Abstract
We aimed to evaluate the available evidence on the effectiveness of surgical interventions for a number of conditions resulting in low back pain (LBP) or spine-related irradiating leg pain. We searched the Cochrane databases and PubMed up to June 2013. We included systematic reviews and randomised controlled trials (RCTs) on degenerative disc disease (DDD), herniated disc, spondylolisthesis and spinal stenosis due to degenerative osteoarthritis. We included comparisons between surgery and conservative care and between different techniques. The quality of the systematic reviews was evaluated using assessment of multiple systematic reviews (AMSTAR). Twenty systematic reviews were included which covered the following diagnoses: disc herniation ( n = 9), spondylolisthesis ( n = 2), spinal stenosis ( n = 3), DDD ( n = 4) and combinations ( n = 2). For most of the comparisons, no significant and/or clinically relevant differences between interventions were identified. In general, surgery is only indicated for relief of leg pain in clear indications such as disc herniation, spondylolisthesis or spinal stenosis.
Introduction
The burden of low back pain (LBP) on patients and society is substantial and it ranks first as the disease with most years lived with disability (see also chapter 1 in this edition). LBP has an estimated point prevalence of 10.2% and a lifetime prevalence of up to 84% . More than 80% of those who suffer from LBP seek medical attention . Most episodes are temporary and resolve without treatment in about 25–58% of patients, even when specific causes, such as herniated discs, are present . LBP is associated with high direct costs of health-care utilisation and indirect costs due to lost productivity . While conservative therapy, including a wait-and-see policy, is the first step in the management of LBP, in the case of persistent pain and a clearly identified pain source, targeted injections or surgical intervention may be indicated.
The objective of this overview was to evaluate the available evidence from systematic reviews on the effectiveness of surgical interventions for a number of conditions, including degenerative disc disease (DDD), disc herniation, spondylolisthesis and spinal stenosis resulting in LBP or low back-related irradiating leg pain and/or paraesthesias. A secondary objective was to determine if the evidence was up to date.
Existing evidence for surgical interventions
We searched Cochrane databases and PubMed up to June 2013 to identify the available evidence on the effectiveness of surgical interventions for degenerative low back disorders. Systematic reviews and randomised controlled trials (RCTs) were included. We included studies on DDD, herniated disc, spondylolisthesis and spinal stenosis due to degenerative osteoarthritis. We included comparisons of surgery versus conservative care and of different surgical techniques compared to each other (see Methods box ). The quality of the systematic reviews was evaluated using AMSTAR by two reviewers independently ( Table 1 ). Twenty systematic reviews on surgical interventions for LBP and/or spine-related leg pain with at least a comprehensive search strategy and a risk of bias assessment were included in this overview ( Table 2 ). The additional search for RCTs yielded 18 studies. About 45% of reviews included observational studies and 55% RCTs . Two reviews included a broad spectrum of low back disorders. The second decade of this century sees more focussed reviews on disc herniation (nine reviews ), spondylolisthesis (two reviews ), stenosis (five reviews ) and DDD (six reviews ).
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Search
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Databases: CDSR, DARE, Pubmed (reviews); CENTRAL, Pubmed (RCTs)
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Search strategy: sensitive (variations on search strings), specific on study type (Shojania and Pubmed search filters), available on request.
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Search date: June 2013. Citation tracking of older reviews.
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Study types: Systematic reviews (comprehensive search, RoB assessment) and RCTs (valid randomisation, English, available).
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Disorders: lumbar disc herniation with radiculopathy, lumbar spondylolisthesis, lumbar spinal stenosis or degenerative lumbar disc disease.
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Interventions: Conservative interventions versus surgery or Surgery versus surgery
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Publication dates: from 2001 (reviews), from 2010 or since last included review (RCTs).
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Analysis
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Risk of bias: Amstar (Quality appraisal of Reviews) .
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Outcomes: Subjective outcome data (pain, functional status, recovery, physiological/objective data (e.g., success of fusion according to clinician)).
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Analysis: Not pooled, descriptive from presented meta-analyses, complemented with descriptive results from RCTs.
