Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline

Bussières, André; Cancelliere, Carol; Ammendolia, Carolina; Comer, Christine; Zoubi, Fadi Al; Châtillon, Claude-Édouard; Chernish, Greg; Cox, James M.; Gliedt, Jordan A.; Haskett, Danielle; Jensen, Rikke Krüger; Marchand, Andrée-Anne; Tomkins-Lane, Christy; O’Shaughnessy, Julie; Passmore, Steven; Schneider, Michael J.; Shipka, Peter; Stewart, Gregory W.; Stuber, Kent; Yee, Albert; Ornelas, Joseph

doi:10.1016/j.jpain.2021.03.147

Cited by 56 publications

(60 citation statements)

References 138 publications

(183 reference statements)

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“…However, a recent clinical practice guideline for the management of LSS leading to neurogenic claudication concurred with our findings and recommended, based on moderate-quality evidence, multimodal care consisting of education with home exercises and manual therapy. 65 These guidelines also recommended against the use of epidural steroid injections, based on high-quality evidence. A recent systematic review and meta-analysis of RCTs evaluating conservative non-pharmacological therapies for degenerative LSS also concluded, based on low-tomoderate evidence, that manual therapy and supervised exercises significantly improve outcomes compared with self-directed or group exercises.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2022

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ObjectivesNeurogenic claudication due to lumbar spinal stenosis (LSS) is a growing health problem in older adults. We updated our previous Cochrane review (2013) to determine the effectiveness of non-operative treatment of LSS with neurogenic claudication.DesignA systematic review.Data sourcesCENTRAL, MEDLINE, EMBASE, CINAHL and Index to Chiropractic Literature databases were searched and updated up to 22 July 2020.Eligibility criteriaWe only included randomised controlled trials published in English where at least one arm provided data on non-operative treatment and included participants diagnosed with neurogenic claudication with imaging confirmed LSS.Data extraction and synthesisTwo independent reviewers extracted data and assessed risk of bias using the Cochrane Risk of Bias Tool 1. Grading of Recommendations Assessment, Development and Evaluation was used for evidence synthesis.ResultsOf 15 200 citations screened, 156 were assessed and 23 new trials were identified. There is moderate-quality evidence from three trials that: Manual therapy and exercise provides superior and clinically important short-term improvement in symptoms and function compared with medical care or community-based group exercise; manual therapy, education and exercise delivered using a cognitive-behavioural approach demonstrates superior and clinically important improvements in walking distance in the immediate to long term compared with self-directed home exercises and glucocorticoid plus lidocaine injection is more effective than lidocaine alone in improving statistical, but not clinically important improvements in pain and function in the short term. The remaining 20 new trials demonstrated low-quality or very low-quality evidence for all comparisons and outcomes, like the findings of our original review.ConclusionsThere is moderate-quality evidence that a multimodal approach which includes manual therapy and exercise, with or without education, is an effective treatment and that epidural steroids are not effective for the management of LSS with neurogenic claudication. All other non-operative interventions provided insufficient quality evidence to make conclusions on their effectiveness.PROSPERO registration numberCRD42020191860.

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Section: Discussionmentioning

confidence: 99%

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

et al. 2022

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“…However, there is no agreed source of clear and comprehensive advice and education for patients with LSS and such resources may yet need to be developed using appropriate coproduction methods. Exercise treatments, often incorporated in multimodal non-surgical treatment packages, are recommended in some clinical guidelines [19,21]. Emerging evidence suggests supervised exercise with manual therapy may be more effective than self-directed care [40] but remains insu cient to inform the most effective treatment combination or to determine the optimum exercises type or dosage.…”

Section: Discussionmentioning

confidence: 99%

“…These included psychologically informed approaches, manual therapy, medications and spinal injections. Limited evidence and sometimes con icting guidance [19,21,41] mean that the value of these treatments remains contentious in the management of LSS. For example, a recent review highlights recommendations both for and against manual therapy in different clinical practice guidelines [7].…”

Section: Discussionmentioning

confidence: 99%

“…However, the study steering group decided that there was inadequate evidence [7,21,41] or participant agreement to advocate any speci c medications in the proposed algorithm. Whilst psychologically informed treatments are not found in LSS clinical practice guidelines, two recent trials include a psychologically informed approach as part of multimodal care for people with LSS [42,43].…”

