Minimum clinically important difference of major patient-reported outcome measures in patients undergoing decompression surgery for lumbar spinal stenosis

Comparison of facet fusion rates and clinical outcomes between cortical bone trajectory screw and percutaneous pedicle screw fixation for degenerative lumbar spondylolisthesis

BACKGROUND CONTEXT

Cortical bone trajectory (CBT) screws have been introduced as an alternative technique for pedicle screw (PS) insertion because they have greater contact with the cortex and a greater uniaxial pullout load than traditional PS. CBT screwing can also minimize muscle dissection. However, CBT screws and traditional PSs have not yet been compared in terms of fusion rates and clinical outcomes for particular operative procedures.

PURPOSE

This study aimed to assess the fusion rate and clinical outcomes of facet fusion (FF) fixed with CBT screws (CBT-FF) and to compare them with those of FF fixed with percutaneous PS (PPS-FF).

STUDY DESIGN

Retrospective study.

PATIENT SAMPLE

Records of 68 patients who underwent CBT-FF for single-level degenerative lumbar spondylolisthesis (DLS) with at least 1 year of follow-up were retrospectively reviewed. The control group comprised 143 patients who underwent PPS-FF under the same conditions.

OUTCOME MEASURES

Computed tomography was performed to confirm fusion. Therapeutic effectiveness was assessed as a clinical outcome using the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), Roland-Morris Disability Questionnaire (RMDQ), and visual analog scale (VAS) preoperatively and 1 year postoperatively. The rate of revision surgery was also calculated. Intraoperative blood loss was measured.

METHODS

Fusion rate, clinical outcomes, revision surgery rate, and intraoperative blood loss of CBT-FF and PPS-FF were compared.

RESULTS

The CBT-FF and PPS-FF fusion rates were 91.2% and 90.1%, respectively. The JOABPEQ category scores demonstrated therapeutic effectiveness in 74.5% and 77.1% of the patients for low back pain; the corresponding proportions for walking ability were 84.7% and 89.3%, respectively. No significant differences in therapeutic effectiveness were observed for any category, including the RMDQ and VAS scores for buttock and lower limb pain. Three patients required revision surgery for adjacent segment disease between 6 months and 3.5 years after CBT-FF (revision surgery rate, 4.4%), whereas the revision surgery rate for PPS-FF was 6.3% (9/143 cases). Average intraoperative blood loss was significantly less in the CBT-FF group than in the PPS-FF group.

CONCLUSIONS

Both procedures were equally useful in terms of fusion rate and clinical outcomes for DLS management.

Patient-reported outcomes after minimally invasive sacro-iliac joint surgery: a cohort study based on the Swedish Spine Registry

BACKGROUND AND PURPOSE

There is conflicting evidence regarding treatment outcomes after minimally invasive sacroiliac joint fusion for long-lasting severe sacroiliac joint pain. The primary aim of our cohort study was to investigate change in patient-reported outcome measures (PROMs) after minimally invasive sacroiliac joint surgery in daily practice in the Swedish Spine Registry. Secondary aims were to explore the proportion of patients reaching a patient acceptable symptom score (PASS) and the minimal clinically important difference (MCID) for pain scores, physical function, and health-related quality of life outcomes; furthermore, to evaluate self-reported satisfaction, walking distance, and changes in proportions of patients on full sick leave/disability leave and report complications and reoperations.

METHODS

Data from the Swedish Spine Registry was collected for patients with first-time sacroiliac joint fusion, aged 21 to 70 years, with PROMs available preoperatively, at 1 or 2 years after last surgery. PROMs included Oswestry Disability Index (ODI), Numeric Rating Scale (NRS) for low back pain (LBP) and leg pain, and EQ-VAS, in addition to demographic variables. We calculated mean change from pre- to postoperative and the proportion of patients achieving MCID and PASS.

RESULTS

68 patients had available pre- and postoperative data, with a mean age of 45 years (range 25-70) and 59 (87%) were female. At follow-up the mean reduction was 2.3 NRS points (95% confidence interval [CI] 1.6-2.9; P < 0.001) for LBP and 14.8 points (CI 10.6-18.9; P < 0.001) for ODI. EQ-VAS improved by 22 points (CI 15.4-30.3, P < 0.001) at follow-up. Approximately half of the patients achieved MCID and PASS for pain (MCID NRS LBP: 38/65 [59%] and PASS NRS LBP: 32/66 [49%]) and physical function (MCID ODI: 27/67 [40%] and PASS ODI: 24/67 [36%]). The odds for increasing the patient's walking distance to over 1 km at follow-up were 3.5 (CI 1.8-7.0; P < 0.0001), and of getting off full sick leave or full disability leave was 0.57 (CI 0.4-0.8; P = 0.001). In the first 3 months after surgery 3 complications were reported, and in the follow-up period 2 reoperations.

