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Kirker K, Masaracchio MF, Loghmani P, Torres-Panchame RE, Mattia M, States R. Management of lumbar spinal stenosis: a systematic review and meta-analysis of rehabilitation, surgical, injection, and medication interventions. Physiother Theory Pract 2023; 39:241-286. [PMID: 34978252 DOI: 10.1080/09593985.2021.2012860] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Kaitlin Kirker
- Department of Physical Therapy, Long Island University, Brooklyn, NY, USA
| | | | - Parisa Loghmani
- Department of Physical Therapy, Long Island University, Brooklyn, NY, USA
| | | | - Michael Mattia
- Department of Allied Health, Kingsborough Community College, Brooklyn, NY, USA
| | - Rebecca States
- Department of Physical Therapy, Long Island University, Brooklyn, NY, USA
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2
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Li T, Yan J, Ren Q, Hu J, Wang F, Liu X. Efficacy and Safety of Lumbar Dynamic Stabilization Device Coflex for Lumbar Spinal Stenosis: A Systematic Review and Meta-analysis. World Neurosurg 2023; 170:7-20. [PMID: 36481444 DOI: 10.1016/j.wneu.2022.11.141] [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: 11/03/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND This systematic review and meta-analysis were performed to investigate evidence for the comparison of lumbar dynamic stabilization device Coflex (Surgalign, Deerfield, IL) with posterior lumbar fusion for lumbar spinal stenosis). METHODS Relational databases were searched to October 2022. The main outcome measures included operation time, Japanese Orthopedic Association score (JOA), visual analog scale (VAS), Oswestry disability index (ODI), total complications, and adjacent segment degeneration (ASD). Statistical analysis was performed with Review Manager 5.3 (Cochrane Collaboration). RESULTS A total of 26 studies were included. The main results of this meta-analysis showed lumbar dynamic stabilization device Coflex had shorter operation time (mean difference [MD] -50.77 min, 95% CI -57.24 to -44.30, P < 0.00001), less intraoperative blood loss (MD -122.21 mL, 95% CI -129.68 to -94.74, P < 0.00001), and shorter hospital stays (MD -3.21 days, 95% CI -4.04 to -2.37, P < 0.00001). What's more, the JOA score and ODI score were higher in the Coflex group during early follow-up. Yet, there was no significant difference between the 2 groups with the extension of follow-up time. Moreover, the Coflex group had a lower VAS score than fusion treatment (P < 0.00001). Finally, the Coflex group had lower total complications rate (P = 0.03), lower ASD rate (P = 0.001), and higher range of motion (P < 0.00001), but there was no significant difference in reoperation rate and internal fixation problems rate. CONCLUSIONS Current evidence suggests that lumbar dynamic stabilization device Coflex is superior to posterior lumbar fusion in early follow-up. However, considering that the dynamic stabilization device group also has its limitations, these findings need to be further verified by multicenter, double-blind, and large-sample randomized controlled trials.
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Affiliation(s)
- Ting Li
- Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China; Department of Postgraduate, Chengdu Medical College, Chengdu, China
| | - Jingxin Yan
- Department of Interventional Therapy, Affiliated Hospital of Qinghai University, Xining, China
| | - Qiuyu Ren
- Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China; Department of Postgraduate, Chengdu Medical College, Chengdu, China
| | - Jiang Hu
- Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Fei Wang
- Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China
| | - Xilin Liu
- Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, China.
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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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Lee JY, Park KS, Kim S, Seo JY, Cho HW, Nam D, Park Y, Kim EJ, Lee YJ, Ha IH. The Effectiveness of Pharmacopuncture in Patients with Lumbar Spinal Stenosis: A Protocol for a Multi-Centered, Pragmatic, Randomized, Controlled, Parallel Group Study. J Pain Res 2022; 15:2989-2996. [PMID: 36176963 PMCID: PMC9514259 DOI: 10.2147/jpr.s382550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 09/14/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Lumbar spinal stenosis (LSS) is a chronic degenerative disease. Non-surgical intervention is recommended, considering the risks and benefits for the affected age group, as well as the characteristics of the disease. However, to date, no studies have compared various non-surgical interventions to ascertain the appropriate first-line non-surgical treatment for LSS. Therefore, the objective of this study will be to assess the efficacy of pharmacopuncture as a non-surgical, conservative treatment for LSS. Patients and Methods A multi-centered, pragmatic, parallel-group study will be conducted. In total, 98 patients will be recruited at seven institutes; recruitment began in May 2022. After two treatment sessions per week over a period of 12 weeks, follow-up assessments will be held at weeks 13, 25, and 53. Results The efficacy of pharmacopuncture and conservative care will be pragmatically compared in patients radiologically diagnosed with LSS. Pain severity will be measured using the numeric rating scale and visual analog scale. Walking distance will also be evaluated. Patient-centered evaluations will include the Zurich Claudication Questionnaire, Short-Form 12 for Health-Related Quality of Life, EuroQoL 5 Dimension 5 Levels, and Patient Global Impression of Change. Conclusion The results of this study will confirm the efficacy of pharmacopuncture in comparison to conventional non-surgical treatment and will thus facilitate the prioritization of patient-centered interventions for LSS. Trial registration This study was registered at Clinicaltrials.gov (registration identifier: NCT05242497) and CRiS (registration identifier: KCT0007145).
