Review ArticleA critical appraisal of clinical practice guidelines for the treatment of lumbar spinal stenosis
Introduction
Lumbar spinal stenosis is the narrowing of the lumbar spinal canal via thickened ligamentum flavum, osteophytes, or disk bulging [1] that may lead to clinical symptoms. The main clinical feature of central lumbar spinal stenosis is neurogenic claudication, which is the presence of pain, fatigue, numbness or weakness in the gluteals, and/or legs [2] with standing or walking, that is alleviated with forward bending (ie, lumbar flexion) [3].
With the world population ageing, the prevalence of lumbar spinal stenosis is expected to increase [4], and with that, its disability and financial burden. Lumbar spinal stenosis is a leading cause of disability and pain in older adults [2], with a prevalence range in adults aged over 40 of between 5% [5] and 47% [6]. Currently, a total of $1.65 billion is spent annually in the United States [7] on health care for lumbar spinal stenosis [7]. Current care for lumbar spinal stenosis includes conservative treatments, such as exercise, manual therapy, nonsteroidal anti-inflammatory medicines (NSAIDs), epidural steroid injections, and analgesics (eg, opioids) [8], [9], [10]. If conservative treatments fail to improve the patient's symptoms, surgical procedures such as decompression (ie, increasing the diameter of the narrowed spinal canal) with or without spinal fusion are considered.
Despite the prevalence and costs associated with lumbar spinal stenosis, little consensus exists around the preferred care pathway. The main objective of clinical practice guidelines is to facilitate consistent, efficient, and evidence-based care for health conditions. Given that guidelines need to be context-specific, practice guidelines are often developed by different professional groups and countries. This study had four aims:
- i)
Systematically review the literature and to identify international clinical practice guidelines for the management of lumbar spinal stenosis.
- ii)
Appraise the methodological quality of the guidelines.
- iii)
Present each guideline's recommendations.
- iv)
Assess the strength of evidence for each guideline recommendation.
Section snippets
Methods
The protocol for this review was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines [11] and was registered on PROSPERO (www.crd.york.ac.uk) on 05/09/2018 and accepted on 21/01/2019.
Selection of guidelines
As shown in Figure, after duplicates were removed, the search strategy identified 3,667 records. After two reviewers independently screened titles, abstracts, and full texts according to the inclusion and exclusion criteria, 10 guidelines [14], [15], [16], [17], [18], [19], [20], [21], [22], [23] were included. Nine of the guidelines were developed in the United States, with one guideline from Denmark [22]. Relevant sections of the Danish guideline were translated into English for the purpose
Discussion
Ten clinical practice guidelines [14], [15], [16], [17], [18], [19], [20], [21], [22], [23] published on the management of lumbar spinal stenosis were included in this review. Less than half of the guidelines were of adequate methodological quality according to the AGREE II instrument. Nine of the guidelines were from the United States, with one guideline coming from Denmark [22]. Two organizations (North American Spine Society and American Society of Interventional Pain Providers) accounted
Conclusions
Ten guidelines on the management of lumbar spinal stenosis were identified in the systematic review, but only four were of adequate methodological quality. While the evidence underpinning the various types of interventions was similar, guidelines tended to endorse surgery and injections but not nonsurgical interventions and medicines. These results support the need for greater rigor and inclusion of steps to minimize bias in the production of guidelines.
PubMed
"spinal stenosis"[MeSH Major Topic] OR "back pain/surgery"[MeSH Major Topic] OR "lumbar vertebrae/surgery"[MeSH Major Topic] OR "spinal canal/surgery"[MeSH Major Topic] OR "spinal canal/therapy"[MeSH Major Topic]; “letter”[Publication Type] OR “patient education handout”[Publication Type] OR “popular works”[Publication Type] OR “congresses”[Publication Type] OR “consensus development conference”[Publication Type] OR “consensus development conference, nih”[Publication Type] OR “practice
Central
MeSH descriptor: [Spinal Stenosis] explode all trees; spinal osteophyte; neurogenic claudication; canal stenosis; lumbar; spondylosis; lumbar radicular pain; practice guidelines; MeSH descriptor: [Guidelines as Topic] explode all trees; MeSH descriptor: [Consensus Development Conferences as Topic] explode all trees
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FDA device/drug status: Not applicable.
Author disclosures: DBA: Nothing to disclose. KdL: Nothing to disclose. RKJ: Nothing to disclose. JPE: Nothing to disclose. JMVG: Nothing to disclose. JLF: Nothing to disclose. CGM: Trips/Travel Reimbursement: Professional associations (B); Research Support (Investigator Salary, Staff/Materials): Flexeze (donated materials retail value D); Grants: I have received grants from numerous Government and not for profit agencies not related to this submitted work career grant income = I. MLF: Grants: Government & Research Foundation of placebo-controlled trial of surgery for lumbar spinal stenosis.