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Li P, Shi Z, Jiang Y, Peng Z, Wang Y. Clinical Observation of 10-mm Endoscopic Minimally Invasive Interlaminar Decompression in the Treatment of Ossified Lumbar Spinal Stenosis. World Neurosurg 2024:S1878-8750(24)00609-0. [PMID: 38621501 DOI: 10.1016/j.wneu.2024.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE This study aims to observe the safety and effectiveness of 10-mm endoscopic minimally invasive interlaminar decompression in the treatment of ossified lumbar spinal stenosis. METHODS The clinical data of 50 consecutive patients with ossified lumbar spinal stenosis were retrospectively analyzed. All patients underwent minimally invasive interlaminar decompression with 10-mm endoscope. Patient demographics, perioperative data, and clinical outcomes were recorded. Visual analog scale scores, Oswestry disability index scores, and modified Macnab criteria were used to assess clinical outcomes. The lateral recess angle, real spinal canal area, and effective intervertebral foramen area were used to assess the effect of decompression. RESULTS The mean age of all patients was 59.0 ± 12.3 years. The mean operative time and intraoperative blood loss were 43.7 ± 8.7 minutes and <20 ml, respectively. Two years after surgery, the leg pain Visual analog scale score decreased from 7.4 ± 1.0 to 1.6 ± 0.6 (P < 0.05) and the Oswestry disability index score decreased from 63.8 ± 7.6 to 21.7 ± 3.4 (P < 0.05). The lateral recess angle, real spinal canal area and effective intervertebral foramen area were significantly larger than before surgery (P < 0.05). The overall excellent and good rate at the last follow-up was 92.0% according to the modified Macnab criteria. CONCLUSIONS The 10-mm endoscopic minimally invasive interlaminar decompression can safely and effectively remove the ossification in the spinal canal and achieve adequate decompression in patients with ossified lumbar spinal stenosis.
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Affiliation(s)
- Pengfei Li
- Department of Orthopedic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Zhen Shi
- Department of Orthopedic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Yunduo Jiang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Zhibin Peng
- Department of Orthopedic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Yansong Wang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China; NHC Key Laboratory of Cell Transplantation, Harbin Medical University, Harbin, China; Heilongjiang Provincial Key Laboratory of Hard Tissue Development and Regeneration, Harbin Medical University, Harbin, China.
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Rajjoub R, Arroyave JS, Zaidat B, Ahmed W, Mejia MR, Tang J, Kim JS, Cho SK. ChatGPT and its Role in the Decision-Making for the Diagnosis and Treatment of Lumbar Spinal Stenosis: A Comparative Analysis and Narrative Review. Global Spine J 2024; 14:998-1017. [PMID: 37560946 PMCID: PMC11192138 DOI: 10.1177/21925682231195783] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Abstract
STUDY DESIGN Comparative Analysis and Narrative Review. OBJECTIVE To assess and compare ChatGPT's responses to the clinical questions and recommendations proposed by The 2011 North American Spine Society (NASS) Clinical Guideline for the Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis (LSS). We explore the advantages and disadvantages of ChatGPT's responses through an updated literature review on spinal stenosis. METHODS We prompted ChatGPT with questions from the NASS Evidence-based Clinical Guidelines for LSS and compared its generated responses with the recommendations provided by the guidelines. A review of the literature was performed via PubMed, OVID, and Cochrane on the diagnosis and treatment of lumbar spinal stenosis between January 2012 and April 2023. RESULTS 14 questions proposed by the NASS guidelines for LSS were uploaded into ChatGPT and directly compared to the responses offered by NASS. Three questions were on the definition and history of LSS, one on diagnostic tests, seven on non-surgical interventions and three on surgical interventions. The review process found 40 articles that were selected for inclusion that helped corroborate or contradict the responses that were generated by ChatGPT. CONCLUSIONS ChatGPT's responses were similar to findings in the current literature on LSS. These results demonstrate the potential for implementing ChatGPT into the spine surgeon's workplace as a means of supporting the decision-making process for LSS diagnosis and treatment. However, our narrative summary only provides a limited literature review and additional research is needed to standardize our findings as means of validating ChatGPT's use in the clinical space.
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Affiliation(s)
- Rami Rajjoub
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Juan Sebastian Arroyave
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bashar Zaidat
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Wasil Ahmed
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mateo Restrepo Mejia
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Justin Tang
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jun S. Kim
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samuel K. Cho
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Peene L, Cohen SP, Kallewaard JW, Wolff A, Huygen F, Gaag AVD, Monique S, Vissers K, Gilligan C, Van Zundert J, Van Boxem K. 1. Lumbosacral radicular pain. Pain Pract 2024; 24:525-552. [PMID: 37985718 DOI: 10.1111/papr.13317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Patients suffering lumbosacral radicular pain report radiating pain in one or more lumbar or sacral dermatomes. In the general population, low back pain with leg pain extending below the knee has an annual prevalence that varies from 9.9% to 25%. METHODS The literature on the diagnosis and treatment of lumbosacral radicular pain was reviewed and summarized. RESULTS Although a patient's history, the pain distribution pattern, and clinical examination may yield a presumptive diagnosis of lumbosacral radicular pain, additional clinical tests may be required. Medical imaging studies can demonstrate or exclude specific underlying pathologies and identify nerve root irritation, while selective diagnostic nerve root blocks can be used to confirm the affected level(s). In subacute lumbosacral radicular pain, transforaminal corticosteroid administration provides short-term pain relief and improves mobility. In chronic lumbosacral radicular pain, pulsed radiofrequency (PRF) treatment adjacent to the spinal ganglion (DRG) can provide pain relief for a longer period in well-selected patients. In cases of refractory pain, epidural adhesiolysis and spinal cord stimulation can be considered in experienced centers. CONCLUSIONS The diagnosis of lumbosacral radicular pain is based on a combination of history, clinical examination, and additional investigations. Epidural steroids can be considered for subacute lumbosacral radicular pain. In chronic lumbosacral radicular pain, PRF adjacent to the DRG is recommended. SCS and epidural adhesiolysis can be considered for cases of refractory pain in specialized centers.
