Randomised placebo-controlled trial on the effectiveness of nasal salmon calcitonin in the treatment of lumbar spinal stenosis

Effects of calcitonin on lumbar spinal stenosis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

There is some controversy about the effects of calcitonin (CT) on lumbar spinal stenosis (LSS). This systematic review and meta-analysis is to assess the strength of the evidence supporting the use of CT in the treatment of patients with LSS.

MATERIAL AND METHOD

We performed an electronic search depicting randomized controlled trials (RCTs) through 4 databases from the date of database creation to January 2023. 3 different researchers conducted independent literature screening, data extractions, and quality assessments. The outcome measures included visual analogue scale (VAS), walking distance, and oswestry disability index (ODI). Meta-analysis and trial sequence analysis (TSA) were carried out using RevMan 5.4, Stata 16.0, and TSA 0.9. GRADE 3.6 was used to evaluate the evidence quality.

RESULTS

We accepted 9 studies with 496 participants. The meta-analysis revealed that CT offered no significant improvement in VAS, walking distance, or ODI in patients with LSS.

CONCLUSION

There is no evidence that CT has a benefit in patients with LSS, either alone or in combination with other treatments, or depending on the route of administration, according to the systematic review and meta-analysis of relevant RCTs.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Validity of outcome measures used in randomized clinical trials and observational studies in degenerative lumbar spinal stenosis

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.

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

OBJECTIVE

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

DESIGN

Systematic review.

LITERATURE SEARCH

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

STUDY SELECTION CRITERIA

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

DATA SYNTHESIS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

DESIGN

A systematic review.

DATA SOURCES

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

ELIGIBILITY CRITERIA

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

DATA EXTRACTION AND SYNTHESIS

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

RESULTS

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

CONCLUSIONS

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

PROSPERO REGISTRATION NUMBER

CRD42020191860.

To Assess Whether Lee’s Grading System for Central Lumbar Spinal Stenosis Can Be Used as a Decision-Making Tool for Surgical Treatment

Purpose

To evaluate the correlation between Lee’s grades and surgical intervention for central lumbar spinal stenosis (CLSS) and to assess whether this grading system can be used as a decision-making tool for the surgical treatment of this condition.

Materials and Methods

This retrospective study included 290 patients (M:F = 156:134; mean age, 46 ± 16 years). Radiologists assessed the presence and grade of CLSS at the stenosis point according to Lee’s grading system, in which CLSS is classified into four grades according to the shape of the cauda equina. Correlation coefficients (r_s) between Lee’s grades and the operation were calculated with Spearman rank correlation.

Results

Among the operated patients, grade 2 was the most commonly assigned grade (50%–58%), grade 3 was less common (35%), and grade 0 was the least common (2%–3%). Among the non-operated patients, grade 1 was the most common (63%–65%), grade 0 was less common (15%–16%), and grade 3 was the least common (8%). The distribution of grades differed between the operated and non-operated groups (p < 0.001). Less than 25% of patients who underwent surgery were assigned grades 0 and 1, and more than 88% were assigned grades 2 and 3. A moderate correlation was found between the grade and surgical intervention (r_s = 0.632 and r_s = 0.583).

Conclusion

Lee’s grade was moderately correlated with surgical intervention. Lee’s grading system can be a decision-making tool for the surgical treatment of CLSS.

Calcitonin: A useful old friend

Calcitonin regulates blood calcium levels and possesses certain clinically useful anti-fracture properties. Specifically, it reduces vertebral fractures in postmenopausal osteoporotic women significantly compared to a placebo. Nevertheless, the use of calcitonin has declined over the years and salmon calcitonin is no longer the first-line treatment for many of its indications. Commercial calcitonin only exists in intranasal or injectable preparations, which are less preferable for patients. Efficacy of a potential oral formulation has been under investigation but achieving adequate bioavailability remains a conundrum and the latest phase III trials have not shown promising evidence justifying its use. Associations with cancer have also derailed this treatment option. Furthermore, the rise of bisphosphonates and, more recently, monoclonal antibodies (such as denosumab), has revolutionised the treatment of osteoporotic fractures. Therefore, we are posed with an interesting question: is calcitonin a treatment of the past? This review aims to explore the reasons behind this paradigm shift and outline the potential role of calcitonin in the management of fractures and other conditions in the years to come.

