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Pennington Z, Lakomkin N, Mikula AL, Elsamadicy AA, Astudillo Potes M, Fogelson JL, Grossbach AJ, Elder BD. Decompression Alone Versus Interspinous/Interlaminar Device Placement for Degenerative Lumbar Pathologies: Systematic Review and Meta-Analysis. World Neurosurg 2024; 185:417-434.e3. [PMID: 38508384 DOI: 10.1016/j.wneu.2024.03.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 03/11/2024] [Accepted: 03/12/2024] [Indexed: 03/22/2024]
Abstract
INTRODUCTION Interspinous devices (ISDs) and interlaminar devices (ILDs) are marketed as alternatives to conventional surgery for degenerative lumbar conditions; comparisons with decompression alone are limited. The present study reviews the extant literature comparing the cost and effectiveness of ISDs/ILDs with decompression alone. METHODS Articles comparing decompression alone with ISD/ILD were identified; outcomes of interest included general and disease-specific patient-reported outcomes, perioperative complications, and total treatment costs. Outcomes were analyzed at <6 weeks, 3 months, 6 months, 1 year, 2 years, and last follow-up. Analyses were performed using random effects modeling. RESULTS Twenty-nine studies were included in the final analysis. ILD/ISD showed greater leg pain improvement at 3 months (mean difference, -1.43; 95% confidence interval, [-1.78, -1.07]; P < 0.001), 6 months (-0.89; [-1.55, -0.24]; P = 0.008), and 12 months (-0.97; [-1.25, -0.68]; P < 0.001), but not 2 years (P = 0.22) or last follow-up (P = 0.09). Back pain improvement was better after ISD/ILD only at 1 year (-0.87; [-1.62, -0.13]; P = 0.02). Short-Form 36 physical component scores or Zurich Claudication Questionnaire (ZCQ) symptom severity scores did not differ between the groups. ZCQ physical function scores improved more after decompression alone at 6 months (0.35; [0.07, 0.63]; P = 0.01) and 12 months (0.23; [0.00, 0.46]; P = 0.05). Oswestry Disability Index and EuroQoL 5 dimensions scores favored ILD/ISD at all time points except 6 months (P = 0.07). Reoperations (odds ratio, 1.75; [1.23, 2.48]; P = 0.002) and total care costs (standardized mean difference, 1.19; [0.62, 1.77]; P < 0.001) were higher in the ILD/ISD group; complications did not differ significantly between the groups (P = 0.41). CONCLUSIONS Patient-reported outcomes are similar after decompression alone and ILD/ISD; the observed differences do not reach accepted minimum clinically important difference thresholds. ISD/ILDs have higher associated costs and reoperation rates, suggesting current evidence does not support ILD/ISDs as a cost-effective alternative to decompression alone.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.
| | - Nikita Lakomkin
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
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Hu Y, Yang R, Liu S, Wang H. Bibliometric analysis of interspinous device in treatment of lumbar degenerative diseases. Medicine (Baltimore) 2024; 103:e37351. [PMID: 38428868 PMCID: PMC10906630 DOI: 10.1097/md.0000000000037351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/02/2024] [Indexed: 03/03/2024] Open
Abstract
In recent years, with the introduction of the concept of lumbar non-fusion, the interspinous device has emerged. The purpose of this study is to bibliometrically analyze the state, areas of interest, and emerging trends in the usage of interspinous devices for the treatment of lumbar degeneration disease, as well as related research fields. Between January 1, 2000 and June 14, 2023, a comprehensive collection of publications on the topic of interspinous devices in the treatment of lumbar degenerative disease (IDTLDD) was procured from the Web of Science. A bibliometric analysis and visualization were subsequently conducted, utilizing various tools including HisCite, VOSviewer, CiteSpace, and bibliometrix package. This process involved the gathering of data on the country, institution, author, journal, reference, and keywords. A comprehensive analysis of 401 publications sourced from 149 journals was conducted, with 1718 authors affiliated with 1188 institutes across 240 countries/regions. Notably, the United States emerged as the leading contributor with 134 published articles on interspinous devices in the treatment of lumbar degenerative disease (33.42%). The most productive institution was Capital Medical University, with (10, 2.49%) publications. The author with the highest publication output was Block, Jon E, with 10 publications. European Spine Journal demonstrated the highest level of productivity, with a publication of (n = 39, 9.73%). The term "X-Stop" was the most frequently utilized keyword, followed by "Lumbar spinal stenosis." The study identified various topics of current interest, such as "Invasive decompression" and "Coflex." The present study provides a comprehensive survey of research trends and developments in the application of interspinous device for the treatment of lumbar degenerative diseases, including relevant research findings and collaborative efforts among authors, institutions, and countries.
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Affiliation(s)
- Yunxiang Hu
- School of Graduates, Dalian Medical University, Dalian City, Liaoning Province, China
- Department of Orthopedics, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian City, Liaoning Province, China
| | - Rui Yang
- School of Graduates, Dalian Medical University, Dalian City, Liaoning Province, China
- Department of Orthopedics, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian City, Liaoning Province, China
| | - Sanmao Liu
- School of Graduates, Dalian Medical University, Dalian City, Liaoning Province, China
- Department of Orthopedics, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian City, Liaoning Province, China
| | - Hong Wang
- School of Graduates, Dalian Medical University, Dalian City, Liaoning Province, China
- Department of Orthopedics, Dalian Municipal Central Hospital Affiliated of Dalian Medical University, Dalian City, Liaoning Province, China
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Minetama M, Kawakami M, Teraguchi M, Nakagawa M, Yamamoto Y, Sakon N, Nakatani T, Matsuo S, Nakagawa Y. Minimal clinically important differences in walking capacity and physical activity after nonsurgical treatment in patients with lumbar spinal stenosis: a secondary analysis of a randomized controlled trial. Spine J 2024; 24:256-262. [PMID: 37871657 DOI: 10.1016/j.spinee.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/02/2023] [Accepted: 10/16/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND CONTEXT Little information is available about the minimal clinically important differences (MCIDs) for objective physical measurements in people with lumbar spinal stenosis (LSS). PURPOSE To use disorder-specific anchor and, multiple anchor-, and distribution-based approaches to determine the MCIDs for walking capacity and physical activity in patients with LSS receiving nonsurgical treatment. STUDY DESIGN/SETTING Secondary analysis of a randomized controlled trial. PATIENT SAMPLE Sixty-nine patients with neurogenic claudication caused by LSS receiving outpatient physical therapy. OUTCOME MEASURES Zurich claudication questionnaire (ZCQ), self-paced walking test (SPWT), and number of daily steps measured by pedometry. METHODS All patients completed the ZCQ, SPWT, and pedometry at the baseline and after 6 weeks. For the anchor-based approach, ZCQ symptom severity, physical function, and satisfaction subscales were used as the external anchors. Using the receiver-operating characteristic (ROC) curve, the MCIDs were determined based on the optimal cutoff points for changes in the SPWT or daily steps. For the distribution-based approach, the MCIDs were estimated from the standard deviations (SDs) of the baseline scores of the SPWT and daily steps. RESULTS In the anchor-based approach, only the ZCQ satisfaction subscale for the SPWT (0.73), and ZCQ symptom severity subscale for daily steps (0.71) exceeded the area under the ROC curve value of 0.7, which is considered acceptable. When using these subscales as anchors, the ROC curves and optimal cutoff points indicated MCIDs of 151 m for the SPWT and 1,149 steps for daily steps. The distribution-based approach estimated the MCIDs as 280 m for the SPWT and 1,274 steps for daily steps, and had a moderate effect size (0.5 SD). CONCLUSIONS The anchor-based approach had limited external responsiveness when the ZCQ was used as the anchor. However, this information may be helpful for interpreting walking capacity and physical activity in patients with LSS receiving nonsurgical treatment and for estimating power and sample size when planning new trials.
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Affiliation(s)
- Masakazu Minetama
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama 649-7113, Japan.
| | - Mamoru Kawakami
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama 649-7113, Japan; Department of Orthopaedic Surgery, Saiseikai Wakayama Hospital, Wakayama, Japan, 45 Jyunibancho, Wakayama city, Wakayama, 640-8158, Japan
| | - Masatoshi Teraguchi
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama 649-7113, Japan
| | - Masafumi Nakagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama 649-7113, Japan
| | - Yoshio Yamamoto
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama 649-7113, Japan
| | - Nana Sakon
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama 649-7113, Japan
| | - Tomohiro Nakatani
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama 649-7113, Japan
| | - Sachika Matsuo
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama 649-7113, Japan
| | - Yukihiro Nakagawa
- Spine Care Center, Wakayama Medical University Kihoku Hospital, 219 Myoji, Katsuragi-cho, Ito-gun, Wakayama 649-7113, Japan
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Beyer F, Prasse T, Eysel P, Bredow J. Quality of life in lumbar spinal stenosis: Does it correlate with magnetic resonance imaging and spinopelvic parameters? J Orthop 2024; 47:67-71. [PMID: 38022842 PMCID: PMC10679525 DOI: 10.1016/j.jor.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 10/15/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Degenerative lumbar spinal stenosis (LSS) is a common degenerative spinal disorder with debilitating symptoms that can impact quality of life (QoL). However, the anatomical basis for typical complaints has been poorly quantified. This study aims to correlate QoL assessments of patients with LSS with radiographic spinopelvic parameters and magnetic resonance imaging (MRI) measurements. Methods We screened 371 patients hospitalized for LSS and excluded those with a history of spine surgery. Ultimately, we analyzed the data of 34 patients retrospectively. Two independent members of our research group evaluated the alignment parameters on preoperative spinal radiographs, MRI, and classified the images according to the Pfirrmann grading. The spinopelvic alignment was then compared with the clinical QoL scores Core Outcome Measures Index (COMI) and the Oswestry Disability Index (ODI) as collected by the Spine Tango registry. In addition, the interobserver reliability was analyzed. Results The individual MRI measurements correlated significantly. This correlation could not be found when compared with the spinopelvic parameters on radiographs. Neither the COMI nor the ODI scores showed a significant correlation with the MRI or radiographic imaging. Conclusions The severity of LSS related disability according to QoL questionnaires could not be quantified by any MRI or spinopelvic parameter that was measured. There was also no correlation of the MRI and spinopelvic parameters among themselves. Consequently, treatment recommendations for symptomatic LSS should never be based on radiological data only.
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Affiliation(s)
- Frank Beyer
- Department of Orthopedics and Trauma Surgery, Krankenhaus Porz am Rhein, University of Cologne, Urbacher Weg 19, 51149, Cologne, Germany
| | - Tobias Prasse
- Department of Orthopedics and Trauma Surgery, Medical Faculty, University Hospital of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Peer Eysel
- Department of Orthopedics and Trauma Surgery, Medical Faculty, University Hospital of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Jan Bredow
- Department of Orthopedics and Trauma Surgery, Krankenhaus Porz am Rhein, University of Cologne, Urbacher Weg 19, 51149, Cologne, Germany
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Malik KN, Giberson C, Ballard M, Camp N, Chan J. Pain Management Interventions in Lumbar Spinal Stenosis: A Literature Review. Cureus 2023; 15:e44116. [PMID: 37753034 PMCID: PMC10518428 DOI: 10.7759/cureus.44116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 09/28/2023] Open
Abstract
Lumbar spinal stenosis (LSS) occurs due to the narrowing of the space within the vertebral canal and or intervertebral foramina. This results in the compression of the spinal cord and possibly the roots of the spinal nerves. Lower back pain and neurogenic claudication (NC) are major symptoms of spinal stenosis. This is a literature review that summarizes the important findings pertaining to pain management of spinal stenosis. Twenty-four original articles were assessed. Pain can be treated through non-invasive or surgical methods. Conservative techniques include physical exercises, epidural corticosteroid injection, local anesthetic injection therapy, and oral analgesics. Surgical intervention deals with the decompression of the affected spinal region, with or without vertebral fusion surgery. Other novel surgical techniques include implantation of specific equipment, known as interspinous spacer devices and minimally invasive lumbar decompression (MILD). Most studies offering a comparative analysis have demonstrated that surgical intervention is more efficacious than non-surgical interventions to manage pain associated with spinal stenosis.