CONCLUSION

We found moderate treatment outcomes after minimally invasive sacroiliac joint fusion when applied in daily practice with moderate pain relief and small improvements in physical function.

The use of medicaments in the management of symptomatic irreversible pulpitis: A community-based cohort study

AIM

To investigate patient outcomes from either pulpotomy or pulpectomy for the management of symptomatic irreversible pulpitis, with and without application of antibiotic/corticosteroid pastes in urgent primary dental care settings in the United Kingdom.

METHODOLOGY

All patients receiving intervention for symptomatic irreversible pulpitis in three different primary care settings were invited to participate. Pre-operatively, data regarding patients' numerical ratings scale (NRS), pain score (0-10), analgesic use, oral-health impact profile-14 (OHIP-14) and need for time away from work were collected. For 7 days post-operatively, participants recorded their NRS pain score, global rating of change score, medication use and their ability to work. Analysis used a mixed-effects model with post hoc Tukey's multiple comparisons test for continuous data and chi-squared or Fisher's exact test for categorical data. To test the effect of the corticosteroid/antibiotic paste, pulpectomy and pulpotomy groups were combined following Mantel-Haenszel stratified analysis or a weighted average of the difference between pulpotomy and pulpectomy with and without the use of corticosteroid/antibiotic paste. A binary composite score was constructed using pre- and post-operative data, whereby overall treatment success was defined as: (i) patients did not return for treatment due to pain by day seven; (ii) at day three, there was a 33% (or 2-points) reduction in NRS pain score; (iii) there was a change score of +3 in global rating; (iv) the patient was no longer using analgesia and able to return to work.

RESULTS

Eighty-five participants were recruited, with 83 completing follow up. Overall treatment success was 57%, with 25% of participants returning for more treatment due to inadequate pain relief. Overall treatment success did not differ between the two groups (p = .645), although patients self-reported greater improvement with an antibiotic/corticosteroid dressing for global rating of change (p = .015).

CONCLUSIONS

This study identified limited evidence of improved outcomes using antibiotic/corticosteroid dressings in the management of symptomatic irreversible pulpitis in the emergency setting. Further clinical research is needed to understand if these medications are beneficial in affording pain relief, above that of simple excision of irreversibly inflamed pulp tissue.

Spinal manipulation and electrical dry needling as an adjunct to conventional physical therapy in patients with lumbar spinal stenosis: a multi-center randomized clinical trial

BACKGROUND CONTEXT

Nonoperative management of lumbar spinal stenosis (LSS) includes activity modification, medication, injections, and physical therapy. Conventional physical therapy includes a multimodal approach of exercise, manual therapy, and electro-thermal modalities. There is a paucity of evidence supporting the use of spinal manipulation and dry needling as an adjunct to conventional physical therapy in patients with LSS.

PURPOSE

This study aimed to determine the effects of adding thrust spinal manipulation and electrical dry needling to conventional physical therapy in patients with LSS.

STUDY DESIGN/SETTING

Randomized, single-blinded, multi-center, parallel-group clinical trial.

PATIENT SAMPLE

One hundred twenty-eight (n=128) patients with LSS from 12 outpatient clinics in 8 states were recruited over a 34-month period.

OUTCOME MEASURES

The primary outcomes included the Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI). Secondary outcomes included the Roland Morris Disability Index (RMDI), Global Rating of Change (GROC), and medication intake. Follow-up assessments were taken at 2 weeks, 6 weeks, and 3 months.

METHODS

Patients were randomized to receive either spinal manipulation, electrical dry needling, and conventional physical therapy (MEDNCPT group, n=65) or conventional physical therapy alone (CPT group, n=63).

RESULTS

At 3 months, the MEDNCPT group experienced greater reductions in overall low back, buttock, and leg pain (NPRS: F=5.658; p=.002) and related-disability (ODI: F=9.921; p<.001; RMDI: F=7.263; p<.001) compared to the CPT group. Effect sizes were small at 2 and 6 weeks, and medium at 3 months for the NPRS, ODI, and RMDI. At 3 months, significantly (p=.003) more patients in the MEDNCPT group reported a successful outcome (GROC≥+5) than the CPT group.

