Lumbar spinal stenosis - Surgery or manipulation? 2011

This systematic review compares the effectiveness of surgery vs. conservative treatment on pain, disability and loss of quality of life caused by symptomatic lumbar spinal stenosis (LSS).

Lumbar spinal stenosis is reported as the most common reason for spine surgery in subjects over 65 years.

 Randomized controlled trials (RCTs) comparing any form of conservative and surgical treatment were searched for in CENTRAL, Medline, EMBASE and TripDatabase databases until July 2009, with no language restrictions. Additional data was requested from the authors of the original studies and the methodological quality of each study was assessed independently by two reviewers.

739 papers were reviewed. Eleven publications corresponding to five RCTs were included. All five scored as high quality, despite concerns deriving from heterogeneity of treatment, lack of blinding and potential differences in the size of the placebo effect across groups. They included a total of 918 patients in whom conservative treatments had failed for 3-6 months, and included orthosis, rehabilitation, physical therapy, exercise, heat and cold, TENS, ultrasounds, analgesics, non steroidal anti-inflammatory drugs and epidural steroids.

Surgical treatments included the implantation of a specific type of interspinous device and decompressive surgery (with and without fusion, instrumented or not).

In all the studies, surgery showed better results for pain, disability and quality of life, although not for walking ability. Results of surgery were similar among patients with and without spondylolisthesis, and slightly better among those with neurogenic claudication than among those without it.

The advantage of surgery was noticeable at 3-6 months and remained for up to 2-4 years, although at the end of that period differences tended to be smaller.

Conclusions: In patients with symptomatic LSS, the implantation of a specific type of device or decompressive surgery, with or without fusion, are more effective than continued conservative treatment when the latter has failed for 3-6 months


Kovacs FM, Urrútia G, Alarcón JD.     Spine (Phila Pa 1976). 2011 Feb 9

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