[Calcitonin as an analgesic agent: review of mechanisms of action and clinical applications]

BACKGROUND AND OBJECTIVES

Calcitonin is a polypeptide hormone regulating the metabolism calcium in the body. For many years calcitonin has been used to maintain and improve bone mineral density and to reduce the fracture rate. Many studies showed that calcitonin had analgesic role in several painful circumstances. This pain-ameliorating effect is irrelevant to its osteoclastic inhibitory effect and mechanisms like altering Na+ channel and serotonin receptor expression or hypothesis including the endorphin-mediated mechanism were used to explain this effect. In this study we performed a thorough review on the role of calcitonin as an analgesic agent in different scenarios and investigated the fact that calcitonin can be a feasible medication to relieve pain.

METHOD

Many studies focused on the analgesic effect of calcitonin in several painful circumstances, including acute pains related to vertebral fractures, metastasis, migraine and reflex sympathetic dystrophy as well as neuropathic pains related to spinal injuries or diabetes, and phantom pain. Also, calcitonin was showed to be a useful additive to local anesthesia in the case of controlling postoperative pain or trigeminal neuralgia more effectively. However we faced some contradictory data for conditions like lumbar canal stenosis, complex regional pain syndrome, phantom pain and malignancies.

CONCLUSION

This study showed that calcitonin could be helpful analgesic agent in different painful situations. Calcitonin can be considered an eligible treatment for acute pains related to vertebral fractures and a feasible alternative for the treatment of the acute and chronic neuropathic pains where other medications might fail.

Calcitonin as an analgesic agent: review of mechanisms of action and clinical applications

Background and objectives

Calcitonin is a polypeptide hormone regulating the metabolism of calcium in the body. For many years calcitonin has been used to maintain and improve bone mineral density and to reduce the fracture rate. Many studies showed that calcitonin had analgesic role in several painful circumstances. This pain-ameliorating effect is irrelevant to its osteoclastic inhibitory effect and mechanisms like altering Na+ channel and serotonin receptor expression or hypothesis including the endorphin-mediated mechanism were used to explain this effect. In this study we performed a thorough review on the role of calcitonin as an analgesic agent in different scenarios and investigated the fact that calcitonin can be a feasible medication to relieve pain.

Method

Many studies focused on the analgesic effect of calcitonin in several painful circumstances, including acute pains related to vertebral fractures, metastasis, migraine and reflex sympathetic dystrophy as well as neuropathic pains related to spinal injuries or diabetes, and phantom pain. Also, calcitonin was showed to be a useful additive to local anesthesia in the case of controlling postoperative pain or trigeminal neuralgia more effectively. However we faced some contradictory data for conditions like lumbar canal stenosis, complex regional pain syndrome, phantom pain and malignancies.

Conclusion

This study showed that calcitonin could be helpful analgesic agent in different painful situations. Calcitonin can be considered an eligible treatment for acute pains related to vertebral fractures and a feasible alternative for the treatment of the acute and chronic neuropathic pains where other medications might fail.

Neurogenic Claudication: a Review of Current Understanding and Treatment Options

PURPOSE OF REVIEW

With an aging population and increased prevalence of the disease, we set out to evaluate the validity of current diagnostic criteria for neurogenic claudication as well as the efficacy of the treatment options for the main cause, lumbar spinal stenosis (LSS).

RECENT FINDINGS

Epidural steroid injections (ESI) were most efficacious when the injectate is a steroid combined with lidocaine or lidocaine only. There are promising results regarding the efficacy of the minimally invasive lumbar decompression (MILD) procedure as well as interspinous process spacers (IPS) compared to surgical alternatives. Spinal cord stimulators are gaining ground as an effective alternative to surgery in patients with lumbar spinal stenosis that is not responsive to conservative measures or epidural injections. We found that there continues to be a lack of consensus on the diagnostic criteria, management, and treatment options for patients with LSS. The Delphi consensus is the most current recommendation to assist clinicians with making the diagnosis. Physical therapy, NSAIDs, gabapentin, and other conservative therapy measures are unproven in providing long-lasting relief. In patients with radicular symptoms, an ESI may be indicated when a combination of lidocaine with steroids is used or using lidocaine alone. In addition, there is not enough high-quality evidence to make a recommendation regarding the use of MILD versus interspinous spacers for neurogenic claudication. There remains a need for high-quality evidence regarding the efficacy of different conservative treatments, interventional procedures, and surgical outcomes in patients with neurogenic claudication in LSS.