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Affiliation(s)
- Kashif N Malik
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Curren Giberson
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Matthew Ballard
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Nathan Camp
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Justin Chan
- Physical Medicine and Rehabilitation, Western University of Health Sciences, Pomona, USA
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Validity of outcome measures used in randomized clinical trials and observational studies in degenerative lumbar spinal stenosis. Sci Rep 2023; 13:1068. [PMID: 36658179 PMCID: PMC9852241 DOI: 10.1038/s41598-022-27218-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/28/2022] [Indexed: 01/20/2023] Open
Abstract
It is unclear whether outcome measures used in degenerative lumbar spinal stenosis (DLSS) have been validated for this condition. Cross-sectional analysis of studies for DLSS included in systematic reviews (SA) and meta-analyses (MA) indexed in the Cochrane Library. We extracted all outcome measures for pain and disability. We assessed whether the studies provided external references for the validity of the outcome measures and the quality of the validation studies. Out of 20 SA/MA, 95 primary studies used 242 outcome measures for pain and/or disability. Most commonly used were the VAS (n = 69), the Oswestry Disability Index (n = 53) and the Zurich Claudication Questionnaire (n = 22). Although validation references were provided in 45 (47.3%) primary studies, only 14 validation studies for 9 measures (disability n = 7, pain and disability combined n = 2) were specifically validated in a DLSS population. The quality of the validation studies was mainly poor. The Zurich Claudication Questionnaire was the only disease specific tool with adequate validation for assessing treatment response in DLSS. To compare results from clinical studies, outcome measures need to be validated in a disease specific population. The quality of validation studies need to be improved and the validity in studies adequately cited.
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Sun Y, An Y, Fan X, Liu C, Li D, Lei Y, Weng Z, Gong Y, Wang X, Yu C. A Protocol for a Single-Centered, Pragmatic, Randomized, Controlled, Parallel Trial Comparing Comprehensive Nonsurgical Therapy Options for Individuals with Lumbar Spinal Stenosis. J Pain Res 2023; 16:773-784. [PMID: 36923649 PMCID: PMC10010744 DOI: 10.2147/jpr.s398897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 02/20/2023] [Indexed: 03/11/2023] Open
Abstract
Aim Lumbar spinal stenosis (LSS) is a long-term degenerative disease. Considering the risks and advantages of the patient's age range and the characteristics of the condition, non-surgical treatment is recommended. To determine the best first-line non-surgical therapy for LSS, few studies have examined different non-surgical therapies. Therefore, the main objective of this study is to determine whether the selection of comprehensive Chinese medicine (CM) treatment for LSS is more successful than non-surgical conservative treatment. Patients and Methods In this two-armed, parallel, single-centered, pragmatic randomized controlled study, 94 LSS participants will be randomized to receive 24 sessions of comprehensive CM therapy or conservative treatment for 3 months, with follow-up assessments at 6, 9, 12, and 15 months. The primary outcome will be based on the success rate of the Zurich Claudication Questionnaire (ZCQ) for the most clinical important difference (MCID) at 3 and 15 months. Secondary outcomes include Numerical Rating Scale (NRS) scores for back and leg pain, ZCQ scores, Oswestry Disability Index scores for lumbar dysfunction, and Short-Form 12 scores for health-related quality of life at 3, 6, 9, 12, and 15 months. Adverse events and incidences of surgery will be reported anytime during the trial and follow-up. Conclusion This protocol examines the comparative efficacy of comprehensive CM therapy compared with conventional care through a pragmatic randomized controlled trial to present data to facilitate clinical or policy decision-making. The outcomes will make it easier to decide which patient-centered treatments to prioritize for LSS.
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Affiliation(s)
- Ya'nan Sun
- Traditional Chinese Medicine Department, Xuanwu Hospital Capital Medical University, Beijing, People's Republic of China
| | - Yi An
- First Clinical College, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, People's Republic of China
| | - Xiran Fan
- First Clinical College, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, People's Republic of China
| | - Changxin Liu
- Tuina and Pain Management Department, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, People's Republic of China
| | - Duoduo Li
- Tuina and Pain Management Department, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, People's Republic of China
| | - Yuan Lei
- Tuina and Pain Management Department, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, People's Republic of China
| | - Zhiwen Weng
- Tuina and Pain Management Department, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, People's Republic of China
| | - Yuanyuan Gong
- Tuina and Pain Management Department, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, People's Republic of China
| | - Xiyou Wang
- Tuina and Pain Management Department, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, People's Republic of China
| | - Changhe Yu
- Tuina and Pain Management Department, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, People's Republic of China
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Huang P, Liu Z, Liu H, Yu Y, Huang L, Lu M, Jin X. Decompression versus decompression plus fusion for treating degenerative lumbar spinal stenosis: A systematic review and meta-analysis. Pain Pract 2022; 23:390-398. [PMID: 36504445 DOI: 10.1111/papr.13193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 11/05/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Degenerative lumbar spinal stenosis (DLSS) is a complex clinical syndrome that leads to spinal compression. Decompression with fusion has been the most commonly used surgical procedure for treating DLSS symptoms for many years. However, the exact role of fusion and its effectiveness in DLSS therapy has recently been debated. OBJECTIVE The main purpose of this study was to compare the efficacy and safety of decompression alone and decompression plus fusion in the treatment of DLSS with or without spondylolisthesis. STUDY DESIGN A systematic review and meta-analysis of the therapeutic effects of decompression for DLSS with or without the combination of fusion. METHODS A literature search in five relevant databases, including Web of Science, PubMed, Embase, Medline, and Cochrane Library was performed from the inception of the database to March 2022. Only randomized controlled trials (RCTs) assessing the comparison between decompression and decompression plus fusion for DLSS were included. RESULTS A total of seven studies, 894 patients were analyzed in this meta-analysis. Among these, 443 patients were included in the decompression plus fusion group while 451 patients were included in the decompression alone group. Pooled analysis showed that the combination of decompression with fusion had no superior benefits to decompression alone in terms of Oswestry Disability Index (ODI) score in the first 2 years and long-term follow-up after surgery, also no significant difference in the improvement of back and leg pain was found between two groups. Adding fusion to decompression was associated with a longer operation time, higher complication rate, more blood loss, and extended hospital stay. Furthermore, there was no difference in reoperation rates and patients' satisfaction between the two groups at the last follow-up. CONCLUSION Decompression plus fusion may not be associated with a better clinical outcome in ODI scores and back or leg pain improvement but with a longer duration of operation time, extended hospital stay, and more blood loss.
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Affiliation(s)
- Peng Huang
- Department of Pain, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhenxiu Liu
- Department of Pain, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hong Liu
- Department of Pain, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yaqiong Yu
- Department of Pain, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Liqun Huang
- Department of Pain, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Min Lu
- Department of Pain, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaohong Jin
- Department of Pain, The First Affiliated Hospital of Soochow University, Suzhou, China
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Birkenmaier C, Fuetsch M. [Lumbar spinal stenosis]. ORTHOPADIE (HEIDELBERG, GERMANY) 2022; 51:943-952. [PMID: 36083346 DOI: 10.1007/s00132-022-04297-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 06/15/2023]
Abstract
Lumbar spinal stenosis (LSS) represents a frequent degenerative condition, however, striking a clear correlation between typical symptoms and imaging features remains a challenge. Reasons are a high prevalence of radiological LSS in the older population, a considerable percentage of asymptomatic LSS and the existence of differential diagnoses with similar symptomatology. This discrepancy also affects the outcomes - especially of surgically treated patients with LSS. When considering surgical decompression of LSS, the decision with regards to additive instrumentation and/or fusion remains a controversial point of discussion, in particular at the presence of degenerative spondylolisthesis. Recent, well-designed studies, however, clearly point towards a non-inferiority of decompression alone as opposed to the more invasive strategies.
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Affiliation(s)
- Christof Birkenmaier
- Wirbelsäulenchirurgie & Skoliosezentrum, Artemed Klinikum München Süd, Am Isarkanal 30, 81379, München, Deutschland.
| | - Manuel Fuetsch
- Wirbelsäulenchirurgie & Skoliosezentrum, Artemed Klinikum München Süd, Am Isarkanal 30, 81379, München, Deutschland
- Neurochirurgische Klinik und Poliklinik, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland
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Outcome Domain and Measurement Instrument Reporting in Randomized Controlled Trials of Interventions for Lumbar Spinal Stenosis: A Systematic Review. J Orthop Sports Phys Ther 2022; 52:446-A2. [PMID: 35584024 DOI: 10.2519/jospt.2022.10879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Deer TR, Grider JS, Pope JE, Lamer TJ, Wahezi SE, Hagedorn JM, Falowski S, Tolba R, Shah JM, Strand N, Escobar A, Malinowski M, Bux A, Jassal N, Hah J, Weisbein J, Tomycz ND, Jameson J, Petersen EA, Sayed D. Best Practices for Minimally Invasive Lumbar Spinal Stenosis Treatment 2.0 (MIST): Consensus Guidance from the American Society of Pain and Neuroscience (ASPN). J Pain Res 2022; 15:1325-1354. [PMID: 35546905 PMCID: PMC9084394 DOI: 10.2147/jpr.s355285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/06/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Methods Results Discussion Conclusion
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Affiliation(s)
- Timothy R Deer
- Centers for Pain Relief, Charleston, WV, USA
- Correspondence: Timothy R Deer, The Spine and Nerve Centers of the Virginias, 400 Court Street, Suite 100, Charleston, WV, 25301, USA, Tel +1 304 347-6141, Email
| | - Jay S Grider
- UK HealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | | | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Sayed E Wahezi
- Montefiore Medical Center, SUNY-Buffalo, Buffalo, NY, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Steven Falowski
- Director Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Reda Tolba
- Pain Management Department, Anesthesiology Institute, Cleveland Clinic, Abu Dhabi, UAE
| | - Jay M Shah
- SamWell Institute for Pain Management, Colonia, NJ, USA
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Alex Escobar
- Department of Anesthesiology and Pain Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | | | - Anjum Bux
- Bux Pain Management, Lexington, KY, USA
| | | | - Jennifer Hah
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, USA
| | | | - Nestor D Tomycz
- Department of Neurological Surgery, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
| | | | - Erika A Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Dawood Sayed
- Pain Medicine, Multidisciplinary Pain Fellowship, The University of Kansas Health System, Kansas City, KS, USA
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12
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Volovici V, Vogels VI, Dammers R, Meling TR. Neurosurgical Evidence and Randomized Trials: The Fragility Index. World Neurosurg 2022; 161:224-229.e14. [DOI: 10.1016/j.wneu.2021.12.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/26/2021] [Indexed: 10/18/2022]
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Ammendolia C, Hofkirchner C, Plener J, Bussières A, Schneider MJ, Young JJ, Furlan AD, Stuber K, Ahmed A, Cancelliere C, Adeboyejo A, Ornelas J. Non-operative treatment for lumbar spinal stenosis with neurogenic claudication: an updated systematic review. BMJ Open 2022; 12:e057724. [PMID: 35046008 PMCID: PMC8772406 DOI: 10.1136/bmjopen-2021-057724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Carlo Ammendolia
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Rheumatology, Sinai Health System, Toronto, Ontario, Canada
| | - Corey Hofkirchner
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Joshua Plener
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - André Bussières
- School of Physical and Occupational Therapy, Faculy of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Département Chiropratique, Université du Québec à Trois-Rivières, boulevard des Forges, Trois-Rivières Québec, Canada
| | | | - James J Young
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
- Sports Medicine and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Andrea D Furlan
- Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Institute for Work & Health, Toronto, Ontario, Canada
| | - Kent Stuber
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Aksa Ahmed
- Rheumatology, Sinai Health System, Toronto, Ontario, Canada
| | - Carol Cancelliere
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Aleisha Adeboyejo
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Joseph Ornelas
- Health Systems Management, Rush University, Chicago, Illinois, USA
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Schenck CD, Terpstra SES, Moojen WA, van Zwet E, Peul W, Arts MP, Vleggeert-Lankamp CLA. Interspinous process device versus conventional decompression for lumbar spinal stenosis: 5-year results of a randomized controlled trial. J Neurosurg Spine 2021:1-9. [PMID: 34952518 DOI: 10.3171/2021.8.spine21419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 08/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Interspinous process distraction devices (IPDs) can be implanted to treat patients with intermittent neurogenic claudication (INC) due to lumbar spinal stenosis. Short-term results provided evidence that the outcomes of IPD implantation were comparable to those of decompressive surgery, although the reoperation rate was higher in patients who received an IPD. This study focuses on the long-term results. METHODS Patients with INC and spinal stenosis at 1 or 2 levels randomly underwent either decompression or IPD implantation. Patients were blinded to the allocated treatment. The primary outcome was the Zurich Claudication Questionnaire (ZCQ) score at 5-year follow-up. Repeated measurement analysis was applied to compare outcomes over time. RESULTS In total, 159 patients were included and randomly underwent treatment: 80 patients were randomly assigned to undergo IPD implantation, and 79 underwent spinal bony decompression. At 5 years, the success rates in terms of ZCQ score were similar (68% of patients who underwent IPD implantation had a successful recovery vs 56% of those who underwent bony decompression, p = 0.422). The reoperation rate at 2 years after surgery was substantial in the IPD group (29%), but no reoperations were performed thereafter. Long-term visual analog scale score for back pain was lower in the IPD group than the bony decompression group (p = 0.02). CONCLUSIONS IPD implantation is a more expensive alternative to decompressive surgery for INC but has comparable functional outcome during follow-up. The risk of reoperation due to absence of recovery is substantial in the first 2 years after IPD implantation, but if surgery is successful this positive effect remains throughout long-term follow-up. The IPD group had less back pain during long-term follow-up, but the clinical relevance of this finding is debatable.
