Decompression Versus Decompression and Fusion for Degenerative Lumbar Stenosis in a Workers' Compensation Setting

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication

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.

Ligamentum flavum hypertrophy significantly contributes to the severity of neurogenic intermittent claudication in patients with lumbar spinal canal stenosis

Ligamentum flavum hypertrophy (LFH) is a known contributor to lumbar spinal canal stenosis (LSCS). However, the clinical significance and quantitative role of LFH compared to other components, such as disc bulging and facet hypertrophy, have not yet been examined. We investigated the correlation between the quantitative radiological factors, clinical symptoms, and outcomes in patients with LSCS. In total, 163 patients diagnosed with single-level (L4-L5) stenosis were included. The patients were divided into 2 groups according to claudication severity: >100 m for mild (n = 92) and < 100 m for severe (n = 71). The visual analog scale (VAS) was used to quantify back and leg pain, and the Oswestry Disability Index (ODI) and Short form-36 (SF-36) physical component summary (PCS) scores, and Macnab criteria were evaluated as clinical factors 6 months after treatment. We measured the baseline canal cross-sectional area, ligamentum flavum (LF) area, disc herniation area, dural sac area, fat area, and LF thickness using MRI. A comparative analysis was performed to evaluate the association between radiologic and clinical factors. Additionally, further comparative analyses between the types of surgeries were performed. Among various radiologic factors, the baseline LF thickness (odds ratio [OR] 1.73; 95% confidence interval [CI] 1.25-2.41) was the only major contributing factor to the severity of claudication in the multivariate logistic regression analysis. The types of surgery (decompression alone vs fusion) did not significantly differ in terms of their clinical outcomes, including back and leg VAS, ODI, SF-36 PCS, and satisfaction with the MacNab classification. LF thickness is a major factor contributing to claudication severity.

Evaluation of Factors Affecting Return to Work Following Carpal Tunnel Release: A Statewide Cohort Study of Workers' Compensation Subjects

PURPOSE

Most randomized trials comparing open carpal tunnel release (OCTR) to endoscopic carpal tunnel release (ECTR) are not specific to a working population and focus mainly on how surgical technique has an impact on outcomes. This study's primary goal was to evaluate factors affecting days out of work (DOOW) following carpal tunnel release (CTR) in a working population and to evaluate for differences in medical costs, indemnity payments, disability ratings, and opioid use between OCTR and ECTR with the intent of determining whether one or the other surgical method was a determining factor.

METHODS

Using the Ohio Bureau of Workers' Compensation claims database, individuals were identified who underwent unilateral isolated CTR between 1993 and 2018. We excluded those who were on total disability, who underwent additional surgery within 6 months of their index CTR, including contralateral or revision CTR, and those not working during the same month as their index CTR. Outcomes were evaluated at 6 months after surgery. Multivariable linear regression was performed to evaluate covariates associated with DOOW.

RESULTS

Of the 4596 included participants, 569 (12.4%) and 4027 (87.6%) underwent ECTR and OCTR, respectively. Mean DOOW were 58.4 for participants undergoing OCTR and 56.6 for those undergoing ECTR. Carpal tunnel release technique was not predictive of DOOW. Net medical costs were 20.7% higher for those undergoing ECTR. Multivariable linear regression demonstrated the following significant predictors of higher DOOW: preoperative opioid use, legal representation, labor-intensive occupation, increasing lag time from injury to filing of a worker's compensation claim, and female sex. Being married, higher income community, and working in the public sector were associated with fewer DOOW.

CONCLUSIONS

In a large statewide worker's compensation population, demographic, occupational, psychosocial, and litigatory factors have a significant impact on DOOW following CTR, whereas differences in surgical technique between ECTR and OCTR did not.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Workers' Compensation Status and Outcomes Following Lumbar Surgery

OBJECTIVE

To determine the influence of preoperative workers' compensation (WC) status on patient-reported outcome measures following lumbar decompression with or without fusion.