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Affiliation(s)
- Laurens Peene
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
| | - Steven P Cohen
- Pain Medicine Division, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jan Willem Kallewaard
- Department of Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Velp, The Netherlands
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Andre Wolff
- Department of Anesthesiology UMCG Pain Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Huygen
- Department of Anesthesiology and Pain Medicine, Erasmusmc, Rotterdam, The Netherlands
- Department of Anesthesiology and Pain Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Antal van de Gaag
- Department of Anesthesiology and Pain Medicine, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - Steegers Monique
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University, Nijmegen, The Netherlands
| | - Chris Gilligan
- Department of Anesthesiology and Pain Medicine, Brigham & Women's Spine Center, Boston, Massachusetts, USA
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk/Lanaken, Belgium
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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Suputtitada A, Chen CPC, Pongpirul K. Mechanical Needling With Sterile Water Versus Lidocaine Injection for Lumbar Spinal Stenosis. Global Spine J 2024; 14:82-92. [PMID: 35510334 PMCID: PMC10676179 DOI: 10.1177/21925682221094533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Study Design: This was a retrospective observational study that assessed the clinical outcome of ageing patients who received ultrasound-guided (USG) mechanical needling with sterile water injection. In addition, the clinical outcome of age-and gender matched patients randomly selected from patients who received needling with sterile water was compared to the patients injected with lidocaine in a 1:1 ratio.Objective: This present study aimed to explore the clinical effects of USG mechanical needling with sterile water injection for lumbar spinal stenosis (LSS).Methods: The data was extracted from the medical records of ageing patients with LSS who received USG injection at the lumbosacral spine by the first author. Low back pain or axial pain, and leg pain or radicular pain were assessed by the visual analogue scale, and gait ability with walking distance were obtained at six different time points.Results: A total of 4328 medical records were examined. Four thousand two hundred and twenty-eight ageing patients received mechanical needling with sterile water injection and found the efficacy lasted up to 6 months. One hundred patients were compared with 100 patients who received lidocaine injection. Those who received lidocaine had pain returned at 3 months and 6 months post-injection.Conclusions: USG mechanical needling with sterile water injection could help relieve axial and radicular pain for at least 6 months. Removal of calcification and fibrosis as well as reduction of sensitization are all possible mechanisms.
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Affiliation(s)
- Areerat Suputtitada
- Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Carl P. C. Chen
- Department of Physical Medicine & Rehabilitation, Chang Gung Memorial Hospital at Linkou, College of Medicine,Chang Gung University, Taoyuan, Taiwan
| | - Krit Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Kirker K, Masaracchio MF, Loghmani P, Torres-Panchame RE, Mattia M, States R. Management of lumbar spinal stenosis: a systematic review and meta-analysis of rehabilitation, surgical, injection, and medication interventions. Physiother Theory Pract 2023; 39:241-286. [PMID: 34978252 DOI: 10.1080/09593985.2021.2012860] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Lumbar spinal stenosis (LSS) has a substantial impact on mobility, autonomy, and quality of life. Previous reviews have demonstrated inconsistent results and/or have not delineated between specific nonsurgical interventions. OBJECTIVE The purpose of this systematic review is to assess the effectiveness of interventions in the management of LSS. METHODS Eligible studies were randomized controlled trials (RCTs) or prospective studies, included patients with LSS, assessed the effectiveness of any interventions (rehabilitation, surgical, injection, medication), included at least two intervention groups, and included at least one measure of pain, disability, ambulation assessment, or LSS-specific symptoms. Eighty-five articles met inclusion criteria. Meta-analyses were conducted across outcomes. Effect sizes were calculated using Hedge's g and reported descriptively. Formal grading of evidence was conducted. RESULTS Meta-analysis comparing rehabilitation to no treatment/placebo demonstrated significant effects on pain favoring rehabilitation (mean difference, MD -1.63; 95% CI: -2.68, -0.57; I2 = 71%; p = .002). All other comparisons to no treatment/placebo revealed nonsignificant findings. The level of evidence ranged from very low to high for rehabilitation and medication versus no treatment/placebo for pain, disability, ambulation ability, and LSS symptoms. CONCLUSIONS Although the findings of this review are inconclusive regarding superiority of interventions, this accentuates the value of multimodal patient-centered care in the management of patients with LSS.
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Affiliation(s)
- Kaitlin Kirker
- Department of Physical Therapy, Long Island University, Brooklyn, NY, USA
| | | | - Parisa Loghmani
- Department of Physical Therapy, Long Island University, Brooklyn, NY, USA
| | | | - Michael Mattia
- Department of Allied Health, Kingsborough Community College, Brooklyn, NY, USA
| | - Rebecca States
- Department of Physical Therapy, Long Island University, Brooklyn, NY, USA
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Kawakami M, Takeshita K, Inoue G, Sekiguchi M, Fujiwara Y, Hoshino M, Kaito T, Kawaguchi Y, Minetama M, Orita S, Takahata M, Tsuchiya K, Tsuji T, Yamada H, Watanabe K. Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication. J Orthop Sci 2023; 28:46-91. [PMID: 35597732 DOI: 10.1016/j.jos.2022.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/17/2022] [Accepted: 03/29/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine. METHODS The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members. RESULTS Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided. CONCLUSIONS The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.
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Affiliation(s)
| | | | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University, Japan
| | - Miho Sekiguchi
- Department of Orthopaedic Surgery, Fukushima Medical University, Japan
| | - Yasushi Fujiwara
- Department of Orthopaedic Surgery, Hiroshima City Asa Citizens Hospital, Japan
| | - Masatoshi Hoshino
- Department of Orthopaedic Surgery, Osaka City General Hospital, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Osaka University, Japan
| | | | - Masakazu Minetama
- Spine Care Center, Wakayama Medical University Kihoku Hospital, Japan
| | - Sumihisa Orita
- Center for Frontier Medical Engineering (CFME), Department of Orthopaedic Surgery, Chiba University, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Hokkaido University Graduate School of Medicine, Japan
| | | | - Takashi Tsuji
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Japan
| | - Hiroshi Yamada
- Department of Orthopaedic Surgery, Wakayama Medical University, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, Keio University, Japan
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Lee Y, Issa TZ, Kanhere AP, Lambrechts MJ, Ciesielka KA, Kim J, Hilibrand AS, Kepler CK, Schroeder GD, Vaccaro AR, Canseco JA. Preoperative epidural steroid injections do not increase the risk of postoperative infection in patients undergoing lumbar decompression or fusion: a systematic review and meta-analysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3251-3261. [PMID: 36322212 DOI: 10.1007/s00586-022-07436-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 09/29/2022] [Accepted: 10/24/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Epidural corticosteroid injections (ESI) are a mainstay of nonoperative treatment for patients with lumbar spine pathology. Recent literature evaluating infection risk following ESI after elective orthopedic surgery has produced conflicting evidence. Our primary objective was to review the literature and provide a larger meta-analysis analyzing the temporal effects of steroid injections on the risk of infection following lumbar spine surgery. METHODS We conducted a query of the PubMed, Embase, and Scopus databases from inception until April 1, 2022 for studies evaluating the risk of infection in the setting of prior spinal steroid injections in patients undergoing lumbar spine decompression or fusion. Three meta-analyses were conducted, (1) comparing ESI within 30-days of surgery to control, (2) comparing ESI within 30-days to ESI between 1 and 3 months preoperatively, and (3) comparing any history of ESI prior to surgery to control. Tests of proportions were utilized for all comparisons between groups. Study heterogeneity was assessed via forest plots, and publication bias was assessed quantiatively via funnel plots and qualitatively with the Newcastle-Ottawa Scale. RESULTS Nine total studies were included, five of which demonstrated an association between ESI and postoperative infection, while four found no association. Comparison of weighted means demonstrated no significant difference in infection rates between the 30-days ESI group and control group (2.67% vs. 1.69%, p = 0.144), 30-days ESI group and the > 30-days ESI group (2.34% vs. 1.66%, p = 0.1655), or total ESI group and the control group (1.99% vs. 1.70%, p = 0.544). Heterogeneity was low for all comparisons following sensitivity analyses. CONCLUSION Current evidence does not implicate preoperative ESI in postoperative infection rates following lumbar fusion or decompression. Operative treatment should not be delayed due to preoperative steroid injections based on current evidence. There remains a paucity of high-quality data in the literature evaluating the impact of preoperative ESI on postoperative infection rates. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA.
| | - Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Arun P Kanhere
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Mark J Lambrechts
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Kerri-Anne Ciesielka
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - James Kim
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut St, 5th Floor, Philadelphia, PA, 19107, USA
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Godek P, Szczepanowska-Wolowiec B, Golicki D. GOLDIC therapy in degenerative lumbar spinal stenosis: randomized, controlled trial. Regen Med 2022; 17:709-718. [PMID: 35899459 DOI: 10.2217/rme-2022-0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Comparison of the efficacy of conservative treatment methods: epidural GOLDIC serum, epidural steroid injections, manual therapy. Materials & methods: A randomized, controlled trial. Three groups, each containing 30 patients. GOLDIC or steroid injections (dexamethasone) epidural versus manual therapy. Assessment: initial assessment and 4 (T1), 12 (T2) and 24 (T3) weeks after the last intervention. Primary outcomes: Pain intensity in numeric rating scale, Oswestry disability index, Zurich claudication questionnaire, EQ-5D-5L questionnaire. Results: GOLDIC has shown the highest mean differences and number of cases with minimal important difference among groups for every primary outcome. Conclusion: GOLDIC therapy could be a new option for the nonoperative, symptomatic treatment of degenerative lumbar spinal stenosis and is not inferior to epidural steroid injections and manual therapy.
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Affiliation(s)
- Piotr Godek
- Sutherland Medical Center, Warsaw, 04-036, Poland
| | | | - Dominik Golicki
- Department of Experimental & Clinical Pharmacology, Medical University of Warsaw, Warsaw, 02-091, Poland
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Sayeed Y, Chang RG, Chhatre A, Vallabh J, Soin A, Mauck WD, Duszynski BS, Kreiner DS. Response to: Reply to Sayeed et al. J Occup Environ Med 2022; 64:e389-e390. [PMID: 35761428 DOI: 10.1097/jom.0000000000002547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Abstract
IMPORTANCE Lumbar spinal stenosis is a prevalent and disabling cause of low back and leg pain in older persons, affecting an estimated 103 million persons worldwide. Most are treated nonoperatively. Approximately 600 000 surgical procedures are performed in the US each year for lumbar spinal stenosis. OBSERVATIONS The prevalence of the clinical syndrome of lumbar spinal stenosis in US adults is approximately 11% and increases with age. The diagnosis can generally be made based on a clinical history of back and lower extremity pain that is provoked by lumbar extension, relieved by lumbar flexion, and confirmed with cross-sectional imaging, such as computed tomography or magnetic resonance imaging (MRI). Nonoperative treatment includes activity modification such as reducing periods of standing or walking, oral medications to diminish pain such as nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy. In a series of patients with lumbar spinal stenosis followed up for up to 3 years without operative intervention, approximately one-third of patients reported improvement, approximately 50% reported no change in symptoms, and approximately 10% to 20% of patients reported that their back pain, leg pain, and walking were worse. Long-term benefits of epidural steroid injections for lumbar spinal stenosis have not been demonstrated. Surgery appears effective in carefully selected patients with back, buttock, and lower extremity pain who do not improve with conservative management. For example, in a randomized trial of 94 participants with symptomatic and radiographic degenerative lumbar spinal stenosis, decompressive laminectomy improved symptoms more than nonoperative therapy (difference, 7.8 points; 95% CI, 0.8-14.9; minimum clinically important difference, 10-12.8) on the Oswestry Disability Index (score range, 0-100). Among persons with lumbar spinal stenosis and concomitant spondylolisthesis, lumbar fusion increased symptom resolution in 1 trial (difference, 5.7 points; 95% CI, 0.1 to 11.3) on the 36-Item Short Form Health Survey physical dimension score (range, 0-100), but 2 other trials showed either no important differences between the 2 therapies or noninferiority of lumbar decompression alone compared with lumbar decompression plus spinal fusion (MCID, 2-4.9 points). In a noninferiority trial, 71.4% treated with lumbar decompression alone vs 72.9% of those receiving decompression plus fusion achieved a 30% or more reduction in Oswestry Disability Index score, consistent with the prespecified noninferiority hypothesis. Fusion is associated with greater risk of complications such as blood loss, infection, longer hospital stays, and higher costs. Thus, the precise indications for concomitant lumbar fusion in persons with lumbar spinal stenosis and spondylolisthesis remain unclear. CONCLUSIONS AND RELEVANCE Lumbar spinal stenosis affects approximately 103 million people worldwide and 11% of older adults in the US. First-line therapy is activity modification, analgesia, and physical therapy. Long-term benefits from epidural steroid injections have not been established. Selected patients with continued pain and activity limitation may be candidates for decompressive surgery.
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Affiliation(s)
- Jeffrey N Katz
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Zoe E Zimmerman
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hanna Mass
- Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Melvin C Makhni
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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William J, Roehmer C, Mansy L, Kennedy DJ. Epidural Steroid Injections. Phys Med Rehabil Clin N Am 2022; 33:215-231. [DOI: 10.1016/j.pmr.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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12
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Travis R, Andersson GBJ, Belcourt RM, Carragee EJ, Eskay-Auerbach M, Goertz M, Haldeman S, Hegmann KT, Lessenger JE, Mayer T, Mueller KL, Murphy DR, Tellin WG, Thiese MS, Weiss MS, Harris JS. Reply to Sayeed et al. J Occup Environ Med 2022; 64:e84-e86. [PMID: 34873136 DOI: 10.1097/jom.0000000000002453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Russell Travis
- RACOEM Evidence-based Practice Spine Panel University of Utah Salt Lake City, Utah
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Ammendolia C, Hofkirchner C, Plener J, Bussières A, Schneider MJ, Young JJ, Furlan AD, Stuber K, Ahmed A, Cancelliere C, Adeboyejo A, Ornelas J. Non-operative treatment for lumbar spinal stenosis with neurogenic claudication: an updated systematic review. BMJ Open 2022; 12:e057724. [PMID: 35046008 PMCID: PMC8772406 DOI: 10.1136/bmjopen-2021-057724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Neurogenic claudication due to lumbar spinal stenosis (LSS) is a growing health problem in older adults. We updated our previous Cochrane review (2013) to determine the effectiveness of non-operative treatment of LSS with neurogenic claudication. DESIGN A systematic review. DATA SOURCES CENTRAL, MEDLINE, EMBASE, CINAHL and Index to Chiropractic Literature databases were searched and updated up to 22 July 2020. ELIGIBILITY CRITERIA We only included randomised controlled trials published in English where at least one arm provided data on non-operative treatment and included participants diagnosed with neurogenic claudication with imaging confirmed LSS. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed risk of bias using the Cochrane Risk of Bias Tool 1. Grading of Recommendations Assessment, Development and Evaluation was used for evidence synthesis. RESULTS Of 15 200 citations screened, 156 were assessed and 23 new trials were identified. There is moderate-quality evidence from three trials that: Manual therapy and exercise provides superior and clinically important short-term improvement in symptoms and function compared with medical care or community-based group exercise; manual therapy, education and exercise delivered using a cognitive-behavioural approach demonstrates superior and clinically important improvements in walking distance in the immediate to long term compared with self-directed home exercises and glucocorticoid plus lidocaine injection is more effective than lidocaine alone in improving statistical, but not clinically important improvements in pain and function in the short term. The remaining 20 new trials demonstrated low-quality or very low-quality evidence for all comparisons and outcomes, like the findings of our original review. CONCLUSIONS There is moderate-quality evidence that a multimodal approach which includes manual therapy and exercise, with or without education, is an effective treatment and that epidural steroids are not effective for the management of LSS with neurogenic claudication. All other non-operative interventions provided insufficient quality evidence to make conclusions on their effectiveness. PROSPERO REGISTRATION NUMBER CRD42020191860.
