No difference in outcomes between 3 minimally invasive surgical procedures for 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 baseline Oswestry Disability Index (ODI) and operating hospital, there was no statistically significant difference in the change in disability measured with ODI between any of the 3 surgical techniques.

Evidence Rating Level: 1 (Excellent)

Study Rundown: 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 both surgical and nonsurgical interventions. In surgical treatment, there are various options for minimally invasive posterior decompression of the adult lumbar spine, 3 of which are unilateral laminotomy with crossover (UL), bilateral laminotomy (BL), and spinous process osteotomy (SPO). The effectiveness of these techniques relative to one another is, however, unknown. This study compared the effectiveness of these 3 minimally invasive posterior decompression techniques for LSS. In total, 437 patients were randomized to undergo 1 of the 3 surgical techniques, with a median age of 68 years. The primary outcome was change in disability measured with Oswestry Disability Index (ODI) from baseline to 24 months after the surgical procedure. Secondary outcomes included mean change in quality of life, disease-specific symptom severity, back and leg pain, patient perceived benefit and duration of the surgical procedure, perioperative bleeding volume, complications, number of reoperations and length of hospital stay. After completing analyses, no statistically significant differences were found regarding 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 approximately 124 minutes, while the UL and SPO procedure took on average 30 minutes more time. A major strength of this study was its randomized clinical trial design and large sample size. A limitation to this study was that the 3 minimally invasive surgical techniques for treatment of LSS were not compared with a full laminectomy.

Click to read the study in JAMA Network Open

Relevant Reading: Surgical versus nonoperative treatment for 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 laminotomy with crossover (UL), bilateral laminotomy (BL), and spinous process osteotomy (SPO), for the treatment of lumbar spinal stenosis. A total of 437 patients were enrolled and underwent randomization to received 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 outcome 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 the operating 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 to -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= .214). No statistically significant difference in secondary outcomes were observed between the 3 surgical groups, however the BL group was found to have a longer mean duration of the surgical procedure, 123.9 (109.0 to 138.7) minutes, compared with UL, 95.7 (81.1 to 110.3) minutes and SPO, 92.9 (78.2 to 107.7) minutes, (P<.001).

Image: PD

©2022 2 Minute Medicine, Inc. All rights reserved. No works may be reproduced without expressed written consent from 2 Minute Medicine, Inc. Inquire about licensing here. No article should be construed as medical advice and is not intended as such by the authors or by 2 Minute Medicine, Inc.