No difference in outcome between 3 minimally invasive surgical procedures for the treatment of lumbar spinal stenosis

1. In this randomized clinical trial of 437 patients, no significant difference was observed in clinical outcomes between 3 minimally invasive posterior decompression techniques for the treatment of lumbar spinal stenosis over a 2-year period.

2. After adjusting for Oswestry Disability Index (ODI) from baseline and operative hospital, there was no statistically significant difference in the change in disability measured with the ODI between the 3 surgical techniques .

Level of evidence assessment: 1 (Excellent)

Summary of the study: Lumbar spinal stenosis (LSS) is a common condition that is characterized by pain and discomfort in the lower back and extremities. Treatment for LSS can include surgical and non-surgical procedures. In surgical treatment, there are different options for minimally invasive posterior decompression of the adult lumbar spine, 3 of which are unilateral crossing laminotomy (UL), bilateral laminotomy (BL) and spinous process osteotomy (SPO). ). The effectiveness of these techniques relative to each other is, however, unknown. This study compared the effectiveness of these 3 minimally invasive posterior decompression techniques for LSS. A total of 437 patients were randomized to undergo 1 of 3 surgical techniques, with a median age of 68 years. The primary endpoint was the change in disability measured with the Oswestry Disability Index (ODI) between baseline and 24 months after surgery. Secondary outcomes included mean change in quality of life, severity of disease-specific symptoms, back and leg pain, patient perceived benefit and duration of surgery, volume of perioperative bleeding, complications, number of reoperations and length of hospital stay. After completing the analyses, no statistically significant differences were found in the change in disability measured using the ODI between the UL, BL, and SPO surgical groups. The BL technique was found to take the least amount of time at around 124 minutes, while the UL and SPO procedure took an average of 30 minutes longer. A major strength of this study was its randomized clinical trial design and large sample size. A limitation of this study was that the 3 minimally invasive surgical techniques for the treatment of LSS were not compared to full laminectomy.

Click to read the study in JAMA Network Open

Relevant reading: Surgical versus non-operative treatment of lumbar spinal stenosis four-year results of the Spine Patient Outcomes research trial

In depth [randomized controlled trial]: This study investigated the effectiveness of 3 minimally invasive poster decompression techniques: unilateral crossing laminotomy (UL), bilateral laminotomy (BL), and spinous process osteotomy (SPO), for the treatment of lumbar spinal stenosis. A total of 437 patients were recruited and were randomized to receive either UL (n=146), BL (n=142) or SPO (n=149), with a median age of 68 years and included 230 men (53% ). The primary endpoint assessed was change in disability measured using the Oswestry Disability Index (ODI) over 2 years. The mean change in ODI from baseline to 2-year follow-up for the entire cohort was -19.1 (95% CI, -20.8 to -17.5). After adjusting for baseline ODI and operative hospital, the estimated change in ODI after the 2-year follow-up period for UL, BL, and SPO was -17.8 (95% CI, -20.3 at -15.3), -18.7 (95% CI, -21.3 to -16.0) and -21.0 (95% CI, -23.5 to 18.4) respectively. Ultimately, no statistically significant difference was found in the primary outcome between the 3 surgical techniques (P = 0.214). No statistically significant difference in secondary outcomes was observed between the 3 surgical groups, but the BL group was found to have a longer mean duration of surgery, 123.9 (109.0 to 138.7 ) minutes, compared to UL, 95.7 (81.1 to 110.3) minutes and SPO, 92.9 (78.2 to 107.7) minutes, (P

Picture: PD

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