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Affiliation(s)
- Carlo Ammendolia
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Rheumatology, Sinai Health System, Toronto, Ontario, Canada
| | - Corey Hofkirchner
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Joshua Plener
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - André Bussières
- School of Physical and Occupational Therapy, Faculy of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Département Chiropratique, Université du Québec à Trois-Rivières, boulevard des Forges, Trois-Rivières Québec, Canada
| | | | - James J Young
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
- Sports Medicine and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Andrea D Furlan
- Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Institute for Work & Health, Toronto, Ontario, Canada
| | - Kent Stuber
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Aksa Ahmed
- Rheumatology, Sinai Health System, Toronto, Ontario, Canada
| | - Carol Cancelliere
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Aleisha Adeboyejo
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Joseph Ornelas
- Health Systems Management, Rush University, Chicago, Illinois, USA
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Schmidt CT, Ogarek J, Resnik L. Physical Therapy and Health Care Utilization for Older Adults With Lumbar Spinal Stenosis. J Geriatr Phys Ther 2021; 45:E145-E154. [PMID: 34570040 DOI: 10.1519/jpt.0000000000000328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND PURPOSE Lumbar spinal stenosis (LSS) is associated with high health care utilization for older adults. Physical therapy (PT) offers low medical risk and reduced cost burden with functional outcomes that appear to be equivalent to higher risk interventions such as surgery. However, it is unknown whether receipt of PT following incident LSS diagnosis is associated with reduced health care utilization. The objectives of this study were to: (1) compare health characteristics for Medicare beneficiaries who received outpatient PT within 30 days of incident LSS diagnosis to those who did not; (2) compare the 1-year utilization rates for specific health care services for these 2 groups; and (3) quantify the likelihood of progression to specific health services based on the receipt of PT. METHODS This was a retrospective cohort study using nationally representative claims data for Medicare Part B beneficiaries between 2007 and 2010. Lumbar spinal stenosis was determined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Beneficiaries 65 years and older were classified into 2 groups (PT and no PT) based on receipt of PT within 30 days of initial diagnosis. Baseline characteristics were identified at incident diagnosis. Hazard ratios (HRs) were estimated for the risk of receiving health services outcomes including spinal surgery, spinal injections, chiropractic care, advanced imaging, spinal radiographs, opioid medication, nonopioid analgesics, and hospitalizations beginning on day 31 up to 1 year following incident LSS diagnosis. RESULTS AND DISCUSSION Among 60 646 Medicare beneficiaries with incident LSS who met the inclusion criteria, 1124 were classified in the PT group and 59 522 in the no PT group. Compared with the PT group, beneficiaries in the no PT group had a greater risk of having hospitalizations (HR = 1.40), opioid medications (HR = 1.29), spinal surgery (HR = 1.29), and spinal radiographs (HR = 1.19) within 1 year. CONCLUSIONS Fewer than 2% of Medicare beneficiaries received PT within 30 days of initial LSS diagnosis. Receipt of PT was associated with less utilization of higher risk and costly health services for 1 year. These results may inform practitioners when making early decisions about rehabilitative care for older adults with LSS.
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Affiliation(s)
- Catherine T Schmidt
- MGH Institute of Health Professions, Boston, Massachusetts. Center for Gerontology and Health Care Research, Brown University, Providence, Rhode Island. Providence VA Medical Center, Providence, Rhode Island
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Pryzbylkowski P, Bux A, Chandwani K, Khemlani V, Puri S, Rosenberg J, Sukumaran H. Minimally invasive direct decompression for lumbar spinal stenosis: impact of multiple prior epidural steroid injections. Pain Manag 2021; 12:149-158. [PMID: 34344197 DOI: 10.2217/pmt-2021-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: A modified algorithm for the treatment of lumbar spinal stenosis with hypertrophic ligamentum flavum using minimally-invasive lumbar decompression (mild®)was assessed, with a focus on earlier intervention. Patients & methods: Records of 145 patients treated with mild after receiving 0-1 epidural steroid injections (ESIs) or 2+ ESIs were retrospectively reviewed. Pain assessments as measured by visual analog scale (VAS) scores were recorded at baseline and 1-week and 3-month follow-ups. Results: Improvements in VAS scores at follow-ups compared with baseline were significant in both groups. No statistically significant differences were found between the two groups. Conclusion: Multiple ESIs prior to mild showed no benefit. A modified algorithm to perform mild immediately upon diagnosis or after the failure of the first ESI is recommended.
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Affiliation(s)
- Peter Pryzbylkowski
- Relievus Pain Management, 3100 Hingston Ave. Suite 104, Egg Harbor Township, NJ 08234, USA
| | - Anjum Bux
- Ephraim McDowell Regional Medical Center, 230 West Main St., Danville, KY 40422, USA
| | - Kailash Chandwani
- UNC Health Southeastern, 4901 Dawn Dr. Suite 3300, Lumberton, NC 28358, USA
| | - Vishal Khemlani
- Columbia Pain Management, PC, 3601 Klindt Dr. Suite 200, The Dalles, OR 97058, USA
| | - Shawn Puri
- Relievus Pain Management, 9815 Roosevelt Blvd Suite J, Philadelphia, PA 19114, USA
| | - Jason Rosenberg
- SC Pain & Spine Specialists, 4731 Hwy 17 Bypass South, Murrells Inlet, SC 29576, USA
| | - Harry Sukumaran
- The Detroit Medical Center, 3990 John R, Box 162, Detroit, MI 48201, USA
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Schaaf S, Huang W, Perera S, Conley Y, Belfer I, Jayabalan P, Tremont K, Coelho P, Ernst S, Cortazzo M, Weiner D, Vo N, Kang J, Sowa G. Association of Protein and Genetic Biomarkers With Response to Lumbar Epidural Steroid Injections in Subjects With Axial Low Back Pain. Am J Phys Med Rehabil 2021; 100:48-56. [PMID: 32576742 PMCID: PMC8128510 DOI: 10.1097/phm.0000000000001514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this observational study was to examine the association of protein and genetic biomarkers with pain and pain-related disability in individuals with axial low back pain undergoing epidural steroid injections. DESIGN Forty-eight adults with axial low back pain undergoing an epidural steroid injection were recruited from an academic medical center. Blood samples were assayed at baseline and follow-up for plasma proteins and functional single-nucleotide polymorphisms associated with pain. Data regarding pain and function were collected at baseline and follow-up. The characteristics of responders (defined as 50% improvement in pain score) and nonresponders were compared, and the association between response and baseline biomarkers was examined. RESULTS Thirty-five percent of subjects were responders to injection. Responders had lower baseline plasma levels of chondroitin sulfate 846 and higher neuropeptide Y and serotonin levels than nonresponders, and baseline neuropeptide Y level correlated with change in disability levels. In addition, subjects with the variant allele for the catechol-O-methyltransferase single-nucleotide polymorphism demonstrated increased odds of responding to the injection. CONCLUSIONS These data identify candidates who may have utility for patient selection for spinal procedures and provide support for exploration in prospective studies to assess and validate their predictive ability.