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Clinical relevance: Ostelo: 15 for 100mm Visual Analogue Scale, 5 for the Roland Disability Questionnaire and 10 for the ODI.
| 1 | Was an ‘a priori’ design provided? |
| 2 | Was there duplicate study selection and data extraction? |
| 3 | Was a comprehensive literature search performed? |
| 4 | Was the status of publication (i.e. grey literature) used as an inclusion criterion? |
| 5 | Was a list of studies (included and excluded) provided? |
| 6 | Were the characteristics of the included studies provided? |
| 7 | Was the scientific quality of the included studies assessed and documented? |
| 8 | Was the scientific quality of the included studies used appropriately in formulating conclusions?. |
| 9 | Were the methods used to combine the findings of studies appropriate? |
| 10 | Was the likelihood of publication bias assessed? |
| 11 | Was the conflict of interest included? |
| Main Indication | Study | Amstar Item | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Author | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | High Quality | |
| Degenerative disc disease | |||||||||||||
| Total disc replacement versus fusion | Eerenbeemt | N | Y | Y | ? | Y | Y | Y | Y | n/a | N | N | Y |
| Yajun | N | Y | Y | N | N | Y | Y | Y | N | Y | N | ||
| Jacobs | Y | Y | Y | N | Y | Y | Y | Y | Y | Y | Y | Y | |
| Thermal Annular Procedures | Helm | N | Y | N | N | Y | Y | Y | Y | n/a | N | Y | |
| Herniated disc | |||||||||||||
| Conservative versus surgical interventions | Jacobs | N | Y | Y | N | N | Y | Y | Y | ? | Y | N | Y |
| Open discectomy versus MED; MIS techniques | Jacobs | N | N | Y | N | Y | Y | Y | Y | Y | Y | Y | Y |
| Open versus MED with tubular distractors | Dasenbrock | N | N | Y | N | Y | Y | Y | N | Y | Y | Y | |
| Transforaminal endoscopic surgery | Nellensteijn | N | Y | Y | ? | N | Y | Y | Y | Y | N | N | Y |
| Mechanical lumbar disc decompression with nucleoplasty | Manchikanti | N | Y | Y | N | Y | Y | Y | Y | n/a | N | Y | Y |
| Automated Percutaneous Mechanical Lumbar Discectomy | Manchikanti | N | Y | Y | N | Y | Y | Y | Y | n/a | N | Y | Y |
| Percutaneous Lumbar Laser Disc Decompression | Singh | N | Y | Y | N | Y | Y | Y | Y | n/a | N | Y | Y |
| Various | Gibson (HNP) | Y | N | Y | Y | Y | Y | Y | Y | Y | N | N | Y |
| Various | Lewis | Y | Y | Y | Y | N | Y | Y | Y | Y | Y | N | Y |
| Spondylolisthesis | |||||||||||||
| Fusion versus decompression, conservative | Jacobs | N | Y | Y | N | Y | Y | Y | N | n/a | N | N | |
| Fusion versus decompression | Martin | N | N | Y | Y | N | Y | Y | Y | Y | N | N | Y |
| Stenosis | |||||||||||||
| Surgery versus conservative | Kovacs | N | Y | Y | N | Y | Y | Y | Y | Y | N | Y | a |
| May | N | Y | Y | N | N | Y | Y | Y | n/a | N | Y | Y | |
| IPD versus conservative | Moojen | N | Y | Y | ? | Y | Y | Y | Y | Y | N | Y | Y |
| Combinations | |||||||||||||
| Various (HD, DDD, stenosis) | Chou | N | N | Y | N | Y | Y | Y | Y | n/a | N | Y | Y |
| Various (Spl, DDD, stenosis) | Gibson | Y | N | Y | Y | Y | Y | Y | Y | Y | N | N | Y |
a Quality was decreased because of inconsistencies in the evaluation.
Existing evidence for surgical interventions
We searched Cochrane databases and PubMed up to June 2013 to identify the available evidence on the effectiveness of surgical interventions for degenerative low back disorders. Systematic reviews and randomised controlled trials (RCTs) were included. We included studies on DDD, herniated disc, spondylolisthesis and spinal stenosis due to degenerative osteoarthritis. We included comparisons of surgery versus conservative care and of different surgical techniques compared to each other (see Methods box ). The quality of the systematic reviews was evaluated using AMSTAR by two reviewers independently ( Table 1 ). Twenty systematic reviews on surgical interventions for LBP and/or spine-related leg pain with at least a comprehensive search strategy and a risk of bias assessment were included in this overview ( Table 2 ). The additional search for RCTs yielded 18 studies. About 45% of reviews included observational studies and 55% RCTs . Two reviews included a broad spectrum of low back disorders. The second decade of this century sees more focussed reviews on disc herniation (nine reviews ), spondylolisthesis (two reviews ), stenosis (five reviews ) and DDD (six reviews ).
-
Search
-
Databases: CDSR, DARE, Pubmed (reviews); CENTRAL, Pubmed (RCTs)
-
Search strategy: sensitive (variations on search strings), specific on study type (Shojania and Pubmed search filters), available on request.
