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Meta-Analysis
. 2016 Nov 1;11(11):CD012421.
doi: 10.1002/14651858.CD012421.

Surgical options for lumbar spinal stenosis

Gustavo C Machado  1 , Paulo H Ferreira, Rafael Ij Yoo, Ian A Harris, Marina B Pinheiro, Bart W Koes, Maurits W van Tulder, Magdalena Rzewuska, Christopher G Maher, Manuela L Ferreira
Affiliations
Meta-Analysis

Surgical options for lumbar spinal stenosis

Gustavo C Machado et al. Cochrane Database Syst Rev. .

Abstract

Background: Hospital charges for lumbar spinal stenosis have increased significantly worldwide in recent times, with great variation in the costs and rates of different surgical procedures. There have also been significant increases in the rate of complex fusion and the use of spinal spacer implants compared to that of traditional decompression surgery, even though the former is known to incur costs up to three times higher. Moreover, the superiority of these new surgical procedures over traditional decompression surgery is still unclear.

Objectives: To determine the efficacy of surgery in the management of patients with symptomatic lumbar spinal stenosis and the comparative effectiveness between commonly performed surgical techniques to treat this condition on patient-related outcomes. We also aimed to investigate the safety of these surgical interventions by including perioperative surgical data and reoperation rates.

Search methods: Review authors performed electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, Web of Science, LILACS and three trials registries from their inception to 16 June 2016. Authors also conducted citation tracking on the reference lists of included trials and relevant systematic reviews.

Selection criteria: This review included only randomised controlled trials that investigated the efficacy and safety of surgery compared with no treatment, placebo or sham surgery, or with another surgical technique in patients with lumbar spinal stenosis.

Data collection and analysis: Two reviewers independently assessed the studies for inclusion and performed the 'Risk of bias' assessment, using the Cochrane Back and Neck Review Group criteria. Reviewers also extracted demographics, surgery details, and types of outcomes to describe the characteristics of included studies. Primary outcomes were pain intensity, physical function or disability status, quality of life, and recovery. The secondary outcomes included measurements related to surgery, such as perioperative blood loss, operation time, length of hospital stay, reoperation rates, and costs. We grouped trials according to the types of surgical interventions being compared and categorised follow-up times as short-term when less than 12 months and long-term when 12 months or more. Pain and disability scores were converted to a common 0 to 100 scale. We calculated mean differences for continuous outcomes and relative risks for dichotomous outcomes. We pooled data using the random-effects model in Review Manager 5.3, and used the GRADE approach to assess the quality of the evidence.

Main results: We included a total of 24 randomised controlled trials (reported in 39 published research articles or abstracts) in this review. The trials included 2352 participants with lumbar spinal stenosis with symptoms of neurogenic claudication. None of the included trials compared surgery with no treatment, placebo or sham surgery. Therefore, all included studies compared two or more surgical techniques. We judged all trials to be at high risk of bias for the blinding of care provider domain, and most of the trials failed to adequately conceal the randomisation process, blind the participants or use intention-to-treat analysis. Five trials compared the effects of fusion in addition to decompression surgery. Our results showed no significant differences in pain relief at long-term (mean difference (MD) -0.29, 95% confidence interval (CI) -7.32 to 6.74). Similarly, we found no between-group differences in disability reduction in the long-term (MD 3.26, 95% CI -6.12 to 12.63). Participants who received decompression alone had significantly less perioperative blood loss (MD -0.52 L, 95% CI -0.70 L to -0.34 L) and required shorter operations (MD -107.94 minutes, 95% CI -161.65 minutes to -54.23 minutes) compared with those treated with decompression plus fusion, though we found no difference in the number of reoperations (risk ratio (RR) 1.25, 95% CI 0.81 to 1.92). Another three trials investigated the effects of interspinous process spacer devices compared with conventional bony decompression. These spacer devices resulted in similar reductions in pain (MD -0.55, 95% CI -8.08 to 6.99) and disability (MD 1.25, 95% CI -4.48 to 6.98). The spacer devices required longer operation time (MD 39.11 minutes, 95% CI 19.43 minutes to 58.78 minutes) and were associated with higher risk of reoperation (RR 3.95, 95% CI 2.12 to 7.37), but we found no difference in perioperative blood loss (MD 144.00 mL, 95% CI -209.74 mL to 497.74 mL). Two trials compared interspinous spacer devices with decompression plus fusion. Although we found no difference in pain relief (MD 5.35, 95% CI -1.18 to 11.88), the spacer devices revealed a small but significant effect in disability reduction (MD 5.72, 95% CI 1.28 to 10.15). They were also superior to decompression plus fusion in terms of operation time (MD 78.91 minutes, 95% CI 30.16 minutes to 127.65 minutes) and perioperative blood loss (MD 238.90 mL, 95% CI 182.66 mL to 295.14 mL), however, there was no difference in rate of reoperation (RR 0.70, 95% CI 0.32 to 1.51). Overall there were no differences for the primary or secondary outcomes when different types of surgical decompression techniques were compared among each other. The quality of evidence varied from 'very low quality' to 'high quality'.