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Affiliation(s)
- Stephen Schaaf
- From the Departments of Physical Medicine and Rehabilitation (SS, WH, PJ, KT, PC, SE, MC, GS), Medicine (SP, DW), and Orthopaedic Surgery (NV), University of Pittsburgh/UPMC, Pittsburgh, Pennsylvania; School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania (YC); National Institutes of Health, Bethesda, Maryland (IB); Shirley Ryan AbilityLab, Northwestern Feinberg School of Medicine, Chicago, Illinois (PJ); and Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts (JK)
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Xie P, Feng F, Chen Z, He L, Yang B, Chen R, Wu W, Liu B, Dong J, Shu T, Zhang L, Chen CM, Rong L. Percutaneous transforaminal full endoscopic decompression for the treatment of lumbar spinal stenosis. BMC Musculoskelet Disord 2020; 21:546. [PMID: 32799839 PMCID: PMC7429717 DOI: 10.1186/s12891-020-03566-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 08/03/2020] [Indexed: 11/10/2022] Open
Abstract
Background One advantage of an endoscopic approach to treating lumbar spinal stenosis is preservation of spine stability and the adjacent anatomy, and there is a decrease in adjacent segment disc degeneration. The purpose of this study was to discuss the clinical efficacy of percutaneous transforaminal endoscopic decompression for the treatment of lumbar spinal stenosis (LSS). Methods This is a retrospective study. From September 2012 to June 2017, 45 patients who were diagnosed with LSS underwent the treatment of percutaneous transforaminal endoscopic decompression (PTED) and were followed up at 1 week, 3 months and 1 year postoperatively. Low back pain and leg pain were measured by Visual Analogue Scale scoring methods (VAS-back and VAS-leg), while functional outcomes were assessed by using the Oswestry Disability Index (ODI). All patients had one-level lumbar spinal stenosis. Results The most common type of stenosis was lateral recess stenosis (n = 22; 48.9%), followed by central stenosis (n = 13; 28.9%) and foraminal stenosis (n = 10: 22.2%). Regarding comparisons of VAS-back, VAS-leg, and ODI scores before and after operation, VAS and ODI scores significantly improved. The average leg VAS score improved from 7.01 ± 0.84 to 2.28 ± 1.43 (P < 0.001). The average ODI improved from 46.18 ± 10.11 to 14.40 ± 9.59 (P < 0.001). We also examined changes in ODI and VAS scores from baseline according to types of spinal stenosis, stenosis grade, spinal instability, and revision surgery in the same segment. The improvement percentage of leg VAS score was significantly less in patients with severe stenosis at both 3 months and 1 year postoperatively. The improvement percentages of ODI and leg VAS scores were significantly less in patients who had spinal instability and patients who had undergone revision surgery. Conclusion The PTED approach seems to give good results for the treatment of LSS. However, this approach may be less effective for LSS patients who have lumbar instability or require revision surgery in the same segment.
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Affiliation(s)
- Peigen Xie
- Department of Spine Surgery, the 3rd Affiliated Hospital of Sun Yat-sen University, NO. 600 TianHe Road, TianHe District, GuangZhou, GuangDong Province, China
| | - Feng Feng
- Department of Spine Surgery, the 3rd Affiliated Hospital of Sun Yat-sen University, NO. 600 TianHe Road, TianHe District, GuangZhou, GuangDong Province, China
| | - Zihao Chen
- Department of Spine Surgery, the 3rd Affiliated Hospital of Sun Yat-sen University, NO. 600 TianHe Road, TianHe District, GuangZhou, GuangDong Province, China
| | - Lei He
- Department of Spine Surgery, the 3rd Affiliated Hospital of Sun Yat-sen University, NO. 600 TianHe Road, TianHe District, GuangZhou, GuangDong Province, China
| | - Bu Yang
- Department of Spine Surgery, the 3rd Affiliated Hospital of Sun Yat-sen University, NO. 600 TianHe Road, TianHe District, GuangZhou, GuangDong Province, China
| | - Ruiqiang Chen
- Department of Spine Surgery, the 3rd Affiliated Hospital of Sun Yat-sen University, NO. 600 TianHe Road, TianHe District, GuangZhou, GuangDong Province, China
| | - Wenbin Wu
- Department of Spine Surgery, the 3rd Affiliated Hospital of Sun Yat-sen University, NO. 600 TianHe Road, TianHe District, GuangZhou, GuangDong Province, China
| | - Bin Liu
- Department of Spine Surgery, the 3rd Affiliated Hospital of Sun Yat-sen University, NO. 600 TianHe Road, TianHe District, GuangZhou, GuangDong Province, China
| | - Jianwen Dong
- Department of Spine Surgery, the 3rd Affiliated Hospital of Sun Yat-sen University, NO. 600 TianHe Road, TianHe District, GuangZhou, GuangDong Province, China
| | - Tao Shu
- Department of Spine Surgery, the 3rd Affiliated Hospital of Sun Yat-sen University, NO. 600 TianHe Road, TianHe District, GuangZhou, GuangDong Province, China
| | - Liangming Zhang
- Department of Spine Surgery, the 3rd Affiliated Hospital of Sun Yat-sen University, NO. 600 TianHe Road, TianHe District, GuangZhou, GuangDong Province, China
| | - Chien-Min Chen
- Minimally Invasive Spine Center, Changhua Christian Hospital, No.135, Nansiao St., Changhua city, Changhua county, Taiwan.
| | - Limin Rong
- Department of Spine Surgery, the 3rd Affiliated Hospital of Sun Yat-sen University, NO. 600 TianHe Road, TianHe District, GuangZhou, GuangDong Province, China.
