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The evidence on surgical interventions for low back disorders, an overview of systematic reviews

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Abstract

Purpose

Many systematic reviews have been published on surgical interventions for low back disorders. The objective of this overview was to evaluate the available evidence from systematic reviews on the effectiveness of surgical interventions for disc herniation, spondylolisthesis, stenosis, and degenerative disc disease (DDD). An earlier version of this review was published in 2006 and since then, many new, better quality reviews have been published.

Methods

A comprehensive search was performed in the Cochrane database of systematic reviews (CDSR), database of reviews of effectiveness (DARE) and Pubmed. Two reviewers independently performed the selection of studies, risk of bias assessment, and data extraction. Included are Cochrane reviews and non-Cochrane systematic reviews published in peer-reviewed journals. The following conditions were included: disc herniation, spondylolisthesis, and DDD with or without spinal stenosis. The following comparisons were evaluated: (1) surgery vs. conservative care, and (2) different surgical techniques compared to one another. The methodological quality of the systematic reviews was evaluated using AMSTAR. We report (pooled) analyses from the individual reviews.

Results

Thirteen systematic reviews on surgical interventions for low back disorders were included for disc herniation (n = 6), spondylolisthesis (n = 2), spinal stenosis (n = 4), and DDD (n = 4). Nine (69 %) were of high quality. Five reviews provided a meta-analysis of which two showed a significant difference. For the treatment of spinal stenosis, intervertebral process devices showed more favorable results compared to conservative treatment on the Zurich Claudication Questionnaire [mean difference (MD) 23.2 95 % CI 18.5–27.8]. For degenerative spondylolisthesis, fusion showed more favorable results compared to decompression for a mixed aggregation of clinical outcome measures (RR 1.40 95 % CI 1.04–1.89) and fusion rate favored instrumented fusion over non-instrumented fusion (RR 1.37 95 % CI 1.07–1.75).

Conclusions

For most of the comparisons, the included reviews were not significant and/or clinically relevant differences between interventions were identified. Although the quality of the reviews was quite acceptable, the quality of the included studies was poor. Future studies are likely to influence our assessment of these interventions.

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References

  1. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G (2006) Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 15(Suppl 2):S192–S300

    Article  PubMed  Google Scholar 

  2. Anderson PA, Tribus CB, Kitchel SH (2006) Treatment of neurogenic claudication by interspinous decompression: application of the X STOP device in patients with lumbar degenerative spondylolisthesis. J Neurosurg Spine 4(6):463–471

    Article  PubMed  Google Scholar 

  3. Andersson GBJ, Mekhail NA, Block JE (2006) Treatment of intractable discogenic low back pain. A systematic review of spinal fusion and intradiscal electrothermal therapy (IDET). Pain Physician 9(3):237–248

    PubMed  Google Scholar 

  4. Bastian H, Glasziou P, Chalmers I (2010) Seventy-five trials and eleven systematic reviews a day: how will we ever keep up? PLoS Med 7(9):e1000326

    Article  PubMed  Google Scholar 

  5. Bhandari M, Tornetta P, Ellis T, Audige L, Sprague S, Kuo JC, Swiontkowski MF (2004) Hierarchy of evidence: differences in results between non-randomized studies and randomized trials in patients with femoral neck fractures. Arch Orthop Trauma Surg 124(1):10–16

    Article  PubMed  Google Scholar 

  6. Carragee EJ, Hurwitz EL, Weiner BK (2011) A critical review of recombinant human bone morphogenetic protein-2 trials in spinal surgery: emerging safety concerns and lessons learned. Spine J 11(6):471–491

    Article  PubMed  Google Scholar 

  7. Chou R, Baisden J, Carragee EJ, Resnick DK, Shaffer WO, Loeser JD (2009) Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine (Phila Pa 1976) 34(10):1094–1109

    Article  Google Scholar 

  8. Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, Castel LD, Kalsbeek WD, Carey TS (2009) The rising prevalence of chronic low back pain. Arch Intern Med 169(3):251–258