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Affiliation(s)
- Jee Young Lee
- Jaseng Spine & Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - Kyoung Sun Park
- Jaseng Clinical Research Center, Jaseng Hospital of Korean Medicine, Seoul, Republic of Korea
| | - Suna Kim
- Jaseng Clinical Research Center, Daejeon Jaseng Hospital of Korean Medicine, Daejeon, Republic of Korea
| | - Ji Yeon Seo
- Jaseng Clinical Research Center, Bucheon Jaseng Hospital of Korean Medicine, Bucheon, Republic of Korea
| | - Hyun-Woo Cho
- Jaseng Clinical Research Center, Haeundae Jaseng Hospital of Korean Medicine, Busan, Republic of Korea
| | - Dongwoo Nam
- Department of Acupuncture & Moxibustion, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Yeoncheol Park
- Department of Acupuncture & Moxibustion, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Eun-Jung Kim
- Department of Acupuncture & Moxibustion, College of Korean Medicine, Dongguk University Bundang Oriental Hospital, Seongnam, Republic of Korea
| | - Yoon Jae Lee
- Jaseng Spine & Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
| | - In-Hyuk Ha
- Jaseng Spine & Joint Research Institute, Jaseng Medical Foundation, Seoul, Republic of Korea
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Onggo JR, Nambiar M, Maingard JT, Phan K, Marcia S, Manfrè L, Hirsch JA, Chandra RV, Buckland AJ. The use of minimally invasive interspinous process devices for the treatment of lumbar canal stenosis: a narrative literature review. JOURNAL OF SPINE SURGERY 2021; 7:394-412. [PMID: 34734144 DOI: 10.21037/jss-21-57] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 08/19/2021] [Indexed: 11/06/2022]
Abstract
Minimally invasive interspinous process devices (IPD), including interspinous distraction devices (IDD) and interspinous stabilizers (ISS), are increasingly utilized for treating symptomatic lumbar canal stenosis (LCS). There is ongoing debate around their efficacy and safety over traditional decompression techniques with and without interbody fusion (IF). This study presents a comprehensive review of IPD and investigates if: (I) minimally invasive IDD can effectively substitute direct neural decompression and (II) ISS are appropriate substitutes for fusion after decompression. Articles published up to 22nd January 2020 were obtained from PubMed search. Relevant articles published in the English language were selected and critically reviewed. Observational studies across different IPD brands consistently show significant improvements in clinical outcomes and patient satisfaction at short-term follow-up. Compared to non-operative treatment, mini-open IDD was had significantly greater quality of life and clinical outcome improvements at 2-year follow-up. Compared to open decompression, mini-open IDD had similar clinical outcomes, but associated with higher complications, reoperation risks and costs. Compared to open decompression with concurrent IF, ISS had comparable clinical outcomes with reduced operative time, blood loss, length of stay and adjacent segment mobility. Mini-open IDD had better outcomes over non-operative treatment in mild-moderate LCS at 2-year follow-up, but had similar outcomes with higher risk of re-operations than open decompression. ISS with open decompression may be a suitable alternative to decompression and IF for stable grade 1 spondylolisthesis and central stenosis. To further characterize this procedure, future studies should focus on examining enhanced new generation IPD devices, longer-term follow-up and careful patient selection.
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Affiliation(s)
- James R Onggo
- Interventional Radiology Service, Monash Imaging, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Mithun Nambiar
- Interventional Radiology Service, Monash Imaging, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Julian T Maingard
- Interventional Radiology Service, Monash Imaging, Monash Medical Centre, Clayton, Victoria, Australia
| | - Kevin Phan
- Department of Neurosurgery, NeuroSpine Surgery Research Group (NSURG), Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales (UNSW), Sydney, New South Wales, Australia
| | - Stefano Marcia
- Department of Radiology, SS Trinità Hospital ASSL Cagliari ATS Sardegna, Cagliari, Italy
| | - Luigi Manfrè
- Department of Interventional Spine Neuroradiology-Neurosurgery, Mediterranean Institute for Oncology, Viagrande, Italy
| | - Joshua A Hirsch
- Interventional Spine Service, NeuroInterventional Radiology, Massachusetts General Hospital, Boston, USA