Authors' conclusions: The results of this Cochrane review show a paucity of evidence on the efficacy of surgery for lumbar spinal stenosis, as to date no trials have compared surgery with no treatment, placebo or sham surgery. Placebo-controlled trials in surgery are feasible and needed in the field of lumbar spinal stenosis. Our results demonstrate that at present, decompression plus fusion and interspinous process spacers have not been shown to be superior to conventional decompression alone. More methodologically rigorous studies are needed in this field to confirm our results.

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Conflict of interest statement

The review authors declare that they have no competing interests and received no external funding to perform this systematic review. GCM and MBP are supported by an international postgraduate research scholarship/postgraduate award from the Australian Department of Education and Training. CGM is supported by a principal research fellowship from the National Health and Medical Research Council. MLF is supported by a Sydney Medical Foundation Fellowship from the Sydney Medical School, The University of Sydney. BWK is co‐author of one of the included trials (Moojen 2013), but was not involved in the quality assessment or data extraction of this trial. The remaining authors have noting to declare.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
3
3
Forest plot of comparison: 1 Decompression alone versus decompression plus fusion, outcome: 1.1 Pain.
4
4
Forest plot of comparison: 2 Decompression versus interspinous spacer, outcome: 2.1 Pain.
5
5
Forest plot of comparison: 3 Decompression plus fusion versus interspinous spacer, outcome: 3.1 Pain.
6
6
Forest plot of comparison: 4 Laminectomy versus laminotomy, outcome: 4.1 Pain.
1.1
1.1. Analysis
Comparison 1 Decompression alone versus decompression plus fusion, Outcome 1 Pain.
1.2
1.2. Analysis
Comparison 1 Decompression alone versus decompression plus fusion, Outcome 2 Disability.
1.3
1.3. Analysis
Comparison 1 Decompression alone versus decompression plus fusion, Outcome 3 Walking ability.
1.4
1.4. Analysis
Comparison 1 Decompression alone versus decompression plus fusion, Outcome 4 Operation time.
1.5
1.5. Analysis
Comparison 1 Decompression alone versus decompression plus fusion, Outcome 5 Blood loss.
1.6
1.6. Analysis
Comparison 1 Decompression alone versus decompression plus fusion, Outcome 6 Reoperations.
1.7
1.7. Analysis
Comparison 1 Decompression alone versus decompression plus fusion, Outcome 7 Hospitalisation.
2.1
2.1. Analysis
Comparison 2 Decompression versus interspinous spacer, Outcome 1 Pain.
2.2
2.2. Analysis
Comparison 2 Decompression versus interspinous spacer, Outcome 2 Disability.
2.3
2.3. Analysis
Comparison 2 Decompression versus interspinous spacer, Outcome 3 Function.
2.4
2.4. Analysis
Comparison 2 Decompression versus interspinous spacer, Outcome 4 Quality of life.
2.5
2.5. Analysis
Comparison 2 Decompression versus interspinous spacer, Outcome 5 Costs.