    Article  PubMed  Google Scholar 

  9. Freeman BJ (2006) IDET: a critical appraisal of the evidence. Eur Spine J 15(Suppl 3):S448–S457

    Article  PubMed  Google Scholar 

  10. Furlan AD, Pennick V, Bombardier C, van Tulder M (2009) 2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine (Phila Pa 1976) 34(18):1929–1941

    Article  Google Scholar 

  11. Furlan AD, Tomlinson G, Jadad AA, Bombardier C (2008) Examining heterogeneity in meta-analysis: comparing results of randomized trials and nonrandomized studies of interventions for low back pain. Spine (Phila Pa 1976) 33(3):339–348

    Article  Google Scholar 

  12. Gibson J, Waddell G (2005) Surgery for degenerative lumbar spondylosis. Cochrane Database Syst Rev (4):CD001352

  13. Gibson JNA, Waddell G (2007) Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev (2):CD001350

  14. Hestbaek L, Leboeuf-Yde C, Manniche C (2003) Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J 12(2):149–165

    PubMed  Google Scholar 

  15. Hirsch JA, Singh V, Falco FJ, Benyamin RM, Manchikanti L (2009) Automated percutaneous lumbar discectomy for the contained herniated lumbar disc: a systematic assessment of evidence. Pain Physician 12(3):601–620

    PubMed  Google Scholar 

  16. Ioannidis JP, Haidich AB, Pappa M, Pantazis N, Kokori SI, Tektonidou MG, Contopoulos-Ioannidis DG, Lau J (2001) Comparison of evidence of treatment effects in randomized and nonrandomized studies. JAMA 286(7):821–830

    Article  PubMed  CAS  Google Scholar 

  17. Jacobs WC, van Tulder M, Arts M, Rubinstein SM, van Middelkoop M, Ostelo R, Verhagen A, Koes B, Peul WC (2011) Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. Eur Spine J 20(4):513–522

    Article  PubMed  Google Scholar 

  18. Jacobs WC, Vreeling A, de Kleuver M (2006) Fusion for low-grade adult isthmic spondylolisthesis: a systematic review of the literature. Eur Spine J 15(4):391–402

    Article  PubMed  Google Scholar 

  19. Kabir SM, Gupta SR, Casey AT (2010) Lumbar interspinous spacers: a systematic review of clinical and biomechanical evidence. Spine (Phila Pa 1976) 35(25):E1499–E1506

    Article  Google Scholar 

  20. Kovacs FM, Urrutia G, Alarcon JD (2011) Surgery versus conservative treatment for symptomatic lumbar spinal stenosis: a systematic review of randomized controlled trials. Spine (Phila Pa 1976) 36(20):E1335–E1351

    Article  Google Scholar 

  21. Kuijpers T, van Middelkoop M, Rubinstein SM, Ostelo R, Verhagen A, Koes BW, van Tulder MW (2011) A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain. Eur Spine J 20(1):40–50

    Article  PubMed  CAS  Google Scholar 

  22. Lambeek LC, van Tulder MW, Swinkels IC, Koppes LL, Anema JR, van Mechelen W (2011) The trend in total cost of back pain in The Netherlands in the period 2002 to 2007. Spine (Phila Pa 1976) 36(13):1050–1058

    Article  Google Scholar 

  23. Lewis R, Williams N, Matar H, Din N, Fitzsimmons D, Phillips C, Jones M, Sutton A, Burton K, Nafees S, Hendry M, Rickard I, Chakraverty R, Wilkinson C (2011) The clinical effectiveness and cost-effectiveness of management strategies for sciatica: systematic review and economic model. Health Technol Assess 15(39):1–578

    PubMed  CAS  Google Scholar 

  24. Martin CR, Gruszczynski AT, Braunsfurth HA, Fallatah SM, O’Neil J, Wai EK (2007) The surgical management of degenerative lumbar spondylolisthesis: a systematic review. Spine (Phila Pa 1976) 32(16):1791–1798