[Optimization of Nasal Drug Absorption from Powder Formulations: The Feasibility of Controlling Drug Absorption by the Use of Pharmaceutical Excipients]

Nasal application of powder formulations has garnered attention because of its significant potential for systemic drug delivery. Because a powder drug must first diffuse from the formulation and dissolve in the nasal cavity fluid before transepithelial permeation, dissolution and diffusion are distinct but important factors for nasal drug absorption. Since the formulation is directly administered onto the nasal mucosal surface, the effect of excipients on drug absorption may be significant. Therefore, the influence of excipients on nasal drug absorption was evaluated. Three types of hydroxypropyl cellulose (HPC) [HPC (SL), HPC (M), and HPC (H)], lactose, and sodium chloride (NaCl) were used as excipients. Warfarin (WF), piroxicam (PXC), sumatriptan (STP), and norfloxacin (NFX) were selected as model drugs. HPC (M) enhanced the absorption of PXC, while both HPC (M) and HPC (H) enhanced the absorption of STP. All three HPCs failed to enhance the absorption of WF. An increase in the polymerization degree of HPCs decreased the diffusion of drugs in HPC solutions, but prolonged their nasal retention. Lactose and NaCl increased the fluid volume on the nasal mucosal surface by increasing the osmotic pressure, thereby enhancing the nasal absorption of PXC and NFX; however, lactose and NaCl accelerated the nasal clearance of these. These results indicate that nasal drug absorption from powder formulations can be controlled by excipients.

Surgical and nonsurgical treatments for lumbar spinal stenosis

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.

Effects of Nasal Calcitonin vs. Oral Gabapentin on Pain and Symptoms of Lumbar Spinal Stenosis: A Clinical Trial Study

Lumbar spinal stenosis (LSS) is a chronic and prevalent disease that occurs in 10.8% of the general population, mostly in old age. We designed the first clinical trial study to compare the effects of administering the nasal salmon calcitonin spray and gabapentin in patients with LSS. In this clinical trial, 90 patients with symptoms of neurogenic claudication and magnetic resonance imaging-proven LSS were randomly assigned to nasal salmon calcitonin, gabapentin, or placebo treatments for eight weeks (30 participants in each group). This was followed by a washout period of four weeks. After three months of study and after four weeks off the prescription, mean values of Oswestry Disability Index in the calcitonin, gabapentin, and control groups were 23 ± 12.05, 32 ± 16.08, and 38 ± 22.09, respectively (P ≤ 0.05, calcitonin group vs. gabapentin group, and P ≤ 0. 001, calcitonin group vs. control group with respect to pretreatment scores). Thus, three months after the treatment, although most of the patients in the control group had a satisfactory period of improvement, the improvement in the calcitonin group was more than the other two groups with a significant difference (P ≤ 0.05 when compared to gabapentin group and P ≤ 0.01 when compared to placebo group). We revealed that the 200 International Unit (IU) and nasal calcitonin spray daily are more effective compared to 300 mg gabapentin three times per day and the placebo effect for eight weeks of treatment of symptoms of patients with LSS.

Effects of calcitonin on lumbar spinal stenosis: a systematic review and meta-analysis

BACKGROUND

To investigate whether calcitonin can improve walking distance (WD) and visual analog pain scale (VAS) in patients who suffer lumbar spinal stenosis (LSS).

METHODS

We performed a search on CENTRAL, PubMed, Embase and Cochrane databases up to July 2014; we finally found 19 original articles, of which only 6 were in full compliance with the RCT criteria. These full articles were carefully reviewed independent and in blinded way by two previously capacitated reviewers for the objective to extract data and score a quality of these articles by the criteria of Cochrane Handbook (5.1.0).

