Keywords laminectomy - spinal stenosis - lumbar spinal stenosis - intermittent claudication
Introduction
Patients suffering from lumbar spinal stenosis (LSS) can have difficulty walking especially
more than 500 m,[1 ] imposing significant restrictions on their daily living[2 ] and further financial burden on the health care system.[3 ] There are various surgical methods used to relieve pressure on the spinal cord and
nerve roots in the lumbar segment, most notably laminectomy, laminotomy, laminoplasty,
and use of interspinous spacer implantation.[4 ]
[5 ] More recently, minimally invasive trends such as microendoscopic approaches can
also be considered for the treatment of LSS.[6 ] Currently, laminectomy is the preferred method for the majority of cases and is
indicated in LSS without concurrent lumbar instability.[5 ]
[7 ]
Additionally, there are several complications for the aforementioned procedures and
can be divided into three stages depending on the time of occurrence: acute (up to
3 days after surgery), subacute (3 days to 2 weeks after surgery), and chronic (greater
than 2 weeks following surgery).[4 ]
[5 ] The prevalence of these complications varies between 0.5 and 2.3%. Risk factors
for more severe complications include depression, comorbidities restricting walking
ability, scoliosis, cardiovascular diseases, and smoking.[8 ]
Previously, few studies have evaluated long-term outcomes after laminectomy in patients
with LSS.[7 ]
[9 ]
[10 ]
[11 ]
[12 ]
[13 ]
[14 ]
[15 ]
[16 ]
[17 ]
[18 ]
[19 ]
[20 ]
[21 ]
[22 ]
[23 ] There is limited evidence regarding long-term outcomes after laminectomy. Considering
the potential complications of laminectomy and limited evidence with long-term follow-up,
further investigation is needed to assess clinical outcomes after laminectomy to assist
with surgical decision-making regarding the choice of surgical or conservative treatment.
Therefore, the goal of this study was to conduct a systematic review and meta-analysis
to assess patient satisfaction, pain, disability, claudication, complications, and
adverse event in patients with LSS undergoing either single or multilevel laminectomy
procedures.
Material and Methods
Search Strategy
A comprehensive electronic search of MEDLINE, Embase, Scopus, Web of Science, and
the Cochrane Library was conducted and updated until August 2020 using Medical Subject
Headings terms and related keywords ([Appendix Table A1 ]). Additionally, the list of references of relevant articles was manually reviewed
to discover potential further related articles. Preferred Reporting Items for Systematic
Reviews and Meta-Analyses guidelines for systematic review were followed as shown
in [Fig. 1 ]. No language limits were imposed for this literature search.
Fig. 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart.
Selection Method
After the removal of duplicates, four reviewers were divided into two groups, independently
reviewing titles and abstracts of the studies. After collecting the full text of eligible
papers, four reviewers in two groups (M.H.R., S.R., K.S., and A.A.H.) independently
reviewed each article for inclusion and exclusion criteria. The third reviewer (M.G.H.)
resolved any discrepancy regarding the eligibility of studies.
Inclusion and Exclusion Criteria
All cohort studies and randomized controlled trials reporting conventional laminectomy
due to LSS and related outcomes with at least a 5-year follow-up were included in
this study. In articles that described the outcomes of various types of surgical procedures,
only the data of patients with conventional laminectomy were obtained for the analysis.
For studies using the same data set, only the one with a higher number of cases and
data that are more complete was included. Exclusion criteria included patients suffering
from concomitant spondylolisthesis, patients undergoing fusion surgery, and congenital
stenosis.
Data Extraction
Clinical and functional outcome measures that were evaluated included patient satisfaction,
pain, disability, neurogenic intermittent claudication, reoperation rate, complications,
and adverse events. Any association between single or multilevel laminectomy and patient
outcomes was also assessed.
From each study, we collected general information (first author, year of study, country,
journal), methods (study design, sample size), participants (age, gender, preoperative
neurological score), outcomes of surgery, and follow-up time. Two independent reviewers
reviewed each study (K.S. and A.A.H.). If any discordance were present, they were
settled through focused discussion and reference to the original article.