METHODS

All patients undergoing lumbar decompression with or without fusion at a single academic institution between 2013 and 2017 were identified. Patients were split into groups based on WC status: no workers' compensation (NWC), WC), or retired. Intragroup analysis used paired t tests. Outcomes between groups were compared using Kruskal-Wallis H test. Multiple linear regression analysis determined if WC status was a predictor of change in patient-reported outcome measures. Subgroup analysis was conducted for WC patients who returned to work.

RESULTS

Of 571 included patients, 242 (43.4%) had NWC, 83 (14.5%) had WC, and 246 (43.1%) were retired. Comparing within groups, WC patients showed significant improvement in Short Form-12 Health Survey Physical Component Score, Oswestry Disability Index, visual analog scale (VAS) back pain, and VAS leg pain (all P < 0.001) after surgery. However, WC patients improved less than NWC or retired patients in Short Form-12 Health Survey Physical Component Score (P = 0.010), VAS back pain (P = 0.028), and VAS leg pain (P = 0.015). WC was an independent predictor of decreased improvement in Short Form-12 Health Survey Physical Component Score (β = -4.31, P = 0.001), VAS back pain (β = 0.90, P = 0.034), and VAS leg pain (β = 1.50, P = 0.002) on multivariate analysis. WC patients who did not return to work was an independent predictor of decreased improvement in VAS back pain (β = 1.39, P = 0.016) and VAS leg pain (β = 2.11, P = 0.001).

CONCLUSIONS

WC patients improve less than NWC patients. However, WC patients who return to work have similar VAS back and neck pain improvements as NWC patients.

Reasons for Preoperative Opioid Use Are Associated with Persistent Use following Surgery among Patients Undergoing Total Knee and Hip Arthroplasty

OBJECTIVE

Most studies on preoperative opioid use only describe whether or not patients use opioids without characterizing reasons for use. Knowing why patients use opioids can help inform perioperative opioid management. The objective of this study was to explore pain specific reasons for preoperative opioid use prior to total hip and knee arthroplasty (THA and TKA) and their association with persistent use.

METHODS

This is a prospective study of 197 patients undergoing THA (n = 99) or TKA (n = 98) enrolled in the Analgesic Outcomes Study between December 2015 and November 2018. All participants reported preoperative opioid use.

RESULTS

Reasons for preoperative opioid use were categorized as surgical site pain only (81 [41.1%]); pain in other body areas only (22 [11.2%]); and combined pain (94 [47.7%]). Compared to patients taking opioids for surgical site pain, those with combined reasons for use had 1.24 (p = 0.40) and 2.28 (p = 0.16) greater odds of persistent use at 3 and 6 months postoperatively, adjusting for relevant covariates.

CONCLUSIONS

This study provides novel insights into the heterogeneity of reasons for presurgical opioid use in patients undergoing a THA or TKA. One key take away is that not all preoperative opioid use is the same and many patients are taking opioids preoperatively for more than just pain at the surgical site. Combined reasons for use was associated with long-term use, suggesting non-surgical pain, in part, drives persistent opioid use after surgery. Future directions in perioperative care should focus on pain and non-pain reasons for presurgical opioid use to create tailored post-operative opioid weaning plans.

Immediate postoperative MRI findings after lumbar decompression surgery: Correlation of imaging features with clinical outcome

An understanding of the common MRI findings observed after decompression surgery is important. However, to date, no study addressing this has been published. The aim of this study was to analyze and describe the immediate postoperative MRI findings after lumbar decompression surgery. We retrospectively analyzed the immediate postoperative MRIs of 121 consecutive patients who underwent lumbar decompression surgery between July 2017 and June 2018. Changes in stenosis at the decompressed and adjacent levels, epidural fat edema, epidural and subdural fluid collections, nerve root swelling, facet joint effusions, intervertebral disc signal, and paravertebral muscle edema were correlated with clinical characteristics. Both groups had reduced central canal stenosis postoperatively (p < 0.001) but worsened stenosis at adjacent segments. Fluid collection, hemorrhagic or non-hemorrhagic, at the laminectomy site was the commonest finding (one-level: 73.8%, two-level: 88.5%), with a higher percentage of severe central canal compromise in the two-level decompression group (p = 0.003). Other postoperative MRI findings, such as epidural fat edema, nerve root swelling, subdural fluid collection, and facet joint effusion, were noted without statistical significance. In conclusion, even with successful decompression for lumbar canal stenosis, increased central canal stenosis at adjacent segments is common on immediate postoperative MRI scans, showing no statistically significant correlation with the immediate postoperative outcome. Postoperative fluid collection at the laminectomy site is the commonest imaging finding, and higher rates of hemorrhagic fluid and more severe central canal compromise occur in two-level decompression, but rarely cause clinical problems.

