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Nonoperative Treatment of Lumbar Spinal Stenosis with Neurogenic Claudication a Systematic Review

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Nonoperative Treatment of Lumbar Spinal Stenosis with Neurogenic Claudication a Systematic Review SPINE Volume 37, Number 10, pp E609–E616 ©2012, Lippincott Williams & Wilkins LITERATURE REVIEW Nonoperative Treatment of Lumbar Spinal Stenosis With Neurogenic Claudication A Systematic Review Carlo Ammendolia , DC, PhD, *†‡ Kent Stuber, DC, MSc , § Linda K. de Bruin , MSc , ‡ Andrea D. Furlan, MD, PhD , ||‡¶ Carol A. Kennedy, BScPT, MSc , ‡#** Yoga Raja Rampersaud, MD , †† Ivan A. Steenstra , PhD , ‡ and Victoria Pennick, RN, BScN, MHSc ‡‡ or methylcobalamin, improve walking distance. There is very low- Study Design. Systematic review. quality evidence from a single trial that epidural steroid injections Objective. To systematically review the evidence for the improve pain, function, and quality of life up to 2 weeks compared effectiveness of nonoperative treatment of lumbar spinal stenosis with home exercise or inpatient physical therapy. There is low- with neurogenic claudication. quality evidence from a single trial that exercise is of short-term Summary of Background Data. Neurogenic claudication benefi t for leg pain and function compared with no treatment. There can signifi cantly impact functional ability, quality of life, and is low- and very low-quality evidence from 6 trials that multimodal independence in the elderly. nonoperative treatment is less effective than indirect or direct Methods. We searched CENTRAL, MEDLINE, EMBASE, CINAHL, surgical decompression with or without fusion. and ICL databases up to January 2011 for randomized controlled Conclusion. Moderate- and high-GRADE evidence for nonopera- trials published in English, in which at least 1 arm provided tive treatment is lacking and thus prohibiting recommendations to data on nonoperative treatments. Risk of bias in each study was guide clinical practice. Given the expected exponential rise in the independently assessed by 2 reviewers using 12 criteria. Quality prevalence of lumbar spinal stenosis with neurogenic claudication, of the evidence was evaluated using Grades of Recommendations, large high-quality trials are urgently needed. Assessment, Development, and Evaluation (GRADE). Key words: neurogenic claudication , lumbar spinal stenosis , Results. From the 8635 citations screened, 56 were assessed systematic review , nonoperative treatment , elderly. Spine 2012 ; and 21 trials with 1851 participants were selected. There is very 37 : E609 – E616 low-quality evidence from 6 trials that calcitonin is no better than placebo or paracetamol, regardless of mode of administration or outcome. From single small trials, there is low-quality evidence umbar spinal stenosis with neurogenic claudication that prostaglandins, and very low-quality evidence that gabapentin is one of the most commonly diagnosed and treated pathological spinal conditions and frequently affl icts L 1 From the * Institute of Health Policy, Management and Evaluation, University the elderly population. It is characterized by bilateral or of Toronto, Canada ; † Department of Medicine, Mount Sinai Hospital, Toronto, unilateral buttock, thigh, or calf discomfort, pain, or weak- Canada ; ‡ Institute for Work and Health, Toronto, Canada ; § Department of 2 Graduate Education and Research, Canadian Memorial Chiropractic College, ness precipitated by walking and prolonged standing. The Toronto, Canada ; || Department of Medicine, University of Toronto, Toronto, pathophysiology is thought to be compression and/or isch- Canada ; ¶ Toronto Rehabilitation Institute, Toronto, Canada ; # Department of emia of the lumbosacral nerve roots due to narrowing of the Physical Therapy, University of Toronto, Toronto, Canada ; ** Mobility Program Clinical Research Unit, St. Michael’s Hospital, Toronto, Canada ; †† Department lateral and central vertebral canals, usually as a consequence of Surgery, Divisions of Orthopaedic and Neurosurgery, University of Toronto, of osteoarthritic thickening of the articulating facet joints, Toronto Western Hospital, Toronto, Canada; and ‡‡ Dalla Lana School of infolding of the ligamentum fl avum, and degenerative bulging Public Health, University of Toronto, Canada. of the intervertebral discs. 2 , 3 Acknowledgment date: July 7, 2011. First revision date: October 30, 2011. Acceptance date: November 4, 2011. Neurogenic claudication can have a signifi cant impact on The manuscript submitted does not contain information about medical functional ability, quality of life, and independence in the device(s)/drug(s). elderly. Those affl icted have greater walking limitations than Canadian Chiropractic Research Foundation funds were received to support individuals with knee or hip osteoarthritis. 