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Ho EKY, Mobbs RJ, van Gelder JM, Harris IA, Davis G, Stanford R, Beard DJ, Maher CG, Prior J, Knox M, Anderson DB, Buchbinder R, Ferreira ML. Challenges of conducting a randomised placebo-controlled trial of spinal surgery: the SUcceSS trial of lumbar spine decompression. Trials 2023; 24:794. [PMID: 38057932 PMCID: PMC10698887 DOI: 10.1186/s13063-023-07772-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 11/01/2023] [Indexed: 12/08/2023] Open
Abstract
Although placebo-controlled trials are considered the gold standard for evaluating the efficacy of healthcare interventions, they can be perceived to be controversial and challenging to conduct for surgical treatments. The SUcceSS trial is the first placebo-controlled trial of lumbar decompression surgery for symptomatic lumbar canal stenosis. The SUcceSS trial has experienced common issues affecting the implementation of randomised placebo-controlled surgery trials, accentuated by the COVID-19 pandemic. Using the SUcceSS trial as an example, we discuss key challenges and mitigation strategies specific to the conduct of a randomised placebo-controlled surgical trial. Overall, the key lessons learned were (i) involving key stakeholders early and throughout the trial design phase may increase clinician and patient willingness to participate in a placebo-controlled trial of surgical interventions, (ii) additional resources (e.g. budget, staff time) are likely required to successfully operationalise trials of this nature, (iii) the level of placebo fidelity, timing of randomisation relative to intervention delivery, and nuances of the surgical procedure under investigation should be considered carefully. Findings are based on one example of a placebo-controlled surgical trial; however, researchers may benefit from employing or building from the strategies described and lessons learned when designing or implementing future trials of this nature.
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Affiliation(s)
- Emma Kwan-Yee Ho
- The University of Sydney, Sydney Musculoskeletal Health, Charles Perkins Centre, Faculty of Medicine and Health, School of Health Sciences, Sydney, NSW, 2050, Australia.
- The University of Sydney, Sydney Musculoskeletal Health and the Kolling Institute, Faculty of Medicine and Health, School of Health Sciences, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia.
| | - Ralph Jasper Mobbs
- NeuroSpine Surgery Reserach Group (NSURG), Sydney, NSW, 2031, Australia
- Prince of Wales Hospital, Barker Street, Randwick, NSW, 2031, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - James Montague van Gelder
- Department of Neurosurgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Sydney Spine Institute, Burwood, NSW, 2134, Australia
| | - Ian Andrew Harris
- South West Sydney Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW, 2170, Australia
| | - Gavin Davis
- Neurosurgery, Cabrini & Austin Hospitals; and School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3800, Australia
| | - Ralph Stanford
- Prince of Wales Hospital, Barker Street, Randwick, NSW, 2031, Australia
| | - David John Beard
- The University of Sydney, Sydney Musculoskeletal Health, Charles Perkins Centre, Faculty of Medicine and Health, School of Health Sciences, Sydney, NSW, 2050, Australia
- NHMRC CTC, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | | | - Joanna Prior
- The University of Sydney, School of Health Sciences, Faculty of Medicine and Health, Sydney, NSW, 2050, Australia
| | - Michael Knox
- The University of Sydney, Sydney Musculoskeletal Health and the Kolling Institute, Faculty of Medicine and Health, School of Health Sciences, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
| | - David Barrett Anderson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3800, Australia
| | - Rachelle Buchbinder
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
| | - Manuela Loureiro Ferreira
- The University of Sydney, Sydney Musculoskeletal Health and the Kolling Institute, Faculty of Medicine and Health, School of Health Sciences, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
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Campbell MK, Beard DJ, Blazeby JM, Cousins S. Further considerations for placebo controls in surgical trials. Trials 2023; 24:391. [PMID: 37301819 PMCID: PMC10257825 DOI: 10.1186/s13063-023-07417-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
The use of invasive placebo controls in surgical trials can be challenging. The ASPIRE guidance, published in the Lancet in 2020, provided advice for the design and conduct of surgical trials with an invasive placebo control. Based on a more recent international expert workshop in June 2022, we now provide further insights into this topic. These include the purpose and design of invasive placebo controls, patient information provision and how findings from these trials may be used to inform decision-making.