Section: Discussionmentioning

confidence: 99%

“…Evidence was made available to participants through links embedded within the survey questionnaire. This evidence included high level systematic literature reviews produced by the Cochrane collaboration [11,13,18] and published clinical practice guidelines [19][20][21]. The aim was to facilitate the incorporation of current evidence into the development of treatment pathways, and to convey to participants that the process should be based on available evidence [22,23].…”

Section: Phasementioning

confidence: 99%

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Consensus on a Standardised Treatment Pathway Algorithm for Lumbar Spinal Stenosis: an International Delphi Study

Comer

Ammendolia

Battié

et al. 2022

Preprint

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Background Lumbar spinal stenosis (LSS) is a common degenerative spinal condition in older adults associated with disability, diminished quality of life, and substantial healthcare costs. Individual symptoms and needs vary. With sparse and sometimes inconsistent evidence to guide clinical decision-making, variable clinical care may lead to unsatisfactory patient outcomes and inefficient use of healthcare resources.Methods A three-phase modified Delphi study comprising four consensus rounds was conducted on behalf of the International Taskforce for the Diagnosis and Management of LSS to develop a treatment algorithm based on multi-professional international expert consensus. Participants with expertise in the assessment and management of people with LSS were invited using an international distribution process used for two previous Delphi studies led by the Taskforce. Separate treatment pathways for patients with different symptom types and severity were developed and incorporated into a proposed treatment algorithm through consensus rounds 1 to 3. Agreement with the proposed algorithm was evaluated in the final consensus round.Results The final algorithm combines stratified and stepped approaches. When indicated, immediate investigation and surgery is advocated. Otherwise, a stepped approach is suggested when self-directed care is unsatisfactory. This starts with tailored rehabilitation, then more complex multidisciplinary care, investigations and surgery options if needed. Treatment options in each step depend on clinical phenotype and symptom severity. Treatment response guides pathway entrance and exit points. Of 397 study participants, 86% rated their agreement >4 for the proposed algorithm on a 0-6 scale, of which 22% completely agreed. Only 7% disagreed. Over 70% of participants felt that the algorithm would be useful for clinicians in public healthcare (both primary care and specialist settings) and in private healthcare settings, and that a simplified version would help patients in shared decision-making.Conclusions International and multi-professional agreement was achieved for a proposed LSS treatment algorithm developed through expert consensus. The algorithm advocates different pathway options depending on clinical indications. It is not intended as a treatment protocol and will require evaluation against current care for clinical and cost-effectiveness. It may, however, serve as a clinical guide until evidence is sufficient to inform a fully stratified care model.

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Consensus for Statements Regarding a Definition for Spinal Osteoarthritis for Use in Research and Clinical Practice: A Delphi Study

Luca

Chiarotto

Cicuttini

et al. 2023

Arthritis Care & Research

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Objective To determine consensus among an international, multidisciplinary group of experts regarding definitions of spinal osteoarthritis for research and for clinical practice. Methods A 15‐member, multidisciplinary steering committee generated 117 statements for a 3‐round Delphi study. Experts in back pain and/or osteoarthritis were identified and invited to participate. In round 1, participants could propose additional statements for voting. All statements were rated on a 1–9 Likert scale, and consensus was set at ≥70% of respondents agreeing or disagreeing with the statement and <15% of respondents providing the opposite response. Results In total, 255 experts from 11 different professional backgrounds were invited. From 173 available experts, 116 consented to participate. In round 1, 103 participants completed the survey, followed by 85 of 111 participants in round 2 (77%) and 87 of 101 participants in round 3 (86%). One‐third of participants were from Europe (30%), most were male (58%), one‐fifth were physical therapists (21%), and over one‐third had been in their profession for 11–20 years (35%). Of 131 statements, consensus was achieved for 71 statements (54%): 53 in agreement (75%) and 18 in disagreement (25%). Conclusion Although there was consensus for statements for definitions of spinal osteoarthritis that were analogous to definitions of osteoarthritis in appendicular joints, a future definition still needs refinement. Importantly, this Delphi highlighted that a future definition should be considered across a spectrum of structural changes and patient symptoms and expressed on a progressive scale.

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Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline

Cited by 56 publications

References 138 publications

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

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

Consensus on a Standardised Treatment Pathway Algorithm for Lumbar Spinal Stenosis: an International Delphi Study

Consensus for Statements Regarding a Definition for Spinal Osteoarthritis for Use in Research and Clinical Practice: A Delphi Study

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