Journal List > J Korean Soc Spine Surg > v.26(Suppl 1) > 1142100

Kim, Ahn, Seo, Kim, and Kim: The Evidence for Nonoperative Treatment of Lumbar Spinal Diseases

Abstract

Study Design

Review article.

Objectives

To assess the evidence for nonoperative treatment of various degenerative spinal degenerative diseases.

Summary of Literature Review

No study has yet evaluated the evidence for preoperative nonoperative treatment of lumbar spinal diseases.

Methods

The evidence regarding nonoperative treatment for each disease was reviewed through NASS guidelines, and the treatment effect compared to surgical treatment was reviewed through the SPORT series. The efficacy of nonoperative treatment according to disease severity and certain special conditions was investigated through corresponding individual articles.

Results

No kind of nonoperative treatment could change the fundamental progression of degenerative spinal disease. The natural course of lumbar disc herniation is favorable regardless of treatment. More than 70% of routine cases improve within 6 weeks. However, it does not take a full 6 weeks to decide whether to perform surgery or not. The evidence for transforaminal epidural steroid injections for short-term pain control is grade A. There is grade B evidence for nonoperative treatment with the goal of mid- to long-term pain control. However, we cannot say that those outcomes are better than the natural course of the disease itself. In cases of radicular weakness, the degree of weakness is correlated with the final outcomes, but it is not evident whether the duration of weakness is correlated with surgical outcomes. Early surgery is usually necessary due to intolerable pain, rather than stable motor weakness. The social cost of herniated discs arises from the loss of patients’ productivity, rather than from direct medical expenses. The natural course of spinal stenosis involves provoked pain and the need for palliative care. Unlike disc herniation, rapid deterioration and marked improvement do not occur. The symptoms of mild to moderate lumbar stenosis are unchanged in 70% of cases, improve in 15%, and worsen in 15%. No study has compared nonoperative treatment with the natural course of the disease. There is no evidence for nonoperative treatment of severe stenosis. Epidural spinal injections are effective for controlling short-term pain. Spontaneous recovery of radicular weakness does not occur, and urgent surgery is necessary in such cases. There is no evidence regarding the natural course and nonoperative treatment of degenerative spondylolisthesis. The working group consensus recommends that it should follow the pattern of nonoperative treatment of spinal stenosis when radicular stenosis symptoms are predominant. Overall, 40%-66% of cases of adult bilateral isthmic spondylolysis progress to symptomatic spondylolisthesis. No studies have investigated nonoperative treatment except physical exercise.

Conclusions

Although short-term symptom amelioration can be achieved by nonoperative treatment, the fundamental progression of the disease is not affected. For conditions excluded from most studies, such as prior spine surgery, cauda equina syndrome, progressive neurological deficit, and uncontrollable severe pain associated with instability, deformity, or vertebral fractures, there were not enough studies to reach informed conclusions. Our review found no evidence regarding nonoperative treatment for such conditions. Furthermore, the treatment methods for each disease are not clearly distinguished from each other, and the techniques used for disc herniation have been applied to other diseases without any evidence.

