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BMJ (Clinical Research Ed.) Jan 2016Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal... (Review)
Review
Lumbar spinal stenosis (LSS) affects more than 200,000 adults in the United States, resulting in substantial pain and disability. It is the most common reason for spinal surgery in patients over 65 years. Lumbar spinal stenosis is a clinical syndrome of pain in the buttocks or lower extremities, with or without back pain. It is associated with reduced space available for the neural and vascular elements of the lumbar spine. The condition is often exacerbated by standing, walking, or lumbar extension and relieved by forward flexion, sitting, or recumbency. Clinical care and research into lumbar spinal stenosis is complicated by the heterogeneity of the condition, the lack of standard criteria for diagnosis and inclusion in studies, and high rates of anatomic stenosis on imaging studies in older people who are completely asymptomatic. The options for non-surgical management include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation. However, few high quality randomized trials have looked at conservative management. A systematic review concluded that there is insufficient evidence to recommend any specific type of non-surgical treatment. Several different surgical procedures are used to treat patients who do not improve with non-operative therapies. Given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is almost always elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. Outcomes (leg pain and disability) seem to be better for surgery than for non-operative treatment, but the evidence is heterogeneous and often of limited quality.
Topics: Analgesics; Anti-Inflammatory Agents; Decision Support Techniques; Decompression, Surgical; Diagnostic Imaging; Humans; Incidence; Injections, Epidural; Intermittent Claudication; Lumbar Vertebrae; Musculoskeletal Pain; Physical Therapy Modalities; Postoperative Care; Prevalence; Scoliosis; Spinal Fusion; Spinal Stenosis; Spondylolisthesis; Steroids; United States
PubMed: 26727925
DOI: 10.1136/bmj.h6234 -
Spine Jan 2016A systematic review with meta-analysis. (Meta-Analysis)
Meta-Analysis Review
STUDY DESIGN
A systematic review with meta-analysis.
OBJECTIVE
The aim of this study was to conduct a systematic review and meta-analysis of current evidence evaluating the effectiveness of rehabilitation following lumbar fusion surgery (LFS).
SUMMARY OF BACKGROUND DATA
LFS for the management of lower back pain, with(out) neurogenic leg pain, is increasing as the population ages. Clinical outcomes commonly lag behind surgical outcomes and 40% of patients experience significant back-related disability 12 months after LFS. Identifying rehabilitation strategies to improve function and quality of life following LFS is important.
METHODS
A systematic review of databases were searched, including MEDLINE, CINAHL, and grey literature. Studies identified were screened for inclusion by title and abstract. Full text of eligible/potentially eligible studies was evaluated against predetermined eligibility criteria. Included studies were subjected to critical appraisal and risk of bias evaluation. The GRADE approach to quality of evidence was utilized. A meta-analysis comparing usual care with "complex rehabilitation," comprising exercise and cognitive behavioral therapy, for outcomes relating to pain, disability, fear of movement, and mental health was conducted at short and longer term (<3 and >12 months postsurgery) time points.
RESULTS
Three studies were identified for the systematic review and 2 included in the meta-analysis (n = 237, female = 62%, mean age = 55). Low-quality evidence suggests that "complex rehabilitation" provides short-term improvement in disability [effect size, -0.85, 95% confidence interval (95% CI), -1.41 to -0.29] and fear avoidance behavior (-1.07, 95% CI -1.33, -0.80), compared with usual care. Low-quality evidence exists favoring "complex rehabilitation" over usual care for longer term disability (-0.84, 95% CI -1.11 to -0.58) and fear avoidance behavior (-1.40, 95% CI -1.69 to -1.12).
CONCLUSIONS
A small number of low-quality studies suggest that "complex rehabilitation" reduces short and long-term disability and fear avoidance behavior following LFS. More, high-quality research is required to confirm the effectiveness of "complex rehabilitation" programs.