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Affiliation(s)
- Marion K Campbell
- Royal College of Surgeons of England (RCSEng) Aberdeen Surgical Trials Centre; Health Services Research Unit, Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences; RCSEng Surgical Intervention Trials Unit; National Institute for Health and Care Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Jane M Blazeby
- NIHR Bristol Biomedical Research Centre; RCSEng Bristol Surgical Trials Centre, Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, BS8 2PS, Bristol, UK
| | - Sian Cousins
- NIHR Bristol Biomedical Research Centre; RCSEng Bristol Surgical Trials Centre, Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, BS8 2PS, Bristol, UK.
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Sudo H, Miyakoshi T, Watanabe Y, Ito YM, Kahata K, Tha KK, Yokota N, Kato H, Terada T, Iwasaki N, Arato T, Sato N, Isoe T. Protocol for treating lumbar spinal canal stenosis with a combination of ultrapurified, allogenic bone marrow-derived mesenchymal stem cells and in situ-forming gel: a multicentre, prospective, double-blind randomised controlled trial. BMJ Open 2023; 13:e065476. [PMID: 36731929 PMCID: PMC9896178 DOI: 10.1136/bmjopen-2022-065476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION In patients with combined lumbar spinal canal stenosis (LSCS), a herniated intervertebral disc (IVD) that compresses the dura mater and nerve roots is surgically treated with discectomy after laminoplasty. However, defects in the IVD after discectomy may lead to inadequate tissue healing and predispose patients to the development of IVD degeneration. Ultrapurified stem cells (rapidly expanding clones (RECs)), combined with an in situ-forming bioresorbable gel (dMD-001), have been developed to fill IVD defects and prevent IVD degeneration after discectomy. We aim to investigate the safety and efficacy of a new treatment method in which a combination of REC and dMD-001 is implanted into the IVD of patients with combined LSCS. METHODS AND ANALYSIS This is a multicentre, prospective, double-blind randomised controlled trial. Forty-five participants aged 20-75 years diagnosed with combined LSCS will be assessed for eligibility. After performing laminoplasty and discectomy, participants will be randomised 1:1:1 into the combination of REC and dMD-001 (REC-dMD-001) group, the dMD-001 group or the laminoplasty and discectomy alone (control) group. The primary outcomes of the trial will be the safety and effectiveness of the procedure. The effectiveness will be assessed using visual analogue scale scores of back pain and leg pain as well as MRI-based estimations of morphological and compositional quality of the IVD tissue. Secondary outcomes will include self-assessed clinical scores and other MRI-based estimations of compositional quality of the IVD tissue. All evaluations will be performed at baseline and at 1, 4, 12, 24 and 48 weeks after surgery. ETHICS AND DISSEMINATION This study was approved by the ethics committees of the institutions involved. We plan to conduct dissemination of the outcome data by presenting our data at national and international conferences, as well as through formal publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER jRCT2013210076.