CONCLUSION

Patients with LSS who received electrical dry needling and spinal manipulation in addition to impairment-based exercise, manual therapy and electro-thermal modalities experienced greater improvements in low back, buttock and leg pain and related-disability than those receiving exercise, manual therapy, and electro-thermal modalities alone at 3 months, but not at the 2 or 6 week follow-up.

Moderate sagittal plane deformity patients have similar radiographic and functional outcomes with either anterior or posterior surgery

PURPOSE

This study aimed to compare the functional and radiographic outcomes of two surgical interventions for adult spinal deformity (ASD): anterior lumbar interbody fusion with anterior column realignment (ALIF-ACR) and posterior approach using Smith-Peterson osteotomy with transforaminal lumbar interbody fusion and pedicle screw fixation (TLIF-Schwab2).

METHODS

A retrospective cohort study included 61 ASD patients treated surgically between 2019 and 2020 at a single tertiary orthopedic specialty hospital. Patients were divided into two groups: Group 1 (ALIF-ACR, 29 patients) and Group 2 (TLIF-Schwab2, 32 patients). Spinopelvic radiographic parameters and functional outcomes were evaluated at 3, 6, and 12 months postsurgery.

RESULTS

Perioperative outcomes favored the ALIF-ACR group, with significantly smaller blood loss, shorter hospital stay, and operative time. Radiographic and functional outcomes were similar for both groups; however, the ALIF-ACR group did have a greater degree of correction in lumbar lordosis at 12 months. Complication profiles varied, with the ALIF-ACR group experiencing mostly hardware-related complications, while the TLIF-Schwab2 group faced dural tears, wound dehiscence, and proximal junctional kyphosis. Both groups had similar revision rates.

CONCLUSION

Both ALIF-ACR and TLIF-Schwab2 achieved similar radiographic and functional outcomes in ASD patients with moderate sagittal plane deformity at 1-year follow-up. However, the safety profiles of the two techniques differed. Further research is required to optimize patient selection for each surgical approach, aiming to minimize perioperative complications and reoperation rates in this challenging patient population.

Combined Rehabilitation with Alpha Lipoic Acid, Acetyl-L-Carnitine, Resveratrol, and Cholecalciferolin Discogenic Sciatica in Young People: A Randomized Clinical Trial

Background and Objectives: In the Western world, back pain and sciatica are among the main causes of disability and absence from work with significant personal, social, and economic costs. This prospective observational study aims to evaluate the effectiveness of a rehabilitation program combined with the administration of Alpha Lipoic Acid, Acetyl-L-Carnitine, Resveratrol, and Cholecalciferol in the treatment of sciatica due to herniated discs in young patients in terms of pain resolution, postural alterations, taking painkillers, and quality of life. Materials and Methods: A prospective observational study was conducted on 128 patients with sciatica. We divided the sample into 3 groups: the Combo group, which received a combination of rehabilitation protocol and daily therapy with 600 mg Alpha Lipoic Acid, 1000 mg Acetyl-L-Carnitine, 50 mg Resveratrol, and 800 UI Cholecalciferol for 30 days; the Reha group, which received only a rehabilitation protocol; and the Supplement group, which received only oral supplementation with 600 mg Alpha Lipoic Acid, 1000 mg Acetyl-L-Carnitine, 50 mg Resveratrol, and 800 UI Cholecalciferol. Clinical assessments were made at the time of recruitment (T0), 30 days after the start of treatment (T1), and 60 days after the end of treatment (T2). The rating scales were as follows: the Numeric Rating Scale (NRS); the Oswestry Disability Questionnaire (ODQ); and the 36-item Short Form Health Survey (SF-36). All patients also underwent an instrumental stabilometric evaluation. Results: At T1, the Combo group showed statistically superior results compared to the other groups for pain (p < 0.05), disability (p < 0.05), and quality of life (p < 0.05). At T2, the Combo group showed statistically superior results compared to the other groups only for pain (p < 0.05) and quality of life (p < 0.05). From the analysis of the stabilometric evaluation data, we only observed a statistically significant improvement at T2 in the Combo group for the average X (p < 0.05) compared to the other groups. Conclusions: The combined treatment of rehabilitation and supplements with anti-inflammatory, pain-relieving, and antioxidant action is effective in the treatment of sciatica and can be useful in improving postural stability.