Topics: Adolescent; Adult; Aged; Cognitive Behavioral Therapy; Exercise Therapy; Female; Humans; Lumbar Vertebrae; Male; Middle Aged; Physical Therapy Modalities; Quality of Life; Spinal Fusion; Treatment Outcome; Young Adult
PubMed: 26555833
DOI: 10.1097/BRS.0000000000001132 -
The Cochrane Database of Systematic... Jan 2016Lumbar spinal stenosis (LSS) is a debilitating condition associated with degeneration of the spine with aging. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Lumbar spinal stenosis (LSS) is a debilitating condition associated with degeneration of the spine with aging.
OBJECTIVES
To evaluate the effectiveness of different types of surgery compared with different types of non-surgical interventions in adults with symptomatic LSS. Primary outcomes included quality of life, disability, function and pain. Also, to consider complication rates and side effects, and to evaluate short-, intermediate- and long-term outcomes (six months, six months to two years, five years or longer).
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, five other databases and two trials registries up to February 2015. We also screened reference lists and conference proceedings related to treatment of the spine.
SELECTION CRITERIA
Randomised controlled trials (RCTs) comparing surgical versus non-operative treatments in participants with lumbar spinal stenosis confirmed by clinical and imaging findings.
DATA COLLECTION AND ANALYSIS
For data collection and analysis, we followed methods guidelines of the Cochrane Back and Neck Review Group (Furlan 2009) and those provided in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).
MAIN RESULTS
From the 12,966 citations screened, we assessed 26 full-text articles and included five RCTs (643 participants).Low-quality evidence from the meta-analysis performed on two trials using the Oswestry Disability Index (pain-related disability) to compare direct decompression with or without fusion versus multi-modal non-operative care showed no significant differences at six months (mean difference (MD) -3.66, 95% confidence interval (CI) -10.12 to 2.80) and at one year (MD -6.18, 95% CI -15.03 to 2.66). At 24 months, significant differences favoured decompression (MD -4.43, 95% CI -7.91 to -0.96). Low-quality evidence from one small study revealed no difference in pain outcomes between decompression and usual conservative care (bracing and exercise) at three months (risk ratio (RR) 1.38, 95% CI 0.22 to 8.59), four years (RR 7.50, 95% CI 1.00 to 56.48) and 10 years (RR 4.09, 95% CI 0.95 to 17.58).Low-quality evidence from one small study suggested no differences at six weeks in the Oswestry Disability Index for patients treated with minimally invasive mild decompression versus those treated with epidural steroid injections (MD 5.70, 95% CI 0.57 to 10.83; 38 participants). Zurich Claudication Questionnaire (ZCQ) results were better for epidural injection at six weeks (MD -0.60, 95% CI -0.92 to -0.28), and visual analogue scale (VAS) improvements were better in the mild decompression group (MD 2.40, 95% CI 1.92 to 2.88). At 12 weeks, many cross-overs prevented further analysis.Low-quality evidence from a single study including 191 participants favoured the interspinous spacer versus usual conservative treatment at six weeks, six months and one year for symptom severity and physical function.All remaining studies reported complications associated with surgery and conservative side effects of treatment: Two studies reported no major complications in the surgical group, and the other study reported complications in 10% and 24% of participants, including spinous process fracture, coronary ischaemia, respiratory distress, haematoma, stroke, risk of reoperation and death due to pulmonary oedema.
AUTHORS' CONCLUSIONS
We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment. No clear benefits were observed with surgery versus non-surgical treatment. These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects. High-quality research is needed to compare surgical versus conservative care for individuals with lumbar spinal stenosis.
Topics: Aged; Braces; Decompression, Surgical; Exercise Therapy; Female; Humans; Injections, Epidural; Laminectomy; Lumbosacral Region; Male; Middle Aged; Pain Measurement; Randomized Controlled Trials as Topic; Spinal Cord Compression; Spinal Fusion; Spinal Stenosis
PubMed: 26824399
DOI: 10.1002/14651858.CD010264.pub2 -
BioMed Research International 2023We conducted this meta-analysis to provide better evidence of the efficacy of manual therapy (MT) on adolescent idiopathic scoliosis (AIS). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
We conducted this meta-analysis to provide better evidence of the efficacy of manual therapy (MT) on adolescent idiopathic scoliosis (AIS).