Assessment of Methodological Quality
The risk of bias of the included studies was evaluated using the Newcastle-Ottawa
checklist for cohort studies ([Table 1 ]). We considered studies with at least seven stars to be at low risk of bias, leading
to eight studies being determined to have a low risk of bias[9 ]
[10 ]
[11 ]
[12 ]
[13 ]
[14 ]
[15 ]
[20 ] and the remaining four as high risk.[16 ]
[17 ]
[18 ]
[19 ]
Table 1
Quality assessment according to Newcastle-Ottawa quality assessment for cohort studies
Study/Quality assessment questions
Foulongne et al, 2013
Shabat et al, 2011
Malter et al, 1998
Iguchi et al, 2000
Kim et al, 2013
Kao et al, 2018
Lehto and Honkanen, 1995
Chang et al, 2005
Mannion et al, 2010
Lurie et al, 2015
Lee et al, 2014
Atlas and Delitto, 2006
1. Representativeness of the exposed cohort
*
*
*
*
*
*
*
*
*
*
*
2. Selection of the non-exposed cohort
*
*
*
*
*
*
*
*
*
*
*
*
3. Ascertainment of exposure
*
*
*
*
*
*
*
*
*
*
4. Demonstration that outcome of interest was not present at start of study
5. Comparability of cohorts on the basis of the design or analysis controlled for
confounders
**
**
**
**
**
**
**
**
**
*
**
6. Assessment of outcome
*
*
*
*
*
*
*
*
*
*
*
7. Was follow-up long enough for outcomes to occur
*
*
*
*
*
*
*
*
*
*
*
*
8. Adequacy of follow-up of cohorts
*
*
*
*
Low
Low
Low
Low
Low
Low
Low
High
High
High
High
Low
Note: This scale evaluates each study based on eight items, categorized into three
groups: selection, comparability, and outcome. Each item numbered in the Selection
and Outcome categories was given a maximum of one star and a maximum of two stars
within the comparability category.
Statistical Analysis
Meta-analysis was only performed for reoperation rate. Heterogeneity among the results
of studies was quantified using I
2 statistics. The results were reported using a random-effects model with 95% confidence
interval (CI). Subgroup analysis was performed based on the quality of the included
studies. A meta-analytic approach was not feasible for other outcome measures due
to heterogeneous methods of reporting among the studies. Statistical analysis was
performed using Stata V.14.
Results
Included Studies
Initially, 18,666 records were retrieved from the databases and after removing the
duplicate documents and screening the titles and abstracts, 126 articles were selected
for full-text screening. Finally, 12 records met all eligibility criteria, all of
which were included for qualitative analysis, and 10 articles were included for meta-analysis[9 ]
[10 ]
[11 ]
[12 ]
[13 ]
[14 ]
[15 ]
[16 ]
[17 ]
[18 ]
[19 ]
[20 ] ([Fig. 1 ]). Our search results did not yield any published randomized clinical trials, therefore,
all included studies were cohort studies with at least 5 years of follow-up. A total
number of 83,492 LSS patients were included in these articles ([Table 2 ]). All patients had undergone standard decompression laminectomy with a follow-up
period between 5 and 10 years. Outcomes assessed included patient satisfaction, leg
and lumbar pain intensity, disability, neurogenic intermittent claudication, reoperation
rate, complications, and adverse events which are summarized in [Table 3 ]. The effect of multilevel compared with single-level laminectomy on patient outcomes
was also assessed in a few studies.
