Decompression of lumbar canal stenosis with a bilateral interlaminar versus classic laminectomy technique: a prospective randomized study

Effect of Different Interventions on Lumbar Spinal Stenosis: A Systematic Evaluation and Network Meta-Analysis

BACKGROUND

Surgery is the preferred option for lumbar spinal stenosis (LSS) when conservative methods cannot meet the needs. Recent advancements in surgical techniques have brought various new methods for treating LSS.

METHODS

Four databases, PubMed, Embase, the Cochrane Library, and Web of Science, were searched, covering the period from the establishment of the databases until May 2024. Randomized controlled trials were carried out to treat LSS using different surgical approaches. The outcome measures included the visual analog scale (VAS) score, Oswestry disability index score, surgical duration, intraoperative blood loss, and length of hospital stay of patients. Bayesian random-effects network meta-analysis was performed using R software (V4.4) and STATA17.0 software to analyze each surgical approach.

RESULTS

A total of 29 studies involving 4200 patients were included. Nine intervention methods, including laminotomy, decompression, decompression plus fusion, endoscopic decompression, interspinous process spacer device (IPSD), laminectomy, minimally invasive decompression, spinous process osteotomy, and lumbar interbody fusion, were analyzed. Network meta-analysis results indicated that endoscopic decompression (surface under the cumulative ranking curve [SUCRA = 88.70%) was the most effective in reducing short-term back VAS scores. IPSD (SUCRA = 98.00%) was the most effective in reducing long-term back VAS scores, surgical duration (SUCRA = 95.20%), and intraoperative blood loss (SUCRA = 100.00%). Endoscopic decompression (SUCRA = 83.60%) also showed the most significant effect in reducing hospital stays.

CONCLUSIONS

Endoscopic decompression can effectively improve short-term back VAS scores and reduce hospital stays, while IPSD is effective in reducing long-term back VAS scores with minimal surgical duration and blood loss.

Surgical interventions for degenerative lumbar spinal stenosis: a systematic review with network meta-analysis

BACKGROUND

Several surgical options for degenerative lumbar spinal stenosis (LSS) are available, but current guidelines do not recommend which one should be prioritized. Although previous network meta-analyses (NMAs) have been performed on this topic, they have major methodological problems and could not provide the convincing evidence and clinical practical information required.

METHODS

Randomized controlled trials (RCTs) comparing at least two surgical interventions were included by searching AMED, CINAHL, EMBASE, the Cochrane Library, and MEDLINE (inception to August 2023). A frequentist random-effects NMA was performed for physical function and adverse events due to any reason. For physical function, three follow-up time points were included: short-term (< 6 months post-intervention), mid-term (≥ 6 months but < 12 months), and long-term (≥ 12 months). Laminectomy was the reference comparison intervention.

RESULTS

A total of 43 RCTs involving 5017 participants were included in the systematic review and 28 RCTs encompassing 14 types of surgical interventions were included in the NMA. For improving physical function (scale 0-100), endoscopic-assisted laminotomy (mean difference: - 8.61, 95% confidence interval: - 10.52 to - 6.69; moderate-quality evidence), laminectomy combined with Coflex (- 8.41, - 13.21 to - 3.61; moderate quality evidence), and X-stop (- 6.65, - 8.60 to - 4.71; low-quality evidence) had small effects at short-term follow-up; no statistical difference was observed at mid-term follow-up (very low- to low-quality evidence); at long-term follow-up, endoscopic-assisted laminotomy (- 7.02, - 12.95 to - 1.08; very low-quality evidence) and X-stop (- 10.04, - 18.16 to - 1.93; very low-quality evidence) had a small and moderate effect, respectively. Compared with laminectomy, endoscopic-assisted laminotomy was associated with fewer adverse events due to any reason (odds ratio: 0.27, 0.09 to 0.86; low-quality evidence).

CONCLUSIONS

For adults with degenerative LSS, endoscopic-assisted laminotomy may be the safest and most effective intervention in improving physical function. However, the available data were insufficient to indicate whether the effect was sustainable after 6 months.

TRIAL REGISTRATION

PROSPERO (CRD42018094180).

The clinical effect of unilateral decompressive laminectomy plus fusion with unilateral biportal endoscopic technique for single level lumbar spinal stenosis

PURPOSE

This study aimed to compare and analyze the effectiveness of unilateral biportal endoscopic (UBE) decompressive laminectomy plus fusion and microscope-assisted open decompressive laminectomy plus fusion.

METHODS

A total of 143 patients with lumbar spinal stenosis were enrolled in this study between March 2020 and February 2021 with a minimum 2 years follow-up visit to our hospital. Sixty-five patients underwent the unilateral biportal endoscopic technique and were assigned to the UBE group, and the remaining 78 patients with microscope assistant were assigned to the Microscope group. The baseline characteristics, clinical outcomes, and radiological data were retrospectively collected and analyzed, as well as Clinical outcomes, radiological data and complications.