METHODS
All RCTs of MT for the management of patients with AIS were included in the present study. The treatment difference between the experimental and control group was mainly MT. The outcomes consisted of the total effective rate, the Cobb angle, and Scoliosis Research Society-22 (SRS-22) questionnaire score. Electronic database searches were conducted from database inception to July 2022, including the Cochrane Library, PubMed, Web of Science, Embase, Wanfang Data, CNKI, and VIP. The pooled data were analyzed using RevMan 5.4 software.
RESULTS
Four RCTs with 213 patients in the experimental group were finally included. There are 2 studies of standalone MT in the experimental group and 3 studies of MT with identical conservative treatments in the control group. Three trials reported total effective rate, and a statistically significant difference was found ( = 0.004). Three trials reported Cobb angle, and a statistical difference was found ( = 0.01). Then, sensitivity analysis showed that there was a significant difference in the additional MT subgroup ( < 0.00001) while not in the standalone MT subgroup ( = 0.41). Three trials reported SRS-22 scores ( = 0.55) without significant differences.
CONCLUSION
There is insufficient data to determine the effectiveness of spinal manipulation limited by the very low quality of included studies. High-quality studies with appropriate design and follow-up periods are warranted to determine if MT may be beneficial as an adjunct therapy for AIS. Currently, there is no evidence to support spinal manipulation.
Topics: Humans; Adolescent; Scoliosis; Randomized Controlled Trials as Topic; Kyphosis; Manipulation, Spinal; Spinal Fusion
PubMed: 36644168
DOI: 10.1155/2023/7928429 -
Journal of Clinical Orthopaedics and... Nov 2017Our objective was to perform a systematic review of the literature and conduct a meta-analysis to investigate the outcomes of open versus arthroscopic methods of ankle... (Review)
Review
OBJECTIVES
Our objective was to perform a systematic review of the literature and conduct a meta-analysis to investigate the outcomes of open versus arthroscopic methods of ankle fusion.
METHODS
In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we performed a systematic review. Electronic databases MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised and non-randomised studies comparing outcomes of arthroscopic and open ankle arthrodesis. The Newcastle-Ottawa scale was used to assess the methodological quality and risk of bias of the selected studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data.
RESULTS
We identified one prospective cohort study and 5 retrospective cohort studies, enrolling a total of 286 patients with ankle arthritis. Our analysis showed that open ankle fusion was associated with a lower fusion rate (OR 0.26, 95% CI 0.13-0.52, P = 0.0002), longer tourniquet time (MD 16.49, 95% CI 9.46-23.41, P < 0.00001), and longer length of stay (MD 1.60,95% CI 1.10-2.10, P < 0.00001) compared to arthroscopic ankle fusion; however, there was no significant difference between two groups in terms of infection rate (OR 2.41, 95% CI 0.76-7.64, P = 0.14), overall complication rate (OR: 1.54, 95% CI 0.80-2.96, P = 0.20), and operation time (MD 4.09, 95% CI -2.49-10.66, P = 0.22). The between-study heterogeneity was high for tourniquet time but low or moderate for other outcomes. The direction of the effect sizes remains unchanged throughout sensitivity analyses.
CONCLUSIONS
The best available evidence demonstrates that arthroscopic ankle fusion may be associated with a higher fusion rate, shorter tourniquet time, and shorter length of stay compared to open ankle fusion. We found no significant difference between two groups in terms of infection rate, overall complication rate, and operation time. The best available evidence is not adequately robust to make definitive conclusions. Long-term results of the comparative efficacy of arthroscopic ankle fusion over open ankle fusion are not currently available. Further high quality randomised controlled trials that are adequately powered are required.