RESULTS

We accepted 6 studies with 232 participants. There is no evidence show calcitonin is better than placebo or paracetamol regardless of mode of administration.

CONCLUSIONS

This meta-analysis suggest that calcitonin provide no significant improvement in pain symptoms or walking distance in LSS patients.

The efficacy of intramuscular calcitonin injection in the management of lumbar spinal stenosis

Study Design

A prospective, cross-sectional, non-randomized study.

Purpose

To assess the effectiveness of intramuscular calcitonin injection in the treatment of lumbar spinal stenosis (LSS).

Overview of Literature

LSS, manifesting as chronic low back pain and neurogenic claudication, is a chronic condition with an increasing incidence in the elderly population having inadequate effective conservative treatment options.

Methods

In this study, 36 patients with LSS who were diagnosed based on the clinical findings and magnetic resonance imaging were included. Patients received 100 IU of calcitonin per week for one month and were evaluated before and after treatment using the Oswestry disability index (ODI) questionnaire and visual analogue scale (VAS). Before treatment, the patients were divided into two subgroups based on their ODI results: patients with mild to moderate low back pain (disability, 0%-40%) and patients with severe or very severe low back pain (disability, 40%-100%).

Results

In patients with mild to moderate low back pain, there were no significant changes in the ODI and VAS after calcitonin injection. But in patients with severe or very severe low back pain, pain severity, personal functions, ability to lift and carry objects, time interval between standing and initiation of pain, social life, disability percentage, and VAS were significantly improved after treatment with calcitonin.

Conclusions

It seems that an intramuscular injection of low dose of calcitonin may have some beneficial effects on the pain due to LSS, especially in patients who suffer from severe or very severe low back pain.

What interventions improve walking ability in neurogenic claudication with lumbar spinal stenosis? A systematic review

PURPOSE

To investigate what interventions can improve walking ability in neurogenic claudication with lumbar spinal stenosis.

METHODS

We searched CENTRAL, Medline, EMBASE, CINAHL and ICL databases up to June 2012. Only randomized controlled trials published in English and measuring walking ability were included. Data extraction, risk of bias assessment, and quality of the evidence evaluation were performed using methods of the Cochrane Back Review Group.

RESULTS

We accepted 18 studies with 1,220 participants. There is very low quality evidence that calcitonin is no better than placebo or paracetamol regardless of mode of administration. There is low quality evidence that prostaglandins, and very low quality evidence that gabapentin or methylcobalamin, improves walking distance. There is low and very low quality evidence that physical therapy was no better in improving walking ability compared to no treatment, oral diclofenac plus home exercises, or combined manual therapy and exercise. There is very low quality evidence that epidural injections improve walking distance up to 2 weeks compared to placebo. There is low- and very low-quality evidence that various direct decompression surgical techniques show similar significant improvements in walking ability. There is low quality evidence that direct decompression is no better than non-operative treatment in improving walking ability. There is very low quality evidence that indirect decompression improves walking ability compared to non-operative treatment.

CONCLUSIONS

Current evidence for surgical and non-surgical treatment to improve walking ability is of low and very low quality and thus prohibits recommendations to guide clinical practice.

Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication

BACKGROUND

Lumbar spinal stenosis with neurogenic claudication is one of the most commonly diagnosed and treated pathological spinal conditions. It frequently afflicts the elderly population.

OBJECTIVES

To systematically review the evidence for the effectiveness of nonoperative treatment of lumbar spinal stenosis with neurogenic claudication.

SEARCH METHODS

CENTRAL, MEDLINE, CINAHL, and Index to Chiropractic Literature (ICL) databases were searched up to June 2012.

SELECTION CRITERIA

Randomized controlled trials published in English, in which at least one arm provided data on nonoperative treatments

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration. Risk of bias in each study was independently assessed by two review authors using the 12 criteria recommended by the Cochrane Back Review Group (Furlan 2009). Dichotomous outcomes were expressed as relative risk, continuous outcomes as mean difference or standardized mean difference; uncertainty was expressed with 95% confidence intervals. If possible a meta-analysis was performed, otherwise results were described qualitatively. GRADE was used to assess the quality of the evidence.

