Two-Year Evaluation of the X-STOP Interspinous Spacer in Different Primary Patient Populations With Neurogenic Intermittent Claudication Because of Lumbar Spinal Stenosis

A Differential Clinical Benefit Examination of Full Lumbar Endoscopy vs Interspinous Process Spacers in the Treatment of Spinal Stenosis: An Effect Size Meta-Analysis of Clinical Outcomes

STUDY DESIGN

A design-agnostic standardized effect meta-analysis of 48 randomized, prospective, and retrospective studies on clinical outcomes with spinal endoscopic and interspinous process spacer (IPS) surgery.

OBJECTIVE

The study aimed to provide reference set of Oswestry Disability Index (ODI) and visual analog scale (VAS) effect size data for back and leg pain following endoscopic and IPS decompression for lumbar herniated disc, foraminal, or lateral recess spinal stenosis.

BACKGROUND

Mechanical low back pain following endoscopic transforaminal decompression may be more reliably reduced by simultaneous posterior column stabilization with IPS.

METHODS

A systematic search of the PubMed, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials from 1 January 2000 to 2 April 2020, identified 880 eligible endoscopy and 362 IPS studies varying in design and metrics. The authors compared calculated standardized effect sizes (Cohen's d) for extracted ODI, VAS-back, and VAS-leg data.

RESULTS

The pooled standardized effect size combining the ODI, VAS-back, and VAS-leg data for the total sample of 19862 data sets from the 30 endoscopy and 18 IPS was 0.877 (95% CI = 0.857-0.898). When stratified by surgery, the combined effect sizes were 0.877 (95% CI = 0.849-0.905) for endoscopic decompression and 0.863 (95% CI = 0.796-0.930; P = 0.056) for IPS implantation. The ODI effect sizes calculated on 6462 samples with directly visualized endoscopic decompression were 0.917 (95% CI = 0.891-0.943) versus 0.798 (95% CI = 0.713-0.883; P < 0.001) with indirect IPS decompression (P < 0.001). The VAS-back effect sizes calculated on 3672 samples were 0.661 (95% CI = 0.585-0.738) for endoscopy and 0.784 (95% CI: 0.644-0.923; P = 0.187) for IPS. The VAS-leg effect sizes calculated on 7890 samples were 0.885 (95% CI = 0.852-0.917) for endoscopic decompression and 0.851 (95% CI = 0.767-0.935; P = 0.427).

CONCLUSION

Lumbar IPS implantation produces larger reduction in low back pain than spinal endoscopy. On the basis of this meta-analysis, the combination of lumbar transforaminal endoscopy with simultaneous IPS has merits and should be formally investigated in higher grade clinical studies.

CLINICAL RELEVANCE

Meta-analysis on the added clinical benefit of combining lumbar endoscopic decompression with an interspinous process spacer.

The use of minimally invasive interspinous process devices for the treatment of lumbar canal stenosis: a narrative literature review

Minimally invasive interspinous process devices (IPD), including interspinous distraction devices (IDD) and interspinous stabilizers (ISS), are increasingly utilized for treating symptomatic lumbar canal stenosis (LCS). There is ongoing debate around their efficacy and safety over traditional decompression techniques with and without interbody fusion (IF). This study presents a comprehensive review of IPD and investigates if: (I) minimally invasive IDD can effectively substitute direct neural decompression and (II) ISS are appropriate substitutes for fusion after decompression. Articles published up to 22^nd January 2020 were obtained from PubMed search. Relevant articles published in the English language were selected and critically reviewed. Observational studies across different IPD brands consistently show significant improvements in clinical outcomes and patient satisfaction at short-term follow-up. Compared to non-operative treatment, mini-open IDD was had significantly greater quality of life and clinical outcome improvements at 2-year follow-up. Compared to open decompression, mini-open IDD had similar clinical outcomes, but associated with higher complications, reoperation risks and costs. Compared to open decompression with concurrent IF, ISS had comparable clinical outcomes with reduced operative time, blood loss, length of stay and adjacent segment mobility. Mini-open IDD had better outcomes over non-operative treatment in mild-moderate LCS at 2-year follow-up, but had similar outcomes with higher risk of re-operations than open decompression. ISS with open decompression may be a suitable alternative to decompression and IF for stable grade 1 spondylolisthesis and central stenosis. To further characterize this procedure, future studies should focus on examining enhanced new generation IPD devices, longer-term follow-up and careful patient selection.

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.