2.6
2.6. Analysis
Comparison 2 Decompression versus interspinous spacer, Outcome 6 Operation time.
2.7
2.7. Analysis
Comparison 2 Decompression versus interspinous spacer, Outcome 7 Blood loss.
2.8
2.8. Analysis
Comparison 2 Decompression versus interspinous spacer, Outcome 8 Reoperations.
2.9
2.9. Analysis
Comparison 2 Decompression versus interspinous spacer, Outcome 9 Hospitalisation.
3.1
3.1. Analysis
Comparison 3 Decompression plus fusion versus interspinous spacer, Outcome 1 Pain.
3.2
3.2. Analysis
Comparison 3 Decompression plus fusion versus interspinous spacer, Outcome 2 Disability.
3.3
3.3. Analysis
Comparison 3 Decompression plus fusion versus interspinous spacer, Outcome 3 Quality of life.
3.4
3.4. Analysis
Comparison 3 Decompression plus fusion versus interspinous spacer, Outcome 4 Operation time.
3.5
3.5. Analysis
Comparison 3 Decompression plus fusion versus interspinous spacer, Outcome 5 Blood loss.
3.6
3.6. Analysis
Comparison 3 Decompression plus fusion versus interspinous spacer, Outcome 6 Reoperations.
3.7
3.7. Analysis
Comparison 3 Decompression plus fusion versus interspinous spacer, Outcome 7 Hospitalisation.
4.1
4.1. Analysis
Comparison 4 Laminectomy versus laminotomy, Outcome 1 Pain.
4.2
4.2. Analysis
Comparison 4 Laminectomy versus laminotomy, Outcome 2 Disability.
4.3
4.3. Analysis
Comparison 4 Laminectomy versus laminotomy, Outcome 3 Walking ability.
4.4
4.4. Analysis
Comparison 4 Laminectomy versus laminotomy, Outcome 4 Operation time.
4.5
4.5. Analysis
Comparison 4 Laminectomy versus laminotomy, Outcome 5 Blood loss.
4.6
4.6. Analysis
Comparison 4 Laminectomy versus laminotomy, Outcome 6 Reoperations.
4.7
4.7. Analysis
Comparison 4 Laminectomy versus laminotomy, Outcome 7 Hospitalisation.
5.1
5.1. Analysis
Comparison 5 Decompression versus split‐decompression, Outcome 1 Pain.
5.2
5.2. Analysis
Comparison 5 Decompression versus split‐decompression, Outcome 2 Disability.
5.3
5.3. Analysis
Comparison 5 Decompression versus split‐decompression, Outcome 3 Recovery.
5.4
5.4. Analysis
Comparison 5 Decompression versus split‐decompression, Outcome 4 Operation time.
5.5
5.5. Analysis
Comparison 5 Decompression versus split‐decompression, Outcome 5 Blood loss.
5.6
5.6. Analysis
Comparison 5 Decompression versus split‐decompression, Outcome 6 Reoperations.
5.7
5.7. Analysis
Comparison 5 Decompression versus split‐decompression, Outcome 7 Hospitalisation.
6.1
6.1. Analysis
Comparison 6 Decompression versus endoscopic decompression, Outcome 1 Disability.
6.2
6.2. Analysis
Comparison 6 Decompression versus endoscopic decompression, Outcome 2 Operation time.
6.3
6.3. Analysis
Comparison 6 Decompression versus endoscopic decompression, Outcome 3 Blood loss.
6.4
6.4. Analysis
Comparison 6 Decompression versus endoscopic decompression, Outcome 4 Reoperations.
6.5
6.5. Analysis
Comparison 6 Decompression versus endoscopic decompression, Outcome 5 Hospitalisation.
See this image and copyright information in PMC