| | - Ronil V Chandra
- Interventional Radiology Service, Monash Imaging, Monash Medical Centre, Clayton, Victoria, Australia.,School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Aaron J Buckland
- Spine Research Center, Department of Orthopaedic Surgery, NYU Langone Health, New York, USA.,Melbourne Orthopaedic Group, Melbourne, Victoria, Australia
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Evaluation of Effectiveness of Treatment Strategies for Degenerative Lumbar Spinal Stenosis: A Systematic Review and Network Meta-Analysis of Clinical Studies. World Neurosurg 2021; 152:95-106. [PMID: 34129972 DOI: 10.1016/j.wneu.2021.06.016] [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: 03/09/2021] [Revised: 06/01/2021] [Accepted: 06/02/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Lumbar spinal stenosis (LSS) is a common disease in spinal surgery. Many related treatment methods have been reported, but their effectiveness still lacks a systematic comparison. We aimed to evaluate the clinical outcomes related to the efficacy and safety of these treatment strategies via a network meta-analysis. METHODS Relevant clinical studies were retrieved from the databases of PubMed, Embase, Web of Science, and Cochrane library updated to July 29, 2020. The data were extracted from the eligible literature and the results were presented as standardized mean differences with 95% confidence intervals (CIs). A network meta-analysis was executed using the netmeta, rjags, and gemtc packages in R software, and Begg and Egger tests were used to assess the publication bias within the included studies. RESULTS A total of 21 eligible studies based on 2890 patients with degenerative LSS were included. The newer microdecompression technique (bilateral decompression via unilateral laminotomy [BDUL]) performed better in decreasing the visual analog scale (VAS) score compared with conventional decompressive laminectomy (VAS score back pain, 1.22; 95% CI, 0.28-2.17; VAS score leg pain, 1.39; 95% CI, 0.82-1.96), but its Oswestry Disability Index improvement was slightly inferior to that of posterolateral fusion. CONCLUSIONS BDUL could effectively alleviate VAS pain of patients, and had a lower incidence of complications. Although BDUL was slightly inferior to posterolateral fusion in terms of Oswestry Disability Index improvement, the postoperative quality of life of patients treated with BDUL had been significantly improved compared with that before surgery.
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Kanaan T, Abusaleh R, Abuasbeh J, Al Jammal M, Al-Haded S, Al-Rafaiah S, Kanaan A, Alnaimat F, Khreesha L, Al Hadidi F, Al-Sabbagh Q. The Efficacy of Therapeutic Selective Nerve Block in Treating Lumbar Radiculopathy and Avoiding Surgery. J Pain Res 2020; 13:2971-2978. [PMID: 33239905 PMCID: PMC7680787 DOI: 10.2147/jpr.s276331] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/21/2020] [Indexed: 11/23/2022] Open
Abstract
Background Selective nerve root block (SNRB) is a procedure that can be used as a diagnostic or a therapeutic method. SNRB can be used in multiple sites, including cervical and lumbar . Our study aims to investigate the clinical effectiveness of the use of fluoroscopically guided therapeutic selective nerve root block as a non-surgical symptom management of lumbar radiculopathy. Patients and Methods This is a prospective study of therapeutic nerve root block in 76 patients with low back pain and/or sciatica at Jordan University Hospital. Data was collected by independent clinical interviewers, and visual analogue score (VAS) was used to measure pain severity. Results A total of 76 patients, 25 (32.8%) males and 51 (67.2%) females, underwent SNRB. 69 (90.7%) patients improved immediately after the procedure. Out of the total, 22 (28.9%) patients showed a long-term relief of symptoms and did not experience any recurrence during the three months of follow-up, while 47 (61.8%) experienced a recurrence of pain. In patients experiencing recurrence of symptoms, 35 needed surgery. Conclusion Therapeutic SNRB is an important procedure in the pain management of patients with lumbar radiculopathy caused by lumbar disc prolapse and foraminal stenosis. Our study showed that avoidance of surgery was achieved in up to 54% of patients; pain relief for at least 6 months was achieved in up to 29% of patients after a single SNRB. This makes it a very good second line of management after conservative treatment and a possible method to delay, and sometimes cease, the need for surgery.