MAIN RESULTS

From the 8635 citations screened, 56 full-text articles were assessed and 21 trials (1851 participants) were included. There was very low-quality evidence from six trials that calcitonin is no better than placebo or paracetamol, regardless of mode of administration or outcome assessed. From single small trials, there was low-quality evidence for prostaglandins, and very low-quality evidence for gabapentin or methylcobalamin that they improved walking distance. There was very low-quality evidence from a single trial that epidural steroid injections improved pain, function, and quality of life, up to two weeks, compared with home exercise or inpatient physical therapy. There was low-quality evidence from a single trial that exercise is of short-term benefit for leg pain and function compared with no treatment. There was low and very low-quality evidence from six trials that multimodal nonoperative treatment is less effective than indirect or direct surgical decompression with or without fusion. A meta-analysis of two trials comparing direct decompression with or without fusion to multimodal nonoperative care found no significant difference in function at six months (mean difference (MD) -3.66, 95% CI -10.12 to 2.80) and one year (MD -6.18, 95% CI -15.03 to 2.66), but at 24 months a significant difference was found favouring decompression (MD -4.43, 95% CI -7.91 to -0.96).

AUTHORS' CONCLUSIONS

Moderate and high-quality evidence for nonoperative treatment is lacking and thus prohibits recommendations for guiding clinical practice. Given the expected exponential rise in the prevalence of lumbar spinal stenosis with neurogenic claudication, large high-quality trials are urgently needed.

An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update)

BACKGROUND CONTEXT

The evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spinal stenosis by the North American Spine Society (NASS) provides evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of degenerative lumbar spinal stenosis. The guideline is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spinal stenosis as reflected in the highest quality clinical literature available on this subject as of July 2010. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.

PURPOSE

Provide an evidence-based educational tool to assist spine care providers in improving quality and efficiency of care delivered to patients with degenerative lumbar spinal stenosis.

STUDY DESIGN

Systematic review and evidence-based clinical guideline.

METHODS

This report is from the Degenerative Lumbar Spinal Stenosis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. The original guideline, published in 2006, was carefully reviewed. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated by a minimum of three physician reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were arrived at via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.

RESULTS

Sixteen key clinical questions were assessed, addressing issues of natural history, diagnosis, and treatment of degenerative lumbar spinal stenosis. The answers are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence.

CONCLUSIONS

A clinical guideline for degenerative lumbar spinal stenosis has been updated using the techniques of evidence-based medicine and using the best available clinical evidence to aid both practitioners and patients involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, will be available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.

Nonoperative treatment of lumbar spinal stenosis with neurogenic claudication: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To systematically review the evidence for the effectiveness of nonoperative treatment of lumbar spinal stenosis with neurogenic claudication.

SUMMARY OF BACKGROUND DATA

Neurogenic claudication can significantly impact functional ability, quality of life, and independence in the elderly. METHODS.: We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and ICL databases up to January 2011 for randomized controlled trials published in English, in which at least 1 arm provided data on nonoperative treatments. Risk of bias in each study was independently assessed by 2 reviewers using 12 criteria. Quality of the evidence was evaluated using Grades of Recommendations, Assessment, Development, and Evaluation (GRADE).

RESULTS

From the 8635 citations screened, 56 were assessed and 21 trials with 1851 participants were selected. There is very low-quality evidence from 6 trials that calcitonin is no better than placebo or paracetamol, regardless of mode of administration or outcome. From single small trials, there is low-quality evidence that prostaglandins, and very low-quality evidence that gabapentin or methylcobalamin, improve walking distance. There is very low-quality evidence from a single trial that epidural steroid injections improve pain, function, and quality of life up to 2 weeks compared with home exercise or inpatient physical therapy. There is low-quality evidence from a single trial that exercise is of short-term benefit for leg pain and function compared with no treatment. There is low- and very low-quality evidence from 6 trials that multimodal nonoperative treatment is less effective than indirect or direct surgical decompression with or without fusion.