RESULTS

There were no significant differences between the two groups in terms of baseline characteristics (P > 0.05). The UBE group was demonstrated to be significantly superior in CRP, drainage, blood loss, treatment cost and Hospital stay than the Microscope group (P < 0.05), whereas a significant longer operation time was observed (P < 0.05). The VAS-B, ODI, and JOA-L scores of the UBE group at 1 year follow-up were significantly greater than those of the Microscope group (P < 0.05). Regarding radiological data, there were no significant differences in the section area of the spinal canal and fusion grade between the two groups (P > 0.05).

CONCLUSION

In view of the satisfactory clinical outcomes of patients and notable decompression at the stenosed segment, UBE is a feasible, minimally invasive technique for single level lumbar canal stenosis.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Delta large-channel technique versus microscopy-assisted laminar fenestration decompression for lumbar spinal stenosis: a one-year prospective cohort study

PURPOSE

When it comes to treating lumbar spinal stenosis (LSS), a procedure known as microscope-assisted fenestration decompression has expediently become the gold standard. With the advancement of spinal endoscopy, the Delta large-channel approach has shown promising clinical outcomes in the management of lumbar spinal stenosis. However, case studies of this method being used to treat lumbar spinal stenosis are still uncommon. The purpose of this research was to examine how well microscopy-assisted laminectomy and the Delta large-channel approach work in treating LSS in the clinic.

METHODS

From May 2018 to June 2020, 149 patients diagnosed with LSS were divided into 80 patients in Delta large-channel technique groups (FE group) and 69 patients in microscope groups (Micro group). Lower back and lower limb pain were measured using the visual analogue scale (VAS-LBP and VAS-LP), while lower limb numbness was evaluated using the 11-point numerical rating scale (NRS-LN); modified Oswestry Disability Index (ODI) was used to evaluate the quality of life, and modified MacNab criteria were used to assess the clinical efficacy before surgery and at one week, three months, six months, and 12 months after surgery. All patients had single-level lumbar spinal stenosis, and clinical data such as hospital stay, operation time, intraoperative blood loss were statistically analyzed.

RESULTS

Finally, 111 patients (62 in FE group and 49 in Micro group) completed follow-up. Compared with preoperative results, postoperative VAS-LBP, VAS-LP, NRS-LN score and modified ODI score were significantly improved in 2 groups (P < 0.05), but there was no significant difference in postoperative follow-up at each time point (P > 0.05), Except 1 week after surgery, VAS-LBP in FE group was lower than that in Micro group (P < 0.05). It is noteworthy that the FE group had a shorter hospital stay, less intraoperative blood loss, and a quicker time of getting out of bed when compared with the microscope group，but the operation time was just the opposite (P < 0.05). The excellent and good rate was 83.87% in FE group and 85.71% in Micro group (P > 0.05).

CONCLUSIONS

Both microscope-assisted laminar fenestration decompression and Delta large-channel procedures provide satisfactory treatment outcomes, however the Delta large-channel approach has some potential advantages for the treatment of LSS, including quicker recovery and sooner reduced VAS-LBP. Long-term consequences, however, will necessitate additional follow-up and research.

Comparison of posterior decompression techniques and conventional laminectomy for lumbar spinal stenosis

Objectives

To compare the efficacy of posterior decompression techniques with conventional laminectomy for lumbar spinal stenosis.

Methods

The Embase, PubMed, and Cochrane Library databases were searched with no language limitations from inception to January 13, 2022. The main outcomes were functional disability, perceived recovery, leg and back pain, complications. A random effects model was used to pooled data. Risk ratio (RR), mean difference (MD) and 95% confidence interval (CI) were used to report results. The study protocol was published in PROSPERO (CRD42022302218).

Results

14 trials including 1,106 participants were included in the final analysis. Bilateral laminotomy was significantly more efficacious in improve functionality than laminectomy [MD: -2.94; (95% CI, -4.12 to -1.76)]. Low incidence of iatrogenic instability due to bilateral laminectomy compared with laminectomy [RR: 0.11; (95% CI, 0.02 to 0.59)]. In addition, between those who received bilateral laminotomy and those undergoing laminectomy, the result showed significant difference regarding recovery [RR: 1.31; (95% CI, 1.03 to 1.67)].

Conclusions

This study provides evidence that bilateral laminotomy has advantages in functional recovery, postoperative stability, and postoperative rehabilitation outcomes. Further research is needed to determine whether posterior techniques provide a safe and effective option for conventional laminectomy.

Comparison of Microscopic Decompression and Biportal Endoscopic Spinal Surgery in the Treatment of Lumbar Canal Stenosis and Herniated Disc: A One-year Follow-up

Backgrounds. Microscopic decompression (MD) has been widely used as an alternative to open decompression. Lately, biportal endoscopic spinal surgery (BESS) - a new approach in minimal-invasive spinal surgery – has also been used with good results.  Although both groups can achieve adequate lumbar decompression, there is still a lack of evidence regarding their comparison. We aim to compare the outcomes of both techniques in a one-year follow-up. Methods. This is a retrospective study in 100 consecutive patients with symptomatic lumbar spine compression due to herniated nucleus pulposus (HNP) and lumbar canal stenosis (LCS) that was treated by either BESS or MD. Clinical evaluations using Visual Analog Score (VAS), Oswestry Disability Index (ODI), and SF-36 questionnaire were obtained. Objective data such as surgery duration, amount of postoperative drain production, and hospital length of stay were collected. Complications were noted throughout the follow-up time. Results. The BESS group had a significantly lesser surgical duration, drain production, and length of stay. At one year follow-up, both groups achieved significant improvement in VAS, ODI, and SF-36 compared to the preoperative condition. Complications were not observed in the BESS group. Conclusions. Both procedures were comparably effective to treat lumbar stenosis. Although this study shows superiority with BESS technique in immediate and long-term follow-up, the final choice may depend on the surgeon's preference

