Lumbar Spinal Stenosis Materclass: Surgical management of lumbar spinal stenosis:

Transcription

1 Lumbar Spinal Stenosis Materclass: Surgical management of lumbar spinal stenosis: Presented By: Michelle Emsley Senior Spinal In-Patient Physiotherapist

2 Learning objectives Indications Evidence Post operative complications Surgical Management Who for? Effectiveness Types

3 Who? Patients who have failed conservative management 3-6 mths (Kovacs 2011) Over 65 age group (Deyo 2010, Ciol 1996, Weinstein 2008) Moderate to severe symptoms (Amundsen et al 2000). Confirmed stenosis via MRI and symptomology (Naine et al 2012) Patients with reduction in quality of life and function (Chad 2007)

4 Indications Radicular lower limb pain (Weinstein et al 2008) Neurogenic claudication (Chad 2007 & McGregor et al 2012) Reduced walking capacities (Naine et al 2012) Poor balance Sensory loss Muscle weakness (Iverson 2001, Johnssson 1987; Stucki 1995)

5 To increase space in the spinal canal by decompressing the effected elements to reduce symptomology (Tomkins et al 2012) Spinal stenosis Spinal injury/trauma/fracture Disc prolapse Cord compression (tumours, metastases) Aims of surgery

6 Types of decompression Laminectomy Laminotomy (hemilaminectomy)

7 Types of Decompression Foraminotomy Facetectomy

8 Types of Decompression Flavectomy Discectomy/Microdiscectomy

9 Is surgery the Gold standard? Evidence for Kovacs at al 2011 results consistently favoured surgery for: improvement in pain Function Quality of life Patient satisfaction. Johnson et al 1991 Surgical 60 % improved and 25 % deteriorated Conservative 30 % improved and 60 % unchanged. McGregor et al 2012 success rates for functional improvement ranged between 58% - 69% satisfaction ranging from 15% - 81%

10 Effectiveness Kovacs at al 2011 Surgical advantage was noticeable at 3-6 moths Results remained consistent up to 4 years Although differences tended to be smaller Atlas et al 2005 Compared leg and back pain symptoms and patient satisfaction between 8-10 years. Surgery remained superior. No improvement was found walking ability between surgery and conservative management

11 Critique Limited qualitative studies exist (NASS 2011). Very few studies review long term effects Limited use of validated outcome measures such as RMDQ for disability, ODI for functional status and SF36 for health-related quality of life (Kovacs et al 2011). Heterogenous and paucity of the evidence limited conclusions on the efficacy for LSS (Cochrane review 2005).

12 Considerations True comparisons are difficult as cross over rates form are as high as 54% (Weinstein et al 2007 & 2008, Kovacs et al 2011). Intention to treat and patient choice may influence results (Atlas et al 2000). Symptomatic improvement is never complete and can be short lived (Thienprasit 2011). Spinal instability is between 8-13% (Thienprasit 2011). 17% risk of further surgery (Deyo 2011).

13 Key points Surgery is superior for patients with moderate to severe spinal stenosis (Amundsen et al 2000). Surgical patients will experience a significant improvement in function (Athiviraham et al 2007). Conservative management should always be considered first (Amundsen et al 2000). Can have residual symptoms (Athiviraham et al 2007). Both groups have good results but surgical is higher Benefits can reduce over time Favourable surgical outcome are lacking (Gibson & Waddell 2008)

14 Final Thought Many factors are involved in the deterioration of results such as age and the natural degenerative process (Thienprasit 2011). Insufficient evidence exists on the effectiveness of surgery on clinical outcomes to draw any firm conclusions. No surgical or conservative predictors on treatment outcome are available (Amundsen et al 2000). Different baselines between each group.