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Affiliation(s)
- Catharina D Schenck
- 1Department of Neurosurgery and
- 3Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
| | | | - Wouter A Moojen
- 1Department of Neurosurgery and
- 3Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- 4Department of Neurosurgery, HAGA Teaching Hospital, The Hague, The Netherlands; and
| | - Erik van Zwet
- 2Department of Biostatistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilco Peul
- 1Department of Neurosurgery and
- 3Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Mark P Arts
- 3Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Carmen L A Vleggeert-Lankamp
- 1Department of Neurosurgery and
- 3Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
- 4Department of Neurosurgery, HAGA Teaching Hospital, The Hague, The Netherlands; and
- 5Department of Neurosurgery, Spaarne Hospital, Hoofddorp/Haarlem, The Netherlands
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Tanaka S, Wada K, Kumagai G, Asari T, Aburakawa S, Yamasaki Y, Yokoyama T, Takeuchi K, Ishibashi Y. Comparison of Short-Term Clinical Results and Radiologic Changes Between Two Different Minimally Invasive Decompressive Surgical Methods for Lumbar Canal Stenosis: Lumbar Spinous Process Splitting Laminectomy and Trans-Interspinous Lumbar Decompression. Spine (Phila Pa 1976) 2021; 46:E1136-E1145. [PMID: 33813582 DOI: 10.1097/brs.0000000000004052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A multicenter, retrospective study. OBJECTIVE To clarify the clinical and radiological effects of removing interspinous contextures in lumbar decompression surgery for patients with lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA There have seldom been reports that have compared both clinical results and radiological changes among minimally invasive decompression methods. METHODS Consecutive 52 patients underwent lumbar spinous process-splitting laminectomy (LSPSL), following which 50 patients underwent trans-interspinous lumbar decompression (TISLD). All patients presented with cauda equina type of lumbar spinal stenosis and underwent a minimum 1-year follow-up. The Japanese Orthopaedic Association (JOA) score and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) score were evaluated to determine the extent of daily living activities. Propensity score (PS)-matched analysis was used to match patients' age and preoperative JOA scores between the two groups. Lumbar lordosis (LL), disc height (DH), segmental range of motion (ROM), and vertebral anterior translation were measured by functional lumbar lateral x-ray, and changes between preoperative and 1-year postoperative values were evaluated. RESULTS Twenty-nine pairs of patients were selected by PS-matching. Mean JOA scores increased from 14.4 to 23.5 (mean recovery rate was 62.3%) in the LSPSL group and from 14.0 to 23.2 (61.3%) in the TISLD group at preoperative and 1-year follow-up, respectively. There were no significant differences in clinical results and changes in LL, ROM, and vertebral anterior translation in each group. The DH at L4/5 level at 1-year after surgery revealed significant decrease in the TISLD group compared with the LSPSL group. There was a correlation between preoperative DH and DH decrease in the LSPSL group, but not in TISLD group. CONCLUSION Removal of interspinous contextures did not influence clinical outcomes at 1 year after surgery, but it may be likely to cause disc height loss when it applied at the L4/5 level.Level of Evidence: 3.
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Affiliation(s)
- Sunao Tanaka
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kanichiro Wada
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Gentaro Kumagai
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Toru Asari
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shuichi Aburakawa
- Department of Orthopaedic Surgery, Aomori Rosai Hospital, Aomori, Japan
| | | | - Toru Yokoyama
- Department of Orthopaedic Surgery, Odate Municipal General Hospital, Odate, Japan
| | - Kazunari Takeuchi
- Department of Orthopaedic Surgery, Odate Municipal General Hospital, Odate, Japan
| | - Yasuyuki Ishibashi
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Borg A, Hill CS, Nurboja B, Critchley G, Choi D. A randomized controlled trial of the X-Stop interspinous distractor device versus laminectomy for lumbar spinal stenosis with 2-year quality-of-life and cost-effectiveness outcomes. J Neurosurg Spine 2021; 34:544-552. [PMID: 33530059 DOI: 10.3171/2020.7.spine20880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/01/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lumbar spinal stenosis (LSS) is a common and debilitating condition that is increasing in prevalence in the world population. Surgical decompression is often standard treatment when conservative measures have failed. Interspinous distractor devices (IDDs) have been proposed as a safe alternative; however, the associated cost and early reports of high failure rates have brought their use into question. The primary objective of this study was to determine the cost-effectiveness and long-term quality-of-life (QOL) outcomes after treatment of LSS with the X-Stop IDD compared with surgical decompression by laminectomy. METHODS A multicenter, open-label randomized controlled trial of 47 patients with LSS was conducted; 21 patients underwent insertion of the X-Stop device and 26 underwent laminectomy. The primary outcomes were monetary cost and QOL measured using the EQ-5D questionnaire administered at 6-, 12-, and 24-month time points. RESULTS The mean monetary cost for the laminectomy group was £2712 ($3316 [USD]), and the mean cost for the X-Stop group was £5148 ($6295): £1799 ($2199) procedural cost plus £3349 mean device cost (£2605 additional cost per device). Using an intention-to-treat analysis, the authors found that the mean quality-adjusted life-year (QALY) gain for the laminectomy group was 0.92 and that for the X-Stop group was 0.81. The incremental cost-effectiveness ratio was -£22,145 (-$27,078). The revision rate for the X-Stop group was 19%. Five patients crossed over to the laminectomy arm after being in the X-Stop group. CONCLUSIONS Laminectomy was more cost-effective than the X-Stop for the treatment of LSS, primarily due to device cost. The X-Stop device led to an improvement in QOL, but it was less than that in the laminectomy group. The use of the X-Stop IDD should be reserved for cases in which a less-invasive procedure is required. There is no justification for its regular use as an alternative to decompressive surgery.Clinical trial registration no.: ISRCTN88702314 (www.isrctn.com).
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Affiliation(s)
- Anouk Borg
- 1Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, University College London Hospitals, London
| | - Ciaran Scott Hill
- 1Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, University College London Hospitals, London.,2UCL Cancer Institute, University College London; and
| | - Besnik Nurboja
- 1Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, University College London Hospitals, London
| | - Giles Critchley
- 3Department of Neurosurgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - David Choi
- 1Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, University College London Hospitals, London
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Wang MC, AlGhamdi MYT. Editorial. Interspinous spacers for lumbar stenosis: time for obsolescence? J Neurosurg Spine 2021; 34:541-542. [PMID: 33530060 DOI: 10.3171/2020.8.spine201205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Spinous Process Inclination in Degenerative Lumbar Spinal Stenosis Individuals. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8875217. [PMID: 33381595 PMCID: PMC7755483 DOI: 10.1155/2020/8875217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/22/2020] [Accepted: 11/30/2020] [Indexed: 11/18/2022]
Abstract
The aim of this study is to determine the sagittal inclination of lumbar spinous processes (SPs) in individuals with degenerative lumbar spinal stenosis (DLSS). It is a retrospective computerized tomography (CT) study including 345 individuals divided into two groups: control (90 males, 90 females) and stenosis (80 males and 85 females. The SP inclination was measured in the midsagittal plane from L1 to L5 levels. Stenosis males (L3-L5) and females (L1, L4) manifested significantly greater SP inclination compared to their counterparts in the control group. Males had significantly horizontal SP orientation compared to females (L1, L2). We also found that SP inclination became steeper as we descend caudally. This study indicates that SP inclinations are significantly associated with DLSS.
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Chen M, Tang H, Shan J, Chen H, Jia P, Bao L, Feng F, Shi G, Wang R. A new interspinous process distraction device BacFuse in the treatment of lumbar spinal stenosis with 5 years follow-up study. Medicine (Baltimore) 2020; 99:e20925. [PMID: 32590804 PMCID: PMC7329017 DOI: 10.1097/md.0000000000020925] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To explore a suitable indication of interspinous process distraction device for lumbar spinal stenosis with BacFuse.Patients of lumbar spinal stenosis (LSS) who experienced interspinous process distraction device surgery with BacFuse from June 2014 to January 2015 in our institute were included. We classified LSS into central and lateral types, and then divided these into severe and moderate according to the degree of stenosis. Each type was divided into 2 groups. Patients in group A underwent distraction without bone decompression (stand-alone), while patients in group B underwent bone decompression combined with distraction. Follow-up was performed at 1 month, 3 months, 6 months, 2 years, and 5 years after surgery. Zurich Claudication Questionnaire (ZCQ) was recorded to assess the patient's postoperative condition at each follow-up.A total of 142 patients were available for follow up at each time interval. There was a significant difference between the preoperative and final follow-up ZCQ scores for every LSS type. In addition, there was no difference between group A and group B in the postoperative ZCQ scores with the exception of the lateral severe type. In the study, 22 of the 23 patients (95.65%) in the lateral moderate type were considered to have a satisfactory result in group B, with a similar result of 93.33% (14/15) in group A (P = .75). In the lateral severe type, the patient satisfaction rate was 65.22% (15/23) and 90.63% (29/32) in group A and group B (P = .02), respectively. In the central moderate type, the patient satisfaction rate was 81.82% (15/23) and 76.92% (10/13) in group A and group B (P = .77), respectively. Satisfaction rate for the follow-up results in the central severe type reached 57.14% (4/7) in group A, and 54.55% (6/11) in group B (P = .91). Moreover, no relationship was found between satisfaction and neurogenic intermittent claudication.The most suitable indication for BacFuse treatment was the lateral moderate type. For lateral severe patients, distraction combined with decompression is suggested for a higher satisfaction rate. Severe central spinal stenosis was shown to be a relative contraindication for BacFuse.
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Affiliation(s)
- Mengmeng Chen
- Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University, Beijing, People's Republic of China
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Manfre L, De Vivo AE, Al Qatami H, Own A, Ventura F, Zhou K, Chandra RV, Hirsch JA. Successful use of percutaneous interspinous spacers and adjunctive spinoplasty in a 9 year cohort of patients. J Neurointerv Surg 2020; 12:673-677. [DOI: 10.1136/neurintsurg-2019-015601] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/07/2019] [Accepted: 12/09/2019] [Indexed: 12/16/2022]
Abstract
PurposeLumbar spinal canal stenosis and lumbar spinal foraminal stenosis are common, degenerative pathologies which can result in neurogenic claudication and have a negative impact on function and quality of life. Percutaneous interspinous devices (PIDs) are a recently-developed, minimally-invasive, alternative treatment option. This study details a 9 year single-centre experience with PIDs and examines the complementary use of spinous process augmentation (spinoplasty) to reduce failure rates.MethodsA retrospective cohort assessment of 800 consecutive patients who presented to a specialized spine hospital was performed with 688 receiving treatment. Inclusion was based on high-grade stenosis, failure of conservative management and electromyography. 256 had a PID alone while 432 had concurrent polymethyl methacrylate (PMMA) augmentation of the adjacent spinous processes. The patients were followed up at 3 and 12 months using the Zurich Claudication Questionnaire (ZCQ) and Oswestry Disability Index (ODI).ResultsBoth groups showed marked improvement in the patients’ ZCQ scores (3.2 to 1.3) and ODI scores (32 to 21), with strong satisfaction results (1.7). The symptom recurrence rate from complications for the group which received concurrent spinous process augmentation was reduced when compared with the PID alone cohort (<1% vs 11.3%).ConclusionThis study demonstrates the efficacy of percutaneous interspinous devices in treating lumbar spinal stenosis. It also provides evidence that concurrent spinous process augmentation reduces the rate of symptom recurrence.
