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Research Review By Dr. Kent Stuber©


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Date Posted:

March 2012

Study Title:

Non-operative treatment for lumbar spinal stenosis with neurogenic claudication: a systematic review


Ammendolia C, Stuber K, de Bruin LK et al.

Author's Affiliations:

Department of Health Policy, Management and Evaluation, University of Toronto; Department of Graduate Education and Research, Canadian Memorial Chiropractic College; Institute for Work and Health.

Publication Information:

Spine 2012; 37(10): E609-16.

Background Information:

Lumbar spinal stenosis with neurogenic claudication is already a common condition afflicting elderly patients, being the number one reason for spinal surgery among this group. With the increasing age of the population in Western nations in particular, it is a condition whose prevalence will continue to rise in the foreseeable future. The impact of neurogenic claudication resulting from spinal stenosis is particularly important as the limitation on one’s ability to walk can impact the quality of life and independence of those affected. Non-surgical treatment is considered the first line option in the majority of cases of neurogenic claudication. Given the prevalence and impact of the condition, finding viable non-surgical treatments is imperative to achieve satisfactory results for patients, while avoiding draining health care resources and escalating costs of care. Therefore, the purpose of this study was to “systematically evaluate the clinical effectiveness of non-operative treatments for lumbar spinal stenosis with neurogenic claudication”.

The signs and symptoms of neurogenic claudication vary, but typically upon prolonged standing and/or walking there will be pain, weakness or paresthesia in the buttock, thigh, or calf, either unilaterally or bilaterally.

In this review, neurogenic claudication was defined as 'buttock or leg pain or aching, numbness, tingling, weakness or fatigue with or without back pain, precipitated by standing or walking'.

Pertinent Results:

Over 8500 articles were screened, 56 were assessed, and 21 trials with 1851 subjects were included. Only 4 studies were found to have a low risk of bias. Either low or very low quality evidence was found to either support or refute any of the non-operative treatments that were evaluated. In general, whenever a non-operative treatment was found to be potentially beneficial it was only at short-term follow-up. When non-operative treatments had statistically significant differences in outcomes, there were generally small effect sizes calling into question their relative clinical importance.

Some non-operative treatments for lumbar spinal stenosis with neurogenic claudication were supported, however minimally. There was low quality evidence from one study that prostaglandins improve walking distance and leg pain when compared to a conventional NSAID. Similarly, there was low quality evidence for medium and long-term improvement in walking distance and pain intensity when comparing gabapentin with placebo. There was very low quality evidence supporting methylcabalamin (vitamin B12) along with conservative care in terms of walking distance when compared with conservative care alone. There was low quality evidence supporting exercise when compared to no treatment for short-term leg pain and function. There was very low quality evidence showing that in-patient physical therapy aided pain intensity, function, and quality of life when compared with diclofenac and home exercise. There was also very low quality evidence that supported a combination of manual therapy, exercise, and un-weighted treadmill walking when compared with flexion exercise, walking, and sham ultrasound.

There was very low quality evidence when evaluating epidural injections, and the results of those 4 trials were varied, some showing improvements when compared with other treatments, but others not showing any difference when compared with placebo injections. There were 5 trials that evaluated multi-modal non-operative treatment regimens when compared with surgery, there was great discrepancy between the treatment programs involved and all had very low or low quality levels of evidence, most of which were found to produce either equal or inferior results when compared to different surgical interventions. Peri –operative (5.4%-14%) and post-operative (8.2%-18%) complication rates were reported in these five trials.

Numerous other non-operative treatments for lumbar spinal stenosis with neurogenic claudication were not supported. There was very low quality evidence of the effectiveness of calcitonin when comparing it with placebo or paracetamol. Based on low quality evidence un-weighted treadmill walking was not superior to stationary cycling for any outcome.

Clinical Application & Conclusions:

There is a lack of high quality research on this topic and conclusive recommendations for practice cannot be made. The evidence identified was either low quality or very low quality. The effectiveness of physical and manual therapies is questionable at this point, owing to the minimal amount of low or very low quality evidence currently available. This is a frustrating set of circumstances for those who see patients with spinal stenosis with neurogenic claudication, but highlights the need for further high quality research particularly when considering the number of patients likely to be affected by this condition in the future.

In the opinion of this author (*disclaimer*), non-operative treatment should likely still be the first line option for management of spinal stenosis with neruogenic claudication. However, the question still remains, which non-operative treatment to use? One promising approach for those who utilize manual and exercise therapies was outlined by Murphy, Hurwitz, et al. (3) in a practice-based observational cohort study. Their approach employed distraction manipulation, neural mobilization, and complimentary exercises for the lumbar spine (such as the cat-camel and nerve-flossing), and in some cases additional exercises such as mobilization and/or stabilization exercises, all while employing pragmatic and clinically achievable treatment plans. Statistically and clinically significant improvements were noted in several outcome measures at long-term follow-up in this study. While this treatment approach is yet to be followed-up with an RCT or further publications, it does seem like a potentially useful approach.

Study Methods:

Multiple databases were searched electronically in English for RCTs comparing at least one form of non-operative treatment for lumbar spinal stenosis (confirmed by imaging) that caused neurogenic claudication. Individual study quality was assessed by two reviewers using criteria recommended by the Cochrane Back Review Group. Outcomes of interest included walking ability, pain intensity, function, quality of life, and global improvement, along with safety data with short-term, intermediate, and long term follow-ups all being evaluated. Data was pooled and meta-analysis performed when possible. The overall quality of the evidence was formally evaluated and synthesized using GRADE (Grades of Recommendations, Assessment, Development and Evaluation).

Study Strengths / Weaknesses:

Among the strengths of this review was the inclusion of RCTs that included any and all non-operative interventions, including pharmacological and non-pharmacological treatments. The methods employed in the review were robust, including the use of GRADE to analyze the overall quality of the literature. The inclusion criteria also allowed for the evaluation of studies that compared surgical versus non-surgical treatments for neurogenic claudication due to lumbar spinal stenosis. In addition, having a consistently applied definition of neurogenic claudication caused by lumbar spinal stenosis as viewed on imaging was important as such definitions are often omitted from studies and reviews.

Weaknesses of the review include the inclusion of only articles published in English. Furthermore, the reliance on imaging to determine the presence of spinal stenosis may be questioned by some, as could some of the operational definitions employed, particularly for risk of bias when assessing study quality.

Additional References:

  1. Weinstein JN et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. New England Journal of Medicine 2008; 358(8): 794-810.
  2. Kovacs FM, Urrútia G, Alarcón JD. Surgery versus conservative treatment for symptomatic lumbar spinal stenosis: a systematic review of randomized controlled trials. Spine 2011; 36(20): 1335-51.
  3. Murphy DR, Hurwitz EL, Gregory AA, Clary R. A nonsurgical approach to the management of lumbar spinal stenosis: a prospective observational cohort study. BMC Musculoskelet Disord 2006;7:16, doi:10.1186/1471-2474-7-16.

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