Comparison of Short-Term Clinical Results and Radiologic Changes Between Two Different Minimally Invasive Decompressive Surgical Methods for Lumbar Canal Stenosis: Lumbar Spinous Process Splitting Laminectomy and Trans-Interspinous Lumbar Decompression

STUDY DESIGN

A multicenter, retrospective study.

OBJECTIVE

To clarify the clinical and radiological effects of removing interspinous contextures in lumbar decompression surgery for patients with lumbar spinal stenosis.

SUMMARY OF BACKGROUND DATA

There have seldom been reports that have compared both clinical results and radiological changes among minimally invasive decompression methods.

METHODS

Consecutive 52 patients underwent lumbar spinous process-splitting laminectomy (LSPSL), following which 50 patients underwent trans-interspinous lumbar decompression (TISLD). All patients presented with cauda equina type of lumbar spinal stenosis and underwent a minimum 1-year follow-up. The Japanese Orthopaedic Association (JOA) score and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) score were evaluated to determine the extent of daily living activities. Propensity score (PS)-matched analysis was used to match patients' age and preoperative JOA scores between the two groups. Lumbar lordosis (LL), disc height (DH), segmental range of motion (ROM), and vertebral anterior translation were measured by functional lumbar lateral x-ray, and changes between preoperative and 1-year postoperative values were evaluated.

RESULTS

Twenty-nine pairs of patients were selected by PS-matching. Mean JOA scores increased from 14.4 to 23.5 (mean recovery rate was 62.3%) in the LSPSL group and from 14.0 to 23.2 (61.3%) in the TISLD group at preoperative and 1-year follow-up, respectively. There were no significant differences in clinical results and changes in LL, ROM, and vertebral anterior translation in each group. The DH at L4/5 level at 1-year after surgery revealed significant decrease in the TISLD group compared with the LSPSL group. There was a correlation between preoperative DH and DH decrease in the LSPSL group, but not in TISLD group.

CONCLUSION

Removal of interspinous contextures did not influence clinical outcomes at 1 year after surgery, but it may be likely to cause disc height loss when it applied at the L4/5 level.Level of Evidence: 3.

[Degenerative lumbar spine stenosis: minimally invasive microsurgical methods of treatment]

Degenerative lumbar spine stenosis is one of the main causes of chronic pain and radiculopathy in advanced age people. Along with increase in average life expectancy, degenerative lumbar spine stenosis becomes the most common indication for spinal surgery. There is still no consensus regarding the most optimal surgical approach due to the variety of modern surgical methods. In recent years, minimally invasive spinal surgery has become a more advisable alternative to open surgery due to its advanced technical features combined with less soft tissue damage, lower risk of complications and shorter postoperative recovery.

SIZE study: study protocol of a multicentre, randomised controlled trial to compare the effectiveness of an interarcuair decompression versus extended decompression in patients with intermittent neurogenic claudication caused by lumbar spinal stenosis

INTRODUCTION

Intermittent neurogenic claudication (INC) is often caused by lumbar spinal stenosis (LSS). Laminectomy is considered a frequently used surgical technique for LSS. Previous studies have shown that laminectomy can potentially cause lumbar instability. Less invasive techniques, preserving midline structures including the bilateral small size interarcuair decompression, are currently applied. Due to lack of evidence and consensus, surgeons have to rely on their training and own experiences to choose the best surgical techniques for their patients. Hence, an observer and patient blinded multicentre, randomised controlled trial was designed to determine the effectiveness and cost-effectiveness of bilateral interarcuair decompression versus laminectomy for LSS.

METHODS AND ANALYSIS

174 patients above 40 years with at least 12 weeks of INC will be recruited. Patients are eligible for inclusion if they have a clinical indication for surgery for INC with an MRI showing signs of LSS. Patients will be randomised to laminectomy or bilateral interarcuair decompression. The primary outcome is functional status measured with the Roland-Morris Disability Questionnaire at 12 months. Secondary outcomes consist of pain intensity, self-perceived recovery, functional status measured with the Oswestry Disability Index and a physical examination. Outcome measurement moments will be scheduled at 3 and 6 weeks, and at 3, 6, 12, 18, 24, 36 and 48 months after surgery. Physical examination will be performed at 6 weeks, and 12, 24 and 48 months. An economic evaluation will be performed and questionnaires will be used to collect cost data.

ETHICS AND DISSEMINATION

The Medical Ethical Committee of the Erasmus Medical Centre Rotterdam approved this study (NL.65826.078.18). The results will be published in an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov (NCT03480893).

IRB APPROVAL STATUS

MEC-2018-093.