Ammendolia Carlo, Stuber Kent J, Rok Elisabeth, Rampersaud Raja, Kennedy Carol A, Pennick Victoria, Steenstra Ivan A, de Bruin Linda K, Furlan Andrea D
Rebecca MacDonald Centre for Arthritis and Autoimmune Diseases, 60 Murray Street, Room L2007, Toronto, ON, Canada, M5T 3L9.
Cochrane Database Syst Rev. 2013 Aug 30;2013(8):CD010712. doi: 10.1002/14651858.CD010712.
Lumbar spinal stenosis with neurogenic claudication is one of the most commonly diagnosed and treated pathological spinal conditions. It frequently afflicts the elderly population.
To systematically review the evidence for the effectiveness of nonoperative treatment of lumbar spinal stenosis with neurogenic claudication.
CENTRAL, MEDLINE, CINAHL, and Index to Chiropractic Literature (ICL) databases were searched up to June 2012.
Randomized controlled trials published in English, in which at least one arm provided data on nonoperative treatments
We used the standard methodological procedures expected by The Cochrane Collaboration. Risk of bias in each study was independently assessed by two review authors using the 12 criteria recommended by the Cochrane Back Review Group (Furlan 2009). Dichotomous outcomes were expressed as relative risk, continuous outcomes as mean difference or standardized mean difference; uncertainty was expressed with 95% confidence intervals. If possible a meta-analysis was performed, otherwise results were described qualitatively. GRADE was used to assess the quality of the evidence.
From the 8635 citations screened, 56 full-text articles were assessed and 21 trials (1851 participants) were included. There was very low-quality evidence from six trials that calcitonin is no better than placebo or paracetamol, regardless of mode of administration or outcome assessed. From single small trials, there was low-quality evidence for prostaglandins, and very low-quality evidence for gabapentin or methylcobalamin that they improved walking distance. There was very low-quality evidence from a single trial that epidural steroid injections improved pain, function, and quality of life, up to two weeks, compared with home exercise or inpatient physical therapy. There was low-quality evidence from a single trial that exercise is of short-term benefit for leg pain and function compared with no treatment. There was low and very low-quality evidence from six trials that multimodal nonoperative treatment is less effective than indirect or direct surgical decompression with or without fusion. A meta-analysis of two trials comparing direct decompression with or without fusion to multimodal nonoperative care found no significant difference in function at six months (mean difference (MD) -3.66, 95% CI -10.12 to 2.80) and one year (MD -6.18, 95% CI -15.03 to 2.66), but at 24 months a significant difference was found favouring decompression (MD -4.43, 95% CI -7.91 to -0.96).
AUTHORS' CONCLUSIONS: Moderate and high-quality evidence for nonoperative treatment is lacking and thus prohibits recommendations for guiding clinical practice. Given the expected exponential rise in the prevalence of lumbar spinal stenosis with neurogenic claudication, large high-quality trials are urgently needed.
伴有神经源性间歇性跛行的腰椎管狭窄症是最常被诊断和治疗的脊柱病理性疾病之一。它常困扰老年人群。
系统评价非手术治疗伴有神经源性间歇性跛行的腰椎管狭窄症有效性的证据。
检索CENTRAL、MEDLINE、CINAHL和脊椎按摩文献索引（ICL）数据库至2012年6月。
以英文发表的随机对照试验，其中至少有一组提供了非手术治疗的数据。
我们采用了Cochrane协作网期望的标准方法程序。两位综述作者根据Cochrane背部综述小组推荐的12条标准（Furlan 2009）独立评估每项研究的偏倚风险。二分法结局以相对危险度表示，连续性结局以平均差或标准化平均差表示；不确定性以95%置信区间表示。如果可能，进行荟萃分析，否则对结果进行定性描述。采用GRADE评估证据质量。
在筛选的8635条文献中，评估了56篇全文文章，纳入了21项试验（1851名参与者）。六项试验提供了质量极低的证据，表明无论给药方式或评估的结局如何，降钙素并不比安慰剂或对乙酰氨基酚更有效。从单项小型试验中，有低质量证据支持前列腺素，有极低质量证据支持加巴喷丁或甲钴胺可改善步行距离。一项试验提供了质量极低的证据，表明与家庭锻炼或住院物理治疗相比，硬膜外类固醇注射在长达两周的时间内可改善疼痛、功能和生活质量。一项试验提供了低质量证据，表明与不治疗相比，锻炼对腿痛和功能有短期益处。六项试验提供了低质量和极低质量的证据，表明多模式非手术治疗与间接或直接手术减压（无论是否融合）相比效果较差。对两项比较直接减压（无论是否融合）与多模式非手术治疗的试验进行荟萃分析发现，六个月时功能无显著差异（平均差（MD）-3.66，95%置信区间-10.12至2.80），一年时也无显著差异（MD -6.18，95%置信区间-15.03至2.66），但在24个月时发现有利于减压的显著差异（MD -4.43，95%置信区间-7.91至-0.96）。
缺乏非手术治疗的中高质量证据，因此无法为指导临床实践提供建议。鉴于伴有神经源性间歇性跛行的腰椎管狭窄症患病率预计将呈指数级上升，迫切需要开展大型高质量试验。