REFERENCES

1. Roelofs PD, Deyo RA, Koes BW, et al. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev. 2008 Jan 23; 1:): DOI: 10.1097/BRS.0b013e31817e69d3.
crossref
2. Valat JP, Genevay S, Marty M, et al. Sciatica. Best Pract Res Clin Rheumatol. 2010 Apr; 24(2):241–52. DOI: 10.1016/j.berh.2009.11.005.
crossref
3. Luijsterburg PA, Verhagen AP, Ostelo RW, et al. Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. Eur Spine J. 2007 Jul; 16(7):881–99. DOI: 10.1007/s00586-007-0367-1.
crossref
4. Piperno M, Hellio le Graverand MP, Reboul P, et al. Phospholipase A2 activity in herniated lumbar discs. Clinical cor-relations and inhibition by piroxicam. Spine (Phila Pa 1976). 1997 Sep 15; 22(18):2061–5. DOI: 10.1097/00007632-199709150-00001.
5. Gronblad M, Virri J, Ronkko S, et al. A controlled bio-chemical and immunohistochemical study of human sy-novial-type (group II) phospholipase A2 and inflammatory cells in macroscopically normal, degenerated, and herniated human lumbar disc tissues. Spine (Phila Pa 1976). 1996 Nov 15; 21(22):2531–8. DOI: 10.1097/00007632-199611150-00001.
6. Kawakami M, Tamaki T, Hayashi N, et al. Possible mech-anism of painful radiculopathy in lumbar disc herniation. Clin Orthop Relat Res. 1998 Jun; 351:241–51.
crossref
7. Ozaktay AC, Cavanaugh JM, Asik I, et al. Dorsal root sensitivity to interleukin-1 beta, interleukin-6 and tumor necrosis factor in rats. Eur Spine J. 2002 Oct; 11(5):467–75. DOI: 10.1007/s00586-002-0430-x.
8. Madigan L, Vaccaro AR, Spector LR, et al. Management of symptomatic lumbar degenerative disk disease. J Am Acad Orthop Surg. 2009 Feb; 17(2):102–11.
crossref
9. Jamison RN, Raymond SA, Slawsby EA, Nedeljkovic SS, Katz NP. Opioid therapy for chronic noncancer back pain. A randomized prospective study. Spine (Phila Pa 1976). 1998 Dec; 23:2591–600. DOI: 10.1097/00007632-199812010-00014.
10. Yaksi A, Ozgonenel L, Ozgonenel B. The efficiency of gabapentin therapy in patients with lumbar spinal stenosis. Spine (Phila Pa 1976). 2007 Apr; 32:939–42. DOI: 10.1097/01.brs.0000261029.29170.e6.
crossref
11. Skljarevski V, Desaiah D, Liu-Seifert H, et al. Efficacy and safety of duloxetine in patients with chronic low back pain. Spine (Phila Pa 1976). 2010 Jun; 35:E578–85. DOI: 10.1097/BRS.0b013e3181d3cef6.
crossref
12. Krause M, Refshauge KM, Dessen M, et al. Lumbar spine traction: evaluation of effects and recommended application for treatment. Man Ther. 2000 May; 5(2):72–81. DOI: 10.1054/math.2000.0235.
crossref
13. van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006 March; 15(2 Suppl):S169–91. DOI: 10.1007/s00586-006-1071-2.
crossref
14. Wegner I, Widyahening IS, van Tulder MW, et al. Traction for low-back pain with or without sciatica. Cochrane Database Syst Rev. 2013 Aug 19; 8:). DOI: 10.1002/14651858. CD003010.pub5.
crossref
15. Onel D, Tuzlaci M, Sari H, et al. Computed tomographic investigation of the effect of traction on lumbar disc herniations. Spine (Phila Pa 1976). 1989 Jan; 14(1):82–90. DOI: 10.1097/00007632-198901000-00017.
crossref
16. Blomberg S: A new pragmatic management strategy for low-back pain-An integrated multimodal programme. Textbook of Musculoskeletal Medicine;2005.
17. Beurskens AJ, de Vet HC, Koke AJ, et al. Efficacy of traction for nonspecific low back pain: a randomised clinical trial. Lancet. 1995 Dec 16; 346(8990):1596–600. DOI: 10.1016/s0140-6736 (95)91930-9.
crossref
18. Shekelle PG. Spinal manipulation. Spine (Phila Pa 1976). 1994 Apr 1; 19(7):858–61. DOI: 10.1097/00007632-199404000-00026.
19. Jayson MI, Sims-Williams H, Young S, Baddeley H, et al. Mobilization and manipulation for low-back pain. Spine (Phila Pa 1976). 1981 Jul-Aug; 6(4):409–6. DOI: 10.1097/00007632-198107000-00012.
crossref
20. Wilder DG, Pope MH, Frymoyer JW. The biomechanics of lumbar disc herniation and the effect of overload and instability. Journal of spinal disorders. 1988; 1(1):16–32.
crossref
21. Triano J. Studies on the biomechanical effect of a spinal ad-justment. Journal of manipulative and physiological thera-peutics. 1992 Jan; 15(1):71–5.
22. van Tulder M, Koes B. Low back pain and sciatica: chronic. Clinical Evidence. 2002 Jun; 7:1032.
23. Santilli V, Beghi E, Finucci S. Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Spine J. 2006 Mar-Apr; 6(2):131–7. DOI: 10.1016/j.spinee.2005.08.001.