Comparative Analysis of Early and Long-Term Outcomes of Patients with Degenerative Lumbar Spine Disease Using the DIAM Stabilizer and Standard Rehabilitation Program: A Preliminary Prospective Randomized Controlled Trial with 1-Year Follow-Up

Low back pain (LBP) is a leading cause of disability and work absenteeism. The cause of LBP may be degeneration of the intervertebral disc. LBP is characterized by considerable variability and tends to develop into chronic pain. Treatment of LBP includes conservative and rehabilitative treatments, surgery, and so-called minimally invasive treatment. One of the most commonly performed procedures is interspinous stabilization using a dynamic interspinous DIAM (device for intervertebral assisted motion) stabilizer. There is still no clear, strong evidence for the effectiveness and superiority of surgical treatment over conservative treatment. This study aimed to compare the early and long-term outcomes of patients with LBP using the DIAM interspinous stabilizer in relation to patients treated conservatively. A group of 86 patients was prospectively randomized into two comparison groups: A (n = 43), treated with the DIAM dynamic stabilizer for degenerative lumbar spine disease (mean age = 43.4 years ± SD = 10.8 years), and B (n = 43), treated conservatively. Pain severity was assessed using the visual analog scale (VAS), whereas disability was assessed using the Oswestry disability index (ODI). The difference in preoperative and postoperative ODI scores ≥ 15 points was used as a criterion for treatment effectiveness, and the difference in VAS scores ≥ 1 point was used as a criterion for pain reduction. In patients under general anesthesia, the procedure only included implantation of the DIAM system. Patients in the control group underwent conservative treatment, which included rehabilitation, a bed regimen, analgesic drug treatment and periarticular spinal injections of anti-inflammatory drugs. It was found that all patients (n = 43) continued to experience LBP after DIAM implantation (mean VAS score of 4.2). Of the 36 patients who experienced LBP with sciatica before the procedure, 80.5% (n = 29) experienced a reduction in pain. As for the level of fitness, the average ODI score was 19.3 ± 10.3 points. As for the difference in ODI scores in the pre-treatment results vs. after treatment, the average score was 9.1 ± 10.6. None of the patients required reoperation at 12 months after surgery. There were no statistically significant differences between the two groups in either early (p = 0.45) or long-term outcomes (p = 0.37). In conclusion, neurosurgical treatment with the DIAM interspinous stabilizer was as effective as conservative treatment and rehabilitation during the one-year follow-up period.

Values derived from patient reported outcomes in spine surgery: a systematic review of the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state

PURPOSE

While patient reported outcome measures (PROMs) define value in spine surgery, several values such as minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) help guide the interpretation of PROMs and identify thresholds of clinical significance. Significant variation exists in reported values and their calculation, so the primary objective of this study was to systematically review the spine surgery literature for metrics of clinical significance derived from PROMs.

METHODS

We conducted a query of PubMed/MEDLINE and Scopus databases from inception to January 1, 2023, for studies that derived quantitative metrics (e.g., SCB, MCID, PASS) from PROMs in the setting of spine surgery with minimum 1-year follow-up. Details regarding the specific PROMs were collected including which PROM was measured, whether anchor- or distribution-based methods were utilized, the specific calculations, and the recommended value for a given PROM based on all evaluated calculations.

RESULTS

Thirty-seven studies of 21,780 patients were included. The most commonly evaluated PROM-derived value was the MCID (n = 28), followed by PASS (n = 6) and SCB (n = 4). Twenty-one studies only utilized anchor-based calculations, 15 utilized both anchor-based and distribution-based methods, and one only utilized distribution-based calculations. The most commonly evaluated legacy PROMs were the Oswestry Disability Index (ODI) (N = 11, MCID range 4-20) and visual analog scale back pain (N = 5, MCID range 0.5-4.6). All 10 studies that derived SCB or PASS utilized the receiver operating characteristic methods. Among the six studies deriving a PASS value, four only evaluated ODI, identifying PASS ranging from 5 to 22.

CONCLUSION

While calculated measures of clinical significance such as MCID, PASS, and SCB exist, significant heterogeneity exists in the current literature. Current shortcomings include a wide variability of reported value thresholds across the literature, and limited applicability to more heterogenous patient populations than the targeted cohorts included in published investigations. Continued investigations that apply these methods to heterogenous, large-scale populations can help increase generalizability and validity of these measures.

LEVEL OF EVIDENCE

III.

