lumbar spinal stenosis. Sixty-eight participants were randomised to receive either a 6-week supervised exercise-based prehabilitation program or hospital usual care. The outcomes included both clinical and physical measures. Data collection occurred at post-intervention, and 6 weeks, 3- and 6-months post-surgery. Significant but small improvements were found in favour of the experimental group at the post-intervention assessment for pain intensity, lumbar spinal stenosis-related disability, lumbar strength in flexion, low back extensor muscles endurance, total ambulation time, and sit to stand performance. A significant difference in favor of the intervention group was found starting at the 3-month postoperative follow-up for low back-related disability. No adverse events were reported. Exercise-based prehabilitation did not improve short-term postoperative recovery in patients with lumbar spinal stenosis.

Effectiveness of Conservative Nonpharmacologic Therapies for Pain, Disability, Physical Capacity, and Physical Activity Behavior in Patients With Degenerative Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate the effectiveness of conservative nonpharmacologic therapies on pain, disability, physical capacity, and physical activity outcomes in patients with degenerative lumbar spinal stenosis (LSS).

DATA SOURCES

Systematic search of MEDLINE, EMBASE, CENTRAL, and PsycINFO from inception to November 4, 2019, without language restrictions.

STUDY SELECTION

Pairs of review authors independently identified randomized controlled trials published in peer-reviewed scientific journals reporting on the effects of rehabilitation interventions on pain intensity (back or leg), disability, symptom severity, physical capacity, physical activity behavior, or adverse events (secondary outcome) in adults with LSS. The search identified 1718 records; data from 21 reports of 19 trials (1432 patients) were included.

DATA EXTRACTION

Review author pairs independently extracted data and assessed included studies. We assessed risk of bias with the Cochrane tool, and overall study quality with the Grading of Recommendations Assessment, Development and Evaluation classification.

DATA SYNTHESIS

We pooled data using random-effects meta-analyses; treatment effects were reported as mean differences (MD) and 95% confidence intervals (CI). Directed exercise and manual therapy was superior to self-directed or group exercise for improving short-term walking capacity (MD, 293.3 m; 95% CI, 61.7-524.9 m; low-quality evidence), back pain (MD, -1.1; 95% CI, -1.8 to -0.4; moderate quality evidence), leg pain (MD, -.9; 95% CI, -0.2 to -1.5; moderate-quality evidence), and symptom severity (MD, -0.3; 95% CI, -0.4 to -0.2; low quality evidence). There is very low quality evidence that rehabilitation is no better than surgery at improving intermediate- or long-term disability. Single trials provided conflicting evidence of effectiveness for a variety of therapies.

CONCLUSIONS

For patients with LSS, there is low- to moderate-quality evidence that manual therapy with supervised exercises improves short-term walking capacity and results in small improvements in pain and symptom severity compared with self-directed or group exercise. The choice between rehabilitation and surgery for LSS is very uncertain owing to the very low quality of available evidence.

A short-term oral corticosteroid for refractory lumbar spinal stenosis: a double-blinded randomized placebo-controlled clinical trial

Although epidural corticosteroids have been evaluated for the lumbar spinal stenosis (LSS) as an alternative treatment, oral corticosteroids have not been considered as a possible option for the patients with constant pain who have resistant against routine treatments. Therefore, this study aimed to investigate the efficacy of the short-term, low-dose oral prednisolone for refractory LSS. In this double-blinded randomized placebo-controlled clinical trial, 100 participants with the refractory LSS were selected from the out-patient clinics; however, 7 of them excluded before randomization. The patients were randomly allocated into two groups with a 1:1 ratio: the intervention group that received 10 mg prednisolone per day for 1 week and the control group that received the exact placebo. The patients' severity of pain in terms of the numerical rating scale, ability to walk in meters, and Oswestry Disability Index (ODI) were assessed and then compared to the baseline after 2 months. The baseline variables were NS between these two groups. At the 2-month follow-up, the ability to walk in meters has increased and the severity of pain and ODI have decreased in both groups. Notably, except for the walking distance, none of the differences were statistically significant. Except for the significant change in walking distance between the groups, no other significant difference was observed in any variables when comparing the delta of each variable (after-before). One-week treatment with daily 10 mg oral prednisolone was not effective on the patients with refractory LSS in the short-term follow-up.

Supervised physical therapy versus unsupervised exercise for patients with lumbar spinal stenosis: 1-year follow-up of a randomized controlled trial

OBJECTIVE

To compare the 1-year outcomes of patients with lumbar spinal stenosis treated with supervised physical therapy or unsupervised exercise.

DESIGN

A single-center randomized controlled trial with concealed allocation, blinded assessor and intention-to-treat analysis.

SETTING

Spine care center.

SUBJECTS

A total of 86 patients presenting with symptoms of neurogenic claudication caused by lumbar spinal stenosis.

INTERVENTIONS

The physical therapy group received supervised physical therapy sessions twice a week for 6 weeks and home exercise program. The home exercise group received 6-week home exercise program only.

MAIN MEASURES

The primary outcome was symptom severity on the Zurich claudication questionnaire at 1 year. Secondary outcomes included physical function, pain, health-related quality of life and the surgery rate after 1 year.