15 References Ciol MA, Deyo RA, Howell E, Krief S. An Assessment of Surgery for Spinal Stenosis Time Trends, Geographic Variations, Complications and Reoperations. J Amer Geront Soc. 1996;44: F M Kovacs & J D Alarcon.. Surgery Verses Conservative Treatment for Symptomatic Lumbar Spine Stenosis; A Systematic Review of Randomised Controlled Trials. Spine 2011;36 (20) North American Spine Society (NASS) Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and Treatment of Degenerative Lumbar Spine Stenosis Athiviraham A, Yen D. Is Spinal Stenosis Better Treated Surgically or Non-surgically? Clin Orthop Relat Res :90-3. Amundsen T,et al. Lumbar Spine Stenosis: Conservative or Surgical Management?;A Prospective 10 Year Study. Spine 2000;25 (11): Johnsson KE, Uden A, Rosen I. The Effect of Decompression on the Natural Course of Spinal Stenosis. A Comparison of Surgically Treated and Untreated Patients. Spine 1987:16: Chad DA. Lumbar Spinal Stenosis. Neurologic Clinics 2007; 25(2): Khan, Mustafa H.Rihn, Jeffery,Steele, Garen, Davis, Rick Donaldson, William F. III Kang, James D. Lee, Joon Y. Postoperative Management Protocol for Incidental Dural Tears During Degenerative Lumbar Spine Surgery: A Review of 3,183 Consecutive Degenerative Lumbar Cases European Spine Journal, April 2005, Volume 14, Issue 3, pp Suhayl I Tafazal, Philip J Sell. Incidental Durotomy in Lumbar Spine Surgery: incidence and management. European Spine Journal April 2005, Volume 14, Issue 3, pp Weinstein JN, Laurie JD, Tosteson TD, et al. SPORT Investigators. Surgical Verses Nonsurgical Therapy for Lumbar Spinal Stenosis. N Engl J Med 2008, 358 pp

16 References Gibson JNA, Waddell G. Surgery for Degenerative Spondylosis (review). The Cochrane Collaboration 2008 issue 4. McGregor AH, Probyn K, Dore CJ, Burton AK, Cro S, Crispin A, Balague F, Morris S, Pincus T, Fairbank J. Rehabilitation Following Surgery for Lumbar Spinal Stenosis (Protocol). The Cochrane Collaberation 2012, Issue 2. Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical Versus Non-Surgical Treatment for Lumbar Spinal Stenosis (Protocol). The Cochrame Collaberation 2012, Issue 12. Amundsen T et al. Lumbar Spinal Stenosis: Conservative or Surgical Management? A 10 Year Prospective Study. Spine 2000, Vol 25, Number Deyo RA, Martin BI, Kreuter W, Jarvik JG, Aniger H, Mirza Sk. Reviosn Surgery Following Operations for Lumbar Stenosis. The Journal of Bone and Joint Surgery 2011:93 (21), Iverson MD, Katz JN. Examination Findings and Self Reported Walking Capacity in Patients With Lumbar Spinal Stenosis. Physical Therapy 2001; 81 (7): Veeravagu, Anand MD Patil, Chirag G. MD; Lad, Shivanand P. MD, PhD; Boakye, Maxwell MD. Risk Factors for Postoperative Spinal Wound Infections After Spinal Decompression and Fusion Surgeries. Spine: 1 August Volume 34 - Issue 17 - pp Thienprasit P. Review Article.Treatment Options for Lumbar Spinal Stenosis in the Elderly An Evidenced Based Approach to a Staged Stepwise Surgical Treatment. The Bangkok Medical Journal 2011, p Atlas SJ, Keller RB, Robson D, Deyo RA, Singer DE. Surgical and Nonsurgical Management of umbar Spinal Stenosis. Four year Outcomes From the Maine Lumbar Spine Study. Spine 200 Vol 25, No 5, pp Weinstein JN, Laurie JD, Tosteson TD, et al. Surgical Verses Nonsurgical Treatment for Lumbar Degenerative Spondylolithesis. N Engl J Med 2007, 356 (22) pp