A Matched Comparison of the Rates of Achieving the Minimal Clinically Important Difference Following Conversion and Primary Total Hip Arthroplasty

BACKGROUND

Patient-reported outcome measures (PROMs) are often lower following conversion total hip arthroplasty (cTHA) compared to matched primary total hip arthroplasty (THA) controls. However, the minimal clinically important differences (MCIDs) for any PROMs are yet to be analyzed for cTHA. This study aimed to (1) determine if patients undergoing cTHA achieve primary THA-specific 1-year PROM MCIDs at comparable rates to matched controls undergoing primary THA and (2) establish 1-year MCID values for specific PROMs following cTHA.

METHODS

A retrospective case-control study was conducted using 148 cases of cTHA which were matched 1:2 to 296 primary THA patients. Previously defined anchor values for 2 PROM measures in primary THA were used to compare cTHA to primary THA, while novel cTHA-specific MCID values for 2 PROMs were calculated through a distribution method. Predictors of achieving the MCID of PROMs were analyzed through multivariate logistic regressions.

RESULTS

Conversion THA was associated with decreased odds of achieving the primary THA-specific 1-year Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement PROM (Odds Ratio: 0.319, 95% Confidence Interval: 0.182-0.560, P < .001) and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a PROM (Odds Ratio: 0.531, 95% Confidence Interval: 0.313-0.900, P = .019) MCIDs in reference to matched primary THA patients. Less than 60% of cTHA patients achieved an MCID. The 1-year MCID of the Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement and Patient Reported Outcomes Measurement Information System Physical Function Short-Form-10a specific to cTHA were +10.71 and +4.68, respectively.

CONCLUSION

While cTHA is within the same diagnosis-related group as primary THA, patients undergoing cTHA have decreased odds of achieving 1-year MCIDs of primary THA-specific PROMs.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Mirogabalin for Central Neuropathic Pain After Spinal Cord Injury: A Randomized, Double-Blind, Placebo-Controlled, Phase 3 Study in Asia

BACKGROUND AND OBJECTIVES

Patients with spinal cord injury (SCI) commonly experience central neuropathic pain (CNeP), which is challenging to treat. Mirogabalin is effective for peripheral neuropathic pain, but evidence for CNeP is lacking.

METHODS

This randomized, double-blind, placebo-controlled, phase 3 study investigated mirogabalin efficacy and safety for the treatment of CNeP in patients with traumatic SCI. Adult patients from 120 sites throughout Japan, Korea, and Taiwan were randomized (1:1) to receive placebo or mirogabalin (5 mg twice daily [BID] for 1 week, 10 mg BID for 1 week, and 10 or 15 mg BID for 12 weeks). Patients with moderate renal impairment received half the dosage. The primary efficacy endpoint was change from baseline in the weekly average daily pain score (ADPS) at week 14. The secondary endpoints included ADPS responder rates, the Short-Form McGill Pain Questionnaire (SF-MPQ), average daily sleep interference score (ADSIS), and Neuropathic Pain Symptom Inventory (NPSI). Adverse events were monitored for safety.

RESULTS

Each treatment group comprised 150 patients. Mirogabalin elicited a statistical and clinically relevant improvement in change from baseline in the weekly ADPS at week 14 (least-squares mean difference [95% CI] vs placebo -0.71 [-1.08 to -0.34], p = 0.0001). Responder rates at week 14 were higher for mirogabalin than those for placebo (odds ratio [95% CI] 1.91 [1.11-3.27] for the ≥30% responder rate; 2.52 [1.11-5.71] for the ≥50% responder rate). Statistical improvements (i.e., least-squares mean difference [95% CI] vs placebo) were also observed in the SF-MPQ (-2.4 [-3.8 to -1.1]), ADSIS -0.71 (-1.04 to -0.38), and NPSI -7.7 (-11.1 to -4.4) scores. Most treatment-emergent adverse events were mild; no serious adverse drug reactions were reported.

DISCUSSION

Mirogabalin elicited clinically relevant decreases in pain and was well tolerated, suggesting that mirogabalin is a promising treatment for patients with CNeP due to SCI.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov (NCT03901352); first submitted April 3, 2019; first patient enrolled March 14, 2019; available at clinicaltrials.gov/ct2/show/NCT03901352.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that in adult patients with CNeP due to traumatic SCI, mirogabalin, 10 or 15 mg BID, effectively improves weekly ADPS at week 14.

