Effectiveness of Surgery for Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis

Abstract

BackgroundThe management of spinal stenosis by surgery has increased rapidly in the past two decades, however, there is still controversy regarding the efficacy of surgery for this condition. Our aim was to investigate the efficacy and comparative effectiveness of surgery in the management of patients with lumbar spinal stenosis.MethodsElectronic searches were performed on MEDLINE, EMBASE, AMED, CINAHL, Web of Science, LILACS and Cochrane Library from inception to November 2014. Hand searches were conducted on included articles and relevant reviews. We included randomised controlled trials evaluating surgery compared to no treatment, placebo/sham, or to another surgical technique in patients with lumbar spinal stenosis. Primary outcome measures were pain, disability, recovery and quality of life. The PEDro scale was used for risk of bias assessment. Data were pooled with a random-effects model, and the GRADE approach was used to summarise conclusions.ResultsNineteen published reports (17 trials) were included. No trials were identified comparing surgery to no treatment or placebo/sham. Pooling revealed that decompression plus fusion is not superior to decompression alone for pain (mean difference –3.7, 95% confidence interval –15.6 to 8.1), disability (mean difference 9.8, 95% confidence interval –9.4 to 28.9), or walking ability (risk ratio 0.9, 95% confidence interval 0.4 to 1.9). Interspinous process spacer devices are slightly more effective than decompression plus fusion for disability (mean difference 5.7, 95% confidence interval 1.3 to 10.0), but they resulted in significantly higher reoperation rates when compared to decompression alone (28% v 7%, P < 0.001). There are no differences in the effectiveness between other surgical techniques for our main outcomes.ConclusionsThe relative efficacy of various surgical options for treatment of spinal stenosis remains uncertain. Decompression plus fusion is not more effective than decompression alone. Interspinous process spacer devices result in higher reoperation rates than bony decompression.

Predictors of Reoperation after Microdecompression in Lumbar Spinal Stenosis

“…The operative treatment for LSS and degenerative spondylolisthesis provides substantial lasting benefit compared with nonoperative care172327). As a result, the number of surgical procedures performed for LSS has increased steadily as the oldest sector of the population continues to grow1416). However, the optimal procedure remains controversial, and no obvious superiority of any specific technique has been identified1415).…”

“…As a result, the number of surgical procedures performed for LSS has increased steadily as the oldest sector of the population continues to grow1416). However, the optimal procedure remains controversial, and no obvious superiority of any specific technique has been identified1415).…”

Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery

“…New surgical techniques including minimally invasive techniques have rapidly evolved in spinal surgery over recent years, and a recent systematic review and meta-analysis of the effectiveness of surgery for lumbar spinal stenosis was undertaken [46]. There was no difference in the effectiveness of the most commonly used surgical techniques to improve outcomes.…”

The Law and Social Values: Medical Necessity and Criminal Prosecution

“…The late Kerr White MD, the founding chair of The Department of Health Policy and Management at Johns Hopkins University and the Deputy Director for Health Care Services for the Rockefeller Foundation stated it another way in Medicine & Culture [11], ''About 15% of all contemporary clinical interventions are supported by objective scientific evidence that they do more good than harm.'' In orthopaedic surgery specifically, questions have been recently raised about the effectiveness of common operations such as knee arthroscopy [7], knee replacement [13], and spinal surgery [9].…”