Elsevier

The Spine Journal

Volume 21, Issue 3, March 2021, Pages 455-464
The Spine Journal

Review Article
A critical appraisal of clinical practice guidelines for the treatment of lumbar spinal stenosis

https://doi.org/10.1016/j.spinee.2020.10.022Get rights and content

Abstract

OBJECTIVE

The aim of the review was to appraise clinical practice guidelines and their recommendations for the treatment of lumbar spinal stenosis.

METHODS

PubMed, Medline, CINAHL, Embase, and Cochrane Central Register of Controlled Trials were searched up until 25/01/2020 for clinical practice guidelines on the management of lumbar spinal stenosis with a systematic process to generate recommendations and were publicly available.

RESULTS

Ten guidelines were included, with a total of 76 recommendations for the treatment of lumbar spinal stenosis. Only 4 of the 10 guidelines were of satisfactory methodological quality according to the AGREE II instrument. Around three-quarters of recommendations (72.4%) were presented with poor evidence, with the remaining 21 presenting (27.6%) fair evidence. No recommendation presented good evidence. Recommendations were made on four types of interventions: surgery, injections, medications, and other nonsurgical treatments, with supporting evidence similar for all four treatment types. Positive recommendations were more common for injections (12/13=92.3%) and surgery (10/15=66%) than for nonsurgical treatments (6/21=28.6%) or medications (1/27=3.75%).

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.

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

References (25)

  • F Zaina et al.

    Surgical versus non-surgical treatment for lumbar spinal stenosis

    Cochrane Database Syst Rev

    (2016)
  • JN Weinstein et al.

    Surgical versus nonsurgical therapy for lumbar spinal stenosis

    N Engl J Med

    (2008)
  • Cited by (21)

    • A critical appraisal of clinical practice guidelines for management of four common complications after spinal cord injury

      2023, Spine Journal
      Citation Excerpt :

      Two reviewers verified the accuracy of their work. Recommendations were categorized as for, against, or neither for nor against (meaning that the guideline stated that there was insufficient evidence to make a clear recommendation) [14]. We considered inconsistencies to exist among recommendations when at least one guideline recommended for a certain measure and another recommended against it.

    • A critical appraisal of clinical practice guidelines on pharmacological treatments for spinal cord injury

      2023, Spine Journal
      Citation Excerpt :

      We considered that there were inconsistencies among recommendations on one certain pharmacological agent, when at least one guideline recommended for it and another recommended against it. Considering that the topic of one prior study published in The Spine Journal was close to ours [8], the evidence assessment system (Appendix 4) used by the prior study were utilized in our study to categorize the quality of the supporting evidence for each recommendation as poor, fair, or good. After duplicates were removed, 12,017 articles were retrieved.

    View all citing articles on Scopus

    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.

    View full text