CONCLUSION

Moderate- and high-GRADE evidence for nonoperative treatment is lacking and thus prohibiting recommendations to guide clinical practice. Given the expected exponential rise in the prevalence of lumbar spinal stenosis with neurogenic claudication, large high-quality trials are urgently needed.

Quantitative radiologic criteria for the diagnosis of lumbar spinal stenosis: a systematic literature review

Background

Beside symptoms and clinical signs radiological findings are crucial in the diagnosis of lumbar spinal stenosis (LSS). We investigate which quantitative radiological signs are described in the literature and which radilogical criteria are used to establish inclusion criteria in clincical studies evaluating different treatments in patients with lumbar spinal stenosis.

Methods

A literature search was performed in Medline, Embase and the Cochrane library to identify papers reporting on radiological criteria to describe LSS and systematic reviews investigating the effects of different treatment modalities.

Results

25 studies reporting on radiological signs of LSS and four systematic reviews related to the evaluation of different treatments were found. Ten different parameters were identified to quantify lumbar spinal stenosis. Most often reported measures for central stenosis were antero-posterior diameter (< 10 mm) and cross-sectional area (< 70 mm²) of spinal canal. For lateral stenosis height and depth of the lateral recess, and for foraminal stenosis the foraminal diameter were typically used. Only four of 63 primary studies included in the systematic reviews reported on quantitative measures for defining inclusion criteria of patients in prognostic studies.

Conclusions

There is a need for consensus on well-defined, unambiguous radiological criteria to define lumbar spinal stenosis in order to improve diagnostic accuracy and to formulate reliable inclusion criteria for clinical studies.

Pharmacotherapy of low back pain: targeting nociceptive and neuropathic pain components

AIM

To review pharmacological management of chronic low back pain (LBP), with respect to management of nociceptive and neuropathic components.

METHODS

Studies were identified by a PubMed search of English-language papers from the last 10  years, with additional hand searches of relevant reviews.

DISCUSSION

Paracetamol, non-steroidal anti-inflammatory drugs and cyclo-oxygenase-2 inhibitors target the nociceptive component of chronic LBP, and do not affect neuropathic pain mechanisms. Antidepressants target the neuropathic component of chronic LBP; however, conflicting efficacy results have been reported. Opioids target both nociceptive and to a lesser extent neuropathic pain. They are effective in chronic LBP, but many patients require higher doses or combination treatment. The long-term efficacy of opioids in chronic LBP has been questioned because of the absence of high-quality data and concerns regarding tolerability and dependence. The topical preparation lidocaine 5% plaster, indicated in post-herpetic neuralgia, is effective in localized neuropathic pain in patients with chronic LBP. Pregabalin is ineffective as monotherapy for chronic LBP but is effective when combined with celecoxib or opioids. Muscle relaxant monotherapy is ineffective in chronic LBP. Combination therapy is often necessary in patients with chronic LBP, in order to manage both nociceptive and neuropathic pain components.

CONCLUSION

Chronic LBP often comprises both nociceptive and neuropathic components, therefore a multimodal and individualized treatment approach is necessary. Combining drugs with different mechanisms of action (e.g. an agent with µ-receptor activity plus an agent of a different class) represents a rational approach to management of chronic LBP with both nociceptive and neuropathic components.

Lumbar spinal stenosis: a brief review of the nonsurgical management

PURPOSE

The purpose of this brief narrative review is to summarize the evidence derived from randomized controlled trials pertaining to the nonsurgical treatment of lumbar spinal stenosis (LSS).

SOURCE

The MEDLINE (January 1950 to the fourth week of January 2010) and EMBASE (January 1980 to 2009, week 53) databases, the MESH term "spinal stenosis", and the key words, "vertebral canal stenosis" and "neurogenic claudication", were searched. Results were limited to randomized controlled trials (RCTs) conducted on human subjects, written in English, and published in peer-reviewed journals. Only RCTs pertaining to nonsurgical treatment were considered. Studies comparing conservative and surgical management or different surgical techniques were not included in the review.