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Akazawa T, Kotani T, Sakuma T, Torii Y, Iinuma M, Asano K, Ueno J, Yoshida A, Murakami K, Minami S, Orita S, Inage K, Shiga Y, Nakamura J, Inoue G, Miyagi M, Saito W, Eguchi Y, Fujimoto K, Takahashi H, Ohtori S, Niki H. MRI evaluation of dural sac enlargement by interspinous process spacers in patients with lumbar spinal stenosis: Does it play a role in the long term? J Orthop Sci 2019; 24:979-984. [PMID: 31537426 DOI: 10.1016/j.jos.2019.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 08/15/2019] [Accepted: 08/27/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND To investigate dural sac enlargements and spinal alignments in patients who underwent indirect decompression with interspinous spacers. METHODS The subjects were 20 patients who underwent indirect decompression using an interspinous spacer (X-STOP) without laminectomy. Of these 20 patients, 1 patient underwent implant removal surgery 1 month after X-STOP surgery and two patients dropped out. Ultimately, 17 patients were included in this study. MRI and X-ray images were investigated before surgery, 1 week after surgery, 3 months after surgery, and 2 years after surgery. RESULTS On MRI, the mean cross-sectional areas of the dural sac were 52.7 mm2 before surgery, 73.2 mm2 1 week after surgery, 62.4 mm2 3 months after surgery, and 58.3 mm2 2 years after surgery. There was a significant 37% increase at 1 week postoperatively compared with that before surgery, but there were no significant differences between 3 months postoperatively and 2 years postoperatively. The disc angle in an extension posture was significantly decreased at 1 week after surgery compared with that before surgery, but there were no significant differences between before surgery, 3 months after surgery, and 2 years after surgery. CONCLUSIONS The interspinous process spacer increased the dural sac area by 37% 1 week after surgery, but the enlargement was not maintained at 3 months or 2 years after surgery. The use of interspinous process spacers produced an enlargement of the dural sac by limiting extension of the stenotic level only. However, its effect diminished 2 years after surgery.
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Affiliation(s)
- Tsutomu Akazawa
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan; Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan.
| | - Toshiaki Kotani
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Tsuyoshi Sakuma
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Yoshiaki Torii
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masahiro Iinuma
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kota Asano
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Jun Ueno
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Atsuhiro Yoshida
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kenichi Murakami
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Shohei Minami
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Sumihisa Orita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kazuhide Inage
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Junichi Nakamura
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Masayuki Miyagi
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Wataru Saito
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yawara Eguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan; Department of Orthopaedic Surgery, National Hospital Organization, Shimoshizu Hospital, Yotsukaido, Japan
| | - Kazuki Fujimoto
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan; Department of Orthopaedic Surgery, Konodai Hospital, National Center for Global Health and Medicine, Ichikawa, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, Sakura, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hisateru Niki
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
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Staats PS, Chafin TB, Golovac S, Kim CK, Li S, Richardson WB, Vallejo R, Wahezi SE, Washabaugh EP, Benyamin RM. Long-Term Safety and Efficacy of Minimally Invasive Lumbar Decompression Procedure for the Treatment of Lumbar Spinal Stenosis With Neurogenic Claudication: 2-Year Results of MiDAS ENCORE. Reg Anesth Pain Med 2018; 43:789-794. [PMID: 30199512 PMCID: PMC6319572 DOI: 10.1097/aap.0000000000000868] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND OBJECTIVES This study evaluated the long-term durability of the minimally invasive lumbar decompression (MILD) procedure in terms of functional improvement and pain reduction for patients with lumbar spinal stenosis and neurogenic claudication due to hypertrophic ligamentum flavum. This is a report of 2-year follow-up for MILD study patients. METHODS This prospective, multicenter, randomized controlled clinical study compared outcomes for 143 patients treated with MILD versus 131 treated with epidural steroid injections. Follow-up occurred at 6 months and at 1 year for the randomized phase and at 2 years for MILD subjects only. Oswestry Disability Index, Numeric Pain Rating Scale, and Zurich Claudication Questionnaire were used to evaluate function and pain. Safety was evaluated by assessing incidence of device-/procedure-related adverse events. RESULTS All outcome measures demonstrated clinically meaningful and statistically significant improvement from baseline through 6-month, 1-year, and 2-year follow-ups. At 2 years, Oswestry Disability Index improved by 22.7 points, Numeric Pain Rating Scale improved by 3.6 points, and Zurich Claudication Questionnaire symptom severity and physical function domains improved by 1.0 and 0.8 points, respectively. There were no serious device-/procedure-related adverse events, and 1.3% experienced a device-/procedure-related adverse event. CONCLUSIONS MILD showed excellent long-term durability, and there was no evidence of spinal instability through 2-year follow-up. Reoperation and spinal fracture rates are lower, and safety is higher for MILD versus other lumbar spine interventions, including interspinous spacers, surgical decompression, and spinal fusion. Given the minimally invasive nature of this procedure, its robust success rate, and durability of outcomes, MILD is an excellent choice for first-line therapy for select patients with central spinal stenosis suffering from neurogenic claudication symptoms with hypertrophic ligamentum flavum. CLINICAL TRIAL REGISTRATION This study was registered at ClinicalTrials.gov, identifier NCT02093520.
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Affiliation(s)
| | - Timothy B. Chafin
- Department of Pain Management and Rehabilitation Medicine, Vidant Roanoke-Chowan Hospital, Ahoskie, NC
| | | | | | - Sean Li
- Premier Pain Centers, Shrewsbury, NJ
| | | | | | - Sayed E. Wahezi
- Departments of Physical Medicine and Rehabilitation and Anesthesiology, Albert Einstein College of Medicine at Montefiore, Montefiore Medical Center, Bronx, NY; and
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Mlyavykh S, Ludwig SC, Kepler CK, Anderson DG. Five-year results of a clinical pilot study utilizing a pedicle-lengthening osteotomy for the treatment of lumbar spinal stenosis. J Neurosurg Spine 2018; 29:241-249. [PMID: 29856305 DOI: 10.3171/2017.11.spine16664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Lumbar spinal stenosis (LSS) is a common condition that leads to significant disability, particularly in the elderly. Current therapeutic options have certain drawbacks. This study evaluates the 5-year clinical and radiographic results of a minimally invasive pedicle-lengthening osteotomy (PLO) for symptomatic LSS. METHODS A prospective, single-arm, clinical pilot study was conducted involving 20 patients (mean age 61.7 years) with symptomatic LSS treated by a PLO procedure at 1 or 2 lumbar levels. All patients had symptoms of neurogenic claudication or radiculopathy secondary to LSS, and had not improved after a minimum 6-month course of nonoperative treatment. Eleven patients had a Meyerding grade I degenerative spondylolisthesis in addition to LSS. Clinical outcomes were measured using the Oswestry Disability Index, Zürich Claudication Questionnaire, 12-Item Short Form Health Survey, and a visual analog scale for back and leg pain. Procedural variables, neurological outcomes, adverse events, and radiological imaging (plain radiographs and CT scans) were collected at the 1.5-, 3-, 6-, 9-, 12-, 24-, and 60-month time points. RESULTS The PLOs were performed through percutaneous incisions, with minimal blood loss in all cases. There were no operative complications. Four adverse events occurred during the follow-up period. Statistically significant improvement was observed in each of the outcome instruments and maintained over the 5-year follow-up period. Imaging studies, reviewed by an independent radiologist, showed no evidence of device subsidence, migration, breakage, or heterotopic ossification. Thin-slice CT scans documented healing of the osteotomy site in all patients at the 6-month time point and an increase of 115% in the mean cross-sectional area of the spinal canal. CONCLUSIONS Treatment of patients with symptomatic LSS with a PLO procedure provided substantial enlargement of the area of the spinal canal and favorable clinical results for both disease-specific and non-disease-specific outcome measures at all follow-up time points out to 5 years. Future research is needed to compare this technique to alternative therapies for LSS.
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Affiliation(s)
- Sergey Mlyavykh
- 1Privolzhski Federal Medical Research Center, Nizhniy Novgorod, Russia
| | - Steven C Ludwig
- 2Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Christopher K Kepler
- 3Department of Orthopaedics, Thomas Jefferson University/Rothman Institute, Philadelphia, Pennsylvania
| | - D Greg Anderson
- 3Department of Orthopaedics, Thomas Jefferson University/Rothman Institute, Philadelphia, Pennsylvania
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Urbina MC, Benítez HS, Rivera MÁF, Moga AG, Carranza JEG, Hernández GH. EFFICACY AND SAFETY OF LUMBAR ARTHROPLASTY IN DEGENERATIVE DISC DISEASE. COLUNA/COLUMNA 2018. [DOI: 10.1590/s1808-185120181702190992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: The objective of this longitudinal retrospective study is to assess the efficacy and safety of total lumbar disc replacement in patients with degenerative discopathy (L3-L4, L4-L5, L5-S1). Methods: One hundred and forty-three patients with low back pain, with or without radiculopathy, who met the radiographic criteria underwent anterior arthroplasty between 2000 and 2016. The Oswestry disability index (ODI), the visual analog scale (VAS), patient satisfaction, success criteria, disc height, and range of motion of the operated segment were evaluated preoperatively and at 3, 6, 12, and 24 months following surgery. Results: There were 50 men and 93 women, with an average age of 39.5 years, 13 patients (9%) with previous discectomy. The arthroplasty was performed at level L5-S1 in 97 patients (67.8%), at level L4-L5 in 45 patients (31.5%), and at level L3-L4 in 1 patient. Between the preoperative period and 24 months following surgery, the ODI decreased by 53.86%, the VAS for low back pain decreased by 63.83%, and low back pain with radiculopathy decreased by 60.20%, all statistically significant (p ≤ 0.5). Eighty-two percent of the patients were completely satisfied and 18% were satisfied. There was an average increase in disc height of 12 mm (p <0.001). The range of motion of the affected segment increased by 4° to 7° after surgery (p <0.004). Conclusions: Lumbar arthroplasty of a segment is recommended as an effective treatment for patients with degenerative disc disease with low back pain with or without a root component who meet the inclusion criteria. Level of Evidence III, Systematic reviewb of Level III studies.
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Ravindra VM, Ghogawala Z. Is There Still a Role for Interspinous Spacers in the Management of Neurogenic Claudication? Neurosurg Clin N Am 2018; 28:321-330. [PMID: 28600006 DOI: 10.1016/j.nec.2017.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Lumbar spinal stenosis with neurogenic claudication is prevalent in the elderly population. Decompression for this condition is the operation most commonly used to treat older patients. Because of the risks associated with open decompression procedures, particularly in older patients with comorbidities, minimally invasive procedures with implantation of interspinous process devices have been developed. This article reviews the current role of interspinous spacers in the treatment of lumbar spinal stenosis with neurogenic claudication and discusses the body of literature surrounding this treatment alternative.
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Affiliation(s)
- Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 North Medical Drive East, Salt Lake City, UT 84132, USA; Department of Neurosurgery, Alan and Jacqueline Stuart Spine Research Center, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA
| | - Zoher Ghogawala
- Department of Neurosurgery, Alan and Jacqueline Stuart Spine Research Center, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA; Department of Neurosurgery, Tufts University School of Medicine, 145 Harrison Avenue, Boston, MA 02111, USA.
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Tapp SJ, Martin BI, Tosteson TD, Lurie JD, Weinstein MC, Deyo RA, Mirza SK, Tosteson ANA. Understanding the value of minimally invasive procedures for the treatment of lumbar spinal stenosis: the case of interspinous spacer devices. Spine J 2018; 18:584-592. [PMID: 28847740 DOI: 10.1016/j.spinee.2017.08.246] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 07/19/2017] [Accepted: 08/21/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Minimally invasive lumbar spinal stenosis procedures have uncertain long-term value. PURPOSE This study sought to characterize factors affecting the long-term cost-effectiveness of such procedures using interspinous spacer devices ("spacers") relative to decompression surgery as a case study. STUDY DESIGN Model-based cost-effectiveness analysis. PATIENT SAMPLE The Medicare Provider Analysis and Review database for the years 2005-2009 was used to model a group of 65-year-old patients with spinal stenosis who had no previous spine surgery and no contraindications to decompression surgery. OUTCOME MEASURES Costs, quality-adjusted life years (QALYs), and cost per QALY gained were the outcome measures. METHODS A Markov model tracked health utility and costs over 10 years for a 65-year-old cohort under three care strategies: conservative care, spacer surgery, and decompression surgery. Incremental cost-effectiveness ratios (ICER) reported as cost per QALY gained included direct medical costsfor surgery. Medicare claims data were used to estimate complication rates, reoperation, and related costs within 3 years. Utilities and long-term reoperation rates for decompression were derived frompublished studies. Spacer failure requiring reoperation beyond 3 years and post-spacer health utilities are uncertain and were evaluated through sensitivity analyses. In the base-case, the spacer failure rate was held constant for years 4-10 (cumulative failure: 47%). In a "worst-case" analysis, the 10-year cumulative reoperation rate was increased steeply (to 90%). Threshold analyses were performed to determine the impact of failure and post-spacer health utility on the cost-effectiveness of spacer surgery. RESULTS The spacer strategy had an ICER of $89,500/QALY gained under base-case assumptions, and remained under $100,000 as long as the 10-year cumulative probability of reoperation did not exceed 54%. Under worst-case assumptions, the spacer ICER was $482,000/QALY and fell below $100,000 only if post-spacer utility was 0.01 greater than post-decompression utility or the cost of spacer surgery was $1,600 less than the cost of decompression surgery. CONCLUSIONS Spacers may provide a reasonably cost-effective initial treatment option for patients with lumbar spinal stenosis. Their value is expected to improve if procedure costs are lower in outpatient settings where these procedures are increasingly being performed. Decision analysis is useful for characterizing the long-term cost-effectiveness potential for minimally invasive spinal stenosis treatments and highlights the importance of complication rates and prospective health utility assessment.