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Fornari M, Robertson SC, Pereira P, Zileli M, Anania CD, Ferreira A, Ferrari S, Gatti R, Costa F. Conservative Treatment and Percutaneous Pain Relief Techniques in Patients with Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations. World Neurosurg X 2020; 7:100079. [PMID: 32613192 PMCID: PMC7322792 DOI: 10.1016/j.wnsx.2020.100079] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/25/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Degenerative lumbar spinal stenosis (LSS) is a progressive disease with potentially dangerous consequences that affect quality of life. Despite the detailed literature, natural history is unpredictable. This uncertainty presents a challenge making the correct management decisions, especially in patients with mild to moderate symptoms, regarding conservative or surgical treatment. This article focused on conservative treatment for degenerative LSS. METHODS To standardize clinical practice worldwide as much as possible, the World Federation of Neurosurgical Societies Spine Committee held a consensus conference on conservative treatment for degenerative LSS. A team of experts in spinal disorders reviewed the literature on conservative treatment for degenerative LSS from 2008 to 2018 and drafted and voted on a number of statements. RESULTS During 2 consensus meetings, 14 statements were voted on. The Committee agreed on the use of physical therapy for up to 3 months in cases with no neurologic symptoms. Initial conservative treatment could be applied without major complications in these cases. In patients with moderate to severe symptoms or with acute radicular deficits, surgical treatment is indicated. The efficacy of epidural injections is still debated, as it shows only limited benefit in patients with degenerative LSS. CONCLUSIONS A conservative approach based on therapeutic exercise may be the first choice in patients with LSS except in the presence of significant neurologic deficits. Treatment with instrumental modalities or epidural injections is still debated. Further studies with standardization of outcome measures are needed to reach high-level evidence conclusions.
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Affiliation(s)
- Maurizio Fornari
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Scott C. Robertson
- Neurosurgery Department, Laredo Medical Center, University of the Incarnate Word School of Osteopathic Medicine, Laredo, Texas, USA
| | - Paulo Pereira
- Department of Neurosurgery, University Hospital Center of São João and Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mehmet Zileli
- Department of Neurosurgery, Ege University Faculty of Medicine, Bornova, Izmir, Turkey
| | - Carla D. Anania
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ana Ferreira
- Department of Neurosurgery, University Hospital Center of São João and Faculty of Medicine of the University of Porto, Porto, Portugal
| | | | | | - Francesco Costa
- Neurosurgery Department, Humanitas Research Hospital, Rozzano, Milan, Italy
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19
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Oliveira CB, Maher CG, Ferreira ML, Hancock MJ, Oliveira VC, McLachlan AJ, Koes BW, Ferreira PH, Cohen SP, Pinto RZ. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev 2020; 4:CD013577. [PMID: 32271952 PMCID: PMC7145384 DOI: 10.1002/14651858.cd013577] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Lumbosacral radicular pain (commonly called sciatica) is a syndrome involving patients who report radiating leg pain. Epidural corticosteroid injections deliver a corticosteroid dose into the epidural space, with the aim of reducing the local inflammatory process and, consequently, relieving the symptoms of lumbosacral radicular pain. This Cochrane Review is an update of a review published in Annals of Internal Medicine in 2012. Some placebo-controlled trials have been published recently, which highlights the importance of updating the previous review. OBJECTIVES To investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection on pain and disability in patients with lumbosacral radicular pain. SEARCH METHODS We searched the following databases without language limitations up to 25 September 2019: Cochrane Back and Neck group trial register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and two trial registers. We also performed citation tracking of included studies and relevant systematic reviews in the field. SELECTION CRITERIA We included studies that compared epidural corticosteroid injections of any corticosteroid drug to placebo injections in patients with lumbosacral radicular pain. We accepted all three anatomical approaches (caudal, interlaminar, and transforaminal) to delivering corticosteroids into the epidural space. We considered trials that included a placebo treatment as delivery of an inert substance (i.e. one with no pharmacologic activity), an innocuous substance (e.g. normal saline solution), or a pharmacologically active substance but not one considered to provide sustained benefit (e.g. local anaesthetic), either into the epidural space (i.e. to mimic epidural corticosteroid injection) or adjacent spinal tissue (i.e. subcutaneous, intramuscular, or interspinous tissue). We also included trials in which a local anaesthetic with a short duration of action was used as a placebo and injected together with corticosteroid in the intervention group. DATA COLLECTION AND ANALYSIS Two authors independently performed the screening, data extraction, and 'Risk of bias' assessments. In case of insufficient information, we contacted the authors of the original studies or estimated the data. We grouped the outcome data into four time points of assessment: immediate (≤ 2 weeks), short term (> 2 weeks but ≤ 3 months), intermediate term (> 3 months but < 12 months), and long term (≥ 12 months). We assessed the overall quality of evidence for each outcome and time point using the GRADE approach. MAIN RESULTS We included 25 clinical trials (from 29 publications) investigating the effects of epidural corticosteroid injections compared to placebo in patients with lumbosacral radicular pain. The included studies provided data for a total of 2470 participants with a mean age ranging from 37.3 to 52.8 years. Seventeen studies included participants with lumbosacral radicular pain with a diagnosis based on clinical assessment and 15 studies included participants with mixed duration of symptoms. The included studies were conducted mainly in North America and Europe. Fifteen studies did not report funding sources, five studies reported not receiving funding, and five reported receiving funding from a non-profit or government source. Eight trials reported data on pain intensity, 12 reported data on disability, and eight studies reported data on adverse events. The duration of the follow-up assessments ranged from 12 hours to 1 year. We considered eight trials to be of high quality because we judged them as having low risk of bias in four out of the five bias domains. We identified one ongoing trial in a trial registry. Epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing leg pain at short-term follow-up (mean difference (MD) -4.93, 95% confidence interval (CI) -8.77 to -1.09 on a 0 to 100 scale; 8 trials, n = 949; moderate-quality evidence (downgraded for risk of bias)). For disability, epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing disability at short-term follow-up (MD -4.18, 95% CI -6.04 to -2.17, on a 0 to 100 scale; 12 trials, n = 1367; moderate-quality evidence (downgraded for risk of bias)). The treatment effects are small, however, and may not be considered clinically important by patients and clinicians (i.e. MD lower than 10%). Most trials provided insufficient information on how or when adverse events were assessed (immediate or short-term follow-up) and only reported adverse drug reactions - that is, adverse events that the trialists attributed to the study treatment. We are very uncertain that epidural corticosteroid injections make no difference compared to placebo injection in the frequency of minor adverse events (risk ratio (RR) 1.14, 95% CI 0.91 to 1.42; 8 trials, n = 877; very low quality evidence (downgraded for risk of bias, inconsistency and imprecision)). Minor adverse events included increased pain during or after the injection, non-specific headache, post-dural puncture headache, irregular periods, accidental dural puncture, thoracic pain, non-local rash, sinusitis, vasovagal response, hypotension, nausea, and tinnitus. One study reported a major drug reaction for one patient on anticoagulant therapy who had a retroperitoneal haematoma as a complication of the corticosteroid injection. AUTHORS' CONCLUSIONS This study found that epidural corticosteroid injections probably slightly reduced leg pain and disability at short-term follow-up in people with lumbosacral radicular pain. In addition, no minor or major adverse events were reported at short-term follow-up after epidural corticosteroid injections or placebo injection. Although the current review identified additional clinical trials, the available evidence still provides only limited support for the use of epidural corticosteroid injections in people with lumbosacral radicular pain as the treatment effects are small, mainly evident at short-term follow-up and may not be considered clinically important by patients and clinicians (i.e. mean difference lower than 10%). According to GRADE, the quality of the evidence ranged from very low to moderate, suggesting that further studies are likely to play an important role in clarifying the efficacy and tolerability of this treatment. We recommend that further trials should attend to methodological features such as appropriate allocation concealment and blinding of care providers to minimise the potential for biased estimates of treatment and harmful effects.
