Further Aspects of the Therapeutic Options
The article (1) provides a good overview of the treatment options in lumbar spinal stenosis. However, crucial aspects were not mentioned: many patients are treated with complex surgery if imaging shows spinal stenosis when what they actually have is local back pain, not spinal claudication.
While some treatments are superior to others in some partial aspects (different surgical techniques, conservative treatment), “superior” does not actually give any indication about the actual degree of improvement—especially as far as walking performance is concerned, which is the main criterion for impairment (the defining criterion of spinal stenosis, as diagnosed by means of imaging modalities, is spinal claudication). Being able to walk without leg pain for a distance of 100 meters before surgery and of 500 meters after surgery is a notable improvement statistically, but clinically and in absolute terms a rather negligible one. It may be assumed that this is not sufficiently explained to patients in the preoperative discussion. The meta-analysis by Kovacs et al (2) on the treatment of spinal canal stenosis—which was not mentioned by the authors—included 739 publications on the subject. The authors of this study mentioned this (“In all the studies, surgery showed better results for pain, disability, and quality of life, although not for walking” ). The psychological comorbidity of these often multimorbid patients has been less thoroughly investigated than their imaging results. But for the purposes of rehabilitation, it is of crucial importance, therapeutically and prognostically, to know whether depression and/or anxiety (e.g. fear of movement) are present.
A critical explanation of further aspects of these therapeutic options would have benefited this CME article, especially in terms of a better understanding among general practitioners and health services researchers.
Prof. Dr. med. Marcus Schiltenwolf
Departement Orthopädie, Unfallchirurgie und Paraplegiologie
Universitätsklinikum Heidelberg, firstname.lastname@example.org
|1.||Kalff R, Ewald C, Waschke A, Gobisch L, Hopf C: Degenerative lumbar spinal stenosis in older people—current treatment options. Dtsch Arztebl Int 2013; 110(37): 613–24. VOLLTEXT|
|2.||Kovacs FM, Urrútia G, Alarcón JD: Surgery versus conservative treatment for symptomatic lumbar spinal stenosis: a systematic review of randomized controlled trials. Spine 2011; 36: E1335–51. CrossRef MEDLINE|
|3.||Adogwa O, Parker SL, Shau DN, et al.: Preoperative Zung Depression Scale predicts outcome after revision lumbar surgery for adjacent segment disease, recurrent stenosis, and pseudarthrosis. Spine J 2012; 12: 179–85. CrossRef MEDLINE|
|4.||Guilfoyle MR, Seeley H, Laing RJ: The Short Form 36 health survey in spine disease--validation against condition-specific measures. Br J Neurosurg 2009; 23: 401–5. CrossRef MEDLINE|