Table 2
Baseline characteristic of the 12 included studies
Code
Title
First author
Study design
Study population
Age (mean ± SD)
Surgery method
Follow-up (y)
Outcomes
1
Lumbar spinal stenosis: Which predictive factors of favorable functional results after
decompressive laminectomy
E. Foulongne
Prospective cohort
98 (94 M, 4 F)
67.3 ± 8.8
Decompressive laminectomy in lumbar stenosis
5
Walking distance, reoperation rate, complication
2
Long-term follow-up of revision decompressive lumbar spinal surgery in elderly patients
Shay Shabat
Retrospective cohort
31
> 65
Lumbar decompressive spinal surgery
10
Pain, reoperation rate, patient's satisfaction
3
5-year reoperation rates after different types of lumbar spine surgery
Alex D. Malter
Population-based cohort study
6,376 (3,764 M, 2,612 F)
48
Lumbar surgery
5
Reoperation rate, complication
4
Minimum 10-year outcome of decompressive laminectomy for degenerative lumbar spinal
stenosis
Tetsuhiro Iguchi
Retrospective cohort
151
60
Decompressive laminectomy
10
Back pain, leg pain, neurogenic claudication, patient's satisfaction, multilevel laminectomy
5
Reoperation rate after surgery for lumbar spinal stenosis without spondylolisthesis:
a nationwide cohort study
Chi Heon Kim
Retrospective cohort
8,795 (55.6 F, 44.4 M)
56.7 ± 12.1
Decompression without fusion (laminectomy and/or discectomy)
6
Reoperation rate, complication
6
Short-term and long-term revision rates after lumbar spine discectomy versus laminectomy:
a population-based cohort study
Feng-Chen Kao
Retrospective cohort
66,754 (47.88 F, 52.11 M)
59.91 ± 14.02
Laminectomy
5
Reoperation rate
7
Factors influencing the outcome of operative treatment for lumbar spinal stenosis
M.U. Lehto
Retrospective cohort
96 (50 M, 46 F)
59
Laminectomy
5.5
Satisfaction, multilevel laminectomy, complication
8
The effect of surgical and nonsurgical treatment on longitudinal outcomes of lumbar
spinal stenosis over 10 years
Yuchiao Chang
Prospective observational cohort
144 (54 M, 90 F)
65
LSS
10
Pain, disability, reoperation rate, patient's satisfaction
9
Five-year outcome of surgical decompression of the lumbar spine without fusion
Anne F. Mannion
Prospective cohort
143 (92 M, 51 F)
64
Lumbar decompression surgery without fusion
5
Leg pain and back pain intensity, self-rated disability, reoperation rates
10
Long-term outcomes of lumbar spinal stenosis: 8-year results of the spine patient
outcomes research trial (sport)
Jon D. Lurie
Randomized trial with a concurrent observational cohort study
654 (385 M, 249 F)
64
Decompressive laminectomy
8
Patient's satisfaction, reoperation rate, complication
11
Clinical and radiological outcomes following microscopic decompression utilizing tubular
retractor or conventional microscopic decompression in lumbar spinal stenosis with
a minimum of 10-year follow-up
Gun Woo Lee
Retrospective cohort
102
56
Lumbar spinal stenosis
10
Pain, disability, walking distance, reoperation rate
12
Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis
Steven J. Atlas
Prospective observational cohort
148
65
LSS
10
Patient-reported symptoms of leg and back pain, disability, reoperation rate, patient's
satisfaction
Abbreviations: F, female; LLS, lumbar spinal stenosis; M, male; SD, standard deviation.