    Article  Google Scholar 

  25. McGirt MJ, Ambrossi GL, Datoo G, Sciubba DM, Witham TF, Wolinsky JP, Gokaslan ZL, Bydon A (2009) Recurrent disc herniation and long-term back pain after primary lumbar discectomy: review of outcomes reported for limited versus aggressive disc removal. Neurosurgery 64(2):338–344

    Article  PubMed  Google Scholar 

  26. Mirza SK, Deyo RA (2007) Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine (Phila Pa 1976) 32(7):816–823

    Article  Google Scholar 

  27. Moller H, Hedlund R (2000) Surgery versus conservative management in adult isthmic spondylolisthesis—a prospective randomized study: part 1. Spine (Phila Pa 1976) 25(13):1711–1715

    Article  CAS  Google Scholar 

  28. Moojen WA, Arts MP, Bartels RH, Jacobs WC, Peul WC (2011) Effectiveness of interspinous implant surgery in patients with intermittent neurogenic claudication: a systematic review and meta-analysis. Eur Spine J 20(10):1596–1606

    Article  PubMed  Google Scholar 

  29. Nellensteijn J, Ostelo R, Bartels R, Peul W, van Royen B, van Tulder M (2010) Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature. Eur Spine J 19(2):181–204

    Article  PubMed  Google Scholar 

  30. Ostelo RW, Deyo RA, Stratford P, Waddell G, Croft P, Von Korff M, Bouter LM, de Vet HC (2008) Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change. Spine (Phila Pa 1976) 33(1):90–94

    Article  Google Scholar 

  31. Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof JA, Tans JT, Thomeer RT, Koes BW (2007) Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 356(22):2245–2256

    Article  PubMed  CAS  Google Scholar 

  32. Postacchini F, Cinotti G, Perugia D, Gumina S (1993) The surgical treatment of central lumbar stenosis. Multiple laminotomy compared with total laminectomy. J Bone Joint Surg Br 75(3):386–392

    PubMed  CAS  Google Scholar 

  33. Pratt RK, Fairbank JC, Virr A (2002) The reliability of the Shuttle Walking Test, the Swiss Spinal Stenosis Questionnaire, the Oxford Spinal Stenosis Score, and the Oswestry Disability Index in the assessment of patients with lumbar spinal stenosis. Spine (Phila Pa 1976) 27(1):84–91

    Article  Google Scholar 

  34. Revel M, Payan C, Vallee C, Laredo JD, Lassale B, Roux C, Carter H, Salomon C, Delmas E, Roucoules J (1993) Automated percutaneous lumbar discectomy versus chemonucleolysis in the treatment of sciatica. A randomized multicenter trial. Spine (Phila Pa 1976) 18(1):1–7

    Article  CAS  Google Scholar 

  35. Savigny P, Kuntze S, Watson P, Underwood M, Ritchie G, Cotterell M, Hill D, Buchanan E, Coffey P, Dixon P, Drummond C, Flanagan M, Greenough C, Griffiths M, Halliday-Bell J, Hettinga D, Vogel S, Walsh D (2009) NICE clinical guideline 88 low back pain: early management of persistent non-specific low back pain. National Collaborating Centre for Primary Care and Royal College of General Practitioners, London

    Google Scholar 

  36. Shah RV, Albert TJ, Bruegel-Sanchez V, Vaccaro AR, Hilibrand AS, Grauer JN (2005) Industry support and correlation to study outcome for papers published in Spine. Spine (Phila Pa 1976) 30(9):1099–1104

    Article  Google Scholar 

  37. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, Porter AC, Tugwell P, Moher D, Bouter LM (2007) Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 7:10

    Article  PubMed  Google Scholar 

  38. Shojania KG, Bero LA (2001) Taking advantage of the explosion of systematic reviews: an efficient MEDLINE search strategy. Eff Clin Pract 4(4):157–162

    PubMed  CAS  Google Scholar 

  39. Transfeldt EE, Mehbod AA (2007) Evidence-based medicine analysis of isthmic spondylolisthesis treatment including reduction versus fusion in situ for high-grade slips. Spine (Phila Pa 1976) 32(19 Suppl):S126–S129

