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

Abstract

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).

Keywords: Lumbar spinal stenosis; Musculoskeletal disease; Network meta-analysis; Orthopaedics; Surgery; Systematic review.

Fig. 1

Study selection flowchart. *One RCT reported data on three documents (results on 2-year follow-up, 3-year follow-up, and 5-year follow-up), one RCT reported data on two documents (results on 6-month follow-up and 3-year follow-up), one RCT reported data on three documents (results on 2-year follow-up, 3-year follow-up, and 5-year follow-up), one RCT reported data on two documents (results on 2-week follow-up and 1-year follow-up). RCT: Randomized controlled trial

Fig. 2

Network plots of physical function and adverse events due to any reason. The width of the lines is proportional to the number of trials comparing each pair of interventions. The size of the nodes is proportional to the number of participants. Laminectomy + fusion: Laminectomy with fusion; Laminectomy + Coflex: Laminectomy with Coflex; M-subtotal laminectomy: Microscopic-assisted subtotal laminectomy; E-subtotal laminectomy: Endoscopic-assisted subtotal laminectomy; M-SSP-subtotal laminectomy: Microscopic-assisted split–spinous process subtotal laminectomy; M-laminotomy: Microscopic-assisted laminotomy; E-laminotomy: Endoscopic-assisted laminotomy; M-SSP-laminotomy: Microscopic-assisted split–spinous process laminotomy; M-SPO-laminotomy: Microscopic-assisted spinous process osteotomy laminotomy

Fig. 3

Summary plot for primary outcomes showing the number of studies included in the network meta-analysis judged to be low, some, or high risk of bias

Fig. 4

Network meta-analyses for physical function and adverse events due to any reason. Laminectomy + fusion: Laminectomy with fusion; Laminectomy + Coflex: Laminectomy with Coflex; M-subtotal laminectomy: Microscopic-assisted subtotal laminectomy; E-subtotal laminectomy: Endoscopic-assisted subtotal laminectomy; M-SSP-subtotal laminectomy: Microscopic-assisted split–spinous process subtotal laminectomy; M-laminotomy: Microscopic-assisted laminotomy; E-laminotomy: Endoscopic-assisted laminotomy; M-SSP-laminotomy: Microscopic-assisted split–spinous process laminotomy; M-SPO-laminotomy: Microscopic-assisted spinous process osteotomy laminotomy. Laminectomy was the reference comparison intervention. Comparisons should be read from left to right. Physical function and adverse events due to any reason estimates are located at the intersection between the column-defining intervention and the row-defining intervention. For physical function, data are in mean difference (95% CI), and data below 0 favour the column-defining intervention. For adverse events due to any reason, data are in odds ratio (95% CI), and data below 1 favour the column-defining intervention. The certainty of the evidence (according to confidence in network meta-analysis [CINeMA]) was also incorporated in this figure. Estimates in bold denoted significance at p < 0.05