Table 3
Main findings of included 12 articles
Article
Satisfaction
Pain
Disability
Neurogenic intermittent claudication
Reoperation rate
Complication and adverse events
Foulongne et al (2013)
Walking distance increased from 795.61 ± 1,303.58 preoperatively to 2,083.3 ± 2,131.6
at 5 years
Reoperation rate was 10.2%
Four patients needed early surgery due to postoperative complications and 10 patients
needed reoperation due to adjacent level stenosis or destabilization
Shabat et al (2011)
Quote: 72% of patients very or somewhat satisfied with overall results of the operation
Using VAS score there was 4.3 points change in score before and after surgery
Quote: The overall rate of revision was 8.7% at a mean follow-up of 70 months (10%
in females and 7% in males, p > 0.05)
Malter et al (1998)
The 5-year reoperation rate was ∼12%
7% of patients had postoperative complications
In-hospital mortality was 0.3%
Iguchi et al (2000)
75% of patients were satisfied with the result of surgery at 7- to 10-year follow-up;
however, 33% of them had severe back pain, and 53% were unable to walk for two blocks
JOA score of low back pain improved slightly from 1.4 ± 0.7 to 1.9 ± 0.7 points. The
score of leg pain, however, changed from 0.7 ± 0.6 to 2.1 ± 0.7 points. Postoperatively,
32.4% and 21 0.6% of patients had persistent back and leg pain, respectively
Preoperatively, 62.2% patients unable to walk for 100 m that decreased to 8.1% patients,
postoperatively
Kim et al (2013)
Reoperation rate was 14.8% at 6 years
During the first 90 days 33 patients died
Kao et al (2018)
The revision spinal surgery rates was 13.44%
Lehto and Honkanen (1995)
Of all the operated patients 9 (14%) considered the outcome of operation as excellent,
28 (43%) as good, 14 (21.5%) as satisfactory, and 14 (21.5%) as poor
Seven patients died during the follow-up period due to illness not related to the
spinal stenosis or its operative treatment
Chang et al (2005)
7 grade scoring for satisfaction (terrible = 0 to delighted = 6), it was 4 after surgery
and reduced to 3.6 at 10-year follow up
Using leg symptom frequency index (0–24), changes in leg symptom frequency index was
11.1 after surgery. This difference was 8.8 at 5 years and 9.4 at 10 years.
Back pain frequency change for back pain was 2.5 after surgery and was 1.9 at 10-year
follow-up.
After 5 years, change in leg symptoms and functional status continued to favor surgical
treatment, but change in frequency of low back pain and satisfaction with the current
state were no longer statistically significant
Modified Roland scale change was 8.6 (baseline = 16 ± 4.2) immediate postoperatively.
This change was 6.8 at a 10-year follow-up
Fifteen of 77 patients initially treated surgically underwent a second operation during
follow-up
Mannion et al (2010)
In graphic rating scale from preoperative to 2 months postoperative, there was a significant
reduction in mean leg pain of 3.6 ± 2.5 points and 2.2 ± 2.5 points for back pain.
While there was no significant further change from 2 months up to 5 years' follow-up
in leg pain, there was significant but clinically irrelevant increase of 0.5 ± 2.1
points in back pain
There was a significant decrease of 2.7 ± 5.2 points in the mean Roland-Morris (RM)
score from before surgery to 2 months postoperatively (p < 0.0001) and a further decrease of 2.5 ± 3.6 points up to 5 months postoperatively
(p 0.0001) ([fig. 1C ]). After this, no further changes were seen up to 5 years postoperatively
By the time of the 5-year follow-up, 34/143 patients (24%) had undergone reoperation,
at an average of 29.1 ± 20.9 months
Lurie et al (2015)
67% of patients were satisfied after surgery at 8 years
18% of patients had reoperation rate at 8 years
Most common intraoperative complication: dural tear (9%), most common postoperative:
wound infection 7%
Lee et al (2014)
Using VAS score, pain (leg and back pain was not differentiated) improved from mean
score 8.4 preoperatively to 3.8 one-month and 2.8 one-year postoperatively. It was
increased to 4.8 at six- and ten-year follow-up
ODI 41.2 ± 6.3 preoperative decreased gradually to 24.7 ± 5.6 at 1 year postop and
increased to 32.1 ± 3.2 at 10 years postoperatively
Walking distance without pain was 20.1 ± 5.7 preoperatively and increased to 38.1 ± 5.2
postoperatively. It decreased to 25.9 ± 2.7 at 10-year follow-up.
Revision rate was 6.12%
Atlas et al (2005)
59.5% were satisfied 8- to 10-year after surgery
Bothersome score and frequency score changed from 4.5 at baseline to 2.5 for LBP at
8 to 10 years' follow-up. This change was from 4.8 to 1.6 for leg pain. 52.8% and
66.7% of patients reported improvement at 8 to 10 years after surgery for LBP and
leg pain, respectively
Modified Roland scale changed from 15.9 at baseline to 8.7 at 8- to 10-year follow-up
The 10-year reoperation rate was 23%
Abbreviations: JOA, Japanese Orthopedic Association; LBP, low back pain; ODI, Oswestry
Disability Index; VAS, Visual Analog Scale.