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Affiliation(s)
- Stephanie J Tapp
- Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Brook I Martin
- Department of Orthopaedics, University of Utah, Salt Lake City, UT 84158, USA
| | - Tor D Tosteson
- Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Jon D Lurie
- Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Milton C Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard Medical School, 718 Huntington Ave, Boston, MA 02115, USA
| | - Richard A Deyo
- Departments of Family Medicine and Internal Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Sohail K Mirza
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Anna N A Tosteson
- Multidisciplinary Clinical Research Center in Musculoskeletal Diseases, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
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Fishchenko IV, Kravchuk LD, Perepechay OA. Lumbar spinal stenosis: symptoms, diagnosis and treatment (meta-analysis of literature data). PAIN MEDICINE 2018. [DOI: 10.31636/pmjua.v3i1.83] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Lumbar spinal stenosis is a disease in which degenerated discs, ligamentum flavum, facet joints, while aging, lead to a narrowing of the space around the neurovascular structures of the spine. This article presents a meta-analysis of literature data on epidemiology, causes, pathogenesis, diagnosis and various types of treatment of lumbar spinal stenosis.
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28
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Yoshihara H. Indirect decompression in spinal surgery. J Clin Neurosci 2017; 44:63-68. [DOI: 10.1016/j.jocn.2017.06.061] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 06/18/2017] [Indexed: 10/19/2022]
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Nicholson JA, Scott CEH, Duckworth AD, Burke JG, Gibson JNA. Survival analysis of the Wallis interspinous spacer used as an augment to lumbar decompression. Br J Neurosurg 2017; 31:688-694. [PMID: 28691531 DOI: 10.1080/02688697.2017.1351522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECT The Wallis fixed interspinous spacer may augment traditional decompression in the treatment of lumbar spinal stenosis. The aim of this study was to determine factors influencing survival of the Wallis interspinous spacer and to identify specific modes and predictors of failure. METHODS We performed a retrospective cohort study of 244 Wallis interspinous spacers implanted in 195 consecutive patients with a mean age of 56 years (range 21-87) to augment single or multi-level decompression. We examined patient demographics, indications for surgery, surgical techniques and pathology on magnetic resonance imaging (MRI). A Kaplan-Meier survival analysis was performed. RESULTS Median follow-up was 4.5 years (range 2-8). Sixteen patients were lost to follow-up. Repeat MRI was performed in 98 patients (50%). A recurrent stenosis was found in 21% of patients (41/195) and occurred at a similar incidence at the level of the spacer and at adjacent spinal levels. Revision decompression was performed in 19 patients (10%) at 2.8 ± 1.8 years (range 6 months-6 years) with implant removal in 15 and conversion to fusion in 4 patients. No specific patient factors or pre-operative MRI findings predicted failure. Five-year survival was 91% (95% CI: 79-96%). CONCLUSIONS The Wallis implant is generally implanted without complication when used as an adjunct to decompression with a good medium term survival. Though disc heights were maintained, the Wallis spacer did not however appear to reduce the incidence of recurrent spinal or foraminal stenosis from that expected from decompression alone.
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Affiliation(s)
- Jamie A Nicholson
- a Department of Orthopaedics , The Royal Infirmary, University of Edinburgh , Edinburgh , UK
| | - Chloe E H Scott
- a Department of Orthopaedics , The Royal Infirmary, University of Edinburgh , Edinburgh , UK
| | - Andrew D Duckworth
- a Department of Orthopaedics , The Royal Infirmary, University of Edinburgh , Edinburgh , UK
| | - John G Burke
- a Department of Orthopaedics , The Royal Infirmary, University of Edinburgh , Edinburgh , UK
| | - John N Alastair Gibson
- a Department of Orthopaedics , The Royal Infirmary, University of Edinburgh , Edinburgh , UK
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Ma XL, Zhao XW, Ma JX, Li F, Wang Y, Lu B. Effectiveness of surgery versus conservative treatment for lumbar spinal stenosis: A system review and meta-analysis of randomized controlled trials. Int J Surg 2017; 44:329-338. [PMID: 28705591 DOI: 10.1016/j.ijsu.2017.07.032] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 06/28/2017] [Accepted: 07/07/2017] [Indexed: 11/15/2022]
Abstract
PURPOSE Lumbar spinal stenosis (LSS) was a common degenerative disease that affected the lumbar spine function and quality of life, which can be treated both surgery and conservative treatment. We did this study to compare the effectiveness of surgery versus conservative treatment for LSS. METHODS We searched PubMed as well as other databases in September.18th.2016. Randomized controlled trials compared surgery versus conservative treatment for patients with LSS were enrolled. Outcomes and complications were collected with data selection criteria and analyzed with Review Manager Version 5.3. RESULTS Nine RCTs (14 articles) and 1658 patients were included, and three of them were high-quality studies. At first 6 months after treatment, there were no significant differences for ODI scores between two therapeutic groups (P > 0.05), however, surgery group showed significant higher ODI scores at one year (P < 0.05) and two years (P < 0.05). Two studies reported no significant difference between laminectomy and conservative treatment for the SF-36 physical function scores at 3 months, 6 months, 12 months and 24 months (P > 0.05) and two studies reported patients were satisfied with X-STOP implanted at six weeks, six months, and one year. No statistical differences for the adverse events intra-operation or within 72 h (P > 0.05) between surgery and non-surgery groups. Moreover, subgroup analysis showed there were no safety differences between laminectomy and conservative treatment, X-STOP and conservative treatment at early stage of duration. However, the surgical groups had higher complication rates than non-surgery groups throughout the follow-up duration. CONCLUSION Surgery groups showed better late clinical outcomes after one year and higher complication rate throughout the follow-up duration, although it had no significant differences compared with conservative groups in the first six months post-treatment. However, there was no evidence that a definitive method could be firmly recommended to LSS patients. Further researches were needed to achieve high quality and credible results.
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Affiliation(s)
- Xin-Long Ma
- Orthopaedics Institute, Tianjin Hospital, Tianjin 300050, PR China.
| | - Xing-Wen Zhao
- Dali Bai Autonomous Prefecture People's Hospital, Dali 671000, PR China.
| | - Jian-Xiong Ma
- Orthopaedics Institute, Tianjin Hospital, Tianjin 300050, PR China.
| | - Fei Li
- Orthopaedics Institute, Tianjin Hospital, Tianjin 300050, PR China
| | - Yin Wang
- Orthopaedics Institute, Tianjin Hospital, Tianjin 300050, PR China
| | - Bin Lu
- Orthopaedics Institute, Tianjin Hospital, Tianjin 300050, PR China
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Wong AYL, Karppinen J, Samartzis D. Low back pain in older adults: risk factors, management options and future directions. SCOLIOSIS AND SPINAL DISORDERS 2017; 12:14. [PMID: 28435906 PMCID: PMC5395891 DOI: 10.1186/s13013-017-0121-3] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 04/04/2017] [Indexed: 12/12/2022]
Abstract
Low back pain (LBP) is one of the major disabling health conditions among older adults aged 60 years or older. While most causes of LBP among older adults are non-specific and self-limiting, seniors are prone to develop certain LBP pathologies and/or chronic LBP given their age-related physical and psychosocial changes. Unfortunately, no review has previously summarized/discussed various factors that may affect the effective LBP management among older adults. Accordingly, the objectives of the current narrative review were to comprehensively summarize common causes and risk factors (modifiable and non-modifiable) of developing severe/chronic LBP in older adults, to highlight specific issues in assessing and treating seniors with LBP, and to discuss future research directions. Existing evidence suggests that prevalence rates of severe and chronic LBP increase with older age. As compared to working-age adults, older adults are more likely to develop certain LBP pathologies (e.g., osteoporotic vertebral fractures, tumors, spinal infection, and lumbar spinal stenosis). Importantly, various age-related physical, psychological, and mental changes (e.g., spinal degeneration, comorbidities, physical inactivity, age-related changes in central pain processing, and dementia), as well as multiple risk factors (e.g., genetic, gender, and ethnicity), may affect the prognosis and management of LBP in older adults. Collectively, by understanding the impacts of various factors on the assessment and treatment of older adults with LBP, both clinicians and researchers can work toward the direction of more cost-effective and personalized LBP management for older people.
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Affiliation(s)
- Arnold YL Wong
- Department of Rehabilitation Sciences, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong, SAR China
| | - Jaro Karppinen
- Medical Research Center Oulu, Department of Physical and Rehabilitation Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
- Finnish Institute of Occupational Health, Oulu, Finland
| | - Dino Samartzis
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong, SAR China
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Machado GC, Ferreira PH, Yoo RIJ, Harris IA, Pinheiro MB, Koes BW, van Tulder MW, Rzewuska M, Maher CG, Ferreira ML. Surgical options for lumbar spinal stenosis. Cochrane Database Syst Rev 2016; 11:CD012421. [PMID: 27801521 PMCID: PMC6464992 DOI: 10.1002/14651858.cd012421] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hospital charges for lumbar spinal stenosis have increased significantly worldwide in recent times, with great variation in the costs and rates of different surgical procedures. There have also been significant increases in the rate of complex fusion and the use of spinal spacer implants compared to that of traditional decompression surgery, even though the former is known to incur costs up to three times higher. Moreover, the superiority of these new surgical procedures over traditional decompression surgery is still unclear. OBJECTIVES To determine the efficacy of surgery in the management of patients with symptomatic lumbar spinal stenosis and the comparative effectiveness between commonly performed surgical techniques to treat this condition on patient-related outcomes. We also aimed to investigate the safety of these surgical interventions by including perioperative surgical data and reoperation rates. SEARCH METHODS Review authors performed electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, Web of Science, LILACS and three trials registries from their inception to 16 June 2016. Authors also conducted citation tracking on the reference lists of included trials and relevant systematic reviews. SELECTION CRITERIA This review included only randomised controlled trials that investigated the efficacy and safety of surgery compared with no treatment, placebo or sham surgery, or with another surgical technique in patients with lumbar spinal stenosis. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the studies for inclusion and performed the 'Risk of bias' assessment, using the Cochrane Back and Neck Review Group criteria. Reviewers also extracted demographics, surgery details, and types of outcomes to describe the characteristics of included studies. Primary outcomes were pain intensity, physical function or disability status, quality of life, and recovery. The secondary outcomes included measurements related to surgery, such as perioperative blood loss, operation time, length of hospital stay, reoperation rates, and costs. We grouped trials according to the types of surgical interventions being compared and categorised follow-up times as short-term when less than 12 months and long-term when 12 months or more. Pain and disability scores were converted to a common 0 to 100 scale. We calculated mean differences for continuous outcomes and relative risks for dichotomous outcomes. We pooled data using the random-effects model in Review Manager 5.3, and used the GRADE approach to assess the quality of the evidence. MAIN RESULTS We included a total of 24 randomised controlled trials (reported in 39 published research articles or abstracts) in this review. The trials included 2352 participants with lumbar spinal stenosis with symptoms of neurogenic claudication. None of the included trials compared surgery with no treatment, placebo or sham surgery. Therefore, all included studies compared two or more surgical techniques. We judged all trials to be at high risk of bias for the blinding of care provider domain, and most of the trials failed to adequately conceal the randomisation process, blind the participants or use intention-to-treat analysis. Five trials compared the effects of fusion in addition to decompression surgery. Our results showed no significant differences in pain relief at long-term (mean difference (MD) -0.29, 95% confidence interval (CI) -7.32 to 6.74). Similarly, we found no between-group differences in disability reduction in the long-term (MD 3.26, 95% CI -6.12 to 12.63). Participants who received decompression alone had significantly less perioperative blood loss (MD -0.52 L, 95% CI -0.70 L to -0.34 L) and required shorter operations (MD -107.94 minutes, 95% CI -161.65 minutes to -54.23 minutes) compared with those treated with decompression plus fusion, though we found no difference in the number of reoperations (risk ratio (RR) 1.25, 95% CI 0.81 to 1.92). Another three trials investigated the effects of interspinous process spacer devices compared with conventional bony decompression. These spacer devices resulted in similar reductions in pain (MD -0.55, 95% CI -8.08 to 6.99) and disability (MD 1.25, 95% CI -4.48 to 6.98). The spacer devices required longer operation time (MD 39.11 minutes, 95% CI 19.43 minutes to 58.78 minutes) and were associated with higher risk of reoperation (RR 3.95, 95% CI 2.12 to 7.37), but we found no difference in perioperative blood loss (MD 144.00 mL, 95% CI -209.74 mL to 497.74 mL). Two trials compared interspinous spacer devices with decompression plus fusion. Although we found no difference in pain relief (MD 5.35, 95% CI -1.18 to 11.88), the spacer devices revealed a small but significant effect in disability reduction (MD 5.72, 95% CI 1.28 to 10.15). They were also superior to decompression plus fusion in terms of operation time (MD 78.91 minutes, 95% CI 30.16 minutes to 127.65 minutes) and perioperative blood loss (MD 238.90 mL, 95% CI 182.66 mL to 295.14 mL), however, there was no difference in rate of reoperation (RR 0.70, 95% CI 0.32 to 1.51). Overall there were no differences for the primary or secondary outcomes when different types of surgical decompression techniques were compared among each other. The quality of evidence varied from 'very low quality' to 'high quality'. AUTHORS' CONCLUSIONS The results of this Cochrane review show a paucity of evidence on the efficacy of surgery for lumbar spinal stenosis, as to date no trials have compared surgery with no treatment, placebo or sham surgery. Placebo-controlled trials in surgery are feasible and needed in the field of lumbar spinal stenosis. Our results demonstrate that at present, decompression plus fusion and interspinous process spacers have not been shown to be superior to conventional decompression alone. More methodologically rigorous studies are needed in this field to confirm our results.