PubMed: 29339846
DOI: 10.1016/j.jcot.2017.03.010 -
Journal of Hand Surgery Global Online Mar 2021The aims of this systematic review were to examine the use of radiolunate (RL) or radioscapholunate (RSL) arthrodesis as surgical management for patients with advanced...
PURPOSE
The aims of this systematic review were to examine the use of radiolunate (RL) or radioscapholunate (RSL) arthrodesis as surgical management for patients with advanced radiocarpal arthritis that failed conservative management and to assess postoperative outcomes.
METHODS
We reviewed articles from PubMed, EMBASE, and Web of Science from inception through December 2019. We identified complete manuscripts written in English reporting on RL or RSL arthrodesis for treatment of wrist pathology that included the primary outcomes (pain or grip strength) and at least 2 secondary outcomes (range of motion, patient-reported outcomes, or nonunion). Data pooling was used to calculate weighted averages.
RESULTS
We identified 2,252 articles and selected 13 for inclusion. Across all studies, RSL arthrodesis was performed for 180 patients (49% female; 45 years old) and RL for 94 (87% female; 50 years old). Both procedures exhibited improvements in pain score and grip strength. Both cohorts demonstrated postoperative changes in flexion-extension arc, flexion, extension, ulnar deviation, supination, and pronation after data pooling. The nonunion rate for RSL was 15% versus 2% for RL, whereas the rate of progression to total wrist arthrodesis for RSL and RL was 4% and 0%, respectively.
CONCLUSIONS
Both RL and RSL arthrodesis can be successfully used to manage debilitating radiocarpal arthritis by affording patients with pain reduction. Each has its own benefits, in which RSL arthrodesis provides a total arc of motion within the functional demands of most activities of daily living, and RL arthrodesis has low rates of nonunion and progression to total wrist arthrodesis. Further research is needed to compare the 2 surgeries directly and prospectively in comparable patient groups.
TYPE OF STUDY/LEVEL OF EVIDENCE
Therapeutic III.
PubMed: 35415540
DOI: 10.1016/j.jhsg.2020.12.003 -
BMJ Clinical Evidence Mar 2009Bunions are prominent and often inflamed metatarsal heads and overlying bursae, usually associated with hallux valgus where the great toe moves towards the second toe.... (Review)
Review
INTRODUCTION
Bunions are prominent and often inflamed metatarsal heads and overlying bursae, usually associated with hallux valgus where the great toe moves towards the second toe. Hallux valgus is found in at least 2% of children aged 9-10 years, and almost half of adults, with greater prevalence in women.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of conservative treatments, surgery, and postoperative care for bunions? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 21 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: arthrodesis (Lapidus procedure); bone fixation (absorbable pin fixation, screw fixation plus early weight-bearing, standard fixation, suture fixation plus delayed weight-bearing, percutaneous Kirschner-wire fixation); chevron osteotomy plus adductor tenotomy; distal metatarsal osteotomy; early weight-bearing; Keller's arthroplasty; Keller-Lelievre arthroplasty; night splints; orthoses (including antipronatory orthoses in children); phalangeal (Akin) osteotomy plus distal chevron osteotomy; proximal osteotomy, and slipper casts.
Topics: Follow-Up Studies; Hallux Valgus; Humans; Metatarsal Bones; Orthotic Devices; Osteotomy; Weight-Bearing
PubMed: 19445756
DOI: No ID Found -
Journal of Orthopaedic Surgery and... May 2020Osteoarthritis (OA) is a growing health concern that affects approximately 27 million people in the USA and is associated with a $185 billion annual cost burden.... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
Osteoarthritis (OA) is a growing health concern that affects approximately 27 million people in the USA and is associated with a $185 billion annual cost burden. Choosing between open surgery and arthroscopic arthrodesis for ankle arthritis is still controversial. This study compared arthroscopic arthrodesis and open surgery by performing a systematic review and meta-analysis.