Satisfaction
Six of the 12 included studies assessed satisfaction among LSS patients; four had
a low risk of bias,[10 ]
[12 ]
[15 ]
[20 ] whereas two had a high risk of bias.[16 ]
[18 ] Since the method of measuring satisfaction varied in each study, a meta-analysis
was not performed. One study measured satisfaction by asking patients whether they
were satisfied with the results of laminectomy 5 years after surgery and revealed
that 72% were satisfied.[10 ] In another study, 14% of patients considered the outcome of surgery as excellent,
43% as good, 21.5% as satisfactory, and 21.5% as poor.[15 ] In another study, 75% of patients were satisfied with the result of surgery at 7-
to 10-year follow-up.[12 ] When comparing surgical and nonsurgical treatments one study measured satisfaction
with the following question: “If you were to spend the rest of your life with your
back symptoms just the way they are now, how would you feel about that?”[16 ] and another study asked patients whether they would choose their initial treatment
again.[20 ] Both of these studies showed no significant difference between the surgical and
nonsurgical groups 5 to 10 years after the treatment. In contrast, another study reported
that the percentage of surgical patients with severe dissatisfaction was significantly
higher than that of the nonsurgical patients (77% vs. 52%, p < 0.001).[18 ]
Pain
Six of the 12 studies reported pain as an outcome measure; three of which had a high
risk of bias[16 ]
[17 ]
[19 ] and the other three were low risk.[10 ]
[12 ]
[20 ] All studies showed a significant reduction in pain following surgery.[10 ]
[12 ]
[16 ]
[17 ]
[19 ]
[20 ] Two studies did not differentiate leg and back pain; one showed a reduction of 4.53
points in Visual Analog Scale scores after 64 months (p < 0.001),[10 ] while another study showed a change from 8.4 points preoperatively to 4.8 points
at 6 and 10 years postoperatively[19 ]
Four studies assessed low back pain and leg pain separately.[12 ]
[16 ]
[17 ]
[20 ] Two of these four studies compared surgical with nonsurgical treatments and after
adjusting for baseline patient characteristics, the data suggested that surgery was
more effective than nonsurgical treatment in reducing leg and back pain frequency
at 5 years of follow-up.[16 ] Although from 5 to 10 years there was no significant difference in low back pain
between groups, leg pain recovered significantly more after surgical intervention
in this time period.[16 ] In another study with 8 to 10 years of follow-up, the frequency and inconvenience
of low back pain were not significantly different between the surgical and nonsurgical
groups; however, these scores significantly improved for leg pain in patients treated
with surgical management.[20 ] In another study using a graphic rating scale, the mean (±standard deviation) reduction
in leg and back pain intensity was 3.6 ± 2.5 points (p < 0.0001) and 2.2 ± 2.5 points (p < 0.001), respectively, 2 months following laminectomy[1 ]; however, there were no significant changes from the 2-month to the 5-year follow-up.[17 ] In another study using the Japanese Orthopedic Association score, patients showed
a significant improvement in pain from baseline (5.4 ± 2.0 points) to follow-up (10.7 ± 3.2
points). There was minimal change in back pain (1.4 ± 0.7 to 1.9 ± 0.7 points), compared
with the greater improvement in leg pain (0.7 ± 0.6 to 2.1 ± 0.7 points).[12 ]
Disability
The modified Roland scale[17 ]
[20 ] and the Oswestry Disability Index (ODI)[19 ] were used for measurement of disability. Four of the 12 studies assessed disability,
three of which had a high risk of bias[16 ]
[17 ]
[19 ] and one showed a low risk of bias.[20 ]
In one study, the modified Roland scale change at the 10-year follow-up was 6.8 from
a preoperative baseline of 16 ± 4.2. This change was 8.6 immediate postoperatively.[16 ] In another study with 8 to 10 years of follow-up, patients treated surgically had