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Affiliation(s)
- Crystian B Oliveira
- São Paulo State UniversityDepartment of PhysiotherapyRua Roberto Simonsen, 305Presidente PrudenteSão PauloBrazilCEP 19060‐900
| | - Christopher G Maher
- University of SydneySydney School of Public HealthLevel 10 North, King George V Building, Missenden Road, CamperdownSydneyNSWAustralia2050
| | - Manuela L Ferreira
- Sydney Medical School, The University of SydneyInstitute of Bone and Joint Research, The Kolling InstituteSydneyNSWAustralia
| | - Mark J Hancock
- Macquarie UniversityDiscipline of Physiotherapy, Faculty of Medicine and Health SciencesSydneyAustralia
| | - Vinicius Cunha Oliveira
- Universidade Federal dos Vales do Jequitinhonha e Mucuri (UFVJM)Departamento de FisioterapiaCampus JK ‐ Rodovia MGT 367‐ Km 583, nº 5000 ‐ Alto da JacubaDiamantinaMinas GeraisBrazil39100‐000
| | - Andrew J McLachlan
- University of SydneyFaculty of PharmacyA15 ‐ PharmacyRoom N405SydneyNSWAustralia2006
| | - Bart W Koes
- University of Southern DenmarkCenter for Muscle and HealthOdenseDenmark
| | - Paulo H Ferreira
- The University of SydneyDiscipline of Physiotherapy, Faculty of Health Sciences75 East StreetSydneyLidcombe NSWAustralia1825
| | - Steven P Cohen
- Johns Hopkins University School of MedicineBlaustein Pain Treatment Center, Department of AnesthesiologyBaltimoreMarylandUSA
| | - Rafael Zambelli Pinto
- Universidade Federal de Minas Gerais (UFMG)Department of PhysiotherapyAv. Pres. Antônio Carlos, 6627Belo Horizonte ‐ MGBelo Horizonte, Minas GeraisMinas Gerais(MG)BrazilCEP 31270‐901
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20
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Sabbaghan S, Mirzamohammadi E, Ameri Mahabadi M, Nikouei F, Rahbarian F, Ahmadichaboki S, Eftekhari S, Zamankhani M, Aghaie Aghdam A. Short-Term Efficacy of Epidural Injection of Triamcinolone Through Translaminar Approach for the Treatment of Lumbar Canal Stenosis. Anesth Pain Med 2020; 10:e99764. [PMID: 32337171 PMCID: PMC7158243 DOI: 10.5812/aapm.99764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 02/09/2020] [Accepted: 02/13/2020] [Indexed: 12/20/2022] Open
Abstract
Background Epidural steroid injection is a non-operative minimally invasive procedure for pain relief in spinal canal stenosis. However, there is no significant consensus regarding its efficacy. Objectives In this study, we aimed to evaluate the effectiveness of translaminar injection of triamcinolone in lumbar canal stenosis. Methods In a retrospective study, we included 111 patients with MRI-confirmed spinal canal stenosis who were irresponsive to 12 weeks of conservative treatment and underwent epidural injection of triamcinolone through the translaminar approach. Outcome measures were routinely checked before the intervention and four weeks after the intervention, which included the Visual Analog scale (VAS) for low back pain, VAS for lower-limb pain, and Oswestry Disability index (ODI). Results The study population included 32 (28.8%) males and 79 (71.2%) females with the mean age of 61 ± 13.4 years. The mean ODI, VAS for low back pain, and VAS for lower-limb pain significantly improved at the final evaluation session (P < 0.001, P = 0.001, and P < 0.001, respectively). The levels of improvement in ODI, VAS for low back pain, and VAS for lower-limb pain were considerably more in patients with single-level involvement (P < 0.001, P = 0.04, and P < 0.001, respectively). Improvement of lower-limb VAS was negatively correlated with age (r = -0.400, P < 0.001) and BMI (r = -0.525, P < 0.001). The ODI improvement was also negatively correlated with BMI (r = -0.569, P < 0.001). Conclusions Epidural injection of triamcinolone through the translaminar approach could be regarded as an efficacious method for the alleviation of pain and disability in patients with spinal canal stenosis.
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Affiliation(s)
- Saeed Sabbaghan
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Elham Mirzamohammadi
- Occupational Medicine, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Ameri Mahabadi
- Department of Forensic Medicine and Toxicology, Iran University of Medical Sciences, Tehran, Iran
| | - Farshad Nikouei
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Farhad Rahbarian
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Susan Ahmadichaboki
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Samira Eftekhari
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Zamankhani
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Amir Aghaie Aghdam
- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, Iran.
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Facetteninfiltration und periradikuläre Therapie. Radiologe 2020; 60:132-137. [DOI: 10.1007/s00117-019-00634-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Block JE, Lavelle WF, Nunley PD. Toward a cure for lumbar spinal stenosis: The potential of interspinous process decompression. Med Hypotheses 2019; 132:109357. [PMID: 31421414 DOI: 10.1016/j.mehy.2019.109357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/06/2019] [Accepted: 08/09/2019] [Indexed: 11/24/2022]
Abstract
There is a growing impetus to treat aging as a disease in the quest to significantly extend the human life span through cellular regeneration methods. This approach, while promising, overlooks the fact that the evolutionary adaptation to bipedalism puts the human body in a distinctively vulnerable biomechanical and functional position. Orthograde human posture places unusually-high axial compressive loads on the weight-bearing joints of the skeleton, resulting in arthritic deterioration with aging. The effects are particularly robust in the lumbar spine were age-related degeneration, most commonly lumbar spinal stenosis (LSS), is ubiquitous among the elderly. It is postulated that re-establishing a favorable mechanical environment via interventions that unload the affected spinal joint complex may mitigate and potentially reverse the structural damage that is the cardinal pathoanatomical feature of this disease. The hypothesis of this paper is that a minimally-invasive surgical procedure, interspinous process decompression (IPD), which utilizes a stand-alone intervertebral spacer, effectively unloads the diseased spinal motion segment providing a healthy micro-environment to reverse and repair age-related and genetic deterioration of the spinal motion segment. Several lines of supporting evidence are provided from long-term follow-up results of a randomized controlled trial of IPD safety and effectiveness of the Superion® device including clinical outcomes, reoperation rates, opioid analgesic usage and advanced imaging utilization. All of these outcomes show uniquely-favorable trends with time that imply that the benefits of IPD are structural. The compendium of evidence suggests that IPD offers both a durable palliative effect due to direct blocking of back extension and a disease-modifying effect due to unloading of the spinal joint complex.
