Study Design. Systematic review.
Objective. To systematically review the evidence for the effectiveness of nonoperative treatment of lumbar spinal stenosis with neurogenic claudication.
Summary of Background Data. Neurogenic claudication can significantly impact functional ability, quality of life, and independence in the elderly.
Methods. We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and ICL databases up to January 2011 for randomized controlled trials published in English, in which at least 1 arm provided data on nonoperative treatments. Risk of bias in each study was independently assessed by 2 reviewers using 12 criteria. Quality of the evidence was evaluated using Grades of Recommendations, Assessment, Development, and Evaluation (GRADE).
Results. From the 8635 citations screened, 56 were assessed and 21 trials with 1851 participants were selected. There is very low-quality evidence from 6 trials that calcitonin is no better than placebo or paracetamol, regardless of mode of administration or outcome. From single small trials, there is low-quality evidence that prostaglandins, and very low-quality evidence that gabapentin or methylcobalamin, improve walking distance. There is very low-quality evidence from a single trial that epidural steroid injections improve pain, function, and quality of life up to 2 weeks compared with home exercise or inpatient physical therapy. There is low-quality evidence from a single trial that exercise is of short-term benefit for leg pain and function compared with no treatment. There is low- and very low-quality evidence from 6 trials that multimodal nonoperative treatment is less effective than indirect or direct surgical decompression with or without fusion.
Conclusion. Moderate- and high-GRADE evidence for nonoperative treatment is lacking and thus prohibiting recommendations to guide clinical practice. Given the expected exponential rise in the prevalence of lumbar spinal stenosis with neurogenic claudication, large high-quality trials are urgently needed.
Low- and very low-quality evidence suggests that for neurogenic claudication, prostaglandins, gabapentin, and methylcobalamin improve walking ability; exercise improves leg pain and function; calcitonin is no better than placebo or paracetamol; epidural injections provide short-term improvement in pain, function, and quality of life; and indirect and direct surgical decompressions are more effective than multimodal nonoperative care.
*Institute of Health Policy, Management and Evaluation, University of Toronto, Canada
†Department of Medicine, Mount Sinai Hospital, Toronto, Canada
‡Institute for Work and Health, Toronto, Canada
§Department of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Canada
‖Department of Medicine, University of Toronto, Toronto, Canada
¶Toronto Rehabilitation Institute, Toronto, Canada
#Department of Physical Therapy, University of Toronto, Toronto, Canada
**Mobility Program Clinical Research Unit, St. Michael's Hospital, Toronto, Canada
††Department of Surgery, Divisions of Orthopaedic and Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, Canada; and
‡‡Dalla Lana School of Public Health, University of Toronto, Canada.
Address correspondence and reprint requests to Carlo Ammendolia, DC, PhD, Department of Medicine, Mount Sinai Hospital, 60 Murray St, Ste L2-007, Toronto, Ontario, Canada, M5L 3L9; E-mail: firstname.lastname@example.org
Acknowledgment date: July 7, 2011. First revision date: October 30, 2011. Acceptance date: November 4, 2011.
The manuscript submitted does not contain information about medical device(s)/drug(s).
Canadian Chiropractic Research Foundation funds were received to support this work.
No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.