    Article  Google Scholar 

  40. US National library of medicine Pubmed clinical queries filter (2011) 1 June 2011. http://www.ncbi.nlm.nih.gov/pubmed/clinical

  41. van den Eerenbeemt KD, Ostelo RW, van Royen BJ, Peul WC, van Tulder MW (2010) Total disc replacement surgery for symptomatic degenerative lumbar disc disease: a systematic review of the literature. Eur Spine J 19(8):1262–1280 [1432-0932 (Electronic), 0940-6719 (Linking)]

    Article  PubMed  Google Scholar 

  42. van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, van Tulder MW (2011) A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J 20(1):19–39

    Article  PubMed  Google Scholar 

  43. van Tulder MW, Koes B, Seitsalo S, Malmivaara A (2006) Outcome of invasive treatment modalities on back pain and sciatica: an evidence-based review. Eur Spine J 15(Suppl 1):S82–S92

    Article  PubMed  Google Scholar 

  44. Walker BF (2000) The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord 13(3):205–217

    Article  PubMed  CAS  Google Scholar 

  45. Watters WC III, Bono CM, Gilbert TJ, Kreiner DS, Mazanec DJ, Shaffer WO, Baisden J, Easa JE, Fernand R, Ghiselli G, Heggeness MH, Mendel RC, O’Neill C, Reitman CA, Resnick DK, Summers JT, Timmons RB, Toton JF (2009) An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J 9(7):609–614

    Article  PubMed  Google Scholar 

  46. Watters WC III, McGirt MJ (2009) An evidence-based review of the literature on the consequences of conservative versus aggressive discectomy for the treatment of primary disc herniation with radiculopathy. Spine J 9(3):240–257

    Article  PubMed  Google Scholar 

  47. Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo RA (2006) Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 296(20):2441–2450

    Article  PubMed  CAS  Google Scholar 

  48. Yajun W, Yue Z, Xiuxin H, Cui C (2010) A meta-analysis of artificial total disc replacement versus fusion for lumbar degenerative disc disease. Eur Spine J 19(8):1250–1261 [1432-0932 (Electronic), 0940-6719 (Linking)]

    Article  PubMed  Google Scholar 

  49. Zucherman JF, Hsu KY, Hartjen CA, Mehalic TF, Implicito DA, Martin MJ, Johnson DR, Skidmore GA, Vessa PP, Dwyer JW, Puccio S, Cauthen JC, Ozuna RM (2004) A prospective randomized multi-center study for the treatment of lumbar spinal stenosis with the X STOP interspinous implant: 1-year results. Eur Spine J 13(1):22–31

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

We would like to thank Jan Schoones, Waleus library, University Medical Center Leiden for his aid with the search.

Conflict of interest

None.

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Authors and Affiliations

  1. Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, PO Box 9600, 2300, RC, Leiden, The Netherlands

    Wilco C. H. Jacobs, Wouter A. Moojen & Wilco C. Peul

  2. Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands

    Sidney M. Rubinstein & Maurits W. van Tulder

  3. Department of Orthopedic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands

    Paul C. Willems

  4. Department of Orthopedic Surgery, Hospital Vall d’Hebron, Barcelona, Spain

    Ferran Pellisé

  5. Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands

    Cumhur F. Oner

  6. Department of Neurosurgery, Medical Center Haaglanden, The Hague, The Netherlands

    Wilco C. Peul

  7. Department of Health Sciences, Faculty of Earth and Life Science and EMGO Institute for Health and Care Research, VU University, Amsterdam, The Netherlands

    Maurits W. van Tulder

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  1. Wilco C. H. Jacobs
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  2. Sidney M. Rubinstein
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Correspondence to Wilco C. H. Jacobs.

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Jacobs, W.C.H., Rubinstein, S.M., Willems, P.C. et al. The evidence on surgical interventions for low back disorders, an overview of systematic reviews. Eur Spine J 22, 1936–1949 (2013). https://doi.org/10.1007/s00586-013-2823-4

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  • DOI: https://doi.org/10.1007/s00586-013-2823-4

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