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Affiliation(s)
- Gustavo C Machado
- Sydney Medical School, The University of SydneyThe George Institute for Global HealthPO Box M201SydneyAustraliaNSW 2050
| | - Paulo H Ferreira
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health Sciences75 East StreetSydneyLidcombe NSWAustralia1825
| | - Rafael IJ Yoo
- Sydney Medical School, The University of SydneyThe George Institute for Global HealthPO Box M201SydneyAustraliaNSW 2050
| | - Ian A Harris
- South Western Sydney Clinical School, UNSW AustraliaIngham Institute for Applied Medical ResearchElizabeth StreetLiverpoolNew South WalesAustralia2170
| | - Marina B Pinheiro
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health Sciences75 East StreetSydneyLidcombe NSWAustralia1825
| | - Bart W Koes
- Erasmus Medical CenterDepartment of General PracticePO Box 2040RotterdamNetherlands3000 CA
| | - Maurits W van Tulder
- VU University AmsterdamDepartment of Health Sciences, Faculty of Earth and Life SciencesPO Box 7057Room U454AmsterdamNetherlands1007 MB
| | - Magdalena Rzewuska
- University of São PauloDepartment of Social Medicine, Faculty of MedicineAv. Bandeirantes, 3900 ‐ Monte AlegreRibeirão PretoSão PauloBrazil
| | - Christopher G Maher
- Sydney Medical School, The University of SydneyThe George Institute for Global HealthPO Box M201SydneyAustraliaNSW 2050
| | - Manuela L Ferreira
- Sydney Medical School, The University of SydneyThe George Institute for Global Health & Institute of Bone and Joint Research, The Kolling InstituteSydneyNSWAustralia
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Moojen WA, Van der Gaag NA. Minimally invasive surgery for lumbar spinal stenosis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:681-4. [PMID: 27659170 DOI: 10.1007/s00590-016-1828-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Wouter A Moojen
- HAGA Teaching Hospital, Leyweg 275, 2545 CH, The Hague, Netherlands. .,Medical Center Haaglanden, The Hague, Netherlands. .,Leiden University Medical Center, Leiden, Netherlands.
| | - Niels A Van der Gaag
- HAGA Teaching Hospital, Leyweg 275, 2545 CH, The Hague, Netherlands.,Leiden University Medical Center, Leiden, Netherlands
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Conservative Care in Lumbar Spine Surgery Trials: A Descriptive Literature Review. Arch Phys Med Rehabil 2016; 98:165-172. [PMID: 27576191 DOI: 10.1016/j.apmr.2016.07.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/30/2016] [Accepted: 07/27/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the degree to which conservative care and failure were specifically defined in studies comparing nonoperative treatment versus surgery for low back pain (LBP) conditions in adults. DATA SOURCES A comprehensive literature search was conducted by an experienced librarian using MEDLINE (PubMed), Embase, Google Scholar, and CENTRAL from January 2003 to June 2014. Endnote bibliographic management application was used to remove duplicates and organize the citations. STUDY SELECTION Prospective, randomized, or cohort trials comparing surgery versus conservative intervention for patients with LBP conditions. Study selection was conducted by 2 independent reviewers. DATA EXTRACTION Three independent reviewers extracted data from each article using a structured data extraction form. Data extracted included type of study, participant characteristics, sample size, description, and duration of conservative care and whether failed conservative care criterion was defined. DATA SYNTHESIS A total of 852 unique records were screened for eligibility; of those, 72 articles were identified for further full-text review. Thirty-four full texts were excluded based on the exclusion criteria, and 38 articles, representing 20 unique studies, were included for qualitative synthesis. Fifteen of the 20 studies defined the duration of conservative care. Only 3 studies defined the dosage of physical therapy sessions, including total number of visits and visit duration. Two studies described medication usage, including the duration and type. No studies specifically defined what constituted failed conservative therapy. CONCLUSIONS This literature review suggests conservative care is poorly defined in randomized trials, which can lead to ambiguity of research procedures and unclear guidelines for clinicians. Future studies should increase transparency and explicitly define conservative care.
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Two-Year Evaluation of the X-STOP Interspinous Spacer in Different Primary Patient Populations With Neurogenic Intermittent Claudication Because of Lumbar Spinal Stenosis. Clin Spine Surg 2016; 29:305-11. [PMID: 23168396 DOI: 10.1097/bsd.0b013e31827b671f] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Multicenter, prospective single-arm study in patients diagnosed with neurogenic intermittent claudication because of lumbar spinal stenosis. OBJECTIVE To collect data from 2 different primary patient populations, new participants meeting entry criteria [Continued Access Program (CAP)], or subjects who had been randomly assigned to nonsurgical management in the pivotal Investigational Device Exemption study and failed to respond upon study completion [Crossover Study (COS)]. SUMMARY OF BACKGROUND DATA The X-STOP interspinous spacer is a minimally invasive treatment option for neurogenic intermittent claudication shown to improve pain, physical functioning, and/or overall quality of life. METHODS Fifty-five subjects were enrolled, 42 in CAP and 13 in COS. Zurich Claudication Questionnaire (ZCQ) success rates were obtained based on the number of subjects achieving a threshold level of success. Mean SF-36 domain scores were compared with baseline using repeated measures analysis of variance. RESULTS Eighty percent of subjects completed the study. At 2 years, 26/43 subjects (60.5%) achieved clinically significant improvement in the Symptom Severity domain, 25/43 (58.1%) achieved clinically significant improvement in the Physical Function domain, and 31/44 (70.5%) achieved clinically significant improvement in the Patient Satisfaction domain of the ZCQ. Statistically significant improvement in mean scores was obtained in all physical domains of the SF-36 (with the exception of General Health) at 24 months. Mean improvement in ZCQ and SF-36 scores was not as pronounced in the COS cohort compared with the CAP cohort. The most frequently reported device-related or treatment-related adverse event was stenosis pain reported by 3 subjects. CONCLUSIONS Overall data are consistent with the randomized pivotal Investigational Device Exemption trial. On the basis of the COS cohort which was subject to several additional years of failed conservative treatment, overall success rates do not improve as greatly in patients with long-standing lumbar spinal stenosis symptoms.
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Hara N, Matsudaira K, Masuda K, Tohnosu J, Takeshita K, Kobayashi A, Murakami M, Kawamura N, Yamakawa K, Terayama S, Ogihara S, Shiono H, Morii J, Hayakawa K, Kato S, Nakamura K, Oka H, Sawada T, Inuzuka K, Kikuchi N. Psychometric Assessment of the Japanese Version of the Zurich Claudication Questionnaire (ZCQ): Reliability and Validity. PLoS One 2016; 11:e0160183. [PMID: 27467254 PMCID: PMC4965020 DOI: 10.1371/journal.pone.0160183] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/14/2016] [Indexed: 11/18/2022] Open
Abstract
Purpose The Zurich Claudication Questionnaire (ZCQ) is a self-administered measure to evaluate symptom severity, physical function, and surgery satisfaction in lumbar spinal stenosis (LSS). The purpose of this study is to assess the psychometric properties of the Japanese ZCQ in LSS patients. Methods LSS patients who are scheduled to undergo surgery were recruited from 12 facilities. Responses to several questionnaires, including the Japanese ZCQ; the visual analogue scale (VAS) to evaluate the degree of pain in the buttocks/legs, numbness in the buttocks/legs, and low back pain; the Oswestry Disability Index (ODI); and the SF-36v2, were collected before surgery and again 3 months after surgery (the post-surgery ZCQ was administered twice for test-retest reliability). For reliability, test-retest reliability was evaluated using the intra-class coefficient (ICC) and internal consistency was evaluated using Cronbach’s alpha coefficient. Concurrent validity was assessed using Spearman’s correlation coefficients between the Japanese ZCQ and other questionnaires. Effect size (ES) and standard response mean were calculated for responsiveness. All analyses were performed individually for the Japanese ZCQ symptom, function, and satisfaction domains. Results Data from 180 LSS patients were used in this analysis. The ICCs were 0.81, 0.89, and 0.88 and Cronbach’s alpha coefficients were 0.78, 0.84, and 0.92 for the Japanese ZCQ symptom, function, and satisfaction domains, respectively. Regarding the concurrent validity, strong correlations (±0.5) were demonstrated between the Japanese ZCQ domains and the VAS leg pain, ODI, and SF-36v2 physical functioning or bodily pain, whereas correlations were approximately 0.3 in scales measuring other symptoms that are less related to symptom, function, or satisfaction domains. ESs showed high values for the ZCQ symptom and function domains (-1.73 for both). Conclusions These psychometric assessments demonstrate that the Japanese ZCQ is a psychometrically reliable and valid measure in LSS. The Japanese ZCQ can evaluate both multi-dimensional aspects and the level of surgery satisfaction.
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Affiliation(s)
- Nobuhiro Hara
- Department of Orthopaedic Surgery, Musashino Red Cross Hospital, Musashino, Tokyo, Japan
| | - Ko Matsudaira
- Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical & Research Center, Faculty of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
- * E-mail:
| | - Kazuhiro Masuda
- Department of Orthopaedic Surgery, Tokyo Metropolitan Tama Medical Center, Fuchu, Tokyo, Japan
| | - Juichi Tohnosu
- Department of Orthopaedic Surgery, Kanto Rosai Hospital, Kawasaki, Kanagawa, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Atsuki Kobayashi
- Department of Orthopaedic Surgery, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Motoaki Murakami
- Department of Orthopaedic Surgery, Toranomon Hospital, Minato-ku, Tokyo, Japan
| | - Naohiro Kawamura
- Department of Spine and Orthopaedic Surgery, Japanese Red Cross Medical Center, Shibuya-ku, Tokyo, Japan
| | - Kiyohumi Yamakawa
- Department of Orthopaedic Surgery, Tokyo Metropolitan Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Sei Terayama
- Department of Orthopaedic Surgery, Sangubashi Spine Surgery Hospital, Shibuya-ku, Tokyo, Japan
| | - Satoshi Ogihara
- Department of Orthopaedic Surgery, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - Hiroo Shiono
- Department of Orthopaedic Surgery, Toranomon Hospital, Minato-ku, Tokyo, Japan
| | - Jiro Morii
- Department of Orthopaedic Surgery, Sanraku Hospital, Chiyoda-ku, Tokyo, Japan
| | - Keiji Hayakawa
- Department of Orthopaedic Surgery, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - So Kato
- Department of Orthopaedic Surgery, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kozo Nakamura
- National Rehabilitation Center for Persons with Disabilities, Tokorozawa, Saitama, Japan
| | - Hiroyuki Oka
- Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical & Research Center, Faculty of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Surgical and nonsurgical treatments for lumbar spinal stenosis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:695-704. [PMID: 27456169 DOI: 10.1007/s00590-016-1818-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 07/16/2016] [Indexed: 10/21/2022]
Abstract
Lumbar spinal stenosis (LSS) is the most common indication for spinal surgery in older adults; however, the efficacy of surgery for LSS as compared to nonsurgical treatments remains unclear. Here, we reviewed numerous studies, including randomized control trails (RCTs), to compare nonsurgical and surgical treatments for LSS. The nonsurgical management of LSS includes medication, epidural injections, physiotherapy, lifestyle modification, and multidisciplinary rehabilitative approaches. Patients with LSS who do not improve after nonsurgical treatments are typically treated surgically using decompressive surgery, which has the strongest evidence base. Although decompressive surgical treatment is associated with modestly successful outcomes, it remains unclear whether decompression combined with fusion surgery results in clinical outcomes that are superior to those following decompression surgery alone. Future RCTs assessing the effectiveness of specific treatments based on high-quality scientific evidence are expected to aid clinical decision-making and improve treatment outcomes for LSS.