PRINCIPAL FINDINGS

The search criteria yielded 13 RCTs. The average enrolment was 54 subjects per study. Blinded assessment and sample size justification were provided in 85% and 39% of RCTs, respectively. The available evidence suggests that parenteral calcitonin, but not intranasal calcitonin, can transiently decrease pain in patients with LSS. In the setting of epidural blocks, local anesthetics can improve pain and function, but the benefits seem short-lived. The available evidence does not support the addition of steroids to local anesthetic agents. Based on the limited evidence, passive physical therapy seems to provide minimal benefits in LSS. The optimal regimen for active physiotherapy remains unknown. Although benefits have been reported with gabapentin, limaprost, methylcobalamin, and epidural adhesiolysis, further trials are required to validate these findings.

CONCLUSIONS

Because of their variable quality, published RCTs can provide only limited evidence to formulate recommendations pertaining to the nonsurgical treatment of LSS. In this narrative review, no study was excluded based on factors such as sample size justification, statistical power, blinding, definition of intervention allocation, or clinical outcomes. This aspect may represent a limitation as it may serve to overemphasize evidence derived from "weaker" trials. Further well-designed RCTs are warranted.

Lumbar spinal stenosis

Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. LSS is being more commonly diagnosed and may relate to better access to advanced imaging and to an ageing population. This review focusses on radicular symptoms related to degenerative central and lateral stenosis and updates knowledge of LSS pathophysiology, diagnosis and management. Since patients with anatomic LSS can range from asymptomatic to severely disabled, the clinical diagnosis focusses on symptoms and examination findings associated with LSS. Imaging findings are helpful for patients with persistent, bothersome symptoms in whom invasive treatments are being considered. There is limited information from high-quality studies about the relative merits and demerits of commonly used treatments. Interpreting and comparing results of available research are limited by a lack of consensus about the definition of LSS. Nevertheless, evidence supports decompressive laminectomy for patients with persistent and bothersome symptoms. Recommendations favour a shared decision-making approach due to important trade-offs between alternative therapies and differences among patients in their preferences and values.

Variation in eligibility criteria from studies of radiculopathy due to a herniated disc and of neurogenic claudication due to lumbar spinal stenosis: a structured literature review

STUDY DESIGN

A structured literature review.

SUMMARY OF THE BACKGROUND DATA

Widely recognized classification criteria for rheumatologic disorders have resulted in well-defined patient populations for clinical investigation.

OBJECTIVE

We sought to determine whether similar criteria were needed for back pain disorders by examining variability in eligibility criteria in published studies.

METHODS

Studies involving radiculopathy due to lumbar herniated disc (HD) and for neurogenic claudication due to lumbar spinal stenosis (LSS) were identified. Randomized controlled trials published between January 1, 2006 and October 1, 2008 in select peer reviewed journals were retrieved, their eligibility criteria were identified and categorized.

RESULTS

Twelve eligible HD studies were identified. Thirteen unique categories of eligibility criteria were identified with a mean of 3.9 (+/-2.0) and a range from 0 to 8 categories per study. More categories were present for studies that included nonsurgical (5.6 +/- 2.5) treatment for studies with only surgical treatment (2.6 +/- 1.7) P = 0.04). Seven LSS studies met eligibility criteria, and 9 unique categories were identified. A mean of 5.0 (+/-2.2) categories with a range from 2 to 7 was used per study.

CONCLUSION

Wide variation in the number and type of eligibility criteria from randomized clinical trials of well defined back pain syndromes was identified. These results support the need for developing and disseminating international classification criteria for these clinical conditions.

Effectiveness of calcitonin in intermittent claudication treatment of patients with lumbar spinal stenosis: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

Analyze the level of evidence in the effectiveness of calcitonin on the treatment of neurogenic claudication in patients with lumbar spinal stenosis.

SUMMARY OF BACKGROUND DATA

One of the most disabling features of lumbar spinal stenosis is neurogenic claudication. There have been proposed different drug therapies for it. The recommendation for calcitonin use in these patients has been sustained on autocontrolled clinical trial (Streifler et al, Neurol Neurosurg Psychiatry 1989;52:543-4), which only included 6 patients.