RESULTS

At 1 year, more patients in the physical therapy group than in the home exercise group achieved minimum clinically important differences in Zurich claudication questionnaire symptom severity (60.5% vs 32.6%; adjusted odds ratio [AOR] 4.3, [95% CI [1.5-12.3], P = 0.01); Zurich claudication questionnaire physical function (55.8% vs 32.6%; AOR 3.0 [1.1-8.1], P = 0.03); SF-36 bodily pain (48.8% vs 25.6%; AOR 2.8 [1.1-7.3], P = 0.03), and SF-36 general health (20.9% vs 7.0%; AOR 6.1 [1.1-33.0], P = 0.04). The surgery rate at 1 year was lower in the physical therapy than in the home exercise group (7.0% vs 23.3%; AOR 0.2 [0.04-0.9] P = 0.04).

CONCLUSIONS

Supervised physical therapy produced greater improvements in symptom severity and physical function than unsupervised exercise and was associated with lower likelihood of receiving surgery within 1 year.

Associations between psychological factors and daily step count in patients with lumbar spinal stenosis

Background: Body mass index, pain, female sex, and age have been reported as predictors of physical activity in patients with lumbar spinal stenosis (LSS). However, no reports have examined the psychological factors associated with physical activity in people with LSS.Purpose: To use psychological assessments to identify the factors associated with physical activity measured as daily step count in people with LSS.Methods: Seventy-one patients who received outpatient physical therapy were included. All patients completed the following scales at baseline: Zurich Claudication Questionnaire; self-paced walking test (SPWT); numerical rating scale of low back pain, leg pain, and leg numbness; Hospital Anxiety and Depression Scale (HADS); Pain Catastrophizing Scale; Pain Anxiety Symptoms Scale (PASS-20); and Tampa Scale for Kinesiophobia. Physical activity was measured using a pedometer as the average number of daily steps.Results: Daily step count was significantly associated with age, number of stenoses, severity of stenosis at L3-L4, walking distance on the SPWT, PASS-20 total score, cognitive anxiety, escape/avoidance, fear, and HADS depression score (p < .05). Multiple regression analysis showed that age, severity of stenosis at L3-L4, walking distance on the SPWT, and PASS-20 fear predicted daily step count (r² = 0.414).Conclusion: Older age, fewer stenoses, less severe stenosis at L3-L4, lower walking capacity, higher anxiety, and fear-avoidance beliefs about pain and depression are more closely associated with lower daily step count than are back and leg pain. Assessment and treatment of psychological factors might help to increase physical activity in patients with LSS.

Effectiveness of additional deep-water running for disability, lumbar pain intensity, and functional capacity in patients with chronic low back pain: A randomised controlled trial with 3-month follow-up

BACKGROUND

Aquatic exercise (AQE) programme is commonly used as an alternative to the chronic low back pain (CLBP) treatment. The addition of aquatic aerobic exercises to AQE may be beneficial to patients with CLBP.

DESIGN

Randomised controlled trial.

OBJECTIVES

To assess the effectiveness of AQE with the addition of aerobic exercise - deep-water running (DWR) - compared to exclusive AQE in improving disability, lumbar pain intensity, and functional capacity in patients with CLBP.

METHODS

Fifty-four adult patients with CLBP were randomised either to the experimental group (AQE + DWR) or the control group (AQE). An assessor who was blinded to the group allocation performed both pre- and post-interventions assessments. Both treatments lasted 9 weeks, with a 3-month follow-up. The primary outcome was disability, as evaluated using the Roland Morris Disability Questionnaire. The secondary outcomes were pain and functional capacity; pain was assessed using a visual analogue scale (VAS), and functional capacity (travelled distance) was measured using the 6-min walk test (6WT).

RESULTS

A significant difference in pain was observed between groups after intervention in favour of DWR (mean difference -1.3 cm [95% confidence interval (CI) -2.17 to -0.45], d‾ = 0.80 [95% CI 0.22 to 1.33]).

CONCLUSION

Treatment with DWR was effective in the short term for achieving the desired outcome of pain reduction when compared with AQE only but not for disability and functional capacity.

Degenerative Lumbar Spine Stenosis Consensus Conference: the Italian job. Recommendations of the Spinal Section of the Italian Society of Neurosurgery

In the modern era evidence-based medicine, guidelines and recommendations represent a key-point of daily activity. The Spinal Section of the Italian Society of Neurosurgery introduced some recommendations regarding Degenerative Lumbar Spine Stenosis based on those of the Spine Committee of World Federation of Neurosurgical Societies, revising them on the basis of Italian common practice. In June 2019, a Committee of 21 spine surgeons met in Rome to validate the recommendations of the WFNS. Furthermore, they decided to review the ones that did not reach a consensus to create Italian Recommendations on Degenerative Lumbar Spine Stenosis. A literature review of the last ten years was performed and the statements were voted using the Delphi method. Forty-one statements were discussed, and 7 statements were voted again to reach a consensus with respect to those of the WFNS. A total of 40 statements reached a consensus, of which 36 reached a positive consensus and 4 a negative consensus, while no consensus was reached in 1 case. Conservative multimodal therapy, tailored on the patient, is a reasonable and effective first option choice for the treatment of LSS patients with tolerable moderate symptoms. Surgical treatment is reserved for symptomatic patients non-responding to conservative treatment or with neurological deficits. The best surgical technique to use depends on personal experience; modern MISS techniques are equivalent to open decompressive surgery with some advantages and higher cost-effectiveness. Fusion surgery and mobility preserving surgery only have a marginal role in the treatment of DLSS without instability.