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Abstract
STUDY DESIGN A systematic review. OBJECTIVES The aim of this study is to evaluate the effectiveness of different types of surgery compared with different types of nonsurgical interventions in adults with symptomatic lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA LSS is a debilitating condition associated with degeneration of the spine with aging. People with LSS experience a range of symptoms, including back pain, leg pain, numbness and tingling in the legs, and reduced physical function. Main treatment options are surgery, physical therapy, exercise, braces, and injections into the spine. METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, five other databases, and two trials registries up to February 2015, reference lists, and conference proceedings related to treatment of the spine. Randomized controlled trials (RCTs) compared surgical versus nonoperative treatments in participants with LSS.Outcomes included quality of life, disability, function, pain, complication rates, and side effects. RESULTS From the 12,966 citations screened, we included five RCTs (643 participants).Three studies compared spine surgery versus various types of nonsurgical treatment. It is difficult to draw conclusions from these studies because nonsurgical treatments were inadequately described. One study that compared surgery versus bracing and exercise found no differences in pain. Another study compared surgery versus spinal injections and found better physical function with injections, and better pain relief with surgery at six weeks. Still another trial compared surgery with an implanted device versus nonsurgical care. This study reported favorable outcomes of surgery for symptoms and physical function. CONCLUSION We cannot conclude on the basis of this review whether surgical or nonsurgical treatment is better for individuals with LSS. Nevertheless, we can report on the high rate of effects reported in three of five surgical groups, ranging from 10% to 24%. No side effects were reported for any of the conservative treatment options. LEVEL OF EVIDENCE 1.
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van den Akker-van Marle ME, Moojen WA, Arts MP, Vleggeert-Lankamp CLAM, Peul WC. Interspinous process devices versus standard conventional surgical decompression for lumbar spinal stenosis: cost-utility analysis. Spine J 2016; 16:702-10. [PMID: 25452018 DOI: 10.1016/j.spinee.2014.10.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Revised: 08/20/2014] [Accepted: 10/16/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT In the 1980s, a new implant was developed to treat patients with intermittent neurogenic claudication caused by lumbar spinal stenosis (LSS). This implant is now widely used. PURPOSE The objective of this study is to determine whether a favorable cost-effectiveness for interspinous process devices (IPDs) compared with conventional bony decompression is attained. STUDY DESIGN/SETTING Cost-utility analysis was performed alongside a double-blind randomized controlled trial. Five neurosurgical centers (including one academic and four secondary level care centers) included participants for this study. PATIENT SAMPLE One hundred fifty-nine patients with LSS were treated with the implantation of IPD and with bony decompression. Eighty participants received an IPD, and seventy-nine participants underwent spinal bony decompression. OUTCOME MEASURES Outcome measures were quality-adjusted life-years (QALYs) and societal costs in the first year (estimated per quarter), estimated from patient-reported utilities (US and The Netherlands EuroQol 5D [EQ-5D] and EuroQol visual analog scale) and diaries on costs (health-care costs, patient costs, and productivity costs). METHODS All analyses followed the intention-to-treat principle. Given the statistical uncertainty of differences between costs and QALYs, cost-effectiveness acceptability curves graph the probability that a strategy is cost effective, as a function of willingness to pay. Paradigm Spine funded this trial but did not have any part in data analysis or the design and preparation of this article. RESULTS According to the EQ-5D, the valuation of quality of life after IPD and decompression was not different. Mean utilities during all four quarters were, not significantly, less favorable after IPD according to the EQ-5D with a decrease in QALYs according to the US EQ-5D of 0.024 (95% confidence interval, -0.031 to 0.079). From a health-care perspective, the costs of IPD treatment were higher (difference €3,030 per patient, 95% confidence interval, €561-€5,498). This significant difference is mainly because of additional cost of implants of €2,350 apiece. From a societal perspective, a nonsignificant difference of €2,762 (95% confidence interval, -€1,572 to €7,095) in favor of conventional bony decompression was found. CONCLUSIONS Implantation of IPD as indirect decompressing device is highly unlikely to be cost effective compared with bony decompression for patients with intermittent neurogenic claudication caused by LSS. TRIAL REGISTRATION Dutch Trial Register Number: NTR1307.
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Affiliation(s)
| | - Wouter A Moojen
- Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, 2300RC Leiden, The Netherlands; Department of Neurosurgery, Medical Center Haaglanden, PO Box 432, 2501 CK, The Hague, The Netherlands
| | - Mark P Arts
- Department of Neurosurgery, Medical Center Haaglanden, PO Box 432, 2501 CK, The Hague, The Netherlands
| | | | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, 2300RC Leiden, The Netherlands; Department of Neurosurgery, Medical Center Haaglanden, PO Box 432, 2501 CK, The Hague, The Netherlands
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Nomura H. A novel strategy of non-fusion instrumentation with coflex interlaminar stabilization after decompression for lumbar spinal stenosis. JOURNAL OF SPINE SURGERY (HONG KONG) 2016; 2:149-53. [PMID: 27683714 PMCID: PMC5039854 DOI: 10.21037/jss.2016.06.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 06/25/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Hiroshi Nomura
- Department of Orthopaedic Surgery, Hiroshima Red Cross Hospital & Atomic-Bomb Survivors Hospital, Hiroshima, Japan
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Lurie JD. Interspinous spacers for lumbar spinal stenosis: commentary on van den Akker-van Marle et al. Spine J 2016; 16:711-3. [PMID: 27342707 DOI: 10.1016/j.spinee.2015.12.084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 12/21/2015] [Indexed: 02/03/2023]
Abstract
van den Akker-van Marle ME, Moojen WA, Arts MP, Vleggeert-Lankamp CLAM, Peul WC, for the Leiden-The Hague Spine Intervention Prognostic Study Group (SIPS). Interspinous process devices versus standard conventional surgical decompression for lumbar spinal stenosis: cost-utility analysis. Spine J 2016:16:702-10 (in this issue).
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Affiliation(s)
- Jon D Lurie
- Geisel School of Medicine, Dartmouth, Hanover, NH 03755, USA.
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Bisschop A, van Tulder MW. Market approval processes for new types of spinal devices: challenges and recommendations for improvement. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:2993-3003. [PMID: 27235154 DOI: 10.1007/s00586-016-4606-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 05/04/2016] [Accepted: 05/05/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Spinal pathology and related symptoms are among the most common health problems and are associated with high health care costs and productivity losses. Due to the aging population, these costs are further increasing every year. Another important reason for the increasing costs is the market approval of new technologies, such as spinal devices that are usually more expensive than the existing technologies. Previous cases of medical device failure led to concern about possible deficiencies in the market approval process. OBJECTIVE The objective is to provide an overview of U.S. Food and Drug Administration (FDA) regulation regarding spinal implants to delineate the challenges and opportunities that spine surgery currently faces. METHODS In this paper, two cases of market entries of spinal devices are presented and evaluated to illustrate these deficiencies. RESULTS Spinal implant regulation is facing several challenges. New spinal devices should increase patient outcomes and safety at reasonable societal costs. The main challenge is to have a rigorous evaluation before dissemination, while still leaving room for innovative behavior that thrusts the healthcare practice forward. CONCLUSION We have provided recommendations to enhance spinal implant regulation and improve and ensure the patient's safety and the future of spine surgery.
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Affiliation(s)
- Arno Bisschop
- Department of Orthopedic Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences, Faculty of Earth and Life Sciences, VU University, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
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Li M, Yang H, Wang G. Interspinous process devices for the treatment of neurogenic intermittent claudication: a systematic review of randomized controlled trials. Neurosurg Rev 2016; 40:529-536. [PMID: 27178046 DOI: 10.1007/s10143-016-0722-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 11/10/2015] [Accepted: 03/13/2016] [Indexed: 11/28/2022]
Abstract
The aim of this study is to compare interspinous process device (IPD) implantation to other methods for the treatment of neurogenic intermittent claudication (NIC). PubMed and Cochrane library were searched in December 2014. Randomized controlled trials (RCTs) comparing IPD implantation and nonoperative therapy or laminectomy with/without spinal fusion for the treatment of NIC due to spinal stenosis or low-grade degenerative spondylolisthesis were included. Meta-analysis and qualitative analysis were conducted as appropriate. Eleven articles (eight RCTs) were included, with two having high risk of bias. These RCTs were divided into three groups according to control cohort interventions: IPD implantation was compared with nonoperative treatment (group 1, n = 3), laminectomy (group 2, n = 3), and laminectomy associated with instrumented spinal fusion (group 3, n = 2). Group 1 studies reported better Zurich Claudication Questionnaire (ZCQ) scores for the IPD group. In group 2, two studies reported comparable ZCQ scores and one revealed comparable visual analog scale (VAS) and Oswestry Disability Index (ODI) scores; pooled analysis showed a higher reoperation rate in patients treated with IPD. In group 3, one study found that more patients in IPD group gained more than 25 % improvement in VAS and ODI, with lower complication rate; the other reported better ZCQ scores in the IPD group and comparable complication and reoperation rates. IPD implantation is more effective than the other methods, but not superior to laminectomy in treating NIC.
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Affiliation(s)
- Mao Li
- Department of Orthopaedics Surgery, The First Affiliated Hospital of Soochow University, Suzhou, 215006, People's Republic of China
| | - Huilin Yang
- Department of Orthopaedics Surgery, The First Affiliated Hospital of Soochow University, Suzhou, 215006, People's Republic of China.
| | - Genlin Wang
- Department of Orthopaedics Surgery, The First Affiliated Hospital of Soochow University, Suzhou, 215006, People's Republic of China.
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Schenck C, van Susante J, van Gorp M, Belder R, Vleggeert-Lankamp C. Lumbar spinal canal dimensions measured intraoperatively after decompression are not properly rendered on early postoperative MRI. Acta Neurochir (Wien) 2016; 158:981-8. [PMID: 27005673 PMCID: PMC4826663 DOI: 10.1007/s00701-016-2777-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/15/2016] [Indexed: 10/26/2022]
Abstract
BACKGROUND In cases of lumbar spinal stenosis (LSS) treated with surgical decompression, a postoperative magnetic resonance imaging (MRI) is sometimes required. In the experience of the investigators of this study, the obtained decompression observed on early postoperative MRI tends to be disappointing compared to the decompression achieved intraoperatively. This raises the question of whether the early postoperative MRI, performed after lumbar decompression, is a fair representation of the 'real' decompression. This study investigated the correlation between intraoperative and postoperative measurements of the lumbar spinal canal. METHOD Twenty patients with LSS underwent surgical decompression on a single level. The orthopaedic surgeon performed direct intraoperative measurements of width, length and height of the spinal canal. Preoperative supine MR images and postoperative prone and supine MR images were acquired. Two radiologists (R.B. and M.G.) measured width, length and height of the spinal canal on the preoperative and postoperative MRIs. Intraoperative measurements were compared to measurements on postoperative MRI in prone position (thus reproducing the intraoperative situation) to avoid positioning bias. Preoperative and postoperative measurements on MR images were also compared. In addition to this, postoperative measurements on supine and prone MR images were also compared. RESULTS Interobserver reliability for MRI measurements by both radiologists was generally excellent (intraclass correlation coefficients ≥0.71). The postoperative spinal canal dimensions improved on both prone and supine MRI compared to the preoperative imaging (P < 0.05). Intraoperatively measured dimensions demonstrated a significantly greater height (difference 2.8 ± 3.3 [R.B.] and 1.9 ± 3.7 [M.G.]) and greater width (difference 2.1 ± 3.2 [R.B.] and 2.5 ± 2.7 [M.G.]) compared to postoperative MRI in the prone position (P < 0.05). Postoperative dural sac height was greater on the supine MRI compared to the prone MRI (P < 0.05). CONCLUSIONS Surgical decompression of the spinal canal effectively decreases the compression of the dural sac. However, early postoperative MRI after lumbar decompression does not adequately represent the decompression achieved intraoperatively.