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Affiliation(s)
- Hideki Sudo
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo, Japan
| | - Takashi Miyakoshi
- Clinical Research and Medical Innovation Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Yudai Watanabe
- Clinical Research and Medical Innovation Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Yoichi M Ito
- Data Science Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Kaoru Kahata
- Clinical Research and Medical Innovation Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Khin Khin Tha
- Global Center for Biomedical Science and Engineering, Hokkaido University Faculty of Medicine, Sapporo, Japan
| | - Nozomi Yokota
- Clinical Research and Medical Innovation Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Hiroe Kato
- Clinical Research and Medical Innovation Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Tomoko Terada
- Clinical Research and Medical Innovation Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Norimasa Iwasaki
- Department of Orthopaedic Surgery, Hokkaido University Hospital, Sapporo, Japan
| | - Teruyo Arato
- Clinical Research and Medical Innovation Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Norihiro Sato
- Clinical Research and Medical Innovation Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Toshiyuki Isoe
- Clinical Research and Medical Innovation Center, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
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Feise RJ, Mathieson S, Kessler RS, Witenko C, Zaina F, Brown BT. Benefits and harms of treatments for chronic non-specific low back pain without radiculopathy: Systematic review and meta-analysis. Spine J 2022; 23:629-641. [PMID: 36400393 DOI: 10.1016/j.spinee.2022.11.003] [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] [Received: 08/12/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND CONTEXT Currently, there are no published studies that compare non-pharmacological, pharmacological and invasive treatments for chronic low back pain in adults and provide summary statistics for benefits and harms. PURPOSE The aim of this review was to compare the benefits and harms of treatments for the management of chronic low back pain without radiculopathy and to report the findings in a format that facilitates direct comparison (Benefit-Harm Scale: level 1 to 7). DESIGN Systematic review and meta-analysis of randomized controlled trials, including trial registries, from electronic databases up to 23rd May 2022. PATIENT SAMPLE Adults with non-specific chronic low back pain, excluding radicular pain in any clinical setting. OUTCOME MEASURES Comparison of pain at immediate-term (≤2 weeks) and short-term (>2 weeks to ≤12 weeks) and serious adverse events using the Benefit-Harm Scale (level 1 to 7). METHODS This was a registered systematic review and meta-analysis of randomized controlled trials. Interventions included non-pharmacological (acupuncture, spinal manipulation), pharmacological and invasive treatments compared to placebo. Best evidence criteria was used. Two independent reviewers conducted eligibility assessment, data extraction and quality appraisal. RESULTS The search retrieved 17,362 records. Three studies provided data on the benefits of interventions, and 30 provided data on harms. Studies included interventions of acupuncture (n=8); manipulation (n=2); pharmacological therapies (n=9), including NSAIDs and opioid analgesics; surgery (n=8); and epidural corticosteroid injections (n=3). Acupuncture (standardized mean difference (SMD) -0.51, 95%CI -0.88 to -0.14, n=1 trial, moderate quality of evidence, benefit rating of 3) and manipulation (SMD -0.39, 95%CI -0.56 to -0.21, n=2 trials, moderate quality of evidence, benefit rating of 5) were effective in reducing pain intensity compared to sham. The benefit of the other interventions was scored as uncertain due to not being effective, statistical heterogeneity preventing pooling of effect sizes, or the absence of relevant trials. The harms level warnings were at the lowest (eg, indicating rarer risk of events) for acupuncture, spinal manipulation, NSAIDs, combination ingredient opioids, and steroid injections, while they were higher for single ingredient opioid analgesics (level 4) and surgery (level 6). CONCLUSIONS There is uncertainty about the benefits and harms of all the interventions reviewed due to the lack of trials conducted in patients with chronic non-specific low back pain without radiculopathy. From the limited trials conducted, non-pharmacological interventions of acupuncture and spinal manipulation provide safer benefits than pharmacological or invasive interventions. However, more research is needed. There were high harms ratings for opioids and surgery.
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Affiliation(s)
- Ronald J Feise
- Institute of Evidence-Based Chiropractic, 7047 E Greenway Pkwy Suite 250, Scottsdale, AZ 85254, USA.