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Epstein 2006 {published data only}
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Gotfryd 2012a {published data only}
    1. Gotfryd AO, Spolidoro DR, Poletto PR. Descompressão neural isolada ou associada à fusão póstero‐lateral nas afecções degenerativas lombossacras: avaliação da qualidade de vida e incapacidade funcional pós‐operatória. Coluna/Columna 2012;11:17‐20.
Gu 2009 {published data only}
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Halm 2010 {published data only}
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Imagama 2009 {published data only}
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Ito 2010 {published data only}
    1. Ito Z, Matsuyama Y, Sakai Y, Imagama S, Wakao N, Ando K, et al. Bone union rate with autologous iliac bone versus local bone graft in posterior lumbar interbody fusion. Spine 2010;35:E1101‐5. - PubMed
Katz 1997 {published data only}
    1. Katz JN, Lipson SJ, Lew RA, Grobler LJ, Weinstein JN, Brick GW, et al. Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Patient selection, costs, and surgical outcomes. Spine 1997;22:1123‐31. - PubMed
Kawaguchi 2004 {published data only}
    1. Kawaguchi Y, Kanamori M, Ishihara H, Kikkawa T, Matsui H, Tsuji H, et al. Clinical and radiographic results of expansive lumbar laminoplasty in patients with spinal stenosis. Journal of Bone & Joint Surgery ‐ American Volume 2004;86A:292‐9. - PubMed
Kim 2006 {published data only}
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Kim 2007 {published data only}
    1. Kim JW, Park HC, Yoon SH, Oh SH, Roh SW, Rim DC, et al. A multi‐center clinical study of posterior lumbar interbody fusion with the expandable stand‐alone cage (Tychea cage) for degenerative lumbar spinal disorders. Journal of Korean Neurosurgical Society 2007;42:251‐7. - PMC - PubMed
Kim 2007a {published data only}
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Konno 2000 {published data only}
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Kornblum 2004 {published data only}
    1. Kornblum MB, Fischgrund JS, Herkowitz HN, Abraham DA, Berkower DL, Ditkoff JS. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective long‐term study comparing fusion and pseudarthrosis. Spine 2004;29:726‐33; discussion 733‐4. - PubMed
Korovessis 2004 {published data only}
    1. Korovessis P, Papazisis Z, Koureas G, Lambiris E. Rigid, semirigid versus dynamic instrumentation for degenerative lumbar spinal stenosis: a correlative radiological and clinical analysis of short‐term results. Spine 2004; Vol. 29:735‐42. - PubMed
Ledonio 2012 {published data only}
    1. Ledonio CGT, Polly DW, Ghogawala Z, Rampersaud RY, Santos ERG, Sembrano JN, et al. Societal cost impact of decompression alone versus decompression and fusion for degenerative spondylolisthesis. Spine Journal 2012;12:125S‐6S.
Lee 2009 {published data only}
    1. Lee SC, Chen JF, Wu CT, Lee ST. In situ local autograft for instrumented lower lumbar or lumbosacral posterolateral fusion. Journal of Clinical Neuroscience 2009;16:37‐43. - PubMed
Lian 2010 {published data only}
    1. Lian XF, Xu JG, Zeng BF, Zhou W, Kong WQ, Hou TS. Noncontiguous anterior decompression and fusion for multilevel cervical spondylotic myelopathy: a prospective randomized control clinical study. European Spine Journal 2010;19:713‐9. - PMC - PubMed
Liao 2011 {published data only}
    1. Liao JC, Chen WJ, Chen LH, Niu CC, Keorochana G. Surgical outcomes of degenerative spondylolisthesis with L5‐S1 disc degeneration: comparison between lumbar floating fusion and lumbosacral fusion at a minimum 5‐year follow‐up. Spine 2011;36:1600‐7. - PubMed
Mahir 2012 {published data only}
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McConnell 2011 {published data only}
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Michielsen 2013 {published data only}
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Pappas 1994 {published data only}
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Parker 2013 {published data only}
    1. Parker SL, Adogwa O, Davis BJ, Fulchiero E, Aaronson O, Cheng J, et al. Cost‐utility analysis of minimally invasive versus open multilevel hemilaminectomy for lumbar stenosis. Journal of Spinal Disorders & Techniques 2013;26:42‐7. - PubMed
Radcliff 2011 {published data only}
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Radcliff 2012 {published data only}
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Rapp 2009 {published data only}
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Rapp 2011 {published data only}
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Repantis 2009 {published data only}
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Richter 2010 {published data only}
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Rosa 2012 {published data only}
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Rowland 2009 {published data only}
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Satomi 1992 {published data only}
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Sears 2012 {published data only}
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Sengupta 2006 {published data only}
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Shapiro 2005 {published data only}
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Skidmore 2011 {published data only}
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Smoljanovic 2010 {published data only}
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Smorgick 2013 {published data only}
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Videbaek 2010 {published data only}
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Wang 1998 {published data only}
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Willén 2008 {published data only}
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Yamada 2012 {published data only}
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Yu 2008 {published data only}
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