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. 2020 Sep 26:26:45-53.
doi: 10.1016/j.jot.2020.07.003. eCollection 2021 Jan.

Which is the most effective treatment for lumbar spinal stenosis: Decompression, fusion, or interspinous process device? A Bayesian network meta-analysis

Yijian Zhang  1   2 , Dongdong Lu  1   2 , Wei Ji  1   2 , Fan He  1   2 , Angela Carley Chen  3 , Huilin Yang  1   2 , Xuesong Zhu  1   2
Affiliations

Which is the most effective treatment for lumbar spinal stenosis: Decompression, fusion, or interspinous process device? A Bayesian network meta-analysis

Yijian Zhang et al. J Orthop Translat. .

Abstract

Objective: To compare the clinical efficacy, complications, and reoperation rates among three major treatments for lumbar spinal stenosis (LSS): decompression, fusion, and interspinous process device (IPD), using a Bayesian network meta-analysis.

Materials and methods: Databases including Pubmed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science were used for the literature search. Randomized Controlled Trials (RCTs) with three treatment methods were reviewed and included in the study. R software (version 3.6.0), Stata (version 14.0), and Review Manager (version 5.3) were used to perform data analysis.

Results: A total of 10 RCTs involving 1254 patients were enrolled in the present study and each study met an acceptable quality according to our quality assessment described later. In direct comparison, IPD exhibited a higher incidence of reoperation than fusion (OR ​= ​2.93, CI: 1.07-8.02). In indirect comparison, the rank of VAS leg (from best to worst) was as follows: IPD (64%) ​> ​decompression (25%) ​> ​fusion (11%), and the rank of ODI (from best to worst) was: IPD (84%) ​> ​fusion (13%) ​> ​decompression (4%). IPD had the lowest incidence of complications; the rank of complications (from best to worst) was: IPD (60%) ​> ​decompression (27%) ​> ​fusion (14%). However, for the rank of reoperation, fusion showed the best results (from best to worst): fusion (79%) ​> ​decompression (20%) ​> ​IPD (1%). Consistency tests at global and local level showed satisfactory results and heterogeneity tests using loop text indicated a favorable stability.

Conclusion: The present study preliminarily indicates that non-fusion methods including decompression and IPD are optimal choices for treating LSS, which achieves favorable clinical outcomes. IPD exhibits a low incidence of complications, but its high rate of reoperation should be treated with caution.

The translational potential of this article: For the treatment of LSS, several procedures including decompression, fusion, and IPD have been reported. However, each method has its own advantages and disadvantages. To date, the golden standard treatment for LSS is still controversial. In this network meta-analysis, our results demonstrate that both decompression and IPD obtain satisfactory clinical effects for LSS. IPD is accompanied with a low incidence of complications, however, its high rate of reoperation should be acknowledged with discretion.

Keywords: Decompression; Fusion; IPD, interspinous process device; Interspinous process device; LSS, lumbar spinal stenosis; Lumbar spinal stenosis; Network meta-analysis; ODI, oswestry disability index; VAS, visual analogue scale.

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Conflict of interest statement

The authors have no conflicts of interest to disclose in relation to this article.

Figures

Fig. 1
Fig. 1
The flow gram of the searching of identified studies.
Fig. 2
Fig. 2
Quality assessment of each RCT. Three bias levels: high risk of bias, low risk of bias, and unclear risk of bias are labeled with different color.
Fig. 3
Fig. 3
Network of different treatments. (A) comparison for VAS of back; (B) comparison for VAS of leg; (C) comparison for ODI; (D) comparison for complications; (E) comparison for reoperation.
Fig. 4
Fig. 4
Forest plot of direct comparison between different treatments. (A) comparison for VAS of back; (B) comparison for VAS of leg; (C) comparison for ODI; (D) comparison for complications; (E) comparison for reoperation.
Fig. 5
Fig. 5
Bar graph of the rank probabilities among different treatments: (A) comparison for VAS of back; (B) comparison for VAS of leg; (C) comparison for ODI; (D) comparison for complications; (E) comparison for reoperation. Among the three treatments (decompression, fusion, and IPD), of which the rank is the first reflect the maximum VAS and ODI scores or highest incidence of complications and reoperation. Rather, whose rank is the last represent the minimum VAS and ODI or lowest incidence of complications and reoperation.
Fig. 6
Fig. 6
Percentage plot of the rank probabilities among different treatments: (A) comparison for VAS of back; (B) comparison for VAS of leg; (C) comparison for ODI; (D) comparison for complications; (E) comparison for reoperation.
Fig. 7
Fig. 7
Global consistency model test between different treatments: (A) comparison for VAS of back; (B) comparison for VAS of leg; (C) comparison for ODI; (D) comparison for complications; (E) comparison for reoperation.
Fig. 8
Fig. 8
Local consistency model test between different treatments: (A) comparison for VAS of back; (B) comparison for VAS of leg; (C) comparison for ODI; (D) comparison for complications; (E) comparison for reoperation.
Supplementary 1
Supplementary 1
SUCRA results of the rank probabilities among different treatments: (A) comparison for VAS of back; (B) comparison for VAS of leg; (C) comparison for ODI; (D) comparison for complications; (E) comparison for reoperation.
Supplementary 2
Supplementary 2
SUCRA plot of the rank probabilities among different treatments: (A) comparison for VAS of back; (B) comparison for VAS of leg; (C) comparison for ODI; (D) comparison for complications; (E) comparison for reoperation.
Supplementary 3
Supplementary 3
Heterogeneity test among different treatments: (A) comparison for VAS of back; (B) comparison for VAS of leg; (C) comparison for ODI; (D) comparison for complications; (E) comparison for reoperation.
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