ISSLS Prize Winner: Consensus on the Clinical Diagnosis of Lumbar Spinal Stenosis: Results of an International Delphi Study

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN/SETTING

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

PATIENT SAMPLE

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

OUTCOME MEASURES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Walking performance in individuals with lumbar spinal stenosis- possible outcome measures and assessment of known-group validity

BACKGROUND CONTEXT

One of the primary goals of treatments received by individuals with lumbar spinal stenosis with neurogenic claudication is to improve walking ability. Thus, a thorough and valid assessment of walking ability in patients with lumbar spinal stenosis is needed. Duration of continuous walking and steps per day could be relevant when evaluating walking ability in daily living.

PURPOSE

To describe and evaluate a method for estimating continuous walking periods in daily living and to evaluate the known-group validity of steps per day in individuals with lumbar spinal stenosis.

STUDY DESIGN

This is a cross-sectional observational study.

PATIENT SAMPLE

The study contains three study groups: individuals with lumbar spinal stenosis, individuals with low back pain, and a background population from the Lolland-Falster Health Study (LOFUS).

OUTCOME MEASURES

Participants in all three study groups wore an accelerometer on the thigh for seven days.

METHODS

Accelerometer data were processed to summarize the continuous walking periods according to their length: the number of short (4-9 seconds), moderate (10-89 seconds), and extended (≥90 seconds) continuous walking periods per day, and the number of steps per day. Results from the three groups were compared using negative binomial regression with lumbar spinal stenosis as the reference level.

RESULTS

Continuous walking periods of moderate length were observed 1.48 (95% CI 1.27, 1.72) times more often in individuals from the background population than in individuals with LSS. Continuous walking periods of extended length were observed 1.53 (95% CI 1.13, 2.06) times more often by individuals with low back pain and 1.60 (95% CI 1.29, 1.99) times more often by individuals from the background population. The number of steps per day was 1.22 (95% CI 1.03, 1.46) times larger in individuals with LBP and 1.35 (95% CI 1.20, 1.53) times larger in individuals from background population.

CONCLUSIONS

The impact of neurogenic claudication on walking ability in daily living seems possible to describe by continuous walking periods along with steps per day. The results support known-group validity of steps per day. This is the next step toward a clinically relevant and comprehensive assessment of walking in daily living in individuals with lumbar spinal stenosis.

Central sensitization adversely affects quality of recovery following lumbar decompression surgery

BACKGROUND

Central sensitization (CS) is defined as increased responsiveness of nociceptive neurons in the central nervous system to normal or subthreshold afferent input. The CS phenomenon is caused by continuous, intense nociceptor inputs triggering a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in the central nociceptive pathway. Most patients undergoing surgery for lumbar spinal stenosis (LSS) experience symptoms for more than three months; therefore, it is possible that CS is associated with postoperative symptoms of LSS. The aim of this study was to clarify the influence of CS in patients who underwent surgery for LSS.

METHODS

We used the Central Sensitization Inventory (CSI) to evaluate CS preoperatively. Clinical and neurological symptoms were assessed before surgery and three months after surgery using the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOA-BPEQ) and the Oswestry Disability Index (ODI). To evaluate the correlation between the preoperative CSI score and each parameter of the JOA-BPEQ before and three months after surgery, a Pearson correlation coefficient was used. We also evaluated the correlation between preoperative CSI and improvement scores for each parameter of the JOA-BPEQ for surgery. Similarly, the ODI was assessed.

RESULTS

This study included 118 patients. After surgery, the parameters of lumbar function disorder, social life function disorder, and mental health disorder revealed a statistically significant relationship (r = -0.289, -0.0354, and -0.493, respectively). There was no significant correlation between CSI and improvement scores of the JOA-BPEQ. The ODI assessment after surgery revealed a statistically significant relationship (r = 0.344). There was no significant correlation between the CSI and ODI improvement scores.

CONCLUSION

This study showed that the severity of the CSI influenced the postoperative outcomes, and that surgical treatment improved the symptoms of LSS regardless of the occurrence of CS preoperatively.

Similar improvements in patient-reported outcomes for non-specific low back pain patients with and without lumbar spinal stenosis symptoms following a structured education and exercise therapy program

BACKGROUND

People with nonspecific low back pain (NSLBP) can also experience overlapping symptoms of lumbar spinal stenosis (LSS), but the impact on treatment outcomes is unknown. This study investigated differences in treatment outcomes for disability, back pain intensity, and leg pain intensity following an education and exercise therapy program for NSLBP patients with and without comorbid LSS symptoms.

METHODS

This was a longitudinal analysis of 655 Danish participants in the GLA:D® Back program; an education and exercise therapy program for people with persistent NSLBP. Participants were classified as having comorbid LSS symptoms based on self-report. Linear mixed models were used to assess differences in change in disability (Oswestry Disability Index [0-100]) and back and leg pain intensity (Numeric Rating Scale [0-10]) at 3-, 6-, and 12-months between those with and without LSS symptoms.

RESULTS

28% of participants reported LSS symptoms. No certain differences in change in disability or back pain intensity improvement were observed at any time-point between those with and without LSS symptoms. Participants with LSS symptoms had slightly greater improvement in leg pain intensity at 6- (-0.7, 95% CI -1.2 to -0.2) and 12-months (-0.6, 95% CI -1.2 to -0.1).

CONCLUSION

Compared to those without LSS symptoms, patients with persistent NSLBP and LSS symptoms can expect similar improvements in disability and back pain intensity, and slightly greater improvements in leg pain intensity with treatment. Therefore, education and exercise therapy programs designed for NSLBP are likely helpful for those also experiencing LSS symptoms.

Trends of Surgical Service Utilization for Lumbar Spinal Stenosis in South Korea: A 10-Year (2010-2019) Cross-Sectional Analysis of the Health Insurance Review and Assessment Service-National Patient Sample Data

Background and Objectives: This retrospective, cross-sectional, and descriptive study used claims data from the Korean Health Insurance Review and Assessment Service (HIRA) between 2010 and 2019 to analyze the trend of surgical service utilization in patients with lumbar spinal stenosis (LSS). Materials and Methods: The national patient sample data provided by the HIRA, which consisted of a 2% sample of the entire Korean population, was used to assess all patients who underwent decompression or fusion surgery at least once in Korea, with LSS as the main diagnosis from January 2010 to December 2019. An in-depth analysis was conducted to examine the utilization of surgical services, taking into account various demographic characteristics of patients, the frequency of claims for different types of surgeries, reoperation rates, the specific types of inpatient care associated with each surgery type, prescribed medications, and the overall expense of healthcare services. Results: A total of 6194 claims and 6074 patients were analyzed. The number of HIRA claims for patients increased from 393 (2010) to 417 (2019) for decompression, and from 230 (2010) to 244 (2019) for fusion. As for the medical expenses of surgery, there was an increase from United States dollar (USD) 867,549.31 (2010) to USD 1,153,078.94 (2019) for decompression and from USD 1,330,440.37 (2010) to USD 1,780,026.48 (2019) for fusion. Decompression accounted for the highest proportion (65.8%) of the first surgeries, but more patients underwent fusion (50.6%) than decompression (49.4%) in the second surgery. Across all sex and age groups, patients who underwent fusion procedures experienced longer hospital stays and incurred higher medical expenses for their inpatient care. Conclusion: The surgical service utilization of patients with LSS and the prescribing rate of opioids and non-opioid analgesics for surgical patients increased in 2019 compared to 2010. From mid-2010 onward, claims for fusion showed a gradual decrease, whereas those for decompression showed a continuously increasing trend. The findings of this study are expected to provide basic research data for clinicians, researchers, and policymakers.

