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Opciones quirúrgicas para la estenosis lumbar
Gustavo C Machado, Paulo H Ferreira, Rafael IJ Yoo, Ian A Harris, Marina B Pinheiro, Bart W Koes, Maurits W van Tulder, Magdalena Rzewuska, Christopher G Maher, Manuela L Ferreira | 1 noviembre 2016

Respuestas clínicas Cochrane

Topics

Temas

Study flow diagram.
Figuras y tablas -
Figure 1

Study flow diagram.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Forest plot of comparison: 1 Decompression ± fusion vs usual non‐operative care for Oswestry Disability Index, outcome: 1.1 Oswestry Disability Index [%].
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Figure 4

Forest plot of comparison: 1 Decompression ± fusion vs usual non‐operative care for Oswestry Disability Index, outcome: 1.1 Oswestry Disability Index [%].

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Forest plot of comparison: 1 Decompression ± fusion versus usual non‐operative care for adverse events.
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Figure 5

Forest plot of comparison: 1 Decompression ± fusion versus usual non‐operative care for adverse events.

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Comparison 1 Decompression ± fusion vs usual conservative care for Oswestry Disability Index, Outcome 1 Oswestry Disability Index.
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Analysis 1.1

Comparison 1 Decompression ± fusion vs usual conservative care for Oswestry Disability Index, Outcome 1 Oswestry Disability Index.

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Comparison 1 Decompression ± fusion vs usual conservative care for Oswestry Disability Index, Outcome 2 Pain.
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Analysis 1.2

Comparison 1 Decompression ± fusion vs usual conservative care for Oswestry Disability Index, Outcome 2 Pain.

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Comparison 2 Epidural steroid injection vs decompression with or without fusion, Outcome 1 Oswestry Disability Index.
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Analysis 2.1

Comparison 2 Epidural steroid injection vs decompression with or without fusion, Outcome 1 Oswestry Disability Index.

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Comparison 2 Epidural steroid injection vs decompression with or without fusion, Outcome 2 Visual Analogue Scale.
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Analysis 2.2

Comparison 2 Epidural steroid injection vs decompression with or without fusion, Outcome 2 Visual Analogue Scale.

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Comparison 2 Epidural steroid injection vs decompression with or without fusion, Outcome 3 Zurich Claudication Questionnaire.
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Analysis 2.3

Comparison 2 Epidural steroid injection vs decompression with or without fusion, Outcome 3 Zurich Claudication Questionnaire.

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Decompression ±fusion vs usual conservative care for Oswestry Disabilty Index and Visual Analogue Pain Scale (VAS) for lumbar spinal stenosis

Patient or population: lumbar spinal stenosis

Intervention: decompression ± fusion

Comparison: usual conservative care

Outcomes

Relative effect
(95% CI)

Outcome means

Number of participants
(studies)

Quality of the evidence
(GRADE)

Oswestry Disability Index ‐ 6 months

(0 to 100%)

(MD ‐3.66%, 95% CI ‐10.12 to 2.80)

Decompression range: 20.7 to 28.1

Usual conservative care range: 28.3 to 29.0

349 (2)

⊕⊕⊝⊝
Low

Oswestry Disability Index ‐ 1 year

(0 to 100%)

(MD ‐6.17%, 95% CI ‐15.02 to 2.67)

Decompression range: 18.9 to 27.8

Usual conservative care range: 30.0 to 30.2

340 (2)

⊕⊕⊝⊝
Low

Oswestry Disability Index ‐ 2 years

(0 to 100%)

(MD ‐4.43%, 95% CI ‐7.91 to ‐0.96)

Decompression range: 21.2 to 26.3

Usual conservative care range: 29 to 29.8

315 (2)

⊕⊕⊝⊝
Low

Pain ‐ 3 months

(0 to 10)

(RR 1.38, 95% CI 0.22 to 8.59)

Decompression: 5.45

Usual conservative care: 2.81

31 (1)

⊕⊕⊝⊝
Low

Pain ‐ 4 years

(0 to 10)