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Affiliation(s)
- Tareq Kanaan
- Division of Neurosurgery & Spine Unit, Special Surgery Department, University of Jordan, Amman, Jordan
| | - Rami Abusaleh
- School of Medicine, University of Jordan, Amman, Jordan
| | | | | | - Sara Al-Haded
- School of Medicine, University of Jordan, Amman, Jordan
| | | | - Ali Kanaan
- School of Medicine, University of Jordan, Amman, Jordan
| | - Fatima Alnaimat
- Internal Medicine Department, University of Jordan, Amman, Jordan
| | - Lubna Khreesha
- Special Surgery Department, University of Jordan, Amman, Jordan
| | - Fadi Al Hadidi
- Division of Orthopedic Surgery & Spine Unit, Special Surgery Department, University of Jordan, Amman, Jordan
| | - Qussay Al-Sabbagh
- Division of Neurosurgery & Spine Unit, Special Surgery Department, University of Jordan, Amman, Jordan
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Costa F, Innocenzi G, Guida F, Agrillo U, Barbagallo G, Bocchetti A, Bongetta D, Cappelletto B, Certo F, Cimatti M, Cioffi V, Dobran M, Domenicucci M, Guizzardi G, Guizzardi G, Landi A, Marotta N, Marzetti F, Montano N, Anania CD, Nina P, Quaglietta P, Rispoli R, Somma T, Squillante E, Visocchi M, Vitali M, Vitiello V. Degenerative Lumbar Spine Stenosis Consensus Conference: the Italian job. Recommendations of the Spinal Section of the Italian Society of Neurosurgery. J Neurosurg Sci 2020; 65:91-100. [PMID: 32972117 DOI: 10.23736/s0390-5616.20.05042-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In the modern era evidence-based medicine, guidelines and recommendations represent a key-point of daily activity. The Spinal Section of the Italian Society of Neurosurgery introduced some recommendations regarding Degenerative Lumbar Spine Stenosis based on those of the Spine Committee of World Federation of Neurosurgical Societies, revising them on the basis of Italian common practice. In June 2019, a Committee of 21 spine surgeons met in Rome to validate the recommendations of the WFNS. Furthermore, they decided to review the ones that did not reach a consensus to create Italian Recommendations on Degenerative Lumbar Spine Stenosis. A literature review of the last ten years was performed and the statements were voted using the Delphi method. Forty-one statements were discussed, and 7 statements were voted again to reach a consensus with respect to those of the WFNS. A total of 40 statements reached a consensus, of which 36 reached a positive consensus and 4 a negative consensus, while no consensus was reached in 1 case. Conservative multimodal therapy, tailored on the patient, is a reasonable and effective first option choice for the treatment of LSS patients with tolerable moderate symptoms. Surgical treatment is reserved for symptomatic patients non-responding to conservative treatment or with neurological deficits. The best surgical technique to use depends on personal experience; modern MISS techniques are equivalent to open decompressive surgery with some advantages and higher cost-effectiveness. Fusion surgery and mobility preserving surgery only have a marginal role in the treatment of DLSS without instability.
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Affiliation(s)
- Francesco Costa
- Department of Neurosurgery, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy - .,Department of Biomedical Sceinces, Humanitas University, Milan, Italy -
| | | | - Franco Guida
- Department of Neurosurgery, Ospedale dell'Angelo, Mestre, Venice, Italy
| | - Umberto Agrillo
- Department of Neurosurgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | | | - Antonio Bocchetti
- Santa Maria delle Grazie Hospital, ASL Napoli 2 Nord, Pozzuoli, Naples, Italy
| | - Daniele Bongetta
- Department of Neurosurgery, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Barbara Cappelletto
- Section of Spinal Column and Spinal Cord Surgery and Spinal Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Francesco Certo
- Department of Neurosurgery, University of Catania, Catania, Italy
| | - Marco Cimatti
- N.E.S.M.O.S Department, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Valentina Cioffi
- Santa Maria delle Grazie Hospital, ASL Napoli 2 Nord, Pozzuoli, Naples, Italy
| | - Mauro Dobran
- Department of Neurosurgery, Marche Polytechnic University, Ancona, Italy
| | - Maurizio Domenicucci
- Department of Neurology and Psychiatry, Neurosurgery, Polo Pontino, Sapienza University, Rome, Italy
| | | | | | - Alessandro Landi
- Division of Neurosurgery and Spinal Surgery, San Carlo di Nancy Hospital, Rome, Italy
| | - Nicola Marotta
- Division of Neurosurgery and Spinal Surgery, San Carlo di Nancy Hospital, Rome, Italy
| | - Francesco Marzetti
- Neurosurgery Division, Umberto I University Hospital, Sapienza University, Rome, Italy
| | - Nicola Montano
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Carla D Anania
- Department of Neurosurgery, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Pierpaolo Nina
- Unit of Neurosurgery, San Giovanni Bosco Hospital, Naples, Italy
| | - Paolo Quaglietta
- Unit of Neurosurgery, General Hospital of Cosenza, Cosenza, Italy
| | - Rossella Rispoli
- Section of Spinal Column and Spinal Cord Surgery and Spinal Unit, Santa Maria della Misericordia University Hospital, Udine, Italy
| | - Teresa Somma
- Division of Neurosurgery, Federico II University, Naples, Italy
| | | | | | - Matteo Vitali
- Unit of Neurosurgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
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Fan Y, Zhu L. Decompression alone versus fusion and Coflex in the treatment of lumbar degenerative disease: A network meta-analysis. Medicine (Baltimore) 2020; 99:e19457. [PMID: 32176077 PMCID: PMC7220096 DOI: 10.1097/md.0000000000019457] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Lumbar degenerative disease (LDD) is a very common disease. And decompression alone, posterior lumbar interbody fusion (PLIF), and interspinous device (Coflex) are generally accepted surgical techniques. However, the effectiveness and safety of the above techniques are still not clear. Network meta-analysis a comprehensive technique can compare multiple treatments based on indirect dates and all interventions are evaluated and ranked simultaneously. To figure out this problem and offer a better choice for LDD, we performed this network meta-analysis. METHODS PubMed and WanFang databases were searched based on the following key words, "Coflex," "decompression," "PLIF," "Posterior Lumbar Interbody Fusion," "Coflex" "Lumbar interbody Fusion." Then the studies were sorted out on the basis of inclusion criteria and exclusion criteria. A network meta-analysis was performed using The University of Auckland, Auckland city, New Zealand R 3.5.3 software. RESULTS A total of 10 eligible literatures were finally screened, including 946 patients. All studies were randomized controlled trials (RCTs). Compared with decompression alone group, there were no significant differences of Oswestry Disability Index (ODI) in Coflex and lumbar interbody fusion groups after surgery. However, Coflex and PLIF were better in decreasing Visual Analogue Scale (VAS) score compared with decompression alone. Furthermore, we found Coflex have a less complication incidence rate. CONCLUSION Compared with decompression alone, Coflex and lumbar interbody fusion had the similar effectiveness in improving lumbar function and quality of life. However, the latter 2 techniques were better in relieving pain. Furthermore, Coflex included a lower complication incidence rate. So we suggested that Coflex technique was a better choice to cue lumbar spinal stenosis (LSS). LEVEL OF EVIDENCE Systematic review and meta-analysis, level I.