Characteristics associated with comorbid lumbar spinal stenosis symptoms in people with knee or hip osteoarthritis: an analysis of 9,136 good life with osteoArthritis in Denmark (GLA:D®) participants

BACKGROUND

Previous studies have found that lumbar spinal stenosis (LSS) often co-occurs with knee or hip OA and can impact treatment response. However, it is unclear what participant characteristics may be helpful in identifying individuals with these co-occurring conditions. The aim of this cross-sectional study was to explore characteristics associated with comorbid symptoms of lumbar spinal stenosis (LSS) in people with knee or hip osteoarthritis (OA) enrolled in a primary care education and exercise program.

METHODS

Sociodemographic, clinical characteristics, health status measures, and a self-report questionnaire on the presence of LSS symptoms was collected at baseline from the Good Life with osteoArthritis in Denmark primary care program for knee and hip OA. Cross-sectional associations between characteristics and the presence of comorbid LSS symptoms were assessed separately in participants with primary complaint of knee and hip OA, using domain-specific logistic models and a logistic model including all characteristics.

RESULTS

A total of 6,541 participants with a primary complaint of knee OA and 2,595 participants with a primary complaint of hip OA were included, of which 40% and 50% reported comorbid LSS symptoms, respectively. LSS symptoms were associated with similar characteristics in knee and hip OA. Sick leave was the only sociodemographic variable consistently associated with LSS symptoms. For clinical characteristics, back pain, longer symptom duration and bilateral or comorbid knee or hip symptoms were also consistently associated. Health status measures were not consistently related to LSS symptoms.

CONCLUSION

Comorbid LSS symptoms in people with knee or hip OA undergoing a primary care treatment program of group-based education and exercise were common and associated with a similar set of characteristics. These characteristics may help to identify people with co-occurring LSS and knee or hip OA, which can be used to help guide clinical decision-making.

Effect of Lumbar Spinal Stenosis on Treatment of Osteoporosis: Comparison of Three Oral Bisphosphonate Therapies

(1) Background: Lumbar spinal stenosis (LSS) causes uncomfortable neuropathic symptoms, which can negatively affect osteoporosis. The aim of this study was to investigate the effect of LSS on bone mineral density (BMD) in patients treated with one of three oral bisphosphonates (ibandronate, alendronate and risedronate) for initially diagnosed osteoporosis. (2) Methods: We included 346 patients treated with oral bisphosphonates for three years. We compared annual BMD T-scores and BMD increases between the two groups according to symptomatic LSS. The therapeutic efficacies of the three oral bisphosphonates in each group were also evaluated. (3) Results: Annual and total increases in BMD were significantly greater in group I (osteoporosis) compared to group II (osteoporosis + LSS). The total increase in BMD for three years was significantly greater in the ibandronate and alendronate subgroups than that in the risedronate subgroup (0.49 vs. 0.45 vs. 0.25, p < 0.001). Ibandronate showed a significantly greater increase in BMD than that of risedronate in group II (0.36 vs. 0.13, p = 0.018). (4) Conclusions: Symptomatic LSS may interfere with the increase in BMD. Ibandronate and alendronate were more effective in treating osteoporosis than risedronate. In particular, ibandronate was more effective than risedronate in patients with both osteoporosis and LSS.

The glasgow lumbar spinal stenosis scale: an individualised measurement formula for the radiological assessment of lumbar spinal stenosis

BACKGROUND

Lumbar spinal stenosis (LSS) is a common and important spinal surgical problem. Currently there is no universally accepted quantitative approach to the radiological measurement of LSS. LSS can be described qualitatively with reference to facet and ligamentous hypertrophy, lack of perineural or intraforaminal fat, and reduced CSF around the cauda equina. Quantitative descriptions do exist e.g., lumbar canal antero-posterior diameter, but these are unidimensional and do not consider normal variation in anatomy. We propose a universal and individualised measurement system for the quantitative radiological assessment of lumbar spinal stenosis.

METHODS

A retrospective case series of patients who had undergone surgery for symptomatic lumbar spinal stenosis over a 3 year period. Pre-operative lumbar spine MRI were analysed. Each patient had the degree of lumbar canal stenosis quantified using our novel approach.

RESULTS

Our novel formula for the quantitative radiological assessment of lumbar spinal stenosis is two dimensional, repeatable and presented as a percentage, to correct for the individual patient. The surface area of the lumbar spinal canal at the level of stenosis is measured in mm2 plus the adjacent 2 levels which are then averaged. The calculation then becomes (A-S/A) x 100 = R, where S is the canal surface area at the stenosed level in mm2, A is the average canal surface area of the two levels adjacent to the level of interest and R is the relative degree of lumbar spinal canal stenosis expressed as a percentage. Measurements are calculated using axial T2 weighted images.

CONCLUSIONS

This novel quantitative measurement formula for the radiological assessment of lumbar canal spinal stenosis is quick and simple to calculate and most importantly adjusts for the individual patient's normal or degenerative anatomy. This new measurement tool will need validation against specific clinical and operative criteria in the future.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Automated measurement of spine indices on axial MR images for lumbar spinal stenosis diagnosis using segmentation-guided regression network

PURPOSE

Automated measurement of spine indices on axial magnetic resonance (MR) images plays a significant role in lumbar spinal stenosis diagnosis. Existing direct spine indices measurement approaches fail to explicitly focus on the task-specific region or feature channel with the additional information for guiding. We aim to achieve accurate spine indices measurement by introducing the guidance of the segmentation task.

METHODS

In this paper, we propose a segmentation-guided regression network (SGRNet) to achieve automated spine indices measurement. SGRNet consists of a segmentation path for generating the spine segmentation prediction and a regression path for producing spine indices estimation. The segmentation path is a U-Net-like network which includes a segmentation encoder and a decoder which generates multilevel segmentation features and segmentation prediction. The proposed segmentation-guided attention module (SGAM) in the regression encoder extracts the attention-aware regression feature under the guidance of the segmentation feature. Based on the attention-aware regression feature, a fully connected layer is utilized to output the accurate spine indices estimation.

RESULTS

Experiments on the open-access Lumbar Spine MRI data set show that SGRNet achieves state-of-the-art performance with a mean absolute error of 0.49 mm and mean Pearson correlation coefficient of 0.956 for four indices estimation.

CONCLUSIONS

The proposed SGAM in SGRNet is capable of improving the performance of spine indices measurement by focusing on the task-specific region and feature channel under the guidance of the segmentation task.

Correlation between clinical scoring systems and quantitative MRI parameters in degenerative lumbar spinal stenosis

Background

Many quantitative MRI parameters and clinical scores have been used patients with lumbar spinal stenosis (LSS). However, the correlation between clinical scores and MRI parameters is not very clear. The objective of the study was to find out the correlation between commonly used clinical scoring systems and quantitative MRI parameters.

Methods

Eighty two patients (more than 40 years) with clinical and radiological characteristics of degenerative LSS completed 10 clinical questionnaires which included Oswestry disability index (ODI), Swiss spinal stenosis (SSS) questionnaire, Quebec pain disability scale (QPD), Visual analogue scale (VAS), modified Japanese orthopaedic association scale (mJOA), Pain disability index (PDI), Short form health survey (SF-36), Self-paced walking test (SPWT), Euro quality of life-5D (EQ-5D) and Neurogenic claudication outcome score (NCOS). Lumbosacral MRIs were performed and 8 quantitative parameters namely transverse & AP diameter of dural sac (TDD, APDD), anteroposterior diameter of spinal canal (APDS), ligamentous interfacet distance (LID), mid-sagittal diameter of thecal sac (MSDT), cross-sectional area dural sac (CSAD), lateral recess depth and angle (LRD, LRA) were measured at the maximum stenotic level at the level of the disc. The clinical and radiological parameters were then statistically analysed.

Results

There were 51 females and 31 males in the study with a mean age of 53.0253.02 ± 9.18 years. NCOS score had a moderate correlation with CSAD, LID and TDS (p<0.05,0.7>r ≥ 0.3). MSDT showed a moderate negative correlation with SSS, VAS, ODI and QPD (p<0.05,0.7>r ≥ 0.3). LRD had a moderate negative correlation with ODI and VAS score (p<0.05,0.7>r ≥ 0.3). LRA had a moderate correlation with the EQ-5D and ODI (p<0.05,0.7>r ≥ 0.3). The CSAD had a moderate negative correlation with PDI (r = -0.383, p = 0.000). For all other comparisons, there was poor or no correlation. MRI parameters showed poor or no correlation with most of components of SF-36 score.

