Interspinous Spacer versus Traditional Decompressive Surgery for Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis

<div><p>Background</p><p>Dynamic interspinous spacers, such as X-stop, Coflex, DIAM, and Aperius, are widely used for the treatment of lumbar spinal stenosis. However, controversy remains as to whether dynamic interspinous spacer use is superior to traditional decompressive surgery.</p><p>Methods</p><p>Medline, Embase, Cochrane Library, and the Cochrane Controlled Trials Register were searched during August 2013. A track search was performed on February 27, 2014. Study was included in this review if it was: (1) a randomized controlled trial (RCT) or non-randomized prospective comparison study, (2) comparing the clinical outcomes for interspinous spacer use versus traditional decompressive surgery, (3) in a minimum of 30 patients, (4) with a follow-up duration of at least 12 months.</p><p>Results</p><p>Two RCTs and three non-randomized prospective studies were included, with 204 patients in the interspinous spacer (IS) group and 217 patients in the traditional decompressive surgery (TDS) group. Pooled analysis showed no significant difference between the IS and TDS groups for low back pain (WMD: 1.2; 95% CI: −10.12, 12.53; P = 0.03; I² = 66%), leg pain (WMD: 7.12; 95% CI: −3.88, 18.12; P = 0.02; I² = 70%), ODI (WMD: 6.88; 95% CI: −14.92, 28.68; P = 0.03; I² = 79%), RDQ (WMD: −1.30, 95% CI: −3.07, 0.47; P = 0.00; I² = 0%), or complications (RR: 1.39; 95% CI: 0.61, 3.14; P = 0.23; I² = 28%). The TDS group had a significantly lower incidence of reoperation (RR: 3.34; 95% CI: 1.77, 6.31; P = 0.60; I² = 0%).</p><p>Conclusion</p><p>Although patients may obtain some benefits from interspinous spacers implanted through a minimally invasive technique, interspinous spacer use is associated with a higher incidence of reoperation and higher cost. The indications, risks, and benefits of using an interspinous process device should be carefully considered before surgery.</p></div

Flowchart of the study selection process.

<p>Flowchart of the study selection process.</p

Forest plot showing the meta-analysis for the reoperation rate.

<p>Forest plot showing the meta-analysis for the reoperation rate.</p

Forest plot showing the meta-analysis of visual analogue scale (VAS) scores for low back pain (A) and leg pain (B), the Oswestry disability index (C), and the Roland disability questionnaire (D).

<p>Forest plot showing the meta-analysis of visual analogue scale (VAS) scores for low back pain (A) and leg pain (B), the Oswestry disability index (C), and the Roland disability questionnaire (D).</p

The raw data

The data from included studie

Pooled Analysis of Non-Union, Re-Operation, Infection, and Approach Related Complications after Anterior Odontoid Screw Fixation

<div><p>Background</p><p>Anterior odontoid screw fixation (AOSF) has been one of the most popular treatments for odontoid fractures. However, the true efficacy of AOSF remains unclear. In this study, we aimed to provide the pooled rates of non-union, reoperation, infection, and approach related complications after AOSF for odontoid fractures.</p><p>Methods</p><p>We searched studies that discussed complications after AOSF for type II or type III odontoid fractures. A proportion meta-analysis was done and potential sources of heterogeneity were explored by meta-regression analysis.</p><p>Results</p><p>Of 972 references initially identified, 63 were eligible for inclusion. 54 studies provided data regarding non-union. The pooled non-union rate was 10% (95% CI: 7%–3%). 48 citations provided re-operation information with a pooled proportion of 5% (95% CI: 3%–7%). Infection was described in 20 studies with an overall rate of 0.2% (95% CI: 0%–1.2%). The main approach related complication is postoperative dysphagia with a pooled rate of 10% (95% CI: 4%–17%). Proportions for the other approach related complications such as postoperative hoarseness (1.2%, 95% CI: 0%–3.7%), esophageal/retropharyngeal injury (0%, 95% CI: 0%–1.1%), wound hematomas (0.2%, 95% CI: 0%–1.8%), and spinal cord injury (0%, 95% CI: 0%–0.2%) were very low. Significant heterogeneities were detected when we combined the rates of non-union, re-operation, and dysphagia. Multivariate meta-regression analysis showed that old age was significantly predictive of non-union. Subgroup comparisons showed significant higher non-union rates in age ≥70 than that in age ≤40 and in age 40 to <50. Meta-regression analysis did not reveal any examined variables influencing the re-operation rate. Meta-regression analysis showed age had a significant effect on the dysphagia rate.</p><p>Conclusions/Significances</p><p>This study summarized the rates of non-union, reoperation, infection, and approach related complications after AOSF for odontoid factures. Elderly patients were more likely to experience non-union and dysphagia.</p></div

Forest plots showing the rates of dysphagia (boxes) with 95% confidence of intervals (CIs; bars).

<p>Forest plots showing the rates of dysphagia (boxes) with 95% confidence of intervals (CIs; bars).</p

Forest plots showing the non-union rates (boxes) with 95% confidence of intervals (CIs; bars) in different age groups.

<p>Forest plots showing the non-union rates (boxes) with 95% confidence of intervals (CIs; bars) in different age groups.</p

Schematic diagram showing the method for measurement ofC3-L5.

<p><b>WVD</b> is the abbreviation of Width of vertebral body; <b>APDVD</b> is Anteroposterior diameter of vertebral body; <b>LHVD</b> is Left height of vertebral body; <b>RHVD</b> is Right height of vertebral body; <b>WVC</b> is Width of vertebral canal; <b>APDVC</b> is Anteroposterior diameter of vertebral canal; <b>WRP</b> is Width of right pedicle; <b>HRP</b> is Height of right pedicle; <b>WLP</b> is Width of left pedicle; <b>HLP</b> is Height of left pedicle.</p

The parameters of L1–L5 and comparison of data from radiographic images and 3D-printed models.

<p><b>Note</b>: <b>WVD</b>: Width of vertebral body; <b>APDVD</b>: Anteroposterior diameter of vertebral body; <b>LHVD</b>: Left height of vertebral body; <b>RHVD</b>: Right height of vertebral body; <b>WVC</b>: Width of vertebral canal; <b>APDVC</b>: Anteroposterior diameter of vertebral canal; <b>WRP</b>: Width of right pedicle; <b>HRP</b>: Height of right pedicle; <b>WLP</b>: Width of left pedicle; <b>HLP</b>: Height of left pedicle.</p><p>The parameters of L1–L5 and comparison of data from radiographic images and 3D-printed models.</p