Non-operative treatment for lumbar spinal stenosis with neurogenic claudication: an updated systematic review. (Ammendolia C, et al.1)
Good science is for everyone. Using its power, we can equip our patients with trustworthy evidence to make the best decisions about their health care. Science can also show the profound impact we have every day as we quietly go about our work in our clinics, serving our communities one patient at a time. One of our great privileges is serving the elderly among us by managing their symptoms brought about by neurogenic claudication from lumbar spinal stenosis (LSS).
The paper we will review for this blog is a systematic review published in 2022 examining the existing clinical trial literature to answer this question: Are non-operative treatments effective in helping patients who suffer with neurogenic claudication from LSS?
The study team, led by an experienced and respected chiropractic scientist at the University of Toronto, Carlo Ammendolia, used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses) PRISMA guidelines as well as rigorous methodology recommended by the Cochrane Back Review Group to complete this study.
“PICO”
You may recall that “PICO” stands for “Population, Intervention, Comparison, and Outcome.” PICO is a useful way to break down a study into its component parts so we can quickly discover what a paper is about and how it applies to our own patients.
In the Ammendolia et al paper, the Population consisted of individuals with imaging confirmed LSS with or without spondylolisthesis who suffered with buttock or leg pain as well as tingling, numbness, weakness, aching or fatigue with or without back pain, brought on by standing or walking. In other words, they had neurogenic claudication. The Interventions chosen for this review were “all” non-operative treatments reported in the clinical trials identified. The Comparison was any invasive treatment including surgery. To be included in this systematic review a clinical trial needed to report at least one of the following Outcome measures: walking ability, pain intensity, physical function, quality of life, or global improvement.
Using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE2) framework, the quality of evidence was ranked into 4 categories using 5 specific domains. (See reference 2 for details on these domains.) GRADE quality categories are high, moderate, low, and very low. When all 5 domains are satisfied a clinical trial receives a “high” quality ranking. A “very low” quality ranking means that 2 or fewer domains are satisfied. In this case, there is great uncertainty about the estimated efficacy of an intervention reported in a clinical trial.
RESULTS
Of the 15,200 titles and abstracts retrieved from the comprehensive literature search 156 full-text articles were reviewed yielding 44 randomized controlled trials (RCTs) meeting the pre-determined inclusion criteria, including 23 new RCTs since the last Cochrane review on this topic. Thirty-one of the 44 RCTs included satisfied 6 or more risk-of-bias criteria, but of those, only nine qualified as low risk of bias. Of the included studies 17 assessed rehabilitation therapy or multimodal care, 11 examined epidural steroid injections, seven assessed oral medications including pregabalin (Lyrica®) and gabapentin (Neurontin®), six examined calcitonin, two reported on acupuncture, and one evaluated the efficacy of spinal manipulation as a stand-alone treatment. Two studies had enough data to be included in a meta-analysis.
Eight new studies included since the last Cochrane review evaluated 13 rehabilitation and/or multimodal non-operative approaches. One trial3 (N=259) showed moderate-quality evidence that “manual therapy and exercise provides superior and clinically important short-term improvements in symptoms and function compared with medical care or community-based group exercise.” Manual therapy and exercise were provided by chiropractors and physical therapists. Manual therapy included lumbar distraction mobilization, hip joint mobilization, side posture lumbar/sacroiliac mobilization, and neural mobilization. Medical care consisted of three visits to a physical medicine physician over six weeks with treatment primarily consisting of prescriptions for oral medicines, antidepressants or anticonvulsants. Group exercise in this study consisted of participation in an exercise class twice weekly for six weeks.
Another moderate-quality trial of structured comprehensive care4 (including manual therapy, exercise, and education delivered using a cognitive-behavioral approach) vs. self-directed home exercise showed superior and clinically important improvements in walking distance at short-term, intermediate-term, and long-term time points. A standardized combination of side posture high-velocity, low amplitude manipulations, joint and soft tissue mobilizations and stretching, neural mobilizations, and lumbar flexion-distraction manipulations were used.
Collectively, all papers referencing manual therapy in this evidence synthesis incorporated lumbar flexion, but did not refer to a specific chiropractic technique.
Many other comparisons involving low or very-low quality evidence were discussed in this study. Of greatest interest for our patients is that epidural steroid injections are not effective for the management of LSS causing neurogenic claudication.
SUMMARY
Most people with neurogenic claudication from LSS receive non-operative care. Evidence suggests that lumbar manual therapies in combination with exercise – commonly used services available in many chiropractic practices – have as strong or stronger evidence support than many treatments currently being employed, including epidural steroid injection.
Your patients need to know!
Joel Carmichael, DC, PhD practices at The Center for Spine, Sport & Physical Medicine in Colorado. He teaches at Universidad Central del Caribe in Puerto Rico and maintains volunteer clinical faculty status at the University of Colorado School of Medicine. His research seeks to improve the practice habits of sport and spine professionals. Dr. Carmichael loves teaching, latté art, C.S. Lewis, and an occasional morsel of chocolate. He and his wife enjoy morning strolls with their golden retrievers, Stella and Noli.
References
- Ammendolia C, et al. BMJ Open 2022;12:e057724. doi:10.1136/bmjopen-2021-057724
- What is GRADE?
- Schneider MJ, Ammendolia C, Murphy DR, et al. Comparative clinical effectiveness of nonsurgical treatment methods in patients with lumbar spinal stenosis: a randomized clinical trial. JAMA Network Open 2019;2:e186828.
- Ammendolia C, Côté P, Southerst D, et al. Comprehensive nonsurgical treatment versus Self directed care to improve walking ability in lumbar spinal stenosis: a randomized trial. Arch Phys Med Rehabil 2018;99:2408–19.