Conclusions

A poor correlation or no correlation was noted for most of the MRI parameters when compared to commonly used clinical scores. Hence, poor MRI's don't necessarily mean poor clinical scores in LSS. The role of MRI parameters should be supplementary and overreliance on them in LSS management should be avoided.

Associations between comorbid lumbar spinal stenosis symptoms and treatment outcomes in 6,813 patients with knee or hip osteoarthritis following a patient education and exercise therapy program

Objective

People with knee or hip osteoarthritis (OA) can experience comorbid lumbar spinal stenosis (LSS), but the impact on treatment outcomes is unknown. The aim of this study was to investigate associations between comorbid LSS symptoms and changes in pain, function, and quality of life following a patient education and exercise therapy program.

Design

This was a longitudinal analysis of 6813 participants in the Good Life with osteoArthritis in Denmark (GLA:D®) program; a structured patient education and exercise therapy program for knee and hip OA. Participants were classified as having comorbid LSS symptoms based on self-report symptom items. Linear mixed models were used to assess differences in change in pain, function, and quality of life outcomes (0 worst to 100 best) at 3- and 12-month follow-up.

Results

15% and 23% of knee and hip OA participants had comorbid LSS symptoms, respectively. Knee participants with comorbid LSS symptoms had smaller improvement in pain at 3-months (-1.7, 95% CI -3.3 to -0.1) and hip participants with comorbid LSS symptoms had greater improvement in function at 3- (2.5, 95% CI 0.5 to 5.0) and 12-months (3.8, 95% CI 0.9 to 6.6), when compared to those without LSS symptoms. These differences were not clinically significant and no differences in other outcomes were observed.

Conclusion

Knee or hip OA patients with comorbid LSS symptoms should expect similar improvements in knee- or hip-related pain, function, and quality of life outcomes when undergoing a patient education and exercise therapy program compared to those without LSS symptoms.

[Lumbar spinal stenosis]

Lumbar spinal stenosis (LSS) represents a frequent degenerative condition, however, striking a clear correlation between typical symptoms and imaging features remains a challenge. Reasons are a high prevalence of radiological LSS in the older population, a considerable percentage of asymptomatic LSS and the existence of differential diagnoses with similar symptomatology. This discrepancy also affects the outcomes - especially of surgically treated patients with LSS. When considering surgical decompression of LSS, the decision with regards to additive instrumentation and/or fusion remains a controversial point of discussion, in particular at the presence of degenerative spondylolisthesis. Recent, well-designed studies, however, clearly point towards a non-inferiority of decompression alone as opposed to the more invasive strategies.

Is annular repair technique useful for reducing reherniation and reoperation after limited discectomy?

The annular defect because of the primary lumbar disc herniation (LDH) or surgical procedure is considered a primary reason for recurrent herniation and eventually reoperation. Efforts to close the defect with annular repair devices have been attempted several times, but the results were controversial. The present aims to detect whether the annular repair techniques were useful for reducing the re-herniation and re- operation rate. The Pubmed, Cochrane library, and Embase databases were searched to retrieve relevant studies published before January 1, 2021. Continuous variables were compared by calculating the standard difference of the means (SDM), whereas categorical dichotomous variables were assessed using relative risks (RRs). A random-effects model was used if the heterogeneity statistic was significant; otherwise, a fixed-effects model was used. A total of 10 researches were suitable for the meta-analysis, including four different repair techniques and 1907 participates. Compared with the control group, there was no statistical difference with the ODI, VAS-leg, and VAS-back scales for patients treated with the annular repair. However, using an annular repair device was associated with a significant reduction in the re- herniation (p=0.004) and re-operation (0.004) rates. There was no difference between the groups with perioperative complications. However, much more device-related long-term complications happened in the annual repair group (p=0.031) though it still decreased the overall re-operation rate significantly (p=0.006).Our results demonstrated that using an annular repair device was safe and beneficial for reducing re-herniation and re-operation rates.

Step Count in Patients With Lumbar Spinal Stenosis: Accuracy During Walking and Nonwalking Activities

STUDY DESIGN

This is a method development and validation study.

OBJECTIVES

The purpose of this study was to develop and test a method for step detection using accelerometer data in patients with lumbar spinal stenosis (LSS). There are 2 objectives: (1) to describe a method for step detection from accelerations measured at the wrist, hip, lower back, thigh and ankle; (2) to assess the accuracy of the method during walking with and without walking aids and during nonwalking activities.

SUMMARY OF BACKGROUND DATA

Loss of walking ability is one of the main symptoms of LSS, and there is no validated measure to assess walking activity in daily living in patients with LSS.

MATERIALS AND METHODS

Thirty patients with LSS performed a standardized movement protocol that included walking with and without walking aids and performing nonwalking activities while wearing accelerometers on five different wear-sites. After the walking tests, a method was designed for optimal step detection and compared with a gold standard of observed step count.

RESULTS

The method for step detection applied to accelerations from the lower back, hip, thigh, and ankle provided an accurate step counts during continuous walking without walking aids. Accuracy diminished at all wear-sites when walking with walking aids, except the ankle. The wrist provided the most inaccurate step count, and the accelerometers on the thigh and ankle were prone to falsely detecting steps during bicycling.

CONCLUSION

The ankle-worn accelerometer provided the most accurate step count, but wrongly registered steps during nonwalking activities. The developed step detection method shows potential as a measure of walking activity why further development and testing under free-living conditions should be performed.

The Lumbar Stenosis Prognostic Subgroups for Personalizing Care and Treatment (PROSPECTS) study: protocol for an inception cohort study

Background

Lumbar spinal stenosis (LSS) is a common degenerative condition that contributes to back and back-related leg pain in older adults. Most patients with symptomatic LSS initially receive non-operative care before surgical consultation. However, there is a scarcity of data regarding prognosis for patients seeking non-surgical care. The overall goal of this project is to develop and evaluate a clinically useful model to predict long-term physical function of patients initiating non-surgical care for symptomatic LSS.

Methods

This is a protocol for an inception cohort study of adults 50 years and older who are initiating non-surgical care for symptomatic LSS in a secondary care setting. We plan to recruit up to 625 patients at two study sites. We exclude patients with prior lumbar spine surgeries or those who are planning on lumbar spine surgery. We also exclude patients with serious medical conditions that have back pain as a symptom or limit walking. We are using weekly, automated data pulls from the electronic health records to identify potential participants. We then contact patients by email and telephone within 21 days of a new visit to determine eligibility, obtain consent, and enroll participants. We collect data using telephone interviews, web-based surveys, and queries of electronic health records. Participants are followed for 12 months, with surveys completed at baseline, 3, 6, and 12 months. The primary outcome measure is the 8-item PROMIS Physical Function (PF) Short Form. We will identify distinct phenotypes using PROMIS PF scores at baseline and 3, 6, and 12 months using group-based trajectory modeling. We will develop and evaluate the performance of a multivariable prognostic model to predict 12-month physical function using the least absolute shrinkage and selection operator and will compare performance to other machine learning methods. Internal validation will be conducted using k-folds cross-validation.

Discussion

This study will be one of the largest cohorts of individuals with symptomatic LSS initiating new episodes of non-surgical care. The successful completion of this project will produce a cross-validated prognostic model for LSS that can be used to tailor treatment approaches for patient care and clinical trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05598-x.

