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Surgery Versus Conservative Treatment for Symptomatic Lumbar Spinal Stenosis: A Systematic Review of Randomized Controlled Trials

Kovacs, Francisco M. MD, PhD*,∥; Urrútia, Gerard MD†,‡,§,∥; Alarcón, José Domingo MD¶,∥

doi: 10.1097/BRS.0b013e31820c97b1
Literature Review

Study Design. Systematic review.

Objective. To compare the effectiveness of surgery versus conservative treatment on pain, disability, and loss of quality of life caused by symptomatic lumbar spinal stenosis (LSS).

Summary of Background Data. LSS is the most common reason for spine surgery in persons older than 65 years in the United States.

Methods. Randomized controlled trials (RCTs) comparing any form of conservative and surgical treatment were searched in CENTRAL, MEDLINE, EMBASE, and TripDatabase databases until July 2009, with no language restrictions. Additional data were requested from the authors of the original studies. The methodological quality of each study was assessed independently by two reviewers, following the criteria recommended by the Cochrane Back Review Group. Only data from randomized cohorts were extracted.

Results. A total of 739 citations were reviewed. Eleven publications corresponding to five RCTs were included. All five scored as high quality despite concerns deriving from heterogeneity of treatment, lack of blinding, and potential differences in the size of the placebo effect across groups. They included a total of 918 patients in whom conservative treatments had failed for 3 to 6 months, and included orthosis, rehabilitation, physical therapy, exercise, heat and cold, transcutaneous electrical nerve stimulation, ultrasounds, analgesics, nonsteroidal anti-inflammatory drugs, and epidural steroids. Surgical treatments included the implantation of a specific type of interspinous device and decompressive surgery (with and without fusion, instrumented or not). In all the studies, surgery showed better results for pain, disability, and quality of life, although not for walking ability. Results of surgery were similar among patients with and without spondylolisthesis, and slightly better among those with neurogenic claudication than among those without it. The advantage of surgery was noticeable at 3 to 6 months and remained for up to 2 to 4 years, although at the end of that period differences tended to be smaller.

Conclusion. In patients with symptomatic LSS, the implantation of a specific type of device or decompressive surgery, with or without fusion, is more effective than continued conservative treatment when the latter has failed for 3 to 6 months.

Implantation of an interspinous device and decompressive surgery (with or without fusion, instrumented or not) are more effective than continuing a miscellanea of conservative treatments in patients with symptomatic lumbar spinal stenosis, in whom the latter have failed for 3 to 6 months.

*Departamento Científico, Fundación Kovacs, Palma de Mallorca, Spain

Iberoamerican Cochrane Center-Servei d'Epidemiologia Clínica i Salut Pública, Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain

CIBER Epidemiología y Salud Pública, Barcelona, Spain

§Public Health and Research Methodology Programme, Universitat Autonoma de Barcelona, Barcelona, Spain

Iberoamerican Cochrane Network, Universidad Surcolombiana, Neiva, Colombia

Red Española de Investigadores en Dolencias de la Espalda, Paseo Mallorca 36, 07012 Palma de Mallorca, Spain

Address correspondence and reprint requests to Francisco M. Kovacs, MD, PhD, Departamento Científico, Fundación Kovacs, Paseo Mallorca 36, 3°, 1a, 07012 Palma de Mallorca, Spain; E-mail:

Acknowledgement date: June 1, 2010. First Revision date: August 16, 2010. Second Revision date: October 12, 2010. Third Revision date: November 17, 2010. Acceptance date: November 18, 2010.

The device(s)/drug(s) is/are FDA-approved or approved by corresponding national agency for this indication.

Foundation and Governmental funds were received in support of 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.

Gerard Urrutia and José Domingo Alarcón retrieved and independently assessed the references identified through the electronic search. They also independently assessed the methodologic quality of each article and performed data extraction. Francisco M. Kovacs participated with these two authors in solving by consensus any disagreements in quality assessment and data extraction that arose, and also wrote this manuscript. He reports that he had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

© 2011 Lippincott Williams & Wilkins, Inc.