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Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis

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Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis Y Degenerative Spinal Stenosis | NASS Clinical Guidelines 1 G Evidence-Based Clinical Guidelines for Multidisciplinary ETHODOLO Spine Care M NE I DEL I U /G ON Diagnosis and Treatment of I NTRODUCT Degenerative Lumbar I Spinal Stenosis NASS Evidence-Based Clinical Guidelines Committee D. Scott Kreiner, MD Jeffrey Summers, MD Committee Co-Chair, Natural History Co-Chair Medical/Interventional Treatment Chair William O. Shaffer, MD John Toton, MD Committee Co-Chair, Natural History Co-Chair Surgical Treatment Chair Jamie Baisden, MD Steven Hwang, MD Outcome Measures Chair Richard Mendel, MD Thomas Gilbert, MD Charles Reitman, MD Diagnosis/Imaging Chair This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason- ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the phy- sician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution I NTRODUCT 2 Degenerative Spinal Stenosis | NASS Clinical Guidelines I ON Financial Statement This clinical guideline was developed and funded in its entirety by the North American Spine Society (NASS). All partici- /G pating authors have disclosed potential conflicts of interest consistent with NASS’ disclosure policy. Disclosures are listed U I DEL below: I NE Jamie L. Baisden Nothing to disclose. M Thomas J. Gilbert Scientific Advisory Board: Steady State Imaging (Financial, option on 20,000 shares); Other Of- ETHODOLO fice: Medical Director (Financial, option on 20,000 shares ). Steven W. Hwang Nothing to disclose. D. Scott Kreiner Nothing to disclose. G Y Richard C. Mendel Nothing to disclose. Charles A. Reitman Nothing to disclose. William O. Shaffer Consulting: DePuy Spine (Financial, Level B consulting, iliolumbar module 12/09 and none since, Paid directly to institution/employer); Trips/Travel: Synthes (Financial, ProDisc C course. I paid for travel, lodging, meals and car rental. Training at no cost); Relationships Outside the One Year Requirement: DePuy Spine (Upcoming Committee Meeting [Cervical Epidural Work Group], 01/2007, Royalties, Level C for sacropelvic module). Jeffrey T. Summers Board of Directors: First Choice Insurance Group (Financial, I am the Pain Management repre- sentative to the Board. There is a Level A remuneration for each Board meeting attended during weekdays. In the past year, I have been paid Level A), International Spine Intervention Society (ISIS) (Nonfinancial, I am on the ISIS Board of Directors. I also serve as Treasurer. Travel expens- es (airfare, hotel and parking) are provided when traveling to a Board meeting (official business only)). John F. Toton Nothing to disclose. ________________________________________ Range Key: Level A. $100 to $1,000 Level B. $1,001 to $10,000 Level C. $10,001 to $25,000 Level D. $25,001 to $50,000 Level E. $50,001 to $100,000 Level F. $100,001 to $500,000 Level G. $500,001 to $1M Level H. $1,000,001 to $2.5M Level I. Greater than $2.5M Comments Comments regarding the guideline may be submitted to the North American Spine Society and will be considered in de- velopment of future revisions of the work. North American Spine Society Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis Copyright © 2011 North American Spine Society 7075 Veterans Boulevard Burr Ridge, IL 60527 USA 630.230.3600 www.spine.org ISBN 1-929988-29-X This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason- ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the phy- sician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution Y Degenerative Spinal Stenosis | NASS Clinical Guidelines 3 G Table of Contents ETHODOLO M NE I DEL I I. Introduction ...................................................................4 U /G ON II. Guideline Development Methodology ..............................................5 I III. Natural History of Spinal Stenosis .................................................8 NTRODUCT IV. Recommendations for Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis.....12 I A. Diagnosis/Imaging ......................................................................12 B. Outcome Measures for Treatment .........................................................37 C. Medical/Interventional Treatment ..........................................................38 D. Surgical Treatment......................................................................56 V. Appendices...................................................................71 A. Acronyms ............................................................................71 B. Levels of Evidence for Primary Research Questions ...........................................72 C. Grades of Recommendations for Summaries or Reviews of Studies ..............................73 D. Linking Levels of Evidence to Grades of Recommendation......................................74 VI. References . 90 A technical report, including the literature search parameters and evidentiary tables developed by the authors, can be accessed at http://www.spine.org/Documents/2011StenosisTechReport.pdf This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason- ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the phy- sician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution I NTRODUCT 4 Degenerative Spinal Stenosis | NASS Clinical Guidelines I ON I. Introduction /G U I DEL Objective outlines treatment options for adult patients with a diagnosis of I NE The objective of the North American Spine Society (NASS) Clin- degenerative lumbar spinal stenosis. M ical Guideline for the Diagnosis and Treatment of Degenerative THIS GUIDELINE DOES NOT REPRESENT A “STAN- ETHODOLO Lumbar Spinal Stenosis is to provide evidence-based recom- mendations to address key clinical questions surrounding the DARD OF CARE,” nor is it intended as a fixed treatment pro- diagnosis and treatment of degenerative lumbar spinal steno- tocol. It is anticipated that there will be patients who will require sis. The guideline is intended to reflect contemporary treatment less or more treatment than the average. It is also acknowledged G concepts for symptomatic degenerative lumbar spinal stenosis as that in atypical cases, treatment falling outside this guideline Y reflected in the highest quality clinical literature available on this will sometimes be necessary. This guideline should not be seen subject as of July 2010. The goals of the guideline recommenda- as prescribing the type, frequency or duration of intervention. tions are to assist in delivering optimum, efficacious treatment Treatment should be based on the individual patient’s need and and functional recovery from this spinal disorder. doctor’s professional judgment and experience. This document is designed to function as a guideline and should not be used as Scope, Purpose and Intended User the sole reason for denial of treatment and services. This guide- line is not intended to expand or restrict a health care provider’s This document was developed by the North American Spine So- scope of practice or to supersede applicable ethical standards or ciety Evidence-based Guideline Development Committee as an provisions of law. educational tool to assist practitioners who treat patients with degenerative lumbar spinal stenosis. The goal is to provide a tool that assists practitioners in improving the quality and efficiency Patient Population of care delivered to patients with degenerative lumbar spinal The patient population for this guideline encompasses adults (18 stenosis. The NASS Clinical Guideline for the Diagnosis and years or older) with a chief complaint of neurogenic claudication Treatment of Degenerative Lumbar Spinal Stenosis provides a without associated spondylolisthesis. Furthermore, the nature of definition and explanation of the natural history of degenerative the pain and associated patient characteristics (eg, age) should lumbar spinal stenosis, outlines a reasonable evaluation of pa- be more typical of a diagnosis of spinal stenosis than herniated tients suspected to have degenerative lumbar spinal stenosis and disc. This clinical guideline should not be construed as including all proper methods of care or excluding or other acceptable methods of care reason- ably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the phy- sician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution Y Degenerative Spinal Stenosis | NASS Clinical Guidelines 5 G II. Guideline Development Methodology ETHODOLO M NE Through objective evaluation of the evidence and transparency cate the strength of the recommendations made in the guideline I DEL in the process of making recommendations, it is NASS’ goal to based on the quality of the literature. I develop
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