| | - Stephanie Mathieson
- Institute for Musculoskeletal Health, Camperdown, NSW, 2050, Australia; Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Rodger S Kessler
- University of Colorado Denver - Anschutz Medical Campus, 13001 E 17th Pl, Aurora, CO 80045, USA
| | - Corey Witenko
- NewYork-Presbyterian Hospital/ Weill Cornell Medical Center, 525 East 68th Street, New York, NY 10065, USA
| | - Fabio Zaina
- ISICO (Italian Scientifi Spine Institute), Via Roberto Bellarmino 13/1, Milan, 20141, Italy
| | - Benjamin T Brown
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2109, Australia
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Affiliation(s)
- Jeffrey N Katz
- 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
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Krakowiak M, Rulewska N, Rudaś M, Broda M, Sabramowicz M, Jaremko A, Leki K, Sokal P. Interspinous Process Devices Do Not Reduce Intervertebral Foramina and Discs Heights on Adjacent Segments. J Pain Res 2022; 15:1971-1982. [PMID: 35860418 PMCID: PMC9292060 DOI: 10.2147/jpr.s356898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 06/13/2022] [Indexed: 11/23/2022] Open
Abstract
Aim Interspinous process device (IPD) placement is an attractive treatment option for lumbar spinal and foraminal stenosis. The goal of the treatment is to release the stress on facets joints as well as decompress the nerve roots by enlarging the intervertebral foramina and narrowed canal recesses. Purpose To evaluate possible structural changes in the lumbar spine after implantation of an IPD on operated and adjacent segments. Patients and Methods Twenty-two patients were enrolled in the study. Preoperative MRI scans of the lumbar spine evaluated recess and foraminal stenosis prior to the application of an IPD. CT exams were performed and morphometric measurements were made to assess the size of intervertebral foramina after implantation on the operated and adjacent segments. Results Statistically significant enlargements in diameter and surface area of the intervertebral foramen were seen at the operating level. On the right and left sides, foraminal enlargement after the procedure was 1 mm in diameter. The average enlargement of the foramina surface area at the level of implantation was 10 mm2. The median interspinous distance was significantly enlarged by 3.5 mm. No significant changes in adjacent segments were observed. Clinical improvement was confirmed by the Oswestry Disability Index (ODI) and visual analog scale (VAS). Preoperative disability was reduced (mean ODI from 70.5 (12.25) to 49.5 (23.75)), as well as back pain (mean VAS from 8.0 (1.7) to 4.4 (2.6)) and pain in lower limbs (mean VAS from 7.4 (1.9) to 3.8 (2.9)). Conclusion Decompression surgery using an IPD is effective in the treatment of lumbar foraminal and canal stenosis. It provides relief of symptoms in short-term observation through enlargement of intervertebral foramina and decompression of neural roots. It reduces overload of facet joints of the operated segment and does not decrease the size of the intervertebral foramina and disc heights of adjacent segments.
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Affiliation(s)
- Mateusz Krakowiak
- Department of Neurosurgery and Neurology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Natalia Rulewska
- Students' Scientific Circle at the Department of Neurosurgery, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Marcin Rudaś
- Department of Neurosurgery and Neurology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Maciej Broda
- Department of Neurosurgery and Neurology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Michał Sabramowicz
- Department of Neurosurgery and Neurology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Andrzej Jaremko
- Department of Neurosurgery and Neurology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Krzysztof Leki
- Centre for Statistical Analysis, Nicolaus Copernicus University, Toruń, Poland
| | - Paweł Sokal
- Department of Neurosurgery and Neurology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
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Anderson DB, Beard DJ, Sabet T, Eyles JP, Harris IA, Adie S, Buchbinder R, Maher CG, Ferreira ML. Evaluation of placebo fidelity and trial design methodology in placebo-controlled surgical trials of musculoskeletal conditions: a systematic review. Pain 2022; 163:637-651. [PMID: 34382608 DOI: 10.1097/j.pain.0000000000002432] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/26/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT The number of placebo surgical trials on musculoskeletal conditions is increasing, but little is known about the quality of their design and methods. This review aimed to (1) assess the level of placebo fidelity (ie, degree to which the placebo control mimicked the index procedure) in placebo trials of musculoskeletal surgery, (2) describe the trials' methodological features using the adapted Applying Surgical Placebo in Randomised Evaluations (ASPIRE) checklist, and (3) describe each trial's characteristics. We searched 4 electronic databases from inception until February 18, 2021, for randomised trials of surgery that included a placebo control for any musculoskeletal condition. Protocols and full text were used to assess placebo fidelity (categorised as minimal, low, or high fidelity). The adapted 26-item ASPIRE checklist was also completed on each trial. PROSPERO registration number: CRD42021202131. A total of 30,697 studies were identified in the search, and 22 placebo-controlled surgical trials of 2045 patients included. Thirteen trials (59%) included a high-fidelity placebo control, 7 (32%) used low fidelity, and 2 (9%) minimal fidelity. According to the ASPIRE checklist, included trials had good reporting of the "rationale and ethics" (68% overall) and "design" sections (42%), but few provided enough information on the "conduct" (13%) and "interpretation and translation" (11%) of the placebo trials. Most trials sufficiently reported their rationale and ethics, but interpretation and translation are areas for improvement, including greater stakeholder involvement. Most trials used a high-fidelity placebo procedure suggesting an emphasis on blinding and controlling for nonspecific effects.