(RR 7.50, 95% CI 1.00 to 56.48)

Decompression: 5.05

Usual conservative care: 2.72

30 (1)

⊕⊕⊝⊝
Low

Pain ‐ 10 years

(0 to 10)

(RR 4.09, 95% CI 0.95 to 17.58)

Decompression: 4.87

Usual conservative care: 2.74

29 (1)

⊕⊕⊝⊝
Low

CI: confidence interval; MD: mean difference; RR: risk ratio
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

Studies failed on 3 of 5 GRADE factors, including:

  • bias: All but 1 study had high bias risk;

  • design: All but 1 study were not blinded; and

  • imprecision: Only 1 study presented compete outcome data.
Figuras y tablas -
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Epidural steroid injection vs mild decompression ±fusion for lumbar spinal stenosis

Patient or population: lumbar spinal stenosis

Intervention: epidural steroid injection

Comparison: decompression ± fusion

Outcomes

Relative effect
(95% CI)

Outcome means

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Oswestry Disability Index ‐ 6 weeks

(MD 5.70, 95% CI 0.57 to 10.83)

Epidural injection: 34.8

Mild decompression: 27.4

38 (1)

⊕⊕⊝⊝
Low

Visual Analogue Scale (VAS) ‐ 6 weeks

(MD 2.40, 95% CI 1.92 to 2.88)

Epidural injection: 6.3

Mild decompression: 3.8

38 (1)

⊕⊕⊝⊝
Low

Zurich Claudication Questionnaire ‐ 6 weeks

(MD ‐0.60, 95% CI ‐0.77 to ‐0.43)

Epidural injection: 2.8

Mild decompression: 2.2

38 (1)

⊕⊕⊝⊝
Low

CI: confidence interval; MD: mean difference
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low quality: We are very uncertain about the estimate

Although this study had low risk of bias, this was the only study examined. Further research is very likely to have an impact on our confidence

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Comparison 1. Decompression ± fusion vs usual conservative care for Oswestry Disability Index

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Oswestry Disability Index Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Subtotals only

1.1 6 months

2

349

Mean Difference (IV, Random, 95% CI)

‐3.66 [‐10.12, 2.80]

1.2 1 year

2

340

Mean Difference (IV, Random, 95% CI)

‐6.17 [‐15.02, 2.67]

1.3 2 years

2

315

Mean Difference (IV, Random, 95% CI)

‐4.43 [‐7.91, ‐0.96]

2 Pain Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.1 3 months

1

31

Risk Ratio (M‐H, Fixed, 95% CI)

1.38 [0.22, 8.59]

2.2 4 years

1

30

Risk Ratio (M‐H, Fixed, 95% CI)

7.5 [1.00, 56.48]

2.3 10 years

1

29

Risk Ratio (M‐H, Fixed, 95% CI)

4.09 [0.95, 17.58]
Figuras y tablas -
Comparison 1. Decompression ± fusion vs usual conservative care for Oswestry Disability Index
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Comparison 2. Epidural steroid injection vs decompression with or without fusion

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Oswestry Disability Index Show forest plot

1

38

Mean Difference (IV, Fixed, 95% CI)

5.7 [0.57, 10.83]

1.1 6 weeks

1

38

Mean Difference (IV, Fixed, 95% CI)

5.7 [0.57, 10.83]

2 Visual Analogue Scale Show forest plot

1

38

Mean Difference (IV, Fixed, 95% CI)

2.4 [1.92, 2.88]

2.1 6 weeks

1

38

Mean Difference (IV, Fixed, 95% CI)

2.4 [1.92, 2.88]

3 Zurich Claudication Questionnaire Show forest plot

1

38

Mean Difference (IV, Fixed, 95% CI)

‐0.60 [‐0.77, ‐0.43]

3.1 6 weeks

1

38

Mean Difference (IV, Fixed, 95% CI)

‐0.60 [‐0.77, ‐0.43]
Figuras y tablas -
Comparison 2. Epidural steroid injection vs decompression with or without fusion
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