MATERIAL AND METHOD

We performed a search on electronic databases that included Medline and Embase; we recovered 10 original articles, of which only 4 fulfilled the RCT criteria. These articles were reviewed independent and blinded way by 6 previously capacitated reviewers to extract data and score a quality of them by the criteria of Cochrane Handbook (1996) with maximum score of 1.00 and minimum score of 0.33.

RESULTS

Score quality vary in the 4 articles: Porter and Millar, Spine 1988;13:1061-4 (score, 0.68), Eskola et al, Calcif Tissue Int 1992;50:400-3 (score, 0.88), Podichetty et al, Spine 2004;29:2343-9 (score, 0.88), and Tafazal et al, Eur Spine J 2007;16:207-12 (score, 0.92). Due to the great heterogenicity observed (sample sizes, selection criteria, doses, frequency, and duration of calcitonin, and outcome measurements), we were unable to perform a meta-analysis. Only one of these studies (Porter and Millar, Spine 1988;13:1061-4; score, 0.68) found favorable results for the use of calcitonin compared with placebo; of the 3 remaining trials none found significative evidence between drug therapy and placebo.

CONCLUSION

The present data suggest that calcitonin administration in the treatment for neurogenic claudication has no benefit in patients with lumbar spinal stenosis.

The efficacy of prostaglandin E1 derivative in patients with lumbar spinal stenosis

STUDY DESIGN

Randomized controlled trial.

OBJECTIVE

To examine the effect of limaprost, an oral prostaglandin (PG) E1 derivative, on health-related quality of life (HRQOL) in patients with symptomatic lumbar spinal stenosis (LSS), compared to etodolac, a NSAID.

SUMMARY OF BACKGROUND DATA

Limaprost, an oral PGE1 derivative, was developed in Japan to treat numerous ischemic symptoms of thromboangiitis obliterans (TAO) and LSS. Previous studies have demonstrated the effectiveness of limaprost in the symptoms in patients with LSS. However, the evidence for effect on patient-reported outcomes, such as patient's HRQOL or satisfaction, is limited.

METHODS

This study was conducted at 4 study sites in Japan. Briefly, inclusion criteria were: age between 50 and 85 years; presence of both neurogenic intermittent claudication (NIC) and cauda equina symptoms (at least presence of bilateral numbness in the lower limbs); and MRI-confirmed central stenosis with acquired degenerative LSS. Limaprost (15 microg/d) or etodolac (400 mg/d) was administered for 8 weeks. The primary outcome was Short Form (SF)-36, and the secondary outcomes were the verbal rating scale of low back pain and leg numbness, walking distance, subjective improvement, and satisfaction.

RESULTS

A total of 79 participants were randomized (limaprost:etodolac = 39:40). Thirteen participants withdrew from the study (limaprost:etodolac = 5:8) and 66 completed the study (limaprost:etodolac = 34:32). Comparisons showed that limaprost resulted in significantly greater improvements in the SF-36 subscales of physical functioning, role physical, bodily pain, vitality, and mental health. Limaprost was also significantly better than etodolac for leg numbness, NIC distance, and subjective improvement and satisfaction. In the subgroup analysis stratified by symptom severity, limaprost seemed more effective for milder symptoms. No serious adverse effects were reported in either treatment group.

CONCLUSION

In this study, limaprost was found to be efficacious on most outcome measures, such as HRQOL, symptoms and subjective satisfaction, in LSS patents with cauda equina symptoms.

A survey of the "surgical and research" articles in the European Spine Journal, 2007

Over the last couple of years the European Spine Journal has become truly international with papers from all over the world, and at the same time it has increased its size. Professor Mulholland has selected and reviewed some 40 papers from over 200 published in 2007 and that he felt were of particular interest to practicing surgeons and would influence their management of patients, or papers that challenged established beliefs. Papers dealing with back pain, spondylolysis, tumors, spinal stenosis, spinal infection, clinical examination, lumbar disc herniation, spinal fractures, etc. are reviewed and their significance assessed. The aim of the review is to encourage readers to read the papers themselves, hopefully stimulated by the trenchant comments of the reviewer, both critical and laudatory.