Choice of Surgical Treatments for Lumbar Spinal Stenosis
Choice of Surgical Treatments for Lumbar Spinal Stenosis
Figure 1 summarizes the search and inclusion process. Out of 24 systematic reviews, 6 systematic reviews were eligible for the current appraisal. Of the 6 systematic reviews 63 RCTs were reviewed in full text, resulting in exclusion of 54 RCTs. In total, the appraisal included 9 RCTs. Reasons for exclusion of 54 publications are given in Figure 1.
(Enlarge Image)
Figure 1.
Study flow.
The most recent systematic review identified was published in 2013. Six systematic reviews addressed the efficacy of surgical treatments for lumbar spinal stenosis (Table 2). The characteristics of the RCTs included in the current appraisal and the surgical procedures under investigation as well as the definitions of instability are summarized in Additional file 1 http://www.biomedcentral.com/1471-2474/16/96/additional. Two RCTs compared posterolateral fusion with posterolateral instrumented fusion. One RCT compared fusion and decompression. One RCT compared instrumented fusion and decompression. Two RCTs compared two different instrumented fusion procedures. Two RCTs compared two decompression procedures. One RCT compared fusion, instrumented fusion, and decompression. Furthermore, only two RCTs defined the term "instability".
The most recent RCT was conducted in 2005 (range of year of publications 1991–2005).
Of the 9 RCTs one provided no arguments for the choice of their treatments under investigation. Of 8 RCTs arguments for or against a surgical technique were extracted. The arguments are summarized in Table 3 and grouped into arguments for or against decompression alone, fusion, and fusion with instrumentation.
In three RCTs authors argued in favor of decompression alone compared to fusion with or without instrumentation. Three RCTs provided arguments against decompression alone. While four RCTs argued for fusion without instrumentation, two argued against. Three RCTs listed arguments for fusion with instrumentation and two RCTs against this surgical procedure.
Arguments for decompression surgery emphasize the high success rates of decompression (n = 3). The main argument against a decompression alone was an increase or cause of vertebral instability, respectively the spondylolisthesis progression after decompression alone (n = 3). One RCT further argued that the continuous motion of the stenotic segments might compress the nerve roots as well as "produce osteophytes" (n = 1).
Most authors argued for posterolateral fusion because this technique is "done frequently" and well established (n = 2), shows excellent results for degenerative spondylolisthesis (n = 1), has a high observed fusion rates (n = 1), and shows a significant improvement in clinical outcome (n = 1). The arguments against a posterolateral fusion were that less invasive procedure used for decompression leave the relative stability of the spine undisturbed (n = 1), that degenerative changes (osteophytes, decreased disc height, calcified ligaments) increase the stability of the spine and thereby decreasing the need for an arthrodesis (n = 1), and that the indications for fusion in spinal stenosis and degenerative lumbar spondylolisthesis have remained unclear (n = 1).
Arguments in favor of fusion with instrumentation included: increased fusion rate (n = 2), prevention of spondylolisthesis progression (n = 1), and a high fusion rate and a high level of patient satisfaction in 360° (circumferential) fusion (n = 1). Some authors quoted that fusion with instrumentation may improve fusion rate (n = 1), may reduce rehabilitation time (n = 1) and may improve patient outcome (n = 1). Further, that 270° fusion may be effective (n = 1), that pedicle screw fixation increases rigidity despite resection of the posterior elements (n = 1), and that semirigid systems have been advocated of obtaining spinal stability without sacrificing vertebral body bone density (n = 1). Authors that argued against instrumented fusion highlighted potential associated complications (n = 1) as device related osteoporosis. Additionally, they quote the costs and use of great health care resources of the 360° (circumferential) procedure (n = 1).
Results
Study Selection
Figure 1 summarizes the search and inclusion process. Out of 24 systematic reviews, 6 systematic reviews were eligible for the current appraisal. Of the 6 systematic reviews 63 RCTs were reviewed in full text, resulting in exclusion of 54 RCTs. In total, the appraisal included 9 RCTs. Reasons for exclusion of 54 publications are given in Figure 1.
(Enlarge Image)
Figure 1.
Study flow.
Study Characteristics
The most recent systematic review identified was published in 2013. Six systematic reviews addressed the efficacy of surgical treatments for lumbar spinal stenosis (Table 2). The characteristics of the RCTs included in the current appraisal and the surgical procedures under investigation as well as the definitions of instability are summarized in Additional file 1 http://www.biomedcentral.com/1471-2474/16/96/additional. Two RCTs compared posterolateral fusion with posterolateral instrumented fusion. One RCT compared fusion and decompression. One RCT compared instrumented fusion and decompression. Two RCTs compared two different instrumented fusion procedures. Two RCTs compared two decompression procedures. One RCT compared fusion, instrumented fusion, and decompression. Furthermore, only two RCTs defined the term "instability".
The most recent RCT was conducted in 2005 (range of year of publications 1991–2005).
Appraisal of Arguments for or Against a Surgical Technique
Of the 9 RCTs one provided no arguments for the choice of their treatments under investigation. Of 8 RCTs arguments for or against a surgical technique were extracted. The arguments are summarized in Table 3 and grouped into arguments for or against decompression alone, fusion, and fusion with instrumentation.
In three RCTs authors argued in favor of decompression alone compared to fusion with or without instrumentation. Three RCTs provided arguments against decompression alone. While four RCTs argued for fusion without instrumentation, two argued against. Three RCTs listed arguments for fusion with instrumentation and two RCTs against this surgical procedure.
Decompression
Arguments for decompression surgery emphasize the high success rates of decompression (n = 3). The main argument against a decompression alone was an increase or cause of vertebral instability, respectively the spondylolisthesis progression after decompression alone (n = 3). One RCT further argued that the continuous motion of the stenotic segments might compress the nerve roots as well as "produce osteophytes" (n = 1).
Decompression and Fusion
Most authors argued for posterolateral fusion because this technique is "done frequently" and well established (n = 2), shows excellent results for degenerative spondylolisthesis (n = 1), has a high observed fusion rates (n = 1), and shows a significant improvement in clinical outcome (n = 1). The arguments against a posterolateral fusion were that less invasive procedure used for decompression leave the relative stability of the spine undisturbed (n = 1), that degenerative changes (osteophytes, decreased disc height, calcified ligaments) increase the stability of the spine and thereby decreasing the need for an arthrodesis (n = 1), and that the indications for fusion in spinal stenosis and degenerative lumbar spondylolisthesis have remained unclear (n = 1).
Decompression and Fusion With Instrumentation
Arguments in favor of fusion with instrumentation included: increased fusion rate (n = 2), prevention of spondylolisthesis progression (n = 1), and a high fusion rate and a high level of patient satisfaction in 360° (circumferential) fusion (n = 1). Some authors quoted that fusion with instrumentation may improve fusion rate (n = 1), may reduce rehabilitation time (n = 1) and may improve patient outcome (n = 1). Further, that 270° fusion may be effective (n = 1), that pedicle screw fixation increases rigidity despite resection of the posterior elements (n = 1), and that semirigid systems have been advocated of obtaining spinal stability without sacrificing vertebral body bone density (n = 1). Authors that argued against instrumented fusion highlighted potential associated complications (n = 1) as device related osteoporosis. Additionally, they quote the costs and use of great health care resources of the 360° (circumferential) procedure (n = 1).
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