Efficacy and Safety of Add-on Mirogabalin to NSAIDs in Lumbar Spinal Stenosis with Peripheral Neuropathic Pain: A Randomized, Open-Label Study

Introduction

In Japan, conservative therapy for patients with lumbar spinal stenosis (LSS) includes non-steroidal anti-inflammatory drugs (NSAIDs), prostaglandin E1, tramadol, physical/exercise therapy, and nerve blocks. Mirogabalin, a selective oral α2δ ligand, is approved for treating peripheral neuropathic pain, though data regarding visual analog scores (VAS) for pain in patients with LSS are limited. We investigated the efficacy and safety of mirogabalin as an add-on treatment in patients with LSS taking NSAIDs compared with patients taking NSAIDs only.

Methods

This multicenter, randomized, open-label study (MiroTAS) was conducted at 32 centers in Japan between June 2020 and October 2021. Patients were randomly assigned to mirogabalin and NSAIDs or NSAIDs alone in a 1:1 ratio. NSAIDs were administered according to their Japanese package inserts; mirogabalin was administered based on renal function [creatinine clearance (CrCL) ≥ 60 mL/min, 5 mg twice daily (BID) in Weeks 1–2, 10 mg BID in Weeks 3–4, and 15 or 10 mg BID after Week 5; CrCL 30 to < 60 mL/min, 2.5 mg BID Weeks 1–2, 5 mg BID Weeks 3–4, and 7.5 or 5 mg BID after Week 5]. The primary endpoint was the change in VAS score for leg pain from baseline to Week 12. Secondary endpoints were quality of life, evaluated using the EuroQol five-dimensional descriptive system (EQ-5D-5L) (at baseline and Week 12) and Patient Global Impression of Change (PGIC) (at Week 12), and safety. Change in VAS score at Week 12 was calculated using a linear mixed model for repeated measures. The safety endpoints were treatment-emergent adverse events (TEAEs) and adverse drug reactions.

Results

In total, 220 patients who met the eligibility criteria were enrolled. In the mirogabalin and NSAIDs and NSAIDs groups, mean ages (67.8 vs. 70.9 years), proportions of female patients (54.5% vs. 49.0%), mean body weights (63.9 vs. 62.0 kg), mean CrCL values (81.5 vs. 70.7 mL/min), proportions of patients with CrCL 30 to < 60 mL/min (27.3% vs. 33.7%), mean VAS scores (63.8 vs. 62.8 mm), and proportions of patients with VAS score ≥ 60 (53.6% vs. 52.9%) at enrollment were similar. The median durations of LSS were 9.0 and 11.0 months and the spine pain DETECT questionnaire (SPDQ) scores were 6.8 and 7.8, respectively. The least square (LS) mean change in VAS score from baseline to Week 12 was − 24.1 mm in the mirogabalin and NSAIDs group and − 14.2 mm in the NSAIDs group (both P < 0.0001 vs. baseline). The difference in LS mean was − 9.9 [95% confidence interval (CI), − 18.0, − 1.8] (P = 0.0174). The improvement in EQ-5D-5L score at Week 12 was significantly greater in the mirogabalin and NSAIDs group versus the NSAIDs group [mean difference, 0.0529 (95% CI, 0.0036, 0.1022), P = 0.0357]. At Week 12, the proportions of patients with PGIC scores ≤ 3 and ≤ 2 were higher in the mirogabalin and NSAIDs group vs. the NSAIDs group (76.2% vs. 50.0%, P = 0.0006, and 47.6% vs. 32.4%, P = 0.0523). In the mirogabalin and NSAIDs group, the incidences of TEAEs and adverse drug reactions were 60.9% and 57.3%, respectively, and the most common TEAEs were somnolence (30.0%) and dizziness (25.5%).

Conclusions

The addition of mirogabalin to NSAIDs improved VAS, EQ-5D-5L, and PGIC. The main TEAEs were somnolence and dizziness. The addition of mirogabalin to NSAIDs improved peripheral neuropathic pain associated with LSS and raised no new safety concerns.

Trial Registration

Japan Registry of Clinical Trials (jRCTs021200007).

Supplementary Information

The online version contains supplementary material available at 10.1007/s40122-022-00410-z.

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.

Consensus on a standardised treatment pathway algorithm for lumbar spinal stenosis: an international Delphi study

Background

Lumbar spinal stenosis (LSS) is a common degenerative spinal condition in older adults associated with disability, diminished quality of life, and substantial healthcare costs. Individual symptoms and needs vary. With sparse and sometimes inconsistent evidence to guide clinical decision-making, variable clinical care may lead to unsatisfactory patient outcomes and inefficient use of healthcare resources.

Methods

A three-phase modified Delphi study comprising four consensus rounds was conducted on behalf of the International Taskforce for the Diagnosis and Management of LSS to develop a treatment algorithm based on multi-professional international expert consensus. Participants with expertise in the assessment and management of people with LSS were invited using an international distribution process used for two previous Delphi studies led by the Taskforce. Separate treatment pathways for patients with different symptom types and severity were developed and incorporated into a proposed treatment algorithm through consensus rounds 1 to 3. Agreement with the proposed algorithm was evaluated in the final consensus round.

Results

The final algorithm combines stratified and stepped approaches. When indicated, immediate investigation and surgery is advocated. Otherwise, a stepped approach is suggested when self-directed care is unsatisfactory. This starts with tailored rehabilitation, then more complex multidisciplinary care, investigations and surgery options if needed. Treatment options in each step depend on clinical phenotype and symptom severity. Treatment response guides pathway entrance and exit points. Of 397 study participants, 86% rated their agreement ≥ 4 for the proposed algorithm on a 0–6 scale, of which 22% completely agreed. Only 7% disagreed. Over 70% of participants felt that the algorithm would be useful for clinicians in public healthcare (both primary care and specialist settings) and in private healthcare settings, and that a simplified version would help patients in shared decision-making.

Conclusions

International and multi-professional agreement was achieved for a proposed LSS treatment algorithm developed through expert consensus. The algorithm advocates different pathway options depending on clinical indications. It is not intended as a treatment protocol and will require evaluation against current care for clinical and cost-effectiveness. It may, however, serve as a clinical guide until evidence is sufficient to inform a fully stratified care model.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05485-5.

Diagnostic accuracy of the lumbar spinal stenosis-diagnosis support tool and the lumbar spinal stenosis-self-administered, self-reported history questionnaire

Despite the applicability of the lumbar spinal stenosis (LSS)-diagnosis support tool (DST) and the LSS-self-administered, self-reported history questionnaire (SSHQ), their diagnostic accuracy has never been compared with that of the well-known North American Spine Society (NASS) clinical description of LSS. This study aimed to compare the diagnostic accuracy of the two diagnostic tools with that of the NASS guidelines’ clinical description of LSS in a Japanese secondary care hospital setting. This multicenter cross-sectional study used data from the lumbar spinal stenosis diagnostic support tool (DISTO) project, which was conducted from December 1, 2011 to December 31, 2012. Japanese adults with low back pain (LBP) aged ≥20 years were consecutively included. The reference standard was LSS diagnosed by orthopedic physicians. The diagnostic accuracy of the two support tools was compared. Of 3,331 patients, 1,416 (42.5%) patients were diagnosed with LSS. The NASS clinical description of LSS had a sensitivity of 63.9% and specificity of 89.5%. The LSS-DST and LSS-SSHQ had sensitivities of 91.3% and 83.8% and specificities of 76.0% and 57.6%, respectively, with substantial improvements in sensitivity (P < 0.0001). Similar results were obtained when we limited included patients to those aged >60 years. These findings indicated that the LSS-DST and LSS-SSHQ were more sensitive in screening patients with LBP for a diagnosis of LSS than the NASS clinical description of LSS. This study strongly supports prioritizing the use of either of these two diagnostic support tools for screening.

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

Background

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

Methods

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

Results

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

Conclusions

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

Review registration

PROSPERO (CRD42020177759).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05104-3.

Effectiveness and safety of acupotomy on lumbar spinal stenosis: A pragmatic randomized, controlled, pilot clinical trial: A study protocol

INTRODUCTION

Lumbar spinal stenosis (LSS) is a pathological condition that causes a variety of neurological symptoms due to narrowing of the anatomical structures; usually, conservative treatment is recommended, rather than surgical treatment. Acupotomy combines conventional acupuncture with small scalpels; the procedure can be considered minimally invasive, and has recently received considerable attention in clinical practice. Still, there is a lack of data and randomized controlled trials regarding acupotomy related to LSS. Additional studies are necessary, considering the low methodological quality and small size of the study.

