The evidence on surgical interventions for low back disorders, an overview of systematic reviews

Abstract

Purpose Many systematic reviews have been published on surgical interventions for low back disorders. The objective of this overview was to evaluate the available evidence from systematic reviews on the effectiveness of surgical interventions for disc herniation, spondylolisthesis, stenosis, and degenerative disc disease (DDD). An earlier version of this review was published in 2006 and since then, many new, better quality reviews have been published. Methods A comprehensive search was performed in the Cochrane database of systematic reviews (CDSR), database of reviews of effectiveness (DARE) and Pubmed. Two reviewers independently performed the selection of studies, risk of bias assessment, and data extraction. Included are Cochrane reviews and non-Cochrane systematic reviews published in peer-reviewed journals. The following conditions were included: disc herniation, spondylolisthesis, and DDD with or without spinal stenosis. The following comparisons were evaluated: (1) surgery vs. conservative care, and (2) different surgical techniques compared to one another. The methodological quality of the systematic reviews was evaluated using AMSTAR. We report (pooled) analyses from the individual reviews. Results Thirteen systematic reviews on surgical interventions for low back disorders were included for disc herniation (n = 6), spondylolisthesis (n = 2), spinal stenosis (n = 4), and DDD (n = 4). Nine (69 %) were of high quality. Five reviews provided a meta-analysis of which two showed a significant difference. For the treatment of spinal stenosis, intervertebral process devices showed more favorable results compared to conservative treatment on the Zurich Claudication Questionnaire [mean difference (MD) 23.2 95 % CI 18.5-27.8]. For degenerative spondylolisthesis, fusion showed more favorable results compared to decompression for a mixed aggregation of clinical outcome measures (RR 1.40 95 % CI 1.04-1.89) and fusion rate favored instrumented fusion over non-instrumented fusion (RR 1.37 95 % CI 1.07-1.75). 123Eur Spine J ( ) 22:1936( -1949( DOI 10.1007( /s00586-013-2823 Conclusions For most of the comparisons, the included reviews were not significant and/or clinically relevant differences between interventions were identified. Although the quality of the reviews was quite acceptable, the quality of the included studies was poor. Future studies are likely to influence our assessment of these interventions.

Management of degenerative lumbar spinal stenosis: an evidence-based review

“…59,60    Therefore, interspinous dynamic devices (ID) have been designed to limit spinal extension. 61-63 Three high-quality reviews, according to Jacobs et al, 64 compared interspinous process distraction devices with conservative treatment, finding better Zurich claudication questionnaire scores when ID were used, but long-term outcomes and cost-effectiveness need to be assessed. 4,7,12 Although patients may obtain some benefits from interspinous spacers implanted through a MIS technique, ID use is associated with a higher incidence of re-operation and higher costs.…”

Minimally invasive surgery for lumbar spinal stenosis

“…Before the introduction of IPDs, lumbar spines that were ''destabilized'' after LSS were frequently rigidly stabilized by pedicle screws, and since the mid-nineties of the last century vertebral interbody cages were added to this process [21][22][23]. However, pedicle screws and discal interbody cages, whose use is widespread for LSS, were introduced without any evidence of added value compared with conventional surgical decompression without implants, or even any evidence of incidence of spinal instability [24][25][26].…”

“…This practice is not supported through scientific data, while evidence supporting fusion in degenerative spondylolisthesis (slip of two adjacent vertebra), intuitively associated with progressive postsurgical spinal ''instability'', is lacking as well [28,29]. Besides the paucity of data reporting a clear beneficial effect of instrumented fusion, these ''advanced'' techniques are associated with an almost threefold risk of life-threatening complications.…”

The Michel Benoist and Robert Mulholland Yearly European Spine Journal Review: a survey of the “medical” articles in the European Spine Journal, 2013

“…The systematic review by Jacobs et al [15] published in September aims to evaluate the scientific evidence of the efficacy of four surgical interventions: disc herniation, spondylolisthesis, stenosis and degenerative disc disease. The originality of this fine piece of work is that the search for evidence is based on reviewing published systematic reviews.…”