Patient-Reported Outcomes Following Lumbar Decompression Surgery: A Review of 2699 Cases

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Despite numerous advances in the technology and techniques available to spinal surgeons, lumbar decompression remains the mainstay of degenerative lumbar spine surgery. It has proven efficacy in trials, but only limited evidence of advantage over conservative management in large scale systematic reviews. We collated data from a large surgically managed cohort to evaluate the patient-reported outcomes.

METHODS

We performed a retrospective analysis of a prospectively populated database. Patient demographics, surgical details, and patient outcomes (Spine Tango core outcome measures index [COMI]-Low Back) were collected for 2699 lumbar decompression surgeries.

RESULTS

Lumbar decompression was shown to be successful at improving leg pain (mean improvement in visual analogue scale [VAS] at 3 months = 4) and to a lesser extent, back pain (mean improvement in VAS at 3 months = 2.61). Mean improvement in COMI score was 3.15 for all-comers. Minimal clinically important improvement (MCID) in COMI score (-2 points) was achieved in 73% of patients by 2-year follow-up. Primary surgery was more effective than redo surgery: odds ratio 0.547 (95% CI 0.408-0.733, P < .001). The benefits across all outcomes were maintained for the 2-year follow-up period. Patients can be classified according to their outcome as "early responders"; achieving MCID by 3 months (61% primary vs 41% redo), "late responders"; achieving MCID by 2 years (15% vs 20%) or nonresponders (24% vs 39%).

CONCLUSIONS

Lumbar decompression is effective in improving quality of life in appropriately selected patients. Patient-reported outcome measures collected routinely and collated within a registry are a powerful tool for assessing the efficacy of lumbar spine interventions and allow accurate counseling of patients perioperatively.

A comparative study of Lumbar Decompression and Fusion with Internal Fixation versus Simple Decompression in elderly patients with two-segment Lumbar Spinal Stenosis

OBJECTIVE

To investigate and compare the effect of decompression and fusion with internal fixation vs. simple decompression in the treatment of elderly patients with two-segment lumbar spinal stenosis (LSS) in perioperative and postoperative follow-up periods.

METHODS

Twenty-eight elderly patients with two-segment LSS admitted in Baoding First Hospital between Mar. 2017 and Jan. 2018 were retrospectively analyzed. Fifteen patients who underwent simple decompression were included in the simple decompression group, and 13 who underwent decompression and fusion with internal fixation were included in the decompression-fixation group. The general data and perioperative conditions including wound complications, operation time, blood loss, and VAS (legs) and JOA score were analyzed and compared between the two groups.

RESULTS

There was no significant difference in postoperative leg pain (VAS) between the two groups, and a statistically significant difference in JOA score was found between the two groups one month after the operation. The operation time, length of stay, and blood loss in the decompression-fixation group were significantly different from those in the simple decompression group and no significant difference in wound complications was observed between the two groups.

CONCLUSION

There is no significant difference in leg pain relief in elderly patients with two-segment LSS when treated with decompression and fusion with internal fixation or simple decompression. Simple decompression is associated with less intraoperative injuries, better postoperative functional recovery, and reduced hospital stay.

Degenerative Lumbar Stenosis Surgery: Predictive Factors of Clinical Outcome-Experience with 1001 Patients

BACKGROUND

Degenerative lumbar spinal stenosis (DLSS) carries a high risk of morbidity and represents a financial burden to society. A late diagnosis can lead to severe disability. Although lumbar decompressive surgery has been widely used worldwide, the proper preoperative factors to define the ideal candidates for decompression are missing.