METHODS
For the systematic review, a literature search was conducted in 4 English databases (PubMed, Embase, Medline and the Cochrane Library) from inception to February 2020. Three prospective cohort studies and 7 retrospective cohort studies, enrolling a total of 507 patients with ankle arthritis, were included.
RESULTS
For fusion rate, the pooled data showed a significantly higher rate of fusion during arthroscopic arthrodesis compared with open surgery (odds ratio 0.25, 95% CI 0.11 to 0.57, p = 0.0010). Regarding estimated blood loss, the pooled data showed significantly less blood loss during arthroscopic arthrodesis compared with open surgery (WMD 52.04, 95% CI 14.14 to 89.94, p = 0.007). For tourniquet time, the pooled data showed a shorter tourniquet time during arthroscopic arthrodesis compared with open surgery (WMD 22.68, 95% CI 1.92 to 43.43, p = 0.03). For length of hospital stay, the pooled data showed less hospitalisation time for patients undergoing arthroscopic arthrodesis compared with open surgery (WMD 1.62, 95% CI 0.97 to 2.26, p < 0.00001). The pooled data showed better recovery for the patients who underwent arthroscopic arthrodesis compared with open surgery at 1 year (WMD 14.73, 95% CI 6.66 to 22.80, p = 0.0003).
CONCLUSION
In conclusion, arthroscopic arthrodesis was associated with a higher fusion rate, smaller estimated blood loss, shorter tourniquet time, and shorter length of hospitalisation than open surgery.
Topics: Ankle Joint; Arthrodesis; Arthroscopy; Humans; Length of Stay; Osteoarthritis; Prospective Studies; Retrospective Studies
PubMed: 32448398
DOI: 10.1186/s13018-020-01708-4 -
Foot and Ankle Surgery : Official... Apr 2021Open ankle arthrodesis (OAA) remains the most widely used operation in end-stage ankle osteoarthritis. However, there is a large variation in terms of approach and...
BACKGROUND
Open ankle arthrodesis (OAA) remains the most widely used operation in end-stage ankle osteoarthritis. However, there is a large variation in terms of approach and fixation methods. The aim of this systematic review was to assess the effect of different approaches and fixation methods on the union rate, complication rate and functional outcome in OAA.
METHODS
A search of the online databases PubMed, Embase, and Cochrane library was performed to identify patients who underwent OAA with screw- and/or plate-fixation.
RESULTS
We identified 38 studies, including 1250 patients (1290 ankles). The union rate was 98% (95% CI 0.95-0.99) for the anterior, 96% (95% CI 0.92-0.98) for the lateral and 96% (95% CI 0.68-1.00) for the combined medial/lateral approach. Screw-fixation achieved an overall union rate of 96% (95% CI 0.93-0.98) and plate-fixation 99% (95% CI 0.96-0.99). The overall complication rate was 14%, 16% and 31% for the anterior, lateral and combined medial/lateral approaches respectively. It stood at 18% for screw-fixation and 9% for plate-fixation. The infection rate was 4%, 6% and 8% for the anterior, lateral and combined approaches respectively. Screw-fixation had an infection rate of 6% and plate-fixation 3%. The postoperative AOFAS scores were 76.8, 76.5 and 67.6 for the anterior, lateral and combined approaches respectively and 74.9 for screw- compared to 78.5 for plate-fixation. These differences did not reach statistical significance.
CONCLUSION
This study, the first of its kind, found little difference in terms of results between approach and fixation method used in OAA.
LEVEL OF EVIDENCE
Level IIa.
Topics: Adolescent; Adult; Aged; Ankle; Ankle Joint; Arthrodesis; Bone Plates; Bone Screws; Female; Follow-Up Studies; Humans; Male; Middle Aged; Osteoarthritis; Prospective Studies; Retrospective Studies; Treatment Outcome; Young Adult
PubMed: 33419696
DOI: 10.1016/j.fas.2020.12.011