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Affiliation(s)
- Yunpeng Fan
- Department of Orthopedic Surgery, The Affiliated Hangzhou Hospital of Nanjing Medical University
| | - Liulong Zhu
- Department of Orthopedic Surgery, The Affiliated Hangzhou Hospital of Nanjing Medical University
- The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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10
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Nayak NR, Stephen JH, Piazza MA, Obayemi AA, Stein SC, Malhotra NR. Quality of Life in Patients Undergoing Spine Surgery: Systematic Review and Meta-Analysis. Global Spine J 2019; 9:67-76. [PMID: 30775211 PMCID: PMC6362549 DOI: 10.1177/2192568217701104] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Meta-analysis. OBJECTIVE Despite the increasing importance of tracking clinical outcomes using valid patient-reported outcome measures, most providers do not routinely obtain baseline preoperative health-related quality of life (HRQoL) data in patients undergoing spine surgery, precluding objective outcomes analysis in individual practices. We conducted a meta-analysis of pre- and postoperative HRQoL data obtained from the most commonly published instruments to use as reference values. METHODS We searched PubMed, EMBASE, and an institutional registry for studies reporting EQ-5D, SF-6D, and Short Form-36 Physical Component Summary scores in patients undergoing surgery for degenerative cervical and lumbar spinal conditions published between 2000 and 2014. Observational data was pooled meta-analytically using an inverse variance-weighted, random-effects model, and statistical comparisons were performed. RESULTS Ninety-nine articles were included in the final analysis. Baseline HRQoL scores varied by diagnosis for each of the 3 instruments. On average, postoperative HRQoL scores significantly improved following surgical intervention for each diagnosis using each instrument. There were statistically significant differences in baseline utility values between the EQ-5D and SF-6D instruments for all lumbar diagnoses. CONCLUSIONS The pooled HRQoL values presented in this study may be used by practitioners who would otherwise be precluded from quantifying their surgical outcomes due to a lack of baseline data. The results highlight differences in HRQoL between different degenerative spinal diagnoses, as well as the discrepancy between 2 common utility-based instruments. These findings emphasize the need to be cognizant of the specific instruments used when comparing the results of outcome studies.
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Affiliation(s)
- Nikhil R. Nayak
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - James H. Stephen
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Sherman C. Stein
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Neil R. Malhotra
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA,Neil R. Malhotra, Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 3 Silverstein Pavilion, Philadelphia, PA 19104, USA.
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11
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Poetscher AW, Gentil AF, Ferretti M, Lenza M. Interspinous process devices for treatment of degenerative lumbar spine stenosis: A systematic review and meta-analysis. PLoS One 2018; 13:e0199623. [PMID: 29979691 PMCID: PMC6034833 DOI: 10.1371/journal.pone.0199623] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 05/03/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Degenerative lumbar spinal stenosis is a condition related to aging in which structural changes cause narrowing of the central canal and intervertebral foramen. It is currently the leading cause for spinal surgery in patients over 65 years. Interspinous process devices (IPDs) were introduced as a less invasive surgical alternative, but questions regarding safety, efficacy, and cost-effectiveness are still unanswered. OBJECTIVES The aim of this study was to provide complete and reliable information regarding benefits and harms of IPDs when compared to conservative treatment or decompression surgery and suggest directions for forthcoming RCTs. METHODS We searched MEDLINE, EMBASE, Cochrane Library, Scopus, and LILACS for randomized and quasi-randomized trials, without language or period restrictions, comparing IPDs to conservative treatment or decompressive surgery in adults with symptomatic degenerative lumbar spine stenosis. Data extraction and analysis were conducted following the Cochrane Handbook. Primary outcomes were pain assessment, functional impairment, Zurich Claudication Questionnaire, and reoperation rates. Secondary outcomes were quality of life, complications, and cost-effectiveness. This systematic review was registered at Prospero (International prospective register of systematic reviews) under number 42015023604. RESULTS The search strategy resulted in 17 potentially eligible reports. At the end, nine reports were included and eight were excluded. Overall quality of evidence was low. One trial compared IPDs to conservative treatment: IPDs presented better pain, functional status, quality of life outcomes, and higher complication risk. Five trials compared IPDs to decompressive surgery: pain, functional status, and quality of life had similar outcomes. IPD implant presented a significantly higher risk of reoperation. We found low-quality evidence that IPDs resulted in similar outcomes when compared to standard decompression surgery. Primary and secondary outcomes were not measured in all studies and were often published in incomplete form. Subgroup analysis was not feasible. Difficulty in contacting authors may have prevented us of including data in quantitative analysis. CONCLUSIONS Patients submitted to IPD implants had significantly higher rates of reoperation, with lower cost-effectiveness. Future trials should improve in design quality and data reporting, with longer follow-up periods.