METHODS AND ANALYSIS

This is a pragmatic, pilot, randomized controlled trial. The trial comprises 8 weeks of treatment, with 16 visits and a 4-week follow-up period. Forty participants diagnosed with LSS will be randomly assigned to either the experimental or control groups; both groups will receive acupuncture and interferential current therapy twice a week for 8 weeks, while the experimental group will receive an additional acupotomy intervention once a week for 8 weeks. The primary outcome will be assessed using the visual analog scale; the secondary outcome will be measured by self-rated walking distance, Oswestry Disability Index, and short-form McGill Pain Questionnaire. Measurements will be obtained prior to the start of the clinical trial, 4 weeks after the interventional procedure, 8 weeks after the procedure, and 4 weeks after the end of the interventional procedure. Blood tests and adverse reactions will be performed to ensure safety of the treatments.

CONCLUSION

We expect that this study will provide basic data for future large-scale acupotomy studies regarding LSS.

Methods Used to Generate Consensus Statements for Clinical Practice Guidelines: A Primer for the Spine Surgeon

STUDY DESIGN

This was a research methodology study.

OBJECTIVE

This review discusses the most commonly utilized consensus group methodologies for formulating clinical practice guidelines and current methods for accessing rigorous up-to-date clinical practice guidelines.

SUMMARY OF BACKGROUND DATA

In recent years, clinical practice guidelines for the management of several conditions of the spine have emerged to provide clinicians with evidence-based best-practices. Many of these guidelines are used routinely by administrators, payers, and providers to determine the high-quality and cost-effective surgical practices. Most of these guidelines are formulated by consensus groups, which employ methodologies that are unfamiliar to most clinicians.

METHODS

An extensive literature review was performed. The literature was then summarized in accordance with the authors' clinical experience.

RESULTS

The Nominal Group Technique, Delphi method, and RAND-UCLA Appropriateness Model are 3 commonly utilized consensus group methodologies employed in the creation of clinical practice guidelines. Each of these methodologies has inherent advantages and disadvantages, is dependent on rigorously performed systematic reviews and meta-analyses to inform the panel of experts, and can be used to answer challenging clinical questions that remain unanswered due to a paucity of class I evidence.

CONCLUSIONS

This review highlights the most commonly utilized consensus group methodologies and informs spine surgeons regarding options to access current clinical practice guidelines.

LEVEL OF EVIDENCE

Level V.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Pre-operative prognostic factors for walking capacity after surgery for lumbar spinal stenosis: a systematic review

BACKGROUND

Lumbar spinal stenosis (LSS) reduces walking and quality of life. It is the main indication for spinal surgery in older people yet 40% report walking disability post-operatively. Identifying the prognostic factors of post-operative walking capacity could aid clinical decision-making, guide rehabilitation and optimise health outcomes.

OBJECTIVE

To synthesise the evidence for pre-operative mutable and immutable prognostic factors for post-operative walking in adults with LSS.

DESIGN

Systematic review with narrative synthesis.

METHODS

Electronic databases (CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, OpenGrey) were searched for observational studies, evaluating factors associated with walking after surgery in adults receiving surgery for LSS from database inception to January 2020. Two reviewers independently evaluated studies for eligibility, extracted data and assessed risk of bias (Quality in Prognosis Studies). The Grading of Recommendations Assessment, Development and Evaluation method was used to determine level of evidence for each factor.

RESULTS

5526 studies were screened for eligibility. Thirty-four studies (20 cohorts, 9,973 participants, 26 high, 2 moderate, 6 low risk of bias) were included. Forty variables (12 mutable) were identified. There was moderate quality of evidence that pre-operative walking capacity was positively associated with post-operative walking capacity. The presence of spondylolisthesis and the severity of stenosis were not associated with post-operative walking capacity. All other factors investigated had low/very low level of evidence.

CONCLUSION

Greater pre-operative walking is associated with greater post-operative walking capacity but not spondylolisthesis or severity of stenosis. Few studies have investigated mutable prognostic factors that could be potentially targeted to optimise surgical outcomes.

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

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

Prediction of walking ability following posterior decompression for lumbar spinal stenosis

PURPOSE

Following surgery for lumbar spinal stenosis (LSS) up to 40% of people report persistent walking disability. This study aimed to identify pre-operative factors that are predictive of walking ability post-surgery for LSS.

METHODS

An observational cohort study was conducted using data from the British Spine Registry (2017-2018) of adults (≥ 50 years) with LSS, who underwent ≤ 2 level posterior lumbar decompression. Patients receiving fixation or who had previous lumbar surgery were excluded. Walking ability was assessed by a single item on the Oswestry Disability Index and dichotomised into poor/good outcome. Multivariable regression models were performed.

RESULTS

14,485 patients were identified. Pre-operatively 30% patients reported poor walking ability, this decreased to 8% at 12 months follow-up. Predictors associated with poor walking ability at 12 months were: increasing age (≥ 75 years OR 1.54, 95% CI 1.07, 2.18), BMI ≥ 35 kg/m² (OR 1.52, 95% CI 1.00, 2.30), severity of leg pain (OR 1.10, CI 95% 1.01, 1.21), disability (OR 1.01, 95% CI 1.01, 1.02) and quality of life (OR 0.72, 95% CI 0.56, 0.89). Pre-operative maximum walking distance (OR 1.10, 95% CI 1.05, 1.25) and higher education (OR 0.90, 95% CI 0.80, 0.96) were associated with reduced risk of poor walking ability at 12 months; p < 0.05. Depression, fear of movement and symptom duration were not associated with risk of poor outcome.

CONCLUSION

Older age, obesity, greater pre-operative pain and disability and lower quality of life are associated with risk of poor walking ability post-operatively. Greater pre-operative walking and higher education are associated with reduced risk of poor walking ability post-operatively. Patients should be counselled on their risk of poor outcome and considered for rehabilitation so that walking and surgical outcomes may be optimised.

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

STUDY DESIGN

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

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Psychological and Functional Comparison between Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Single-Level Lumbar Spinal Stenosis

Objective

The aim of this study was to investigate whether treatment with minimally invasive transforaminal lumbar interbody fusion (Mis‐TLIF) causes patients suffering from lumbar spinal stenosis (LSS) to experience less anxiety and better clinical efficacy than open transforaminal lumbar interbody fusion (TLIF).

Methods

In this retrospective cohort study, we analyzed 86 patients, including 46 male patients and 41 female patients, who suffered from single‐segmental lumbar spinal stenosis in our department between January 2016 and January 2018. They were divided into two groups: a control group (n = 46), for patients who underwent open TLIF surgery, and an experimental group (n = 40), for patients who underwent Mis‐TLIF surgery. All patients were evaluated based on operation time, intraoperative blood loss, hospital stay, visual analogue scale (VAS), Oswestry disability index (ODI), hospital anxiety depression scale (HADS), fusion rate, and complications (screw misplacement and loosening, cerebrospinal fluid leakage, infection, and delayed wound healing). Patient characteristics were compared within and between groups.

Results

The average incision length was 3.64 ± 0.476 cm in the experimental group, which was smaller than that (8.11 ± 2.406 cm) in the control group (P < 0.05). The operation time of the experimental group was a little longer than that of the control group. The intraoperative blood loss and hospital stay in the experimental group were less than those in the control group.

The mean preoperative low back pain VAS score was 7.525 ± 1.432 in the experimental group and 7.087 ± 1.799 in the control group (P > 0.05). The low back pain VAS scores on postoperative day 3 and at 3, 6, and 12 months postoperatively were 5.000 ± 0.987, 4.075 ± 0.997, 2.150 ± 0.834, and 1.450 ± 0.639 in the experimental group, respectively; these scores were lower than those in the control group (6.870 ± 1.572, P < 0.05; 4.630 ± 1.103, P < 0.05; 2.630 ± 1.103, P < 0.05; and 2.326 ± 1.034, P < 0.05, respectively). There was no obvious difference in the leg pain VAS scores between the two groups at all follow‐up points.