Efficacy and Safety of Add-on Mirogabalin to NSAIDs in Lumbar Spinal Stenosis with Peripheral Neuropathic Pain: A Randomized, Open-Label Study

Introduction

In Japan, conservative therapy for patients with lumbar spinal stenosis (LSS) includes non-steroidal anti-inflammatory drugs (NSAIDs), prostaglandin E1, tramadol, physical/exercise therapy, and nerve blocks. Mirogabalin, a selective oral α2δ ligand, is approved for treating peripheral neuropathic pain, though data regarding visual analog scores (VAS) for pain in patients with LSS are limited. We investigated the efficacy and safety of mirogabalin as an add-on treatment in patients with LSS taking NSAIDs compared with patients taking NSAIDs only.

Methods

This multicenter, randomized, open-label study (MiroTAS) was conducted at 32 centers in Japan between June 2020 and October 2021. Patients were randomly assigned to mirogabalin and NSAIDs or NSAIDs alone in a 1:1 ratio. NSAIDs were administered according to their Japanese package inserts; mirogabalin was administered based on renal function [creatinine clearance (CrCL) ≥ 60 mL/min, 5 mg twice daily (BID) in Weeks 1–2, 10 mg BID in Weeks 3–4, and 15 or 10 mg BID after Week 5; CrCL 30 to < 60 mL/min, 2.5 mg BID Weeks 1–2, 5 mg BID Weeks 3–4, and 7.5 or 5 mg BID after Week 5]. The primary endpoint was the change in VAS score for leg pain from baseline to Week 12. Secondary endpoints were quality of life, evaluated using the EuroQol five-dimensional descriptive system (EQ-5D-5L) (at baseline and Week 12) and Patient Global Impression of Change (PGIC) (at Week 12), and safety. Change in VAS score at Week 12 was calculated using a linear mixed model for repeated measures. The safety endpoints were treatment-emergent adverse events (TEAEs) and adverse drug reactions.

Results

In total, 220 patients who met the eligibility criteria were enrolled. In the mirogabalin and NSAIDs and NSAIDs groups, mean ages (67.8 vs. 70.9 years), proportions of female patients (54.5% vs. 49.0%), mean body weights (63.9 vs. 62.0 kg), mean CrCL values (81.5 vs. 70.7 mL/min), proportions of patients with CrCL 30 to < 60 mL/min (27.3% vs. 33.7%), mean VAS scores (63.8 vs. 62.8 mm), and proportions of patients with VAS score ≥ 60 (53.6% vs. 52.9%) at enrollment were similar. The median durations of LSS were 9.0 and 11.0 months and the spine pain DETECT questionnaire (SPDQ) scores were 6.8 and 7.8, respectively. The least square (LS) mean change in VAS score from baseline to Week 12 was − 24.1 mm in the mirogabalin and NSAIDs group and − 14.2 mm in the NSAIDs group (both P < 0.0001 vs. baseline). The difference in LS mean was − 9.9 [95% confidence interval (CI), − 18.0, − 1.8] (P = 0.0174). The improvement in EQ-5D-5L score at Week 12 was significantly greater in the mirogabalin and NSAIDs group versus the NSAIDs group [mean difference, 0.0529 (95% CI, 0.0036, 0.1022), P = 0.0357]. At Week 12, the proportions of patients with PGIC scores ≤ 3 and ≤ 2 were higher in the mirogabalin and NSAIDs group vs. the NSAIDs group (76.2% vs. 50.0%, P = 0.0006, and 47.6% vs. 32.4%, P = 0.0523). In the mirogabalin and NSAIDs group, the incidences of TEAEs and adverse drug reactions were 60.9% and 57.3%, respectively, and the most common TEAEs were somnolence (30.0%) and dizziness (25.5%).

Conclusions

The addition of mirogabalin to NSAIDs improved VAS, EQ-5D-5L, and PGIC. The main TEAEs were somnolence and dizziness. The addition of mirogabalin to NSAIDs improved peripheral neuropathic pain associated with LSS and raised no new safety concerns.

Trial Registration

Japan Registry of Clinical Trials (jRCTs021200007).

Supplementary Information

The online version contains supplementary material available at 10.1007/s40122-022-00410-z.

Efficacy and characteristics of physiotherapy interventions in patients with lumbar spinal stenosis: a systematic review

PURPOSE

To determine the efficacy of physiotherapy approaches used in the treatment of LSS and compare their delivery characteristics.