a significantly greater improvement in the modified Roland disability scale compared
with nonsurgically treated patients (improvement in surgical patients: 7.3 ± 6.5,
nonsurgical patients: 1.2 ± 7.8, p = 0.02).[20 ] In another study, by 2 months after the procedure, the decrease in Roland-Morris
Scale was 2.7 ± 5.2 points (p < 0.0001), and by 5 months, there was 2.5 ± 3.6 points further decrease, but the
index remained relatively the same up to the 5-year follow-up.[17 ] Using the ODI scale, up to 6 years of follow-up showed a decrease in scores from
41.2 ± 6.3 preoperatively to 29.3 ± 4.8 postoperatively, which is suggestive of improvement
in patients undergoing standard laminectomy.[19 ] In a study comparing disability among patients undergoing first-time surgery and
patients requiring reoperation, by the 5-year follow-up, the improvement in the modified
Roland disability scale was significantly less in patients with revision surgery (improvement
of 1.8 ± 4.8 points vs. 5.6 ± 6.2 points in those without revision surgery; p = 0.0012).[17 ]
Neurogenic Intermittent Claudication
Three studies assessed neurogenic claudication. These studies were observational,
two with a low risk of bias[9 ]
[12 ] and the other with a high risk of bias.[19 ] All studies showed a significant improvement in patients' walking ability. The maximum
walking distance in one study improved from 705.61 ± 1,303.58 m preoperatively to
2,083.3 ± 2,131.6 m at 5 years.[9 ] In another study, 62.2% of patients were not able to walk more than 100 m without
pain, which decreased to 8.1% of patients postoperatively.[12 ] Another study showed an improvement in pain-free walking distance from 20.1 ± 5.7
m preoperatively to 37.2 ± 3.6 at 6 years and 25.9 ± 2.7 at 10 years; however, the
significance of the progress was not reported.[19 ]
Reoperation Rate
The reoperation rate was reported in 10 of the 12 studies, six had a low risk of bias,[9 ]
[10 ]
[11 ]
[13 ]
[14 ]
[20 ] and four had a high risk of bias.[16 ]
[17 ]
[18 ]
[19 ] Meta-analysis revealed a 14% (95% CI: 13–16%, I
[2 ] = 84.20%) reoperation rate among the studies ([Fig. 2 ]). The reoperation rate in the subgroup meta-analysis was 16% (95% CI: 8–25%) in
studies with a high risk of bias and 14% (95% CI: 12–15%) in studies with a low risk
of bias ([Fig. 3 ]). When assessing risk factors that may influence the reoperation rate, no correlation
was found with sex, obesity, and body mass index.[10 ] This study also showed that laminectomy with concurrent discectomy had a higher
chance of further surgical requirements compared with laminectomy alone.[10 ]
Fig. 2 Forest plot of reoperation rate after laminectomy. CI, confidence interval.
Fig. 3 Forest plot of reoperation rate according to quality of studies
Multilevel Laminectomy and Patient Outcomes
The effect of multilevel surgery was explored in two studies, which showed a low risk
of bias.[12 ]
[15 ] The improvement of walking distance was found in 33% of patients who underwent three-level
surgery, 47% with two-level, and 79% with single-level laminectomy (p = 0.015).[15 ] The second study also suggested improved outcomes after single-level laminectomy.[12 ]
Complications and Adverse Events
Complications and adverse events were reported in five studies.[9 ]
[11 ]
[13 ]
[15 ]
[18 ] The most common complications were dural tear (9%) and wound infection (6%) in one
study.[15 ] In another study, four patients needed early revision surgery due to postoperative
complications.[9 ] Malter et al[11 ] reported the incidence of postoperative complications as 7%. Kim et al reported
33 deaths in the first 90 days after surgery.[13 ] In another study, four patients (4.1%) had an early complication requiring further
surgery (three local infections)[18 ] ([Table 3 ]).
Discussion
Surgery for degenerative lumbar diseases is the most common operation within the spine.