METHODS

A total of 1001 patients who had undergone decompressive surgery from 2012 to 2019 for DLSS were screened for the presence of 9 clinical and radiological parameters. For all cases, the differences between the baseline and postoperative Oswestry disability index were calculated and the results categorized as 5 different classes (ranging from very poor outcomes to excellent outcomes) according to the specific scores. Generalized ordinal logistic regression was then used to analyze the significance of the 9 parameters (coded as dummy variables) in predicting the outcome as measured by Oswestry disability index improvement after surgery.

RESULTS

Of the 9 parameters, 8 were found to be significant predictors. The radiological grade of compression was the strongest, followed by polyneuropathy, obesity, symptom duration, gait autonomy, radicular deficits, American Society of Anesthesiologists score, and level of surgery. In contrast, previous back surgery was not predictive of the outcome.

CONCLUSIONS

Our findings have indicated that the ideal candidate for surgery will have the following preoperative characteristics: Schizas grade D, no signs of peripheral polyneuropathy, body mass index <30 kg/m², symptom duration of <2 years, gait autonomy <100 m, no radicular deficits, 1 level of stenosis, and an American Society of Anesthesiologists score of 1, 2, or 3.

Outcome of modified interlaminar decompression: A conservative decompressive surgery for lumbar spine stenosis

Objective:

To evaluate the outcomes of modified interlaminar decompression in patients with degenerative lumbar spinal stenosis (LSS).

Methods:

This descriptive observational study was conducted at the Department of Neurosurgery, Lady Reading Hospital Peshawar from July 2014 to June 2018. All patients with degenerative LSS who underwent modified interlaminar decompression during the study period were included in the study. The patients were followed up to one year after surgery. The data was entered into a structured questionnaire designed according to the study which was then analyzed using SPSS version 21.

Results:

A total of 182 LSS cases were included in the study and 236 levels were operated during the study period. According to the records increased prevalence of LSS was found among males i.e. 58.8%. The common level with degenerative stenosis involved was L4-5. Good to excellent outcomes were observed in 93.9% patients in the 1^st follow-up visit. The most common complication of surgery was dural tear followed by wound infection.

Conclusion:

Modified interlaminar decompression is a conservative surgical technique, proved to be a potential approach with acceptable complications, satisfactory outcomes and it is easy to learn.

Decompression alone vs. decompression plus fusion for claudication secondary to lumbar spinal stenosis

BACKGROUND

Degenerative lumbar spinal stenosis is a common condition, predominantly affecting middle-aged and elderly people. This study focused on patients with neurogenic claudication secondary to lumbar stenosis without spondylolisthesis or deformity.

PURPOSE

To determine whether the addition of fusion to decompression resulted in improved clinical outcomes at 3, 12, and 24 months postsurgery.

STUDY DESIGN/SETTING

The Canadian Spine Outcomes and Research Network (CSORN) prospective database that includes pre- and postoperative data from tertiary care hospitals.

PATIENT SAMPLE

The CSORN database was queried for consecutive spine surgery cases of degenerative lumbar stenosis receiving surgical decompression for neurogenic claudication or radiculopathy. Neurogenic claudication patients with baseline and 2-year follow-up data, from four sites, formed the study sample (n=306). The sample was categorized into two groups: (1) those that had decompression alone, and (2) those that underwent decompression plus fusion.

OUTCOME MEASURES

Change in modified Oswestry Disability Index (ODI), numerical rating scale for back/leg pain, the EuroQol EQ5D, the SF-12 physical, and mental component scores. The primary outcome measure was the ODI at 2 years postoperative.

METHODS

We conducted a multicenter, ambispective review of consecutive spine surgery patients enrolled between October 2012 and January 2018.