METHODS

A systematic search was conducted using MEDLINE/PubMed, EMBASE, Scopus, PEDro, CINAHL and Web of Science databases, from inception until March 2021. Inclusion criteria were clinical diagnosis of LSS confirmed through imaging techniques, RCTs written in English comparing physiotherapy interventions among them or versus placebo or usual care without restrictions on treatment and follow-up duration, outcomes related to pain, physical function, disability and quality of life. Two independent reviewers assessed records for eligibility and methodological quality (PEDro scale) and extracted participants' characteristics, interventions details and outcome measures at each timepoint. Pooled or un-pooled findings were reported as mean difference with 95% confidence interval, depending on heterogeneity. Evidence quality was rated using the GRADE approach.

RESULTS

Twelve studies (944 patients, mean PEDro score 7.6, range 5-9) were included. Three weeks of weight-supported walking improved pain and disability, while 8 weeks of aquatic exercises improved pain and walking tolerance (very low evidence). Six weeks of cycling reduced disability compared to weight-supported walking (low evidence). Six weeks of manual therapy plus exercise was not superior to supervised exercises (low evidence), but improved pain, walking tolerance, disability and quality of life compared to home/group exercises (moderate to very low evidence). Very low evidence supported 2 weeks of electromagnetic fields, whereas TENS (low evidence) and ultrasounds (very low evidence) revealed no effects.

CONCLUSIONS

These findings may assist clinicians in delivering effective physiotherapy interventions in LSS patients.

Diagnosis and Management of Lumbar Spinal Stenosis: A Review

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.

Minimal clinically important difference in patients who underwent decompression alone for lumbar degenerative disease

BACKGROUND CONTEXT

The minimal clinically important difference (MCID) represents the smallest change in an outcome measure recognized as clinically meaningful to a patient after receiving a clinical intervention. Most studies that discussed the MCIDs for lumbar spinal stenosis (LSS) included mixed pathologies or procedures despite that the MCID value should be different depending on the intervention. Moreover, despite the efficacy of adopting percentage-change improvement for the MCID threshold, there are limited reports and discussions in the field of lumbar surgery.

PURPOSE

The aim of the present study was to elucidate the MCIDs for the Oswestry Disability Index (ODI), EuroQOL 5-dimension 3-level (EQ-5D-3L), physical component summary (PCS) of the Short Form of the Medical Outcomes Study, and Numeric Rating Scale (NRS) in patients with degenerative LSS treated with decompression surgery without fusion.

STUDY DESIGN/SETTING

A multicenter retrospective cohort study was performed.

PATIENT SAMPLE

A total of 422 patients who underwent decompression surgery for LSS and answered a complete set of questionnaires were included in the study. Patients who underwent endoscopic or revision surgery were excluded.

OUTCOME MEASURES

Preoperative and 1-year postoperative scores of each health-related quality of life questionnaires (HRQOLs) and patient satisfaction questionnaire response METHODS: The patient satisfaction question was used as an anchor, and the cutoff values were estimated based on absolute point improvement from baseline using a receiver-operating characteristic (ROC) curve analysis and the "mean change" method for MCIDs. The MCID values for percentage-change in HRQOLs were also calculated using ROC curve analysis. The three cutoff values for each HRQOL were validated using the Youden index for determining the most robust MCIDs.

RESULTS

Of the patients, 356 (84.4%) were at least "somewhat satisfied" with the treatment results. The two cutoff values of absolute point-change in each HRQOL, which were estimated by two different anchor-based methods, were similar. The area under the curve of the ROC curve for percentage-change tended to be higher than that for absolute point-change. Moreover, the Youden index of the percentage-change in each HRQOL was higher than that of the absolute point-change calculated by either the "mean change" method or the ROC curve analysis. Based on these results, it was proposed that MCID was 42.4% for percentage-change in ODI, 22.0% for EQ-5D-3L, 13.7% for PCS, 25.0% for NRS (low back pain), 55.6% for NRS (leg pain), 22.2% for NRS (leg numbness).

CONCLUSIONS

The MCIDs of HRQOLs were calculated in patients with LSS treated with decompression surgery without concomitant fusion procedure. The MCID cutoffs based on percentage-change from baseline were more effective than those of absolute point-change.

Treatment of restenosis after lumbar decompression surgery: decompression versus decompression and fusion

OBJECTIVE

The aim of this study was to compare perioperative complications and postoperative outcomes between patients with lumbar recurrent stenosis without lumbar instability and radiculopathy who underwent decompression surgery and those who underwent decompression with fusion surgery.