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Affiliation(s)
| | | | - Mario Ferretti
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Mario Lenza
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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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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Cochrane in CORR ®: Surgical Versus Non-surgical Treatment for Lumbar Spinal Stenosis. Clin Orthop Relat Res 2017; 475:2632-2637. [PMID: 28755156 PMCID: PMC5638738 DOI: 10.1007/s11999-017-5452-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 07/24/2017] [Indexed: 01/31/2023]
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Stokes OM, Cole AA, Breakwell LM, Lloyd AJ, Leonard CM, Grevitt M. Do we have the right PROMs for measuring outcomes in lumbar spinal surgery? 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 2017; 26:816-824. [DOI: 10.1007/s00586-016-4938-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 12/04/2016] [Accepted: 12/25/2016] [Indexed: 10/20/2022]
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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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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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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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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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Patil CG, Sarmiento JM, Ugiliweneza B, Mukherjee D, Nuño M, Liu JC, Walia S, Lad SP, Boakye M. Interspinous device versus laminectomy for lumbar spinal stenosis: a comparative effectiveness study. Spine J 2014; 14:1484-92. [PMID: 24291409 DOI: 10.1016/j.spinee.2013.08.053] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 07/16/2013] [Accepted: 08/25/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Currently no studies directly compare effectiveness between interspinous devices (IDs) and laminectomy in lumbar spinal stenosis (LSS) patients. PURPOSE To compare reoperations, complications, and costs between LSS patients undergoing ID placement versus laminectomy. STUDY DESIGN Retrospective comparative study. PATIENT SAMPLE The MarketScan database (2007-2009) was queried for adults with LSS undergoing ID placement as a primary inpatient procedure. OUTCOME MEASURES Reoperation rates, complication rates, and costs. METHODS Each ID patient was matched with a laminectomy patient using propensity score matching. Reoperations, complications, and costs were analyzed in patients with at least 18 months postoperative follow-up. The authors did not receive funding from any external sources for this study. RESULTS Among 498 inpatients that underwent ID placement between 2007 and 2009; the average age was 73 years. The cumulative reoperation rates after ID at 12 and 18 months were 21% and 23%, respectively. The average inpatient hospitalization lasted 1.6 days with an associated cost of $17,432. Two propensity-matched cohorts of 174 patients that had undergone ID versus laminectomy were analyzed. Longer length of stay was observed in the laminectomy cohort (2.5 days vs. 1.6 days, p<.0001), whereas ID patients accrued higher costs at index hospitalization ($17,674 vs. $12,670, p=.0001). Index hospitalization (7.5% vs. 3.5%, p=.099) and 90-day (9.2% vs. 3.5%, p=.028) complications were higher in the laminectomy cohort compared with the ID cohort. The ID patients had significantly higher reoperation rates than laminectomy patients at 12 months follow-up (12.6% vs. 5.8%, p=.026) and incurred higher cumulative costs than laminectomy patients at 12 months follow-up ($39,173 vs. $34,324, p=.289). CONCLUSIONS Twelve-month reoperation rates and index hospitalization costs were significantly higher among patients who underwent ID compared with laminectomy for LSS.
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Affiliation(s)
- Chirag G Patil
- Department of Neurosurgery, Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, 8631 W. Third St, Suite 800E, Los Angeles, CA 90048, USA.