-
Search date: June 2013. Citation tracking of older reviews.
-
Study types: Systematic reviews (comprehensive search, RoB assessment) and RCTs (valid randomisation, English, available).
-
Disorders: lumbar disc herniation with radiculopathy, lumbar spondylolisthesis, lumbar spinal stenosis or degenerative lumbar disc disease.
-
Interventions: Conservative interventions versus surgery or Surgery versus surgery
-
Publication dates: from 2001 (reviews), from 2010 or since last included review (RCTs).
-
Analysis
-
Risk of bias: Amstar (Quality appraisal of Reviews) .
-
Outcomes: Subjective outcome data (pain, functional status, recovery, physiological/objective data (e.g., success of fusion according to clinician)).
-
Analysis: Not pooled, descriptive from presented meta-analyses, complemented with descriptive results from RCTs.
-
Clinical relevance: Ostelo: 15 for 100mm Visual Analogue Scale, 5 for the Roland Disability Questionnaire and 10 for the ODI.
| 1 | Was an ‘a priori’ design provided? |
| 2 | Was there duplicate study selection and data extraction? |
| 3 | Was a comprehensive literature search performed? |
| 4 | Was the status of publication (i.e. grey literature) used as an inclusion criterion? |
| 5 | Was a list of studies (included and excluded) provided? |
| 6 | Were the characteristics of the included studies provided? |
| 7 | Was the scientific quality of the included studies assessed and documented? |
| 8 | Was the scientific quality of the included studies used appropriately in formulating conclusions?. |
| 9 | Were the methods used to combine the findings of studies appropriate? |
| 10 | Was the likelihood of publication bias assessed? |
| 11 | Was the conflict of interest included? |
| Main Indication | Study | Amstar Item | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Author | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | High Quality | |
| Degenerative disc disease | |||||||||||||
| Total disc replacement versus fusion | Eerenbeemt | N | Y | Y | ? | Y | Y | Y | Y | n/a | N | N | Y |
| Yajun | N | Y | Y | N | N | Y | Y | Y | N | Y | N | ||
| Jacobs | Y | Y | Y | N | Y | Y | Y | Y | Y | Y | Y | Y | |
| Thermal Annular Procedures | Helm | N | Y | N | N | Y | Y | Y | Y | n/a | N | Y | |
| Herniated disc | |||||||||||||
| Conservative versus surgical interventions | Jacobs | N | Y | Y | N | N | Y | Y | Y | ? | Y | N | Y |
| Open discectomy versus MED; MIS techniques | Jacobs | N | N | Y | N | Y | Y | Y | Y | Y | Y | Y | Y |
| Open versus MED with tubular distractors | Dasenbrock | N | N | Y | N | Y | Y | Y | N | Y | Y | Y | |
| Transforaminal endoscopic surgery | Nellensteijn | N | Y | Y | ? | N | Y | Y | Y | Y | N | N | Y |
| Mechanical lumbar disc decompression with nucleoplasty | Manchikanti | N | Y | Y | N | Y | Y | Y | Y | n/a | N | Y | Y |
| Automated Percutaneous Mechanical Lumbar Discectomy | Manchikanti | N | Y | Y | N | Y | Y | Y | Y | n/a | N | Y | Y |
| Percutaneous Lumbar Laser Disc Decompression | Singh | N | Y | Y | N | Y | Y | Y | Y | n/a | N | Y | Y |
| Various | Gibson (HNP) | Y | N | Y | Y | Y | Y | Y | Y | Y | N | N | Y |
| Various | Lewis | Y | Y | Y | Y | N | Y | Y | Y | Y | Y | N | Y |
| Spondylolisthesis | |||||||||||||
| Fusion versus decompression, conservative | Jacobs | N | Y | Y | N | Y | Y | Y | N | n/a | N | N | |
| Fusion versus decompression | Martin | N | N | Y | Y | N | Y | Y | Y | Y | N | N | Y |
| Stenosis | |||||||||||||
| Surgery versus conservative | Kovacs | N | Y | Y | N | Y | Y | Y | Y | Y | N | Y | a |
| May | N | Y | Y | N | N | Y | Y | Y | n/a | N | Y | Y | |
| IPD versus conservative | Moojen | N | Y | Y | ? | Y | Y | Y | Y | Y | N | Y | Y |
| Combinations | |||||||||||||
| Various (HD, DDD, stenosis) | Chou | N | N | Y | N | Y | Y | Y | Y | n/a | N | Y | Y |
| Various (Spl, DDD, stenosis) | Gibson | Y | N | Y | Y | Y | Y | Y | Y | Y | N | N | Y |
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