METHODS

For this retrospective study, the authors identified 2606 consecutive patients who underwent posterior surgery for lumbar spinal canal stenosis at eight affiliated hospitals between April 2017 and June 2019. Among these patients, those with a history of prior decompression surgery and central canal restenosis with cauda equina syndrome were included in the study. Those patients with instability or radiculopathy were excluded. The patients were divided between the decompression group and decompression with fusion group. The demographic characteristics, numerical rating scale score for low-back pain, incidence rates of lower-extremity pain and lower-extremity numbness, Oswestry Disability Index score, 3-level EQ-5D score, and patient satisfaction rate were compared between the two groups using the Fisher's exact probability test for nominal variables and the Student t-test for continuous variables, with p < 0.05 as the level of statistical significance.

RESULTS

Forty-six patients met the inclusion criteria (35 males and 11 females; 19 patients underwent decompression and 27 decompression and fusion; mean ± SD age 72.5 ± 8.8 years; mean ± SD follow-up 18.8 ± 6.0 months). Demographic data and perioperative complication rates were similar. The percentages of patients who achieved the minimal clinically important differences for patient-reported outcomes or satisfaction rate at 1 year were similar.

CONCLUSIONS

Among patients with central canal stenosis who underwent revision, the short-term outcomes of the patients who underwent decompression were comparable to those of the patients who underwent decompression and fusion. Decompression surgery may be effective for patients without instability or radiculopathy.

Impact of leg numbness on patient satisfaction following decompression surgery for lumbar spinal stenosis

Decompression surgery is the most common surgical treatment for lumbar spinal stenosis (LSS). Relatively low satisfaction rate was reported. Patients often complaint of residual numbness despite significant pain relief. We hypothesized that numbness had a significant impact on patient satisfaction, but had not been evaluated, which is associated with low satisfaction rate. This study aimed to examine how much numbness is associated with patient satisfaction. We retrospectively reviewed prospectively collected data from consecutive patients who underwent decompression without fusion for LSS. We evaluated the Numeric Rating Scale (NRS) scores of low back pain (LBP), leg pain, and leg numbness preoperatively and at the final follow-up visit. Improvement was evaluated using minimum clinically important differences (MCIDs). Patient satisfaction was evaluated using the question, "How satisfied are you with the overall result of your back operation?". There are four possible answers consisting of "very satisfied (4-point)", "somewhat satisfied (3-point)", "somewhat dissatisfied (2-point)", or "very dissatisfied (1-point)". Spearman correlation was used to evaluate the association between patient satisfaction and reaching MCIDs. A total of 116 patients were included. All three components had correlation with patient satisfaction with the correlation efficient of 0.30 in LBP, 0.22 in leg pain, and 0.33 in numbness. Numbness had greatest correlation efficient value. We showed that numbness has a greater impact than leg/back pain on patient satisfaction in patients undergoing decompression for LSS. We suggest not only LBP and leg pain but also numbness should be evaluated pre- and postoperatively.

Good clinical outcomes in nonunion cases after facet fusion with a percutaneous pedicle screw system for degenerative lumbar spondylolisthesis

There are many satisfactory long-term outcomes after posterolateral fusion (PLF) for degenerative lumbar spondylolisthesis (DLS); nonunion cases have also achieved good clinical outcomes. Facet fusion (FF), a minimally invasive evolution of PLF, also resulted in good clinical outcomes. We aimed to assess the course of nonunion cases after FF and determine whether the nonunion cases achieved good clinical outcomes. We retrospectively reviewed the records of 136 patients who underwent FF for DLS. Range of motion (ROM) at the fused level was measured using a flexion-extension lateral radiograph preoperatively and 1 year postoperatively. Patients were classified into the Fusion or Unconfirmed Fusion group by computed tomography (CT) 1 year postoperatively. Furthermore, patients in the Unconfirmed Fusion group were classified into the Delayed Union or Nonunion group depending on the confirmation status of FF upon the following CT. The average preoperative ROM and clinical outcomes were compared between the three groups. The Fusion, Delayed Union, and Nonunion groups had 109, 14, and 13 patients, respectively. In the Nonunion group, the average ROM significantly decreased from 13.0° preoperatively to 4.9° postoperatively. There was a significant difference in the average preoperative ROM between the groups. The larger the preoperative ROM, the fewer facets fused. There was no significant difference in clinical outcomes between the groups. Five patients (3.7%) required revision surgery for adjacent segment disease 1-5.5 years after FF. Even nonunion cases after FF achieved good clinical outcomes, likely because the unstable spondylolisthesis was stabilized. FF did not require revision surgery for nonunion itself.