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Zaina F, Tomkins‐Lane C, Carragee E, Negrini S. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev 2016; 2016:CD010264. [PMID: 26824399 PMCID: PMC6669253 DOI: 10.1002/14651858.cd010264.pub2] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Lumbar spinal stenosis (LSS) is a debilitating condition associated with degeneration of the spine with aging. OBJECTIVES To evaluate the effectiveness of different types of surgery compared with different types of non-surgical interventions in adults with symptomatic LSS. Primary outcomes included quality of life, disability, function and pain. Also, to consider complication rates and side effects, and to evaluate short-, intermediate- and long-term outcomes (six months, six months to two years, five years or longer). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, five other databases and two trials registries up to February 2015. We also screened reference lists and conference proceedings related to treatment of the spine. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing surgical versus non-operative treatments in participants with lumbar spinal stenosis confirmed by clinical and imaging findings. DATA COLLECTION AND ANALYSIS For data collection and analysis, we followed methods guidelines of the Cochrane Back and Neck Review Group (Furlan 2009) and those provided in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). MAIN RESULTS From the 12,966 citations screened, we assessed 26 full-text articles and included five RCTs (643 participants).Low-quality evidence from the meta-analysis performed on two trials using the Oswestry Disability Index (pain-related disability) to compare direct decompression with or without fusion versus multi-modal non-operative care showed no significant differences at six months (mean difference (MD) -3.66, 95% confidence interval (CI) -10.12 to 2.80) and at one year (MD -6.18, 95% CI -15.03 to 2.66). At 24 months, significant differences favoured decompression (MD -4.43, 95% CI -7.91 to -0.96). Low-quality evidence from one small study revealed no difference in pain outcomes between decompression and usual conservative care (bracing and exercise) at three months (risk ratio (RR) 1.38, 95% CI 0.22 to 8.59), four years (RR 7.50, 95% CI 1.00 to 56.48) and 10 years (RR 4.09, 95% CI 0.95 to 17.58).Low-quality evidence from one small study suggested no differences at six weeks in the Oswestry Disability Index for patients treated with minimally invasive mild decompression versus those treated with epidural steroid injections (MD 5.70, 95% CI 0.57 to 10.83; 38 participants). Zurich Claudication Questionnaire (ZCQ) results were better for epidural injection at six weeks (MD -0.60, 95% CI -0.92 to -0.28), and visual analogue scale (VAS) improvements were better in the mild decompression group (MD 2.40, 95% CI 1.92 to 2.88). At 12 weeks, many cross-overs prevented further analysis.Low-quality evidence from a single study including 191 participants favoured the interspinous spacer versus usual conservative treatment at six weeks, six months and one year for symptom severity and physical function.All remaining studies reported complications associated with surgery and conservative side effects of treatment: Two studies reported no major complications in the surgical group, and the other study reported complications in 10% and 24% of participants, including spinous process fracture, coronary ischaemia, respiratory distress, haematoma, stroke, risk of reoperation and death due to pulmonary oedema. AUTHORS' CONCLUSIONS We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment. No clear benefits were observed with surgery versus non-surgical treatment. These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects. High-quality research is needed to compare surgical versus conservative care for individuals with lumbar spinal stenosis.
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Affiliation(s)
- Fabio Zaina
- ISICO (Italian Scientific Spine Institute)Via Roberto Bellarmino 13/1MilanItaly20141
| | - Christy Tomkins‐Lane
- Mount Royal UniversityDepartment of Health and Physical Education4825 Mount Royal Gate SWCalgaryAlbertaCanadaT3E 6K6
| | - Eugene Carragee
- Stanford University ClinicsOrthopaedic Spine CenterRedwood CityCAUSA
| | - Stefano Negrini
- University of Brescia ‐ IRCCS Fondazione Don Gnocchi MilanPhysical and Rehabilitation MedicineViale EuropaBresciaItaly25121
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Abstract
Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.
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Affiliation(s)
- Jon Lurie
- Department of Medicine, Dartmouth Medical School, Dartmouth Hitchock Medical Center, NH, USA
| | - Christy Tomkins-Lane
- Department of Health and Physical Education, Mount Royal University, Calgary, Canada
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Gazzeri R, Galarza M, Neroni M, Fiore C, Faiola A, Puzzilli F, Callovini G, Alfieri A. Failure rates and complications of interspinous process decompression devices: a European multicenter study. Neurosurg Focus 2015; 39:E14. [DOI: 10.3171/2015.7.focus15244] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECT
Spacers placed between the lumbar spinous processes represent a promising surgical treatment alternative for a variety of spinal pathologies. They provide an unloading distractive force to the stenotic motion segment, restoring foraminal height, and have the potential to relieve symptoms of degenerative disc disease. The authors performed a retrospective, multicenter nonrandomized study consisting of 1108 patients to evaluate implant survival and failure modes after the implantation of 8 different interspinous process devices (IPDs).
METHODS
The medical records of patients who had undergone placement of an IPD were retrospectively evaluated, and demographic information, diagnosis, and preoperative pain levels were recorded. Preoperative and postoperative clinical assessments in the patients were based on the visual analog scale. A minimum of 3 years after IPD placement, information on long-term outcomes was obtained from additional follow-up or from patient medical and radiological records.
RESULTS
One thousand one hundred eight patients affected by symptomatic 1- or 2-level segmental lumbar spine degenerative disease underwent placement of an IPD. The complication rate was 7.8%. There were 27 fractures of the spinous process and 23 dura mater tears with CSF leakage. The ultimate failure rate requiring additional surgery was 9.6%. The reasons for revision, which always involved removal of the original implant, were acute worsening of low-back pain or lack of improvement (45 cases), recurrence of symptoms after an initial good outcome (42 cases), and implant dislocation (20 cases).
CONCLUSIONS
The IPD is not a substitute for a more invasive 3-column fusion procedure in cases of major instability and spondylolisthesis. Overdistraction, poor bone density, and poor patient selection may all be factors in the development of complications. Preoperatively, careful attention should be paid to bone density, appropriate implant size, and optimal patient selection.
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Affiliation(s)
- Roberto Gazzeri
- 1Department of Neurosurgery, San Giovanni Addolorata Hospital
| | - Marcelo Galarza
- 3Regional Service of Neurosurgery, “Virgen de la Arrixaca” University Hospital, Murcia, Spain; and
| | | | - Claudio Fiore
- 1Department of Neurosurgery, San Giovanni Addolorata Hospital
| | - Andrea Faiola
- 1Department of Neurosurgery, San Giovanni Addolorata Hospital
- 5Department of Neurosurgery, San Filippo Neri Hospital, Rome, Italy
| | | | | | - Alex Alfieri
- 6Department of Neurosurgery and Spinal Surgery, Ruppiner Kliniken, Neuruppin, Germany
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Ramesh A, Lyons F, Kelleher M. Aperius interspinous device for degenerative lumbar spinal stenosis: a review. Neurosurg Rev 2015; 39:197-205; discussion 205. [PMID: 26324829 DOI: 10.1007/s10143-015-0664-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 06/27/2015] [Indexed: 11/26/2022]
Abstract
With an aging population, degenerative lumbar spinal stenosis (DLSS) leading to neurogenic intermittent claudication (NIC) is a growing problem. For patients suffering from this condition, interspinous process distraction devices (IPDs) offer an effective and cheap alternative to conservative or decompressive surgery. Aperius is one such device that has been gaining popularity for its percutaneous insertion under local anesthetic, short operative time, and low risk of complications. The main objective of this review was to carry out a comprehensive search of the literature to evaluate the effectiveness and potential complications of Aperius. A database search, including PubMed, Clinical trials.gov, Cochrane (CENTRAL), MEDLINE, CINAHL, EMBASE, and Scopus, was carried out to identify relevant articles written in English reporting on complications with a minimum 12-month follow-up. The literature search resulted in six eligible studies; two nonrandomized comparative and four prospective case series were available. The analysis revealed that in total, 433 patients underwent treatment with Aperius, with all studies demonstrating an improvement in outcome measures. The average follow-up was 17 months with an overall complication rate of 10.62%. Overall, the quality of evidence is low, suggesting that currently, the evidence is not compelling and further prospective randomized trials including cost-effectiveness studies are required.
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Affiliation(s)
- Ashwanth Ramesh
- RCSI, Department of Anatomy, St. Stephens Green, Dublin 2, Ireland.
| | - Frank Lyons
- Cappagh National Orthopaedic Hospital, Dublin, Ireland
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Stefanovic I, Radisavljevic M, Stojanov D. Aseptic intrafascial and extrafascial abscesses 10 years after a 2-level DIAM insertion procedure. J Neurosurg Spine 2015; 23:647-651. [PMID: 26161514 DOI: 10.3171/2015.3.spine1589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
With the aim to prevent the so-called adjacent-segment disease in spinal fusion surgery and to serve as the primary surgical procedure for the management of low-back pain syndrome or neurogenic claudication in spinal stenosis, the so-called dynamic spine stabilization is applied using specifically designed implants: interspinous spacers, such as DIAM (Device for Intervertebral Assisted Motion), Coflex, and X-stop. It is commonly accepted that interspinous spacers are made from material that is well tolerated by the body, that their placement is simple, that complications are rare, and that they can greatly benefit the patients. So far, there have not been published studies reporting infective or other complications 10 or more years after the placement of DIAM spacers. The aim of this paper was to present a case of an extremely late complication (after 10 years) in the form of intra- and extrafascial dumbbell abscesses, concomitantly appearing at both levels treated with the DIAM spacer. The paper presents the existence of a significant correlation between CT and MRI findings as well as the deterioration in Oswestry Disability Index and visual analog scale scores. Over time, dynamic spine stabilization might possibly impact reactive accumulation of sterile fluid in the vicinity of an implant and could therefore be related to delayed complications even 10 years after surgery. The finding of a growing layer composed of thick aseptic fluid around the DIAM implant, with a simultaneous occurrence of spinous process osteolysis and formation of a mineralized pseudocyst, bears a considerable risk of delayed inflammatory complications, including abscess, and therefore requires the explantation of the DIAM implant.
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Affiliation(s)
| | | | - Dragan Stojanov
- Institute of Radiology, Nis University Hospital, University of Nis, Serbia
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50
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Characterization of lumbar spinous process morphology: a cadaveric study of 2,955 human lumbar vertebrae. Spine J 2015; 15:1645-52. [PMID: 25777742 DOI: 10.1016/j.spinee.2015.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 02/07/2015] [Accepted: 03/07/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite the interest in lumbar spinous process (SP)-based surgical innovation, there are no large published studies that have characterized the morphometry of lumbar SPs. PURPOSE To provide accurate level-specific morphometric data with respect to human lumbar SPs using a human cadaveric lumbar spine model and to describe the morphometric variation of lumbar SPs with respect to gender, race, and age. STUDY DESIGN An anatomic observational study. METHODS This study used 2,955 cadaveric lumbar vertebrae from 591 adult spines at the Hamann-Todd Human Osteological Collection. Specimens were aged 20 to 79 years. Each vertebra was photographed in standardized positions and measured using ImageJ software. Direct measurements were made for the SP length, width, height, slope, and caudal morphology. Gender, race, and age were recorded and analyzed. RESULTS Spinous process length was 24.8±4.6 mm (L5) to 33.9±3.9 mm (L3). Effective length varied from 19.5±2.6 mm (L1) to 24.6±3.3 mm (L4). Height was shortest at L5 (18.2±2.7 mm). Caudal width was greater than the cranial width. Slope, caudal morphology, and radius measures showed large interspecimen variation. Slope at L5 was steeper than other levels (23.7°±10.5°, p<.0001). Most specimens demonstrated convex caudal morphology. L4 had the highest proportion of convexity (80.7%). L1 was the only level with predominantly concave morphology. Measurements for female SPs were smaller, but the slope was steeper. Anatomic and effective SP lengths were longer for specimens from white individuals. Specimens from black individuals had larger width and height, as well as steeper slope. Black specimens had more convex morphology at L4 and L5. With increasing age, the SP length, effective length, and width increased. Height increased with age only at L4 and L5. Slope and caudal radius of curvature decreased with age, and increasingly convex morphology was noted at most levels. CONCLUSIONS This large cadaveric study provides level-specific morphometric data regarding the osseous dimensions of lumbar SPs relevant to techniques and devices targeting the lumbar SPs or the interspinous space. Of particular importance is the recognition that L5 has relatively different morphology when compared with more cranial levels. Potentially important differences were noted comparing women with men, black with white, and aging populations.
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