The mean preoperative ODI score was 58.700% ± 19.703% in the experimental group and 61.696% ± 17.583% in the control group (P > 0.05). The ODI scores at postoperative months 3, 6, and 12 were 25.225% ± 5.554%, 20.150% ± 7.698%, and 16.125% ± 9.565% in the experimental group; these scores were lower than those in the control group (49.130% ± 14.805%, P < 0.05; 34.044% ± 15.148%, P < 0.05; and 29.282% ± 132.567%, P < 0.05, respectively).

The mean preoperative HADS score was 14.475 ± 3.113 in the experimental group and 13.391 ± 2.824 in the control group (P > 0.05). However, the mean HADS scores on postoperative day 3 in the experimental group was 8.500 ± 2.000, decreasing obviously compared to the preoperative scores (P < 0.05). The mean postoperative HADS score on postoperative day 3 in the control group was 12.734 ± 1.949, which had not decreased significantly compared to the preoperative score (P > 0.05). The HADS scores in the experimental group was lower than that in the control group on postoperative day 3 (P < 0.05).

In the correlation analysis, the incision length was correlated to the HADS scores on postoperative day 3 (r = 0.527, P < 0.05). The HADS scores on postoperative day 3 were positively correlated with the low back pain VAS scores on the same day (r = 0.388, P < 0.05). The HADS scores on postoperative day 3were positively correlated with the ODI scores at 3‐month (r = 0.460, P < 0.05), 6‐month (r = 0.429, P < 0.05), and 12‐month follow up (r = 0.349, P < 0.05).

Fusion rates were not significantly different between the two groups. There was no screw misplacement and loosening, infection, or delayed wound healing in either group. The cerebrospinal fluid leakage rate in the control group was higher than that in the experimental group.

Conclusion

Patients undergoing Mis‐TLIF experience less anxiety and have better outcomes than those who undergo open TLIF. The lower level of anxiety experienced by patients undergoing Mis‐TLIF is positively correlated with postoperative VAS and ODI scores.

Long-term, Time-course Evaluation of Ligamentum Flavum Hypertrophy Induced by Mechanical Stress: An Experimental Animal Study

STUDY DESIGN

Experimental animal study.

OBJECTIVE

The aim of this study was to clarify chronological effects of mechanical stress on ligamentum flavum (LF) using a long-term fusion rabbit model.

SUMMARY OF BACKGROUND DATA

LF hypertrophy is a major pathology of lumbar spinal stenosis (LSS), but its mechanism remains unclear. We previously demonstrated mechanical-stress-induced LF hypertrophy with a rabbit model. However, we only investigated LFs at a single time point in the short-term; the effects of long-term mechanical stress have not been elucidated.

METHODS

Eighteen-week-old male New Zealand White rabbits were randomly divided into two groups: the mechanical stress group underwent L2-3 and L4-5 posterolateral fusion and resection of the L3-4 supraspinal muscle, whereas the control group underwent only surgical exposure. Rabbits were sacrificed 16 and 52 weeks after the procedure. Axial specimens of LFs at L3-4 were evaluated histologically. Immunohistochemistry for alpha-smooth muscle actin (α-SMA) was performed to assess the numbers of vessels and myofibroblasts.

RESULTS

In the mechanical stress group, LFs at the L3-4 level exhibited hypertrophy with elastic fiber disruption and cartilage matrix production at 16 and 52 weeks. A trend test indicated that mechanical stress induced LF hypertrophy, elastic fiber disruption, and cartilage matrix production in a time-dependent manner, with the lowest levels before treatment and the highest at 52 weeks. Immunostaining for α-SMA showed similar numbers of vessels in both groups, whereas the percentage of myofibroblasts was significantly larger at 16 and 52 weeks in the mechanical stress group than in the control group.

CONCLUSION

We demonstrated that long-term mechanical stress caused LF hypertrophy with progressive elastic fiber disruption and cartilage matrix production accompanied by enhanced myofibroblasts. In addition, the reported rabbit model could be extended to elucidate the mechanism of LF hypertrophy and to develop new therapeutic strategies for LSS by preventing LF hypertrophy.Level of Evidence: SSSSS.

Low Back Pain in Adolescent and Geriatric Populations

Spinal pain is the most common form of musculoskeletal pain. Chronic low back pain may contain nociceptive, neuropathic, and central components. Children are at risk of developing spinal pain. An increasing proportion of children develop low back pain as they become adolescents. In most adolescents, no specific diagnosis is identified. Psychological factors play a role in adolescents with back pain. Lumbar spinal stenosis causes neurogenic claudication in older patients. Magnetic resonance imaging is the best radiographic technique to detect nerve compression. Surgical decompression with or without fusion may offer greater short-term benefit but may not be significantly better than medical therapy.

Sex-Dependent Differences in Symptom-Related Disability Due to Lumbar Spinal Stenosis

Study Design

Retrospective observational study.

Objective

The objective of this study is to identify possible sex-dependent differences in symptom-related disability in patients with lumbar spinal stenosis.

Methods

103 consecutive outpatients (42 men and 61 women) with lumbar spinal stenosis were assessed on the basis of their medical history, the physical examination, and a series of questionnaires including the Oswestry Disability Index (ODI), the Roland Morris Disability Questionnaire (RMDQ), the Patient Health Questionnaire module 9 (PHQ-9), and the Depression Anxiety Stress Scales (DASS). Narrowing of the spinal canal was graded according to the method established by Schizas. Parameters were statistically analyzed according to the biological sex of the patients. The influence of the variables on the disability scores was analyzed by means of a multivariate regression model.

Results

Symptom severity was equally distributed between men and women. Female patients showed higher RMDQ and ODI scores as well as significantly higher intermediate depression scores. The confounding variables age, pain chronicity, and psychological affection as well as the symptoms level of pain and paresis were dependent on patient sex.

Conclusion

The study shows sex-depended differences in the perception of symptoms of lumbar spinal stenosis and disability of life. The findings suggest that the main mediators are pain perception and psychological influences on the quality of life.

A critical appraisal of clinical practice guidelines for the treatment of lumbar spinal stenosis

OBJECTIVE

The aim of the review was to appraise clinical practice guidelines and their recommendations for the treatment of lumbar spinal stenosis.

METHODS

PubMed, Medline, CINAHL, Embase, and Cochrane Central Register of Controlled Trials were searched up until 25/01/2020 for clinical practice guidelines on the management of lumbar spinal stenosis with a systematic process to generate recommendations and were publicly available.

RESULTS

Ten guidelines were included, with a total of 76 recommendations for the treatment of lumbar spinal stenosis. Only 4 of the 10 guidelines were of satisfactory methodological quality according to the AGREE II instrument. Around three-quarters of recommendations (72.4%) were presented with poor evidence, with the remaining 21 presenting (27.6%) fair evidence. No recommendation presented good evidence. Recommendations were made on four types of interventions: surgery, injections, medications, and other nonsurgical treatments, with supporting evidence similar for all four treatment types. Positive recommendations were more common for injections (12/13=92.3%) and surgery (10/15=66%) than for nonsurgical treatments (6/21=28.6%) or medications (1/27=3.75%).

CONCLUSIONS

Ten guidelines on the management of lumbar spinal stenosis were identified in the systematic review, but only four were of adequate methodological quality. While the evidence underpinning the various types of interventions was similar, guidelines tended to endorse surgery and injections but not nonsurgical interventions and medicines. These results support the need for greater rigor and inclusion of steps to minimize bias in the production of guidelines.