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Affiliation(s)
- David B Anderson
- Faculty of Medicine and Health, School of Health Sciences, Institute of Bone and Joint Research, the Kolling Institute, The University of Sydney, New South Wales, Australia
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, United Kingdom
| | - Tamer Sabet
- Department of Health Professionals, Faculty of Medicine, Health and Human Sciences, Macquarie University, New South Wales, Australia
| | - Jillian P Eyles
- Faculty of Medicine and Health, School of Medicine, Institute of Bone and Joint Research, the Kolling Institute, The University of Sydney, New South Wales, Australia
| | - Ian A Harris
- South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, UNSW Sydney, New South Wales, Australia Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney New South Wales, Australia
- St. George and Sutherland Clinical School, UNSW Sydney, New South Wales, Australia
| | - Sam Adie
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Rachelle Buchbinder
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Vic, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher G Maher
- St. George and Sutherland Clinical School, UNSW Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Faculty of Medicine and Health, School of Health Sciences, Institute of Bone and Joint Research, the Kolling Institute, The University of Sydney, New South Wales, Australia
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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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Bussières A, Cancelliere C, Ammendolia C, Comer CM, Zoubi FA, Châtillon CE, Chernish G, Cox JM, Gliedt JA, Haskett D, Jensen RK, Marchand AA, Tomkins-Lane C, O'Shaughnessy J, Passmore S, Schneider MJ, Shipka P, Stewart G, Stuber K, Yee A, Ornelas J. Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline. THE JOURNAL OF PAIN 2021; 22:1015-1039. [PMID: 33857615 DOI: 10.1016/j.jpain.2021.03.147] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 12/14/2022]
Abstract
Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on nonsurgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. Clinical outcomes evaluated included pain, disability, quality of life, and walking capacity. The target audience for this guideline includes all clinicians, and the target patient population includes adults with LSS (congenital and/or acquired, lateral recess or central canal, with or without low back pain, with or without spondylolisthesis) causing NC. The guidelines panel developed 6 recommendations based on randomized controlled trials and 5 others based on professional consensus, summarized in 3 overarching recommendations: (Grade: statements are all conditional/weak recommendations) Recommendation 1. For patients with LSS causing NC, clinicians and patients may initially select multimodal care nonpharmacological therapies with education, advice and lifestyle changes, behavioral change techniques in conjunction with home exercise, manual therapy, and/or rehabilitation (moderate-quality evidence), traditional acupuncture on a trial basis (very low-quality evidence), and postoperative rehabilitation (supervised program of exercises and/or educational materials encouraging activity) with cognitive-behavioral therapy 12 weeks postsurgery (low-quality evidence). Recommendation 2. In patients LSS causing NC, clinicians and patients may consider a trial of serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants. (very low-quality evidence). Recommendation 3. For patients LSS causing NC, we recommend against the use of the following pharmacological therapies: nonsteroidal anti-inflammatory drugs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants, pregabalin (consensus-based), gabapentin (very low-quality), and epidural steroidal injections (high-quality evidence). PERSPECTIVE: This guideline, on the basis of a systematic review of the evidence on the nonsurgical management of lumbar spine stenosis, provides recommendations developed by a multidisciplinary expert panel. Safe and effective non-surgical management of lumbar spine stenosis should be on the basis of a plan of care tailored to the individual and the type of treatment involved, and multimodal care is recommended in most situations.