Laminectomy and decompression have been commonly utilized for several decades but
still, there is a paucity of evidence for the long-term efficacy of laminectomy for
LSS. The present study investigates the long-term efficacy and safety of surgery for
this condition.
Our review consisted of 83,492 patients with LSS undergoing decompression laminectomy.
The results of this study demonstrate that after at least 5 years of follow-up, compared
with preoperative baseline patients were more satisfied,[10 ]
[12 ]
[15 ]
[16 ]
[18 ]
[20 ] had less pain, both in the leg and low back pain,[10 ]
[12 ]
[16 ]
[17 ]
[19 ]
[20 ] were less disabled,[16 ]
[17 ]
[19 ]
[20 ] could walk further without claudication,[9 ]
[12 ]
[19 ] and had a 14% probability of reoperation.[9 ]
[10 ]
[11 ]
[13 ]
[14 ]
[16 ]
[17 ]
[18 ]
[19 ]
[20 ] Moreover, very low-quality evidence demonstrated that LSS surgery had better outcomes
in single-level laminectomy compared with multilevel surgical decompressive laminectomy.[12 ]
[15 ] The overall quality of evidence was low, considering the nonrandomized design of
the studies, low patient numbers, and lack of precise results reflected by the wide
95% CIs presented.
Several studies have explored short-term outcomes of laminectomy in LSS. Fritsch et
al conducted a systematic review in 2017 to assess pain and disability after laminectomy
surgery and demonstrated that patients with spinal stenosis experience substantial
reductions in pain and disability in the first 3 months after the surgery but little
further improvement is observed afterwards.[21 ] In 2016, Lurie and Tomkins-Lane suggested that patients who underwent laminectomy
reported increased improvement in leg pain compared with the nonsurgical group, which
is consistent with the results from this study.[22 ] In another systematic review from 2016 performed by Zaina et al comparing surgically
and nonsurgically treated patients, the authors reported no significant differences
at 6-month and 1-year follow-up but there was a significant difference favoring decompression
after 24 months.[23 ] In a study conducted in 2013 by Macedo et al comparing surgery and conservative
treatment, the authors reported that surgery was more effective in improving pain
and disability; however, changes in claudication were not found to be significantly
different between the two groups.[24 ] In contrast, Mo et al in a study from 2018 comparing the effectiveness of surgery
and exercise therapy reported relatively equivocal result in mitigating pain and improving
physical activity.[25 ] The results of this study showed that patients could walk farther after laminectomy,
which can be interpreted as an improvement in neurogenic intermittent claudication.
Similarly, in a study from 2012, Ammendolia et al compared surgery with conservative
treatment and reported improvement of LSS in the surgery group.[26 ] After meta-analysis, our results demonstrated that with a low level of evidence
there is a 14% (95% CI: 13–16%) probability that patients will require reoperation
at least 5 years after surgery. In 2018, Goel and Modi reported that comorbid diseases,
smoking, and method of surgery might influence the reoperation rate.[27 ]
Patients with a single-level disease are much simpler to treat and have less comorbidity,
which might explain why the outcomes appeared to be better in single-level laminectomy
in the reviewed studies. In general, standard laminectomy seems to be effective for
relieving the symptoms of patients with LSS, but considering that LSS is a progressive
degenerative disease and the surgery does not prevent disease progression, the results
of surgery are less prominent during the long-term follow-up.
Conclusion
Our review of the available evidence suggests that LSS patients undergoing standard
laminectomy may self-report less pain and disability and walk further without claudication
on long-term follow-up. Despite the high prevalence of the condition, there is a lack
of high-quality evidence for long-term outcomes of surgery. High-quality randomized
studies with long-term follow-ups are warranted to ascertain the benefits of laminectomy.
