A commentary on “Management for lumbar spinal stenosis: A network meta-analysis and systematic review”

Lumbar spinal stenosis (LSS) is a degenerative condition in which changes in the discs, ligamentum flavum, and facet joints with aging cause narrowing of the spaces around the neurovascular structures of the spine. Radiographic findings of spinal stenosis are highly prevalent among those older than 60 years of age and can be as high as 80% in specific populations [1]. Only 30%, however, present severe lumbar stenosis and about 17% have long-term symptoms of intermittent neurogenic claudication. Neurogenic claudication is the most important feature of LSS as it limits patients’ walking ability and causes a major impact on their quality of life. However, there is little evidence suggesting whether a patient with LSS should be treated with surgery. If surgery is recommended, which type of surgery benefits the patient most? To answer these questions, Wei et al. [2] conducted a network meta-analysis and systematic review to compare different interventions in terms of efficacy as well as safety in adult patients with LSS. They concluded that there were no significant differences among the different interventions in improving patient function. Surgical interventions were associated with better pain relief but a higher incidence of complications. Decompression plus fusion is not necessary for patients. Many experts would agree that patients with LSS undergoing surgery have better outcomes at 2 postoperative years versus those not undergoing any surgery. However, there is a long-standing controversy as to whether LSS is better managed with or without fusion. Objective evidence has showed that: (1) decompression plus fusion was associated with significantly higher rates of satisfaction and lower leg pain scores compared with decompression alone; (2) no difference in the Oswestry Disability Index, back pain scores, complication rate, and reoperation rate was found between decompression plus fusion and decompression alone; and (3) decompression alone was associated with significantly less intraoperative blood loss, operative time and hospital stay [3]. Spinal fusion was initially used by Harms and Rolinger [4]. However, as an invasive procedure, fusion has many uncertainties that can greatly influence the final outcomes of LSS. The altered biomechanical function of the spine, such as loss of motion at the fused levels, was compensated for by increased motion at the unfused segments. This process caused certain mechanical stresses, which then accelerated adjacent lumbar level fusion problems and produced back pain and leg pain. Other disadvantage of fusion was the co-existence of other complications and heavier financial costs. Therefore, surgeons should exercise great caution while performing spinal fusion in patients with LSS. A stratification of carefully screened patients on the basis of age, gender, comorbidities, with or without preoperative spondylolisthesis, intraoperative evaluation of slippage possibility, and other considerations should be completed, and the ultimate goal of treating LSS need always focus on the balance between decompression of the compressed nerve and adequate bone retention for spinal mechanical stability. A longer-term analysis, including more comparative trials with moderate and high grade evidence, would be expected to improve the validity and reliability of the conclusion. Provenance and peer review Commentary, internally reviewed. Fund Xinjiang Uygur Autonomous Region Natural Science Fund (2016D01C221). Ethical approval Not required. Sources of funding for your research Xinjiang Uygur Autonomous Region Natural Science Fund (2016D01C221). Author contribution Jun Ren: writing. Lei Li: data analysis and study design. State the trial registry number – ISRCTNp None. Research registration unique identifying number (UIN) None. Guarantor Lei Li. Declaration of competing interest There was no conflict of interest.