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Affiliation(s)
- André Bussières
- School of Physical Medicine & Occupational Therapy, McGill University, Montreal, Quebec, Canada; Département Chiropratique, Université du Québec à Trois-Rivières, Quebec, Canada.
| | - Carolina Cancelliere
- Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Canada
| | - Carlo Ammendolia
- Faculty of Medicine, University of Toronto and Mount Sinai Hospital, Ontario, Canada
| | - Christine M Comer
- Leeds Community Healthcare NHS Trust, Leeds, United Kingdom/ Faculty of Medicine, University of Leeds, United Kingdom
| | - Fadi Al Zoubi
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | | | - Greg Chernish
- Family Medicine at the University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Jordan A Gliedt
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Rikke Krüger Jensen
- NIKKB and Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Denmark
| | - Andrée-Anne Marchand
- Département Chiropratique, Université du Québec à Trois-Rivières, Quebec, Canada
| | - Christy Tomkins-Lane
- Department of Health and Physical Education, Mount Royal University, Calgary, Canada
| | - Julie O'Shaughnessy
- Département Chiropratique, Université du Québec à Trois-Rivières, Quebec, Canada
| | - Steven Passmore
- Faculty of Kinesiology & Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michael J Schneider
- Department of Physical Therapy, University of Pittsburgh, Pennsylvania; Clinical and Translational Science Institute, University of Pittsburgh, Pennsylvania
| | | | | | - Kent Stuber
- Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario
| | - Albert Yee
- Health Systems Management, Rush University, Chicago, Illinois
| | - Joseph Ornelas
- American Hip Institute, Des Plaines, Illinois; Clinical and Translational Science Institute, University of Pittsburgh, Pennsylvania
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10
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Beard DJ, Campbell MK, Blazeby JM, Carr AJ, Weijer C, Cuthbertson BH, Buchbinder R, Pinkney T, Bishop FL, Pugh J, Cousins S, Harris I, Lohmander LS, Blencowe N, Gillies K, Probst P, Brennan C, Cook A, Farrar-Hockley D, Savulescu J, Huxtable R, Rangan A, Tracey I, Brocklehurst P, Ferreira ML, Nicholl J, Reeves BC, Hamdy F, Rowley SC, Lee N, Cook JA. Placebo comparator group selection and use in surgical trials: the ASPIRE project including expert workshop. Health Technol Assess 2021; 25:1-52. [PMID: 34505829 PMCID: PMC8450778 DOI: 10.3310/hta25530] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The use of placebo comparisons for randomised trials assessing the efficacy of surgical interventions is increasingly being considered. However, a placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges. OBJECTIVES To provide a summary of knowledge on placebo controls in surgical trials and to summarise any recommendations for designers, evaluators and funders of placebo-controlled surgical trials. DESIGN To carry out a state-of-the-art workshop and produce a corresponding report involving key stakeholders throughout. SETTING A workshop to discuss and summarise the existing knowledge and to develop the new guidelines. RESULTS To assess what a placebo control entails and to assess the understanding of this tool in the context of surgery is considered, along with when placebo controls in surgery are acceptable (and when they are desirable). We have considered ethics arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be carried out and interpreted. The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with a high risk of bias, particularly because of the placebo effect. CONCLUSIONS The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. An outline for best practice was produced in the form of the Applying Surgical Placebo in Randomised Evaluations (ASPIRE) guidelines for those considering the use of a placebo control in a surgical randomised controlled trial. LIMITATIONS Although the workshop participants involved international members, the majority of participants were from the UK. Therefore, although every attempt was made to make the recommendations applicable to all health systems, the guidelines may, unconsciously, be particularly applicable to clinical practice in the UK NHS. FUTURE WORK Future work should evaluate the use of the ASPIRE guidelines in making decisions about the use of a placebo-controlled surgical trial. In addition, further work is required on the appropriate nomenclature to adopt in this space. FUNDING Funded by the Medical Research Council UK and the National Institute for Health Research as part of the Medical Research Council-National Institute for Health Research Methodology Research programme.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Jane M Blazeby
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Charles Weijer
- Departments of Medicine, Epidemiology and Biostatistics, and Philosophy, Western University, London, ON, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Thomas Pinkney
- Academic Department of Surgery, University of Birmingham, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Felicity L Bishop
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jonathan Pugh
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Sian Cousins
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ian Harris
- Faculty of Medicine, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden
| | - Natalie Blencowe
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Andrew Cook
- Wessex Institute, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Julian Savulescu
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Richard Huxtable
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Health Sciences, University of York, York, UK
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Institute of Bone and Joint Research, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Barnaby C Reeves
- Clinical Trials Evaluation Unit Bristol Medical School, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Freddie Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Naomi Lee
- Editorial Department, The Lancet, London, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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11
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Affiliation(s)
- Rikke Krüger Jensen
- Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Chiropractic Knowledge Hub, Odense, Denmark
| | | | - Frank Huygen
- Department of Anaesthesiology, Pain Medicine, Erasmus Medical Centre, Rotterdam, Netherlands
| | - Bart Koes
- Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Department of General Practice, Erasmus Medical Centre, Rotterdam, Netherlands
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12
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Alves JL. Neurosurgery and the Philosophical Unknowns. World Neurosurg 2021; 152:24-25. [PMID: 34029762 DOI: 10.1016/j.wneu.2021.05.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 05/15/2021] [Indexed: 11/19/2022]
Affiliation(s)
- José Luís Alves
- Department of Neurosurgery, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
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13
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Ferreira GE, Zadro JR, O'Keeffe M, Buchbinder R, Maher C, Latimer J. Challenges faced by musculoskeletal health research in Australia and New Zealand due to the COVID-19 pandemic. Intern Med J 2021; 51:622. [PMID: 33890360 PMCID: PMC8251366 DOI: 10.1111/imj.15254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/19/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Giovanni E Ferreira
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Joshua R Zadro
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Mary O'Keeffe
- Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Rachelle Buchbinder
- Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Chris Maher
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jane Latimer
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Institute for Musculoskeletal Health, Sydney Local Health District, Sydney, New South Wales, Australia
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14
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Mobbs RJ, Mobbs RR, Choy WJ. Proposed objective scoring algorithm for assessment and intervention recovery following surgery for lumbar spinal stenosis based on relevant gait metrics from wearable devices: the Gait Posture index (GPi). JOURNAL OF SPINE SURGERY 2019; 5:300-309. [PMID: 31663040 DOI: 10.21037/jss.2019.09.06] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Lumbar spinal stenosis (LSS) results in significant pain and disability. As spine healthcare providers, monitoring patient's outcomes is of the highest importance, and guides everything we do. However, a large amount of our data has been based solely on subjective, single time-point outcome tools limited by their subjective nature. Methods We herein propose a novel, simple objective scoring system, the Gait Posture index (GPi). Four key objective health metrics, which can be measured using wearable devices have been identified to correlate with health status: (I) step count; (II) gait velocity; (III) step length; (IV) posture. An algorithm combining the above metrics was established to 'score' patient's ambulation from 0 (bed bound)-100 (excellent mobility and gait function). Thirteen surgical patients were assigned to the GPi scoring algorithm and compared with traditional subjective scoring systems Oswestry Disability Index (ODI) and Patient Satisfaction Index (PSI) as a proof of concept and confirmation of validity. Results At 3 months, 11 out of 13 patients following decompression for LSS had an improvement with their GPi 20.79±17.44, P=0.001. In addition, Pearson correlation revealed positive correlation between change in GPi with change in ODI (r=0.682, n=13, P=0.01) and negative correlation between change in GPi with PSI (r=-0.618, n=13, P=0.024). Conclusions The GPi algorithm correlates accurately with preoperative and post-operative mobility which are comparable to traditional subjective scoring systems. GPi affords the health care provider with a relevant measure of patient outcome, and real-time recovery dynamics following decompression for LSS.
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Affiliation(s)
- Ralph J Mobbs
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia.,Neurospine Clinic, Prince of Wales Private Hospital, Randwick, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | | | - Wen Jie Choy
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia.,Neurospine Clinic, Prince of Wales Private Hospital, Randwick, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
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