Appendix Table A1
PubMed
("Lumbar Vertebrae"[Mesh] OR "Lumbar Stenosis, Familial" [Supplementary Concept] OR
"Spinal Stenosis"[Mesh] OR (Lumbar[TIAB] AND (Vertebrae[TIAB] OR Vertebra[TIAB] OR
vertebralis[TIAB] ) ) OR ( (spine [TIAB] OR spinal[TIAB] OR spinalis[TIAB] OR lumb*
[TIAB] ) AND (stenosis[TIAB] OR Stenoses[TIAB] OR stenotic[TIAB])) OR "Cauda Equina"[Mesh]
OR ((equaine[TIAB] OR Equina[TIAB] ) AND Cauda[TIAB] ) OR (Filum[TIAB] AND Terminale[TIAB])
)
AND
( "Decompression, Surgical"[Mesh] OR ((Decompression*[TIAB] OR decompressive[TIAB]
) AND (surger*[TIAB] OR operation[TIAB] )) OR "Laminectomy"[Mesh] OR hemilaminectomy[TIAB]
OR Laminectom* [TIAB] OR Laminotom*[TIAB] OR "Minimally Invasive Surgical Procedures"[Mesh]
OR ( (minimally[TIAB] OR Mini[TIAB] ) AND ( Invasive[TIAB] OR Procedur*[TIAB] )) OR endoscop*[TIAB]
OR (PEDICLE[TIAB] AND SCREW[TIAB] ) OR ((Nerve[TIAB] AND Root[TIAB]) AND Compression*[TIAB]
) OR "Arthrodesis"[Mesh] OR Arthrodes*[TIAB] OR arthrodesia[TIAB] OR (articular[TIAB]
AND process[TIAB] AND fusion[TIAB] ) OR ( joint [TIAB] AND fusion[TIAB] ))
AND
(Year [tiab] OR Years[tiab] OR TERM [tiab] OR TERMS[tiab] OR CHRONIC [tiab] OR CHRONICS[tiab])
AND
("Clinical Trials as Topic"[Mesh] OR "Clinical Trial" [Publication Type] OR RCT[TIAB]
OR RANDOMIZED[TIAB] OR RANDOM*[TIAB] OR TRIAL*[TIAB] OR "Follow-Up Studies"[Mesh]
OR “Follow Up” [TIAB] OR Followup [TIAB] OR "Cohort Studies"[Mesh] OR Cohort [TIAB]
OR Concurrent [TIAB] OR (Incidence[TIAB] AND (Study[TIAB] OR studies[tiab])))
NOT
(("Animals"[Mesh] OR animal*[TIAB] OR rat [TIAB] OR rats[TIAB] OR mice[TIAB] OR mouse[TIAB])
NOT (("Humans"[Mesh] OR human*[TIAB] ) AND ("Animals"[Mesh] OR animal*[TIAB] OR rat
[TIAB] OR rats[TIAB] OR mice[TIAB] OR mouse[TIAB])))
Appendix Table A2
Health care entity relationships and investments of Dr Alexander R. Vaccaro.
Entity
Relationship
Replication Medica
d
Medtronics
c
Stryker Spine
c,
Globus
c,d
Paradigm Spine
d
Stout Medical
d
Progressive Spinal Technologies
d
Advanced Spinal Intellectual Properties
d
Aesculap
c
Spine Medica
d
Computational Biodynamics
d
Spinology
d
Flagship Surgical
d
Cytonics
d
Bonovo Orthopaedics
d
Electrocore
d
Insight Therapeutics
d
FlowPharma
d
Rothman Institute and Related Properties
d
AO Spine
g
Innovative Surgical Design
d
Orthobullets
d
Thieme
c
Jaypee
c
Elseviere
c
Taylor Francis/Hodder and Stoughton
c
Expert testimony
g
Vertiflex
d
Avaz Surgical
d
Dimension Orthotics, LLC
d
SpineWave
c
Atlas Spine
c
Nuvasive
d
Parvizi Surgical Innovation
d
Franklin Bioscience
d
Deep Health
d
Legend
Consulting/independent contractor
Service on scientific advisory board/board of directors/service on committees
Receipt of royalty payments
Stock/stock option ownership interests
Institutional/educational grant
Deputy editor/editor/editorial board
Member in good standing/independent contractor
