Making the Most of Systematic Reviews and Meta-analyses in Spine Surgery: A Primer for the Practicing Spine Surgeon

Systematic Reviews and Meta-Analyses in Pediatric Neurosurgery: Essential Domains for a Pediatric Neurosurgeon

BACKGROUND

A rise in systematic reviews and meta-analyses (SRMAs) within the neurosurgical literature has been fueled by an increasing amount of published metadata. In the pediatric niche, multiple pediatric-specific considerations must be made by pediatric neurosurgeons to ensure that their interpretation of pediatric neurosurgical SRMAs is appropriate. The objective of this review is to highlight 4 essential domains in this setting that will allow readers to more appropriately interpret pediatric neurosurgical SRMAs.

METHODS

The domains reviewed are 1) formulating an appropriate search strategy to incorporate all possible studies involving pediatric patients, 2) understanding how the limited quality of pediatric neurosurgical metadata affects certainty of reported findings, 3) using suitable statistical modeling that adjusts for the intrinsic and interstudy differences between contributing pediatric studies, and 4) ensuring that clinical applications of SRMA findings are appropriate in the pediatric demographic.

RESULTS

Each of the 4 domains can be tailored toward pediatric neurosurgery when composing SRMAs. Examples provided demonstrate where writers should be specific and what readers should be aware of to ensure findings are interpreted correctly and effectively in this niche.

CONCLUSIONS

In understandings these 4 essential domains, practicing pediatric neurosurgeons will be better equipped to critically evaluate SRMAs and ultimately inform their academic and evidence-based practices.

Meta-analysis. What have we learned?

Meta-analyses constitute fundamental tools of the Evidence-Based Medicine (EBM) aiming at synthesizing outcome data from individual trials in order to produce pooled effect estimates for various outcomes of interest. Combining summary data from several studies increases the sample size, improves the statistical power of the findings as well as the precision of the obtained effect estimates. For all these reasons, meta-analyses are thought of providing the best evidence to support clinical practice guidelines. However, the strength of the provided evidence is closely dependent on the quality of included studies as well as the rigour of the meta-analytic process. In addition, over the course of the evolution of the current meta-analytic methodology, some concerns have been expressed on the ultimate usefulness of such a complex and time consuming procedure on establishing timely, valid evidence on various specified topics in the field of Orthopaedics and Trauma Surgery. This article provides an overview of the appropriate methodology, benefits and potential drawbacks of the meta-analytic procedure.

Endoscopic decompression for the treatment of lumbar spinal stenosis: an updated systematic review and meta-analysis

OBJECTIVE

Lumbar stenosis treatment has evolved with the introduction of minimally invasive surgery (MIS) techniques. Endoscopic methods take the concepts applied to MIS a step further, with multiple studies showing that endoscopic techniques have outcomes that are similar to those of more traditional approaches. The aim of this study was to perform an updated meta-analysis and systematic review of studies comparing the outcomes between endoscopic (uni- and biportal) and microscopic techniques for the treatment of lumbar stenosis.

METHODS

Following PRISMA guidelines, a systematic search was performed using the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Ovid Embase, and PubMed databases from their dates of inception to December 14, 2020. All identified articles were then systematically screened against the following inclusion criteria: 1) studies comparing endoscopic (either uniportal or biportal) with minimally invasive approaches, 2) patient age ≥ 18 years, and 3) diagnosis of lumbar spinal stenosis. Bias was assessed using quality assessment criteria and funnel plots. Meta-analysis using a random-effects model was used to synthesize the metadata.

RESULTS

From a total of 470 studies, 14 underwent full-text assessment. Of these 14 studies, 13 comparative studies were included for quantitative analysis, totaling 1406 procedures satisfying all criteria for selection. Regarding postoperative back pain, 9 studies showed that endoscopic methods resulted in significantly lower pain scores compared with MIS (mean difference [MD] -1.0, 95% CI -1.6 to -0.4, p < 0.01). The length of stay data were reported by 7 studies, with endoscopic methods associated with a significantly shorter length of stay versus the MIS technique (MD -2.1 days, 95% CI -2.7 to -1.4, p < 0.01). There was no significant difference with respect to leg visual analog scale scores, Oswestry Disability Index scores, blood loss, surgical time, and complications, and there were not any significant quality or bias concerns.

CONCLUSIONS

Both endoscopic and MIS techniques are safe and effective methods for treating patients with symptomatic lumbar stenosis. Patients who undergo endoscopic surgery seem to report less postoperative low-back pain and significantly reduced hospital stay with a trend toward less perioperative blood loss. Future large prospective randomized trials are needed to confirm the findings in this study.