Lumbar Spinal Stenosis and Potential Management With Prostaglandin E1 Analogs

ABSTRACT

Lumbar spinal stenosis is one of the most commonly diagnosed spinal disorders worldwide and remains a major cause for surgery in older adults. Lumbar spinal stenosis is clinically defined as a progressive degenerative disorder with low back pain and associated neurogenic intermittent claudication. Conservative and surgical management of lumbar spinal stenosis has been shown to be minimally effective on its symptoms. A treatment option that has not been investigated in the United States is the utilization of prostaglandin E1 analogs, which have been used primarily in Japan for the treatment of lumbar spinal stenosis since the 1980s. The vasodilatory and antiplatelet aggregation effects of prostaglandin E1 presumably improve symptoms of lumbar spinal stenosis by increasing blood flow to the spinal nerve roots. This brief report examines the potential vascular pathology of lumbar spinal stenosis, reviews evidence on the use of prostaglandin E1 analog limaprost in Japan for lumbar spinal stenosis, and briefly discusses misoprostol as a possible alternative in the United States. The studies summarized in this report suggest that prostaglandin E1 analogs may provide benefit as a conservative treatment option for patients with lumbar spinal stenosis. However, higher-quality studies conducted in the United States and comparison with other currently used conservative treatments are required before it can be recommended for routine clinical use.

Lumbar Spinal Stenosis: Pathophysiology and Treatment Principle: A Narrative Review

Patients with lumbar spinal stenosis may exhibit symptoms such as back pain, radiating pain, and neurogenic claudication. Although long-term outcome of treatments manifests similar results for both nonsurgical and surgical treatments, positive effects such as short-term improvement in symptoms and decreased fall risk may be expected with surgery. Surgical treatment is basically decompression, and a combination of treatments can be added depending on the degree of decompression and the accompanying instability. Recently, minimally invasive surgery has been found to result in excellent outcomes in the treatment of lumbar spinal stenosis. Therefore, better treatment effects can be anticipated with an approach aimed at understanding the overall pathophysiology and treatment methods of lumbar spinal stenosis.

CT-Guided Percutaneous Lumbar Ligamentum Flavum Release by Needle Knife for Treatment of Lumbar Spinal Stenosis: A Case Report and Literature Review

Case

The patient was a 62-year-old woman presenting with low-back pain of 3 years’ duration and numbness in the right leg.

Diagnosis

She was diagnosed with lumbar spinal stenosis based on combined magnetic resonance imaging, physical examination, and symptoms.

Interventions

Treatment with computed tomography–guided percutaneous release of the ligamentum flavum was delivered.

Outcomes

Relief of symptoms immediately after treatment and complete resolution of symptoms after 1 month were achieved. At follow-up, there was no recurrence of symptoms after 2, 4, 6, and 12 months.

Conclusion

Lumbar ligamentum flavum hypertrophy is an important cause of degenerative lumbar spinal stenosis. The hypertrophic ligamentum flavum can directly compress the spinal canal, squeeze the cauda equina, and simultaneously lead to a reduction in the anteroposterior diameter of the intervertebral foramen, which compresses the nerve roots and causes numbness and other symptoms of lower extremities. In clinical practice, doctors should combine imaging findings with patient symptoms for diagnosis and an individualized treatment plan for each patient with lumbar spinal stenosis, and conduct gradual stepwise treatment using conservative minimally invasive surgery to prevent excessive surgery.

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Diagnostic Screening for Lumbar Spinal Stenosis

Purpose

To develop a self-administered diagnostic screening questionnaire for lumbar spinal stenosis (LSS) consisting of items with high content validity and to investigate the diagnostic value of the questionnaire and the items.

Patients and Methods

A self-reported diagnostic LSS screening questionnaire was developed based on items from the existing literature describing key symptoms of LSS. The screening questionnaire (index test) was to be tested in a cohort of patients with persistent lumbar and/or leg pain recruited from a Danish publicly funded outpatient secondary care spine clinic with clinicians performing the reference test. However, to avoid unnecessary collection of data if the screening questionnaire proved to be of limited value, a case-control design was incorporated into the cohort design including an interim analysis. Additional cases for the case-control study were recruited at two Danish publicly funded spine surgery departments. Prevalence, sensitivity, specificity and diagnostic odds ratio (OR) were calculated for each individual item, and AUC (area under the curve) was calculated to examine the performance of the full questionnaire.

Results

A 13-item Danish questionnaire was developed and tested in 153 cases and 230 controls. The interim analysis was not in favour of continuing the cohort study, and therefore, only results from the case-control study are reported. There was a positive association for all items except the presence of back pain. However, the association was only moderate with ORs up to 3.3. When testing the performance of the whole questionnaire, an AUC of 0.72 was reached with a specificity of 20% for a fixed sensitivity of 95%.

Conclusion

The items were associated with LSS and therefore have some potential to identify LSS patients. However, the association was not strong enough to provide sufficient accuracy for a diagnostic tool. Additional dimensions of symptoms of LSS need identification to obtain a reliable questionnaire for screening purposes.

Treatment for lumbar spinal stenosis secondary to ligamentum flavum hypertrophy using percutaneous endoscopy through interlaminar approach: a retrospective study

Background

This paper is to describe percutaneous endoscopy in the treatment of lumbar spinal stenosis secondary to ligamentum flavum hypertrophy targeted and to investigate the efficacy and safety of percutaneous endoscopy in the treatment of this kind of lumbar spinal stenosis in elderly patients.

Method

A retrospective analysis of 40 elderly patients with lumbar spinal stenosis secondary to ligamentum flavum hypertrophy admitted between January 2016 and January 2018 was performed. According to different surgical methods, they were divided into two groups: the control group and the endoscopy group (interlaminar approach), 20 people per group. There were 9 males and 11 females in the control group; the age of patients was 65.65 ± 4.44 years, and the average disease duration was 4.55 ± 1.85 years. Besides, there were 10 males and 10 females in the endoscopy group; the age of patients was 67.30 ± 4.23 years, and the average disease duration was 4.95 ± 2.04 years. Collect and count surgical-related indicators, preoperative and postoperative radiologic findings, incision visual analog scale (VAS), lumbar and leg pain VAS, lumbar Japanese Orthopaedic Association (JOA), and Oswestry disability index (ODI) scores of all patients.

Result

A series of surgical indicators (including the operation time, the quantity of bleeding, and postoperative hospital stay) in the endoscopy group was significantly lower than that in the control group (p < 0.05). The incision VAS score in the endoscopy group was also significantly lower than that in the control group at each time after surgery (p < 0.05). Besides, compared with the control group, in the endoscopy group, the leg pain VAS score and lumbar ODI score after surgery were significantly decreased (p < 0.05). Compared with the control group, in the endoscopy group, the lumbar JOA score was significantly higher (p < 0.05).

Conclusion

Percutaneous endoscopic technique is a small trauma, quick recovery, safe, and effective minimally invasive surgery for patients with lumbar spinal stenosis secondary to ligamentum flavum hypertrophy.

Indications and Contraindications of Full-Endoscopic Interlaminar Lumbar Decompression

BACKGROUND

Spinal stenosis is a common disease with an increasing incidence. Narrowing of the spinal canal is caused by bone and soft tissue degeneration, such as osteophyte formation, facet and ligamentum flavum hypertrophy, and disc herniation. Various surgical techniques have been used to treat spinal canal stenosis, including open, tubular, microsurgical decompression, and fusion surgery. This article presents the technique for full-endoscopic interlaminar bilateral decompression of the lumbar spine.

METHODS

Surgical approach, anatomy, pathology, indications, contraindications, and surgical equipment are described.

RESULTS

With well-chosen endoscopic equipment, surgical time can be reduced with minimal collateral damage. Clear advantages of full-endoscopic decompression over open or other minimally invasive surgery methods are demonstrated in many clinical studies. The endoscopic technique has been shown to be effective in spinal canal decompression with good to excellent clinical results. The interlaminar endoscopic approach minimizes iatrogenic injury to the stabilizing anatomic structures while achieving full unilateral and bilateral decompression. A significant improvement in pain and functional outcome scores with low complication rates has been demonstrated.