RESULTS

Baseline characteristics were comparable between groups except for female sex and multilevel pathology (both with greater proportion in the decompression plus fusion group). The decompression plus fusion group had clinically meaningfully more operative time, blood loss, rate of perioperative complication, and length of hospital stay (p<.05). These differences were preserved following adjustment for baseline differences between the groups. Both decompression and decompression plus fusion had a large clinically meaningful impact on generic and disease-specific patient-reported outcome measures within 3 months of surgery which was maintained out to 24-month follow-up. At any follow-up time point, there was no statistical evidence of a difference in these effects favoring decompression plus fusion over decompression alone.

CONCLUSIONS

The addition of fusion to decompression did not result in improved outcomes at 3-, 12-, or 24-month follow-up. The addition of fusion to decompression provides no advantage to decompression alone for the treatment of patients with neurogenic claudication secondary to lumbar stenosis without spondylolisthesis or deformity.

Work-disability in low back pain patients with or without surgery, and the role of social insurance regulation changes in Sweden

BACKGROUND

The aims were to study the differences in work-disability in patients with low back pain (LBP) in relation to (i) treatment provided (non-surgical or lumber spine surgery (decompression or fusion), and (ii) two time points, i.e. before and after the social insurance regulation changes in the in 2008.

METHODS

All non-pensioned individuals, aged 19-60 years, living in Sweden, diagnosed with LBP in 2004-06 or 2008-10 were included (n = 153739). Hazard ratios (HRs) with 95% confidence intervals for long-term sickness absence (>90 days, LTSA) and disability pension (DP) for LBP-patients (non-surgical, decompression, fusion, both surgeries) were estimated by Cox regression compared with the matched references from the general population without LBP (n = 566008).

RESULTS

LBP-patients had a higher risk of subsequent work-disability compared with the references before and after insurance regulation changes. LBP-patients receiving decompression surgery had similar risk for later work-disability as those treated non-surgically. However, following regulation changes, LBP-patients undergoing fusion surgery had higher risk estimates of both LTSA (HR: 3.3) and DP (HR: 4.8) than patients treated non-surgically (HR: LTSA 2.1; DP 2.5) or with decompression (HR: LTSA 2.6; DP 2.1). In the adjusted models, risk estimates mainly attenuated after controlling for previous sickness absence.

CONCLUSION

Risk for subsequent work-disability among LBP-patients was higher compared with people without LBP and lumbar spine surgery. Discrepancies in risk were explained by the treatment provided previous sickness absence and changes in the social insurance regulations, specifically LBP-patients treated with fusion surgery had an increased risk of subsequent work-disability after changes in regulations.

Neurogenic Claudication: a Review of Current Understanding and Treatment Options

PURPOSE OF REVIEW

With an aging population and increased prevalence of the disease, we set out to evaluate the validity of current diagnostic criteria for neurogenic claudication as well as the efficacy of the treatment options for the main cause, lumbar spinal stenosis (LSS).

RECENT FINDINGS

Epidural steroid injections (ESI) were most efficacious when the injectate is a steroid combined with lidocaine or lidocaine only. There are promising results regarding the efficacy of the minimally invasive lumbar decompression (MILD) procedure as well as interspinous process spacers (IPS) compared to surgical alternatives. Spinal cord stimulators are gaining ground as an effective alternative to surgery in patients with lumbar spinal stenosis that is not responsive to conservative measures or epidural injections. We found that there continues to be a lack of consensus on the diagnostic criteria, management, and treatment options for patients with LSS. The Delphi consensus is the most current recommendation to assist clinicians with making the diagnosis. Physical therapy, NSAIDs, gabapentin, and other conservative therapy measures are unproven in providing long-lasting relief. In patients with radicular symptoms, an ESI may be indicated when a combination of lidocaine with steroids is used or using lidocaine alone. In addition, there is not enough high-quality evidence to make a recommendation regarding the use of MILD versus interspinous spacers for neurogenic claudication. There remains a need for high-quality evidence regarding the efficacy of different conservative treatments, interventional procedures, and surgical outcomes in patients with neurogenic claudication in LSS.