| | - J Manuel Sarmiento
- Department of Neurosurgery, Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, 8631 W. Third St, Suite 800E, Los Angeles, CA 90048, USA
| | - Beatrice Ugiliweneza
- Department of Neurosurgery, University of Louisville, 220 Abraham Flexner Way, Suite 1103, Louisville, KY 40202, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, 8631 W. Third St, Suite 800E, Los Angeles, CA 90048, USA
| | - Miriam Nuño
- Department of Neurosurgery, Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, 8631 W. Third St, Suite 800E, Los Angeles, CA 90048, USA
| | - John C Liu
- Department of Neurosurgery, Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, 8631 W. Third St, Suite 800E, Los Angeles, CA 90048, USA
| | - Sartaaj Walia
- Department of Neurosurgery, Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center, 8631 W. Third St, Suite 800E, Los Angeles, CA 90048, USA
| | - Shivanand P Lad
- Division of Neurosurgery, Department of Surgery, Duke University Medical Center, 200 Trent Drive, Blue Zone- Room 4529, Durham, NC 27710, USA
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, 220 Abraham Flexner Way, Suite 1103, Louisville, KY 40202, USA; Roblex Rex VA Medical Center, 800 Zorn Ave., Louisville, KY 40206, USA
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Hong P, Liu Y, Li H. Comparison of the efficacy and safety between interspinous process distraction device and open decompression surgery in treating lumbar spinal stenosis: a meta analysis. J INVEST SURG 2014; 28:40-9. [PMID: 25025237 DOI: 10.3109/08941939.2014.932474] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The present study performed a meta-analysis to evaluate the efficacy and safety of interspinous process distraction device (IPD) compared with open decompression surgery (ODS) in treating lumbar spinal stenosis. METHODS Literatures were searched in the databases including Cochrane Library, Pubmed, OvidSP, Sciencedirect, Web of Science, and Springerlin. Published reviews were checked to track missed original research papers. The quality and bias of publications with randomized controlled trial were evaluated using the tool for assessing risk of bias in the Cochrane handbook. The quality and bias of publications with cohort trial were evaluated using the Newcastle-Ottawa Scale. The grades of literatures were evaluated with the guidelines of Grading of Recommendations Assessment Development and Evaluation (GRADE). RESULTS Totally, 21 publications matched the inclusion criteria, including 20 different clinical trials and 54,138 patients. The results indicated that there was no significant difference in improvement rate, Oswestry disability index questionnaire (ODI) score, and visual analog scale (VAS) score of back pain or leg pain between IPD group and ODS group. The postoperation complication rate, perioperation blood loss, hospitalization time, and operation time were lower/shorter in IPD group than ODS group. However, the reoperation rate in IPD group was higher than ODS group. CONCLUSION The results indicated that IPD has better effects and less complication than ODS. However, because of the higher reoperation rate in IPD than ODS, we failed to conclude that IPD could replace ODS as golden standard but may be a viable alternative in treating lumbar spinal stenosis.
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Affiliation(s)
- Peiwei Hong
- 1Department of Obstetrics & Gynecologic and Pediatric, West China Developmental & Stem Cell Institute, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects, Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Schilling C, Pfeiffer M, Grupp TM, Blömer W, Rohlmann A. The effect of design parameters of interspinous implants on kinematics and load bearing: an in vitro study. 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 2014; 23:762-71. [PMID: 24549393 DOI: 10.1007/s00586-014-3237-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 02/04/2014] [Accepted: 02/06/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION A number of concepts with controversy approaches are currently discussed for interspinous stabilization (IPS). However, comparative biomechanical studies among the different systems are rare. Nevertheless, it remains unclear which biomechanical characteristics are influenced by different design features of these implants, such as implant stiffness or an additional tension band. Therefore, the aim of the present study was to compare different interspinous implants to investigate the biomechanical impact of IPS implant design on intersegmental kinematics, such as range of motion, neutral zone, center of rotation (COR), as well as load transfer like intradiscal pressure (IDP), to gain additional experience for clinical indications and limitations. MATERIAL AND METHOD Twelve human lumbar spine specimens were tested in a spine loading apparatus. In vitro flexibility testing was performed by applying pure bending moments of 7.5 Nm without and with additional preload of 400 N in the three principal motion planes. Four interspinous implants, Coflex "COF" (Paradigm Spine, Germany), Wallis "WAL" (Abbott Laboratories, France), DIAM "DIA" (Sofamor Danek, France) and InterActiv (Aesculap AG, Germany) with two treatment options (without dorsal tensioning "IAO" and with dorsal tensioning "IAM") were consecutively tested in comparison to the native situation "NAT" and to a defect situation "DEF" of the functional spinal unit. The tested IPS devices are comprised of a compression stiffness range of 133 to 1,674 N/mm and a tensile stiffness range of 0-39 N/mm. Range of motion, neutral zone, center of rotation and intradiscal pressure were analyzed for all instrumentation steps and load cases. CONCLUSION For the IPS, we found a correlation between compression stiffness and stabilization in extension. Here, the system with the lowest stiffness, DIA, displayed nearly no stabilization of the treated segment, whereas the system with the highest stiffness, WAL and COF, was most pronounced. This applies also for the correlation between device stiffness and IDP. In flexion only the degree of stabilization is in correlation with the tensile stiffness, whereas the IDP stays constant and is not affected by the different tensile stiffness. IPS is not able to stabilize in the frontal and transversal plane. Furthermore IPS does not substantially alter the location of the COR.
