Spinal stenosis is caused by narrowing of the spinal canal resulting in pressure on the nerve roots and/or spinal cord producing leg and back pain, especially whilst walking. Decompression surgery reduces the constriction by removing any excess bone, thickened ligaments, degenerate disc material and other fibrous tissue.
As an Elf that refers patients for surgical assessment, I was keen to explore best post-operative care for this condition and found a systematic review looking at just this.
Here’s what they did
The authors searched CENTRAL, the Cochrane Back Review Group Trials Register, MEDLINE, EMBASE, CINAHL, and PEDro from first issue to March 2013. The population identified was adults (>18 years of age) with lumbar spinal stenosis who had undergone primary spinal decompressive surgery (with or without fusion).
Interventions compared were active rehabilitation (all forms of group or therapist-led exercise training or stabilisation training involving muscle strengthening exercises and flexibility training, as well as educational materials encouraging activity), and ‘usual care’ (varying from limited post-operative advice to stay active to a brief general programme of exercise with the primary aim of preventing deep vein thrombosis).
Quality of studies was assessed using the GRADE approach. To assess whether results were clinically significant, the authors applied predefined outcome-specific minimal clinically important differences (MCID) of 8-12% for functional outcome, and 30% for low back pain (Furlan et al., 2009).
Here’s what they found
1726 articles were identified but only 3 deemed suitable for meta-analysis. The total number of participants in these 3 studies was 373. The studies included a relatively equal split male/female with mean ages 62 – 67.1. Outcomes assessed at short term (3 – 6 months) and long term (12 months) were functional status, leg pain, low back pain and general health. In one study not all participants attended short-term follow up and consequently only 340 were included in analysis. Only two studies assessed general health (n= 238).
Short term outcomes
- Medium effect of rehabilitation on functional status which was clinically significant (log SMD, -0.22; 95% CI, -0.44 to 0.00)
- Medium effect of rehabilitation on low back pain, however this finding was not clinically significant (log MD, -0.18; 95% CI, -0.35 to -0.02)
- The effects of rehabilitation on leg pain and general health were small and were neither statistically nor clinically significant (log MD, -0.17; 95% CI, -0.52 to 0.19 and MD, 1.30; 95% CI, -6.45 to 7.06 respectively)
Long term outcomes
- Medium effect of rehabilitation on functional status which was clinically significant(log SMD, -0.26; 95% CI, -0.46 to -0.05)
- Medium effect of rehabilitation on low back pain was noted, but this was not clinically significant (log MD, -0.20; 95% CI, -0.36 to -0.05)
- The effects of rehabilitation on leg pain and general health were small and statistically significant but not clinically significant (log MD, -0.24; 95% CI, -0.47 to -0.01 and MD, -0.48, 95% CI, -6.41 to 5.4 respectively)
The authors concluded
There is moderate quality evidence indicating that post-operative active rehabilitation after decompression surgery for lumbar stenosis is more effective than usual care in improving both short-term and long-term (back-related) functional status.
The Musculoskeletal Elf’s view
Although deemed to have a generally low risk of bias, in all studies there was a high risk of performance bias as both participants and care providers had knowledge of the allocated interventions. A relatively quick study of the paper may lead the reader to believe that there are other short term (reduction in low back pain) and long term (reduction in low back and leg pain) benefits. However, the improvements quoted did not reach a-priori outcome-specific MICD. Unfortunately, while we are provided with a general idea of what active rehabilitation/ usual care are, we are not provided with specifics.
What do you think?
- What protocols do you use for patients undergoing lumbar spinal decompression surgery?
- Would you suggest improvements in function and reduction in low back pain are in keeping with the review findings?
- If you are not using a protocol is this something which should be cost assessed / addressed?
McGregor A.H., Probyn K., Cro S., Doré C.J., Burton A.K. et al. 2014, ‘Rehabilitation following surgery for lumbar spinal stenosis. A Cochrane review,’ Spine Vol.39, no.13, pp.1044-54 [Abstract]
Furlan A.D., Pennick V., Bombardier C. & van Tulder, M. 2009, ‘2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group’ , Spine Vol. 34, pp.1929 – 41 [Abstract]