Interspinous process stabilization with Rocker via unilateral approach versus X-Stop via bilateral approach for lumbar spinal stenosis: a comparative study

BACKGROUND

Rocker is a novel interspinous process stabilization (IPS) that can be installed via unilateral approach by virtue of its unique design. This controlled study compared the clinical outcome of Rocker versus X-Stop to access the feasibility and validity of the novel IPS.

METHODS

From March 2011 to September 2012, 32 patients treated with Rocker and 30 patients treated with X-Stop were enrolled in this study. The primary clinical outcome measure was Oswestry Disability Index (ODI) score. The secondary clinical outcome measure was Japanese orthopaedics association (JOA) score. Disc height index (DHI) and foraminal height index (FHI) were measured for postoperative radiographic evaluation. Implant failures were also recorded.

RESULTS

There were 55 patients with complete data during 24 months follow-up. Among the 55 patients, 38 patients underwent IPS in combination with microdecompression. At the final follow-up, 49 patients achieved a minimal clinical important difference (≥ 8 points ODI improvement). The mean operative time was 53.6 min (range, 30 to 90 min) in Rocker group and 63.1 min (range, 30 to 100 min) in X-Stop group. The average blood loss was 111 ml (range, 50 to 400 ml) in Rocker group and 138 ml (range, 50 to 350 ml) in X-Stop group. ODI score were significantly improved from preoperative 46.8 ± 9.2 to 12.2 ± 2.6 at 24 months follow-up in the Rocker group and from preoperative 45.8 ± 9.8 to 11.8 ± 2.4 at 24 months follow-up in the X-Stop group. JOA score also improved significantly in both groups. The radiographic parameters of DHI and FHI in both groups increased immediately postoperatively, however, the improvements seemed to revert toward initial value during follow-up. Two patients in Rocker group demonstrated implant dislocation within one week postoperatively and one patient in X-Stop group demonstrated implant migration at two months postoperatively.

CONCLUSIONS

Preliminary clinical and radiographic outcome was similar between Rocker and X-Stop group. For patients of lumbar spinal stenosis with unilateral nerve root involved or mild-to-moderate central canal stenosis, Rocker offers a new alternative with less damage.

Analysis of Internet information on the controversial X-Stop device

BACKGROUND CONTEXT

The Internet is frequently used by patients to aid in medical decision making. Multiple studies display the Internet's ineffectiveness in presenting high-quality information regarding surgical procedures and devices. With recent reports of unacceptably high complication rates and poor outcomes with the X-Stop device, it is important that online information is comprehensive and accurate. This study is the first to examine Internet information on the controversial X-Stop.

PURPOSE

To determine how accurately public information over the Internet portrays the existing primary literature on the X-Stop, how extensively the X-Stop is characterized online, and how patient decision making could foreseeably be affected.

STUDY DESIGN

This cross-sectional study analyzed publicly available Internet information, including videos on the web site YouTube regarding the X-Stop device.

PATIENT SAMPLE

No patients were involved in this study.

OUTCOME MEASURES

No specific outcome measures were used.

METHODS

Search engines Google, Yahoo, and Bing were used to identify 105 web sites providing information on the X-Stop. Videos on the web site YouTube were included. Web sites were categorized based on the authorship. Each site was analyzed for the provision of appropriate patient inclusion and exclusion criteria, surgical and nonsurgical treatment alternatives, purported benefits, common complications, peer-reviewed literature citations, and descriptions/diagrams of the procedure. Data were evaluated for each authorship subgroup and the entire group of sites.

RESULTS

Forty-three percent of sites were authored by a private medical group, 4% by an academic medical group, 16% by an insurance company, 9% by a biomedical industry, 10% by news sources, and 19% by other. Thirty-one percent of web sites and 11% of sites authored by private medical groups contained references to peer-reviewed literature. Fifty-six percent of web sites reported patient inclusion criteria, whereas 33% reported exclusion criteria. Benefits and complications were reported within 91% and 23% of sites, respectively. Surgical and nonsurgical treatment options were mentioned within 59% and 61% of web sites, respectively.

CONCLUSIONS

Our study demonstrates the Internet's ineffectiveness in reporting quality information on the X-Stop. Information was often incomplete and potentially misleading. Significant controversy exists within primary literature regarding the safety and efficacy of the X-Stop. Yet, publicly available Internet information largely provided misinformation and did not reflect any such controversy. This raises the concern that such information lends itself more toward patient recruitment than patient education. Medical professionals need to know how this may affect their patients' decision making.