CONCLUSIONS

This technique is safe for lumbar spinal decompression and more minimally invasive than a microendoscopic approach. However, this technique should be performed by surgeons with advanced skills. Endoscopy could become the gold standard for treatment of canal stenosis in the near future.

Degenerative Lumbar Spinal Stenosis

Degenerative lumbar spinal stenosis is the most frequent cause of low back pain and/or sciatica in the elderly patient. Epidemiology, pathophysiology, clinical manifestations and testing are reviewed in a wide current bibliographic investigation. The importance of the relationship between clinical presentation and imaging study, especially magnetic resonance imaging (MRI), is emphasized. Prior to treatment indication, it is necessary to identify the precise location of pain, as well as the differential diagnosis between neurological and vascular lameness. Conservative treatment combining medications with various physical therapy techniques solves the problem in most cases, while therapeutic testing with injections, whether epidural, foraminal or facetary, is performed when pain does not subside with conservative treatment and before surgery is indicated. Injections usually perform better results in relieving sciatica symptoms and less in neurological lameness. Equine tail and/or root decompression associated or not with fusion is the gold standard when surgical intervention is required. Fusion after decompression is necessary in cases with segmental instability, such as degenerative spondylolisthesis. When canal stenosis occurs at multiple levels and is accompanied by axis deviation, whether coronal and/or sagittal, correction of axis deviations should be performed in addition to decompression and fusion, especially of the sagittal axis, in which a lumbar lordosis correction is required with techniques that correct the rectified lordosis to values close to the pelvic incidence.

Gait features for discriminating between mobility-limiting musculoskeletal disorders: Lumbar spinal stenosis and knee osteoarthritis

BACKGROUND

Functional ambulation limitations are features of lumbar spinal stenosis (LSS) and knee osteoarthritis (OA). With numerous validated walking assessment protocols and a vast number of spatiotemporal gait parameters available from sensor-based assessment, there is a critical need for selection of appropriate test protocols and variables for research and clinical applications.

RESEARCH QUESTION

In patients with knee OA and LSS, what are the best sensor-derived gait parameters and the most suitable clinical walking test to discriminate between these patient populations and controls?

METHODS

We collected foot-mounted inertial measurement unit (IMU) data during three walking tests (fast-paced walk test-FPWT, 6-min walk test- 6MWT, self-paced walk test - SPWT) for subjects with LSS, knee OA and matched controls (N = 10 for each group). Spatiotemporal gait characteristics were extracted and pairwise compared (Omega partial squared - ω_p²) between patients and controls.

RESULTS

We found that normal paced walking tests (6MWT, SPWT) are better suited for distinguishing gait characteristics between patients and controls. Among the sensor-based gait parameters, stance and double support phase timing were identified as the best gait characteristics for the OA population discrimination, whereas foot flat ratio, gait speed, stride length and cadence were identified as the best gait characteristics for the LSS population discrimination.

SIGNIFICANCE

These findings provide guidance on the selection of sensor-derived gait parameters and clinical walking tests to detect alterations in mobility for people with LSS and knee OA.

Evaluation of persons with suspected lumbosacral and cervical radiculopathy: Electrodiagnostic assessment and implications for treatment and outcomes (Part I)

Persons with back, neck, and limb symptoms constitute a major referral population to specialists in electrodiagnostic (EDX) medicine. The evaluation of these patients involves consideration of both the common and less common disorders. The EDX examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and well complements imaging of the spine. Needle EMG in combination with nerve conduction testing is valuable in excluding entrapment neuropathies and polyneuropathy-conditions that frequently mimic radicular symptoms. In this first of a two-part review, the optimal EDX evaluation of persons with suspected radiculopathy is presented. In part two, the implications of EDX findings for diagnosis and clinical management of persons with radiculopathy are reviewed.

Diagnostic tests in the clinical diagnosis of lumbar spinal stenosis: Consensus and Results of an International Delphi Study

PURPOSE

Reach a consensus on which diagnostic tests are most important in confirming the clinical diagnosis of lumbar spinal stenosis (LSS).

METHODS

Phase 1: 22 members of the International Taskforce on the Diagnosis and Management of LSS confirmed 35 diagnostic items. An on-line survey was developed that allows experts to express the logical order in which they consider the diagnostic tests, and the level of certainty ascertained from each test. Phase 2, Round 1: Survey distributed to members of the International Society for the Study of the Lumbar Spine. Round 2: Meeting of 15 members of Taskforce defined final list of 10 items. Round 3: Survey was distributed internationally, followed by Taskforce consensus.

RESULTS

Totally, 432 clinicians from 28 different countries participated. Certainty of the diagnosis was 60% after selecting the first test and significant change in certainty ceasing after eight items at 90.8% certainty (p < 0.05). The most frequently selected tests included MRI/CT scan, neurological examination and walking test with gait observation. The diagnostic test selected most frequently as the first test was neurological examination.

CONCLUSIONS

This is the first study to reach an international consensus on which diagnostic tests should be used in the clinical diagnosis of LSS. The final recommendation includes three core diagnostic items: neurological examination, MRI/CT and walking test with gait observation. The Taskforce also recommends 3 'rule out' tests: foot pulses/ABI, hip examination and test for cervical myelopathy. If applied, this core set of diagnostic tests can standardize outcomes and improve clinical care of LSS globally.

An Algorithmic Approach to Treating Lumbar Spinal Stenosis: An Evidenced-Based Approach

OBJECTIVE

Lumbar spinal stenosis (LSS) can lead to compression of the neural and vascular elements and is becoming more common due to degenerative changes that occur because of aging processes. Symptoms may manifest as pain and discomfort that radiates to the lower leg, thigh, and/or buttocks. The traditional treatment algorithm for LSS consists of conservative management (physical therapy, medication, education, exercise), often followed by epidural steroid injections (ESIs), and when nonsurgical treatment has failed, open decompression surgery with or without fusion is considered. In this review, the variables that should be considered during the management of patients with LSS are discussed, and the role of each treatment option to provide optimal care is evaluated.

RESULTS

This review leads to the creation of an evidence-based practical algorithm to aid clinicians in the management of patients with LSS. Special emphasis is directed at minimally invasive surgery, which should be taken into consideration when conservative management and ESI have failed.

Prevalence of lumbar spinal stenosis in general and clinical populations: a systematic review and meta-analysis

PURPOSE

To estimate the prevalence of degenerative lumbar spinal stenosis (LSS) in adults, identified by clinical symptoms and/or radiological criteria.

METHODS

Systematic review of the literature. Pooled prevalence estimates by care setting and clinical or radiological diagnostic criteria were calculated and plotted [PROSPERO ID: CRD42018109640].

RESULTS

In total, 41 papers reporting on 55 study samples were included. The overall risk of bias was considered high in two-thirds of the papers. The mean prevalence, based on a clinical diagnosis of LSS in the general population, was 11% (95% CI 4-18%), 25% (95% CI 19-32%) in patients from primary care, 29% (95% CI 22-36%) in patients from secondary care and 39% (95% CI 39-39%) in patients from mixed primary and secondary care. Evaluating the presence of LSS based on radiological diagnosis, the pooled prevalence was 11% (95% CI 5-18%) in the asymptomatic population, 38% (95% CI - 10 to 85%) in the general population, 15% (95% CI 13-18%) in patients from primary care, 32% (95% CI 22-41%) in patients from secondary care and 21% (95% CI 16-26%) in a mixed population from primary and secondary care.

CONCLUSIONS

The mean prevalence estimates based on clinical diagnoses vary between 11 and 39%, and the estimates based on radiological diagnoses similarly vary between 11 and 38%. The results are based on studies with high risk of bias, and the pooled prevalence estimates should therefore be interpreted with caution. With an growing elderly population, there is a need for future low risk-of-bias research clarifying clinical and radiological diagnostic criteria of lumbar spinal stenosis. These slides can be retrieved under Electronic Supplementary Material.