4 Lumbar spinal this work. stenosis is the most common reason for spine surgery among No benefi ts in any form have been or will be received from a commercial individuals older than 65 years. 5 party related directly or indirectly to the subject of this manuscript. New cases of neurogenic claudication are expected to rise Address correspondence and reprint requests to Carlo Ammendolia, DC, PhD, Department of Medicine, Mount Sinai Hospital, 60 Murray St, Ste L2- dramatically over the next 20 years when an estimated 23% to 007, Toronto, Ontario, Canada, M5L 3L9; E-mail: [email protected] 25% of the population will be older than 65 years. 6 This will DOI: 10.1097/BRS.0b013e318240d57d signifi cantly impact health care resources in the near future. Spine www.spinejournal.com E609 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. BBRS204850.inddRS204850.indd EE609609 113/04/123/04/12 88:48:48 PPMM LITERATURE REVIEW Nonoperative Treatment of Neurogenic Claudication • Ammendolia et al Most patients who seek care for neurogenic claudication 12-item criteria that signifi cantly increases the risk of bias, are treated nonoperatively. 7 A course of conservative treat- such as very high dropout or crossover rates. ment is also recommended prior to surgical intervention. 7 For each comparison, outcomes were analyzed according However, what constitutes effective conservative or nonop- to these follow-up periods: immediate (up to 1 wk), short- erative treatment is unknown. 7 , 8 The purpose of this review term (between 1 wk and 3 mo), intermediate (between 3 mo is to evaluate the clinical effectiveness of nonoperative treat- and 1 yr), and long-term (1 yr or longer). Outcome data were ments of lumbar spinal stenosis with neurogenic claudication pooled and meta-analyses were performed when trials were systematically. judged to be suffi ciently both clinically and statistically homo- geneous. MATERIALS AND METHODS Data Synthesis Search and Study Selection The quality of the evidence for each outcome and for each An electronic search was performed by an experienced librar- comparison was evaluated using Grades of Recommenda- ian from the Cochrane Back Review Group in CENTRAL tions, Assessment, Development, and Evaluation (GRADE). 9 , 10 (Cochrane Library 2011, issue 1), MEDLINE (1966 to The overall quality of the evidence is based on performance January 2011), EMBASE (1980 to January 2011), CINAHL against 5 domains: (1) risk of bias, (2) consistency of fi ndings, (1982 to January 2011), and Index to Chiropractic Literature (3) directness comparisons, (4) precision, and (5) other con- (1985 to January 2011). The terms “spinal stenosis,” “lumbar siderations such as selective reporting. spinal stenosis,” “neurogenic claudication,” “lumbar radicu- The quality of the evidence starts at high when there are lar pain,” “cauda equina,” and “spondylosis” were combined consistent fi ndings among at least 75% of RCTs with no with a highly sensitive search strategy to identify randomized limitations of the study design; consistent, direct, and precise controlled trials (RCTs). data; and no known or suspected publication bias. It reduces Studies were included if they were RCTs published in a level for each domain not met. Treatment effects between English, at least 1 arm of the trial provided data on effec- comparators (more effective, less effective, or no difference) tiveness of a nonoperative treatment, and at least 80% of were based on statistically signifi cant differences in outcomes. subjects had neurogenic claudication with lumbar spinal High-quality evidence: All 5 domains are met; further stenosis confi rmed by imaging. Neurogenic claudication research is very unlikely to change the confi dence in the was defi ned as buttock or leg pain or aching, numbness, estimate of effect. tingling, weakness, or fatigue with or without back pain, Moderate-quality evidence : One of the domains is not met; precipitated by standing or walking. At least 1 of these out- further research is likely to have an important impact on the comes had to be measured: walking ability, pain intensity, confi dence in the estimate of effect and may change the esti- function, quality of life, and global improvement. Studies mate. evaluating subjects with radiculopathy due to disc lesions Low-quality evidence : Two domains are not met; further were excluded. research is very likely to have an important impact in the con- Studies with mixed populations were included only if sepa- fi dence of the estimate of effect and is likely to change the rate data for subjects with neurogenic claudication due lum- estimate. bar spinal stenosis were provided. Very low evidence : Three or more domains are not met; Two reviewers (C.A. and K.S.) independently screened all there is great uncertainty about the estimate of effect. titles and abstracts identifi ed by the search strategy. Full text Evidence provided by a
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