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Affiliation(s)
- Christoph Schilling
- Aesculap AG, Research and Development, Am Aesculap Platz, 78532, Tuttlingen, Germany,
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Radcliff KE, Kepler CK, Jakoi A, Sidhu GS, Rihn J, Vaccaro AR, Albert TJ, Hilibrand AS. Adjacent segment disease in the lumbar spine following different treatment interventions. Spine J 2013; 13:1339-49. [PMID: 23773433 DOI: 10.1016/j.spinee.2013.03.020] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 11/26/2012] [Accepted: 03/07/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Adjacent segment disease (ASD) is symptomatic deterioration of spinal levels adjacent to the site of a previous fusion. A critical issue related to ASD is whether deterioration of spinal segments adjacent to a fusion is due to the spinal intervention or due to the natural history of spinal degenerative disease. PURPOSE The purpose of this review is to summarize the recent clinical literature on adjacent segment disease in light of the natural history, patient-modifiable risk factors, surgical risk factors, sagittal balance, and new technology. STUDY DESIGN This review will evaluate the recent literature on genetic and hereditary components of spinal degenerative disease and potential links to the development of ASD. METHODS After a meticulous search of Medline for relevant articles pertaining to our review, we summarized the recent literature on the rate of ASD and the effect of various interventions, including motion preservation, sagittal imbalance, arthroplasty, and minimally invasive surgery. RESULTS The reported rate of ASD after decompression and stabilization procedures is approximately 2% to 3% per year. The factors that are consistently associated with adjacent segment disease include laminectomy adjacent to a fusion and a sagittal imbalance. CONCLUSIONS Spinal surgical interventions have been associated with ASD. However, whether such interventions may lead to an acceleration of the natural history of the disease remains questionable.
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Affiliation(s)
- Kristen E Radcliff
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Percutaneous interspinous spacer versus open decompression: a 2-year follow-up of clinical outcome and quality of life. 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 2013; 22:2015-21. [PMID: 23625306 DOI: 10.1007/s00586-013-2790-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Revised: 03/21/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Percutaneous interspinous stand-alone spacers offer a simple and effective technique to treat lumbar spinal stenosis with neurogenic claudication. Nonetheless, open decompressive surgery remains the standard of care. This study compares the effectiveness of both techniques and the validity of percutaneous interspinous spacer use. METHODS Forty-five patients were included in this open prospective non-randomized study, and treated either with percutaneous interspinous stand-alone spacers (Aperius(®)) or bilateral open microsurgical decompression at L3/4 or L4/5. Patient data, operative data, COMI, SF-36, PCS and MCS, ODI, and walking distance were collected 6 weeks, 3, 6, 9, 12, and 24 months post-surgery. RESULTS Group 1 (n = 12) underwent spacer implantation, group 2 (n = 33) open decompression. Five patients from group 1 required implant removal and open decompression during follow-up (FU); one patient was lost to FU. From group 2, seven patients were lost to FU. Remaining patients were assessed as above. After 2 years, back pain, leg pain, ODI, and quality of life improved significantly for group 2. Remaining group 1 patients (n = 6) reported worse results. Walking distance improved for both groups. CONCLUSION Decompression proved superior to percutaneous stand-alone spacer implantation in our two observational cohorts. Therapeutic failure was too high for interspinous spacers.
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Efficacy of an interspinous decompression device versus nonoperative treatment for lumbar spinal stenosis: an example for a randomized, controlled trial. ACTA ACUST UNITED AC 2012. [DOI: 10.4155/cli.12.128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Jarrett MS, Orlando JF, Grimmer-Somers K. The effectiveness of land based exercise compared to decompressive surgery in the management of lumbar spinal-canal stenosis: a systematic review. BMC Musculoskelet Disord 2012; 13:30. [PMID: 22369653 PMCID: PMC3305601 DOI: 10.1186/1471-2474-13-30] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 02/28/2012] [Indexed: 11/30/2022] Open
Abstract
Background Lumbar spinal stenosis (LSS) is prevalent in those over the age of 65 years and the leading cause of spinal surgery in this population. Recent systematic reviews have examined the effectiveness of conservative management for LSS, but not relative to surgical interventions. The aim of this review was to systematically examine the effectiveness of land based exercise compared with decompressive surgery in the management of patients with LSS. Methods A systematic review of randomised controlled trials and clinical trials was undertaken. The databases MEDLINE, Embase, CINAHL, PEDro and Cochrane Library Register of Controlled Trials were searched from January 2000 to June 2011. Only studies that included subjects with lumbar spinal canal stenosis were considered in this review. Studies also had to use a patient reported functional outcome measure for a land based exercise intervention or lumbar decompressive surgery. Results Only one study compared the effectiveness of exercise and decompressive surgery for LSS. Surgery demonstrated statistically significant improvements in patient reported functional outcome scores at 6, 12 and 24-months post-intervention (p < 0.01). To facilitate further analysis, the results from 12 exercise and 10 surgical intervention arms were compared using percentage change in patient reported functional outcome measure scores. Exercise interventions showed initial improvements, ranging from 16 to 29% above baseline. All decompressive surgical interventions demonstrated greater and sustained improvements over 2-years (range 38-67% improvement) with moderate to large effect sizes. The most commonly reported complications associated with surgery were dural tears, while details of adverse effects were lacking in exercise interventions. Conclusions This systematic review of the recent literature demonstrates that decompressive surgery is more effective than land based exercise in the management of LSS. However, given the condition's slowly progressive nature and the potential for known surgical complications, it is recommended that a trial of conservative management with land based exercise be considered prior to consideration of surgical intervention.
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Affiliation(s)
- Mark S Jarrett
- International Centre for Allied Health Evidence, University of South Australia, North Terrace, Adelaide, SA 5000, Australia
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