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Affiliation(s)
- Jon E Block
- 2210 Jackson Street, Ste. 401, San Francisco, CA 94115, United States.
| | - William F Lavelle
- Upstate Bone and Joint Center, East Syracuse, NY 13057, United States.
| | - Pierce D Nunley
- Spine Institute of Louisiana, Shreveport, LA 71101, United States.
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Koltsov JCB, Smuck MW, Zagel A, Alamin TF, Wood KB, Cheng I, Hu SS. Lumbar epidural steroid injections for herniation and stenosis: incidence and risk factors of subsequent surgery. Spine J 2019; 19:199-205. [PMID: 29959098 DOI: 10.1016/j.spinee.2018.05.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/09/2018] [Accepted: 05/24/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbosacral epidural steroid injections (ESIs) have increased dramatically despite a narrowing of the clinical indications for use. One potential indication is to avoid or delay surgery, yet little information exists regarding surgery rates after ESI. PURPOSE The purpose of this research was to determine the proportion of patients having surgery after lumbar ESI for disc herniation or stenosis and to identify the timing and factors associated with this progression. STUDY DESIGN/SETTING This study was a retrospective review of nationally representative administrative claims data from the Truven Health MarketScan databases from 2007 to 2014. PATIENT SAMPLE The study cohort was comprised of 179,025 patients (54±15 years, 48% women) having lumbar ESIs for diagnoses of stenosis and/or herniation. OUTCOME MEASURES The primary outcome measure was the time from ESI to surgery. METHODS Inclusion criteria were ESI for stenosis and/or herniation, age ≥18 years, and health plan enrollment for 1 year before ESI to screen for exclusions. Patients were followed longitudinally until they progressed to surgery or had a lapse in enrollment, at which time they were censored. Rates of surgery were assessed with the Kaplan-Meier survival curves. Demographic and treatment factors associated with surgery were assessed with multivariable Cox proportional hazard models. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work. RESULTS Within 6 months, 12.5% of ESI patients underwent lumbar surgery. By 1 year, 16.9% had surgery, and by 5 years, 26.1% had surgery. Patients with herniation had surgery at rates of up to five-fold to seven-fold higher, with the highest rates of surgery in younger patients and those with both herniation and stenosis. Other concomitant spine diagnoses, male sex, previous tobacco use, and residence a rural areas or regions other than the Northeastern United States were associated with higher surgery rates. Medical comorbidities (previous treatment for drug use, congestive heart failure, obesity, chronic obstructive pulmonary disease, hypercholesterolemia, and other cardiac complications) were associated with lower surgery rates. CONCLUSIONS In the long term, more than one out of every four patients undergoing ESI for lumbar herniation or stenosis subsequently had surgery, and nearly one of six had surgery within the first year. After adjusting for other patient demographics and comorbidities, patients with herniation were more likely have surgery than those with stenosis. The improved understanding of the progression from lumbar ESI to surgery will help to better inform discussions regarding the value of ESI and aid in the shared decision-making process.
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Affiliation(s)
- Jayme C B Koltsov
- Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA.
| | - Matthew W Smuck
- Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA.
| | - Alicia Zagel
- Research Institute, Children's Minnesota, 2525 Chicago Ave South, Minneapolis, MN 55404, USA.
| | - Todd F Alamin
- Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA.
| | - Kirkham B Wood
- Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA.
| | - Ivan Cheng
- Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA.
| | - Serena S Hu
- Stanford University School of Medicine, 450 Broadway St, Pavilion C, 4th Floor, Mail Code 6342, Redwood City, CA 94063, USA.
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Jain NB, Schneider BJ, Murrell WB, Hettrich CM, Archer KR. What's New in Orthopaedic Rehabilitation. J Bone Joint Surg Am 2018; 100:1993-1999. [PMID: 30480605 DOI: 10.2106/jbjs.18.00828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Nitin B Jain
- Departments of Physical Medicine and Rehabilitation (N.B.J., B.J.S., and K.R.A.) and Orthopaedics (N.B.J. and K.R.A.) and Division of Epidemiology (N.B.J.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - Byron J Schneider
- Departments of Physical Medicine and Rehabilitation (N.B.J., B.J.S., and K.R.A.) and Orthopaedics (N.B.J. and K.R.A.) and Division of Epidemiology (N.B.J.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - William B Murrell
- Emirates Hospitals Group, Integra Medical and Surgical Center, Dubai, United Arab Emirates.,Department of Orthopaedics, Rehabilitation, and Podiatry, Ft. Belvoir Community Hospital, Ft. Belvoir, Virginia
| | | | - Kristin R Archer
- Departments of Physical Medicine and Rehabilitation (N.B.J., B.J.S., and K.R.A.) and Orthopaedics (N.B.J. and K.R.A.) and Division of Epidemiology (N.B.J.), Vanderbilt University Medical Center, Nashville, Tennessee
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Nunley PD, Deer TR, Benyamin RM, Staats PS, Block JE. Interspinous process decompression is associated with a reduction in opioid analgesia in patients with lumbar spinal stenosis. J Pain Res 2018; 11:2943-2948. [PMID: 30538533 PMCID: PMC6251434 DOI: 10.2147/jpr.s182322] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Lumbar spinal stenosis (LSS) causes significant pain and functional impairment, and medical management has increasingly included the prescription of opioid-based analgesics. Interspinous process decompression (IPD) provides a minimally-invasive treatment option for LSS. Methods This study estimated the type, dosage, and duration of opioid medications through 5 years of follow-up after IPD with the Superion Indirect Decompression System (Vertiflex Inc., Carlsbad, CA USA). Data were obtained from the Superion-treatment arm of a randomized controlled noninferiority trial. The prevalence of subjects using opiates was determined at baseline through 60 months. Primary analysis included all 190 patients randomized to receive the Superion device. In a subgroup of 98 subjects, we determined opioid-medication prevalence among subjects with a history of opioid use. Results At baseline, almost 50% (94 of 190) of subjects were using opioid medication. Thereafter, there was a sharp decrease in opioid-medication prevalence from 25.2% (41 of 163) at 12 months to 13.3% (20 of 150) at 24 months to 7.5% (8 of 107) at 60 months. Between baseline and 5 years, there was an 85% decrease in the proportion of subjects using opioids. A similar pattern was also observed among subjects with a history of opiates prior to entering the trial. Conclusion Stand-alone IPD is associated with a marked decrease in the need for opioid medications to manage symptoms related to LSS. In light of the current opiate epidemic, such alternatives as IPD may provide effective pain relief in patients with LSS without the need for opioid therapy.
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Affiliation(s)
| | | | | | - Peter S Staats
- National Spine and Pain Centers, Rockville, MD 20852, USA
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Affiliation(s)
- Theodore J Choma
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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