Course and characteristics of work disability 3 years before and after lumbar spine decompression surgery- a national population-based study

Despite decompression surgery being a widespread intervention for patients with dorsopathies (i.e. back pain) affecting the lumbar spine, the scientific knowledge on patterns and characteristics of work disability before and after the surgery is limited. Sickness absence (SA) and disability pension (DP) were examined three years before and after surgery in 8558 patients aged 25–60 years who underwent lumbar spine decompression surgery in Sweden. They were compared to individuals with diagnosed dorsopathies but no surgery and individuals from the general population as matched comparison groups. According to Group Based Trajectory models, in patients with decompression surgery, 39% had low levels of SA/DP during the entire study period and 15% started with low levels of SA/DP, which increased in the year before, and declined to almost zero in the second year after surgery. Three trajectory groups (12%, 17%, and 18%) started at different levels of SA/DP, which increased in the years before, and declined in the third year after surgery. The trajectory groups in the comparison groups showed lower levels of work disability. Sex, education, and the use of antidepressants and analgesics the year before surgery played an important role to explain the variance of trajectory groups in patients with surgery.

Determinants of work disability following lumbar spine decompression surgery

AIMS

Scientific knowledge about risk factors for work disability in terms of long-term sickness absence and disability pension following lumbar spine decompression surgery remains insufficient. This study aimed to investigate the associations between socio-demographic, work-related, and medical characteristics with subsequent long-term sickness absence (>90 days) and disability pension for individuals who underwent lumbar spine decompression surgery.

METHODS

A prospective cohort study of all individuals aged 19-60 years with diagnosed dorsopathies, who underwent lumbar spine decompression surgery 2008-10 in Sweden ( n=7373) was performed. Univariate and multivariate hazard ratios with 95% confidence intervals regarding long-term sickness absence and disability pension with a 3-year follow-up period were estimated by Cox proportional regression.

RESULTS

Low educational level, being a non-European immigrant and preoperative sickness absence were risk factors for both long-term sickness absence and disability pension (hazard ratios: 1.2-3.8). Female sex was a risk factor for long-term sickness absence (hazard ratios: 1.3) whereas age >44 years and being a Nordic immigrant were risk factors for disability pension (hazard ratios: 1.9-2.6). Medical factors as common mental disorders, other mental disorders, prescribed psychiatric medication and somatic comorbidity were risk factors for both long-term sickness absence and disability pension (hazard ratios: 1.2-3.4). A simultaneous lumbar fusion surgery and high preoperative pain severity were risk factors for long-term sickness absence (hazard ratios 1.2-1.8).

CONCLUSIONS

To prevent long-term work disability after lumbar spine decompression surgery, specific focus is required on older and female patients, those with mental or somatic comorbidities, high levels of preoperative pain or sickness absence, with a simultaneous lumbar fusion surgery, a low educational level or a non-European immigrant background.

Optimal treatment for lumbar spinal stenosis: an update

PURPOSE OF REVIEW

Our review of current literature within the past 12-24 months for the treatment of lumbar spinals stenosis (LSS) serves to update providers on recent advances and comparisons regarding therapy spanning lifestyle modification, pharmacologic therapy, minimally invasive interventions, and surgical interventions.

RECENT FINDINGS

Current literature supporting the inclusion of physical therapy and gabapentin/pregabalin within an initial treatment regimen have been positive. A recent randomized, double-blinded clinical trial of adding calcitonin to epidural steroid injections have shown improvement in pain and function up to 1 year. The minimally invasive lumbar decompression (mild) procedure is showing ongoing beneficial results in pain and function. Spinal cord stimulation (SCS) may have a role for select patients with lumbar spinal stenosis. Finally, the benefits of surgical treatment versus nonsurgical treatment is ultimately inconclusive because of the nature of data collection, inconsistencies with the clinical definition of LSS, and a lack of standardized treatment guidelines.

SUMMARY

Our review of current research demonstrates there is a positive role for the current conservative therapies, with favorable results for interventions such as minimally invasive decompression and SCS. Pharmacologic interventions such as systemic prostaglandin analogues and epidural agents such as calcitonin demonstrate early promise, but need to undergo additional safety testing and confirmatory trials. Further long-term research with validated, objective measurements for the aforementioned treatments are needed to draw any definitive conclusions for clinical practice.