crossref
24. McCarron RF, Wimpee MW, Hudkins PG, et al. The inflammatory effect of nucleus pulposus. A possible ele-ment in the pathogenesis of low-back pain. Spine (Phila Pa 1976). 1987 Oct; 12(8):760–4. DOI: 10.1097/00007632-198710000-00009.
25. Ng L, Chaudhary N, Sell P. The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial. Spine (Phila Pa 1976). 2005 Apr 15; 30(8):E857–62. DOI: 10.1097/01. brs.0000158878.93445.a0.
26. Winnie AP, Hartman JT, Meyers HL Jr., et al. Pain clinic. II. Intradural and extradural corticosteroids for sciatica. Anesth Analg. 1972 Nov-Dec; 51(6):990–1003.
27. Coderre TJ. Contribution of protein kinase C to central sen-sitization and persistent pain following tissue injury. Neurosci Lett. 1992 Jun 22; 140(2):181–4. DOI: 10.1016/0304-3940 (92)90097-q.
crossref
28. Johansson A, Hao J, Sjolund B. Local corticosteroid application blocks transmission in normal nociceptive C-fibres. Acta Anaesthesiol Scand. 1990 Jul; 34(5):335–8.
crossref
29. Manchikanti L, Cash KA, McManus CD, et al. Results of 2-year follow-up of a randomized, double-blind, controlled trial of fluoroscopic caudal epidural injections in central spinal stenosis. Pain Physician. 2012 Sep; 15:371–84.
30. Fukusaki M, Kobayashi I, Hara T, et al. Symptoms of spinal stenosis do not improve after epidural steroid injection. Clin J Pain. 1998 Jun; 14:148–51.
crossref
31. Yabuki S, Kikuchi S. Nerve root infiltration and sympathetic block. An experimental study of intraradicular blood flow. Spine (Phila Pa 1976). 1995 Apr 15; 20(8):901–6.
32. Takahashi K, Nomura S, Tomita K, et al. Effects of pe-ripheral nerve stimulation on the blood flow of the spinal cord and the nerve root. Spine (Phila Pa 1976). 1988 Nov; 13(11):1278–83. DOI: 10.1097/00007632-198811000-00013.
crossref
33. Kreiner DS, Shaffer WO, Baisden JL, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J. 2013 Jul; 13(7):734–43. DOI: 10.1016/j.spinee.2012.11.059.
crossref
34. Kreiner DS, Hwang SW, Easa JE, et al. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014 Jan; 14(1):180–91. DOI: 10.1016/j.spinee.2013.08.003.
35. Kreiner DS, Baisden J, Mazanec DJ, et al. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of adult isthmic spondylolisthesis. Spine J. 2016 Dec; 16(12):1478–85. DOI: 10.1016/j.spinee.2016.08.034.
crossref
36. Matz PG, Meagher RJ, Lamer T, et al. Guideline sum-mary review: An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J. 2016 Mar; 16(3):439–48. DOI: 10.1016/j.spinee.2015.11.055.
crossref
37. Rihn JA, Hilibrand AS, Radcliff K, et al. Duration of symptoms resulting from lumbar disc herniation: effect on treatment outcomes: analysis of the Spine Patient Outcomes Research Trial (SPORT). J Bone Joint Surg Am. 2011 Oct 19; 93(20):1906–14. DOI: 10.2106/JBJS.J.00878.
38. Suri P, Pearson AM, Scherer EA, et al. Recurrence of Pain After Usual Nonoperative Care for Symptomatic Lumbar Disk Herniation: Analysis of Data From the Spine Patient Outcomes Research Trial. PM R. 2016 May; 8(5):405–14. DOI: 10.1016/j.pmrj.2015.10.016.
crossref
39. Lurie JD, Tosteson TD, Tosteson AN, et al. Surgical versus nonoperative treatment for lumbar disc herniation: eight-year results for the spine patient outcomes research trial. Spine (Phila Pa 1976). 2014 Jan 1; 39(1):E3–16. DOI: 10.1097/BRS.0000000000000088.
40. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2008 Dec 1; 33(25):E2789–800. DOI: 10.1097/BRS.0b013e31818ed8f4.
41. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976). 2010 Jun 15; 35(14):E1329–38. DOI: 10.1097/BRS.0b013e3181e0f04d.
crossref
42. Weinstein JN, Lurie JD, Tosteson TD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT) observational cohort. JAMA. 2006 Nov 22; 296(20):2451–9. DOI: 10.1001/jama.296.20.2451.
43. Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006 Nov 22; 296(20):2441–50. DOI: 10.1001/jama.296.20.2441.
44. Pearson A, Lurie J, Tosteson T, et al. Who should have surgery for spinal stenosis? Treatment effect predictors in SPORT. Spine (Phila Pa 1976). 2012 Oct 1; 37(21):E1791–802. DOI: 10.1097/BRS.0b013e3182a314d0.
crossref
45. Pearson AM, Lurie JD, Tosteson TD, et al. Who should undergo surgery for degenerative spondylolisthesis? Treatment effect predictors in SPORT. Spine (Phila Pa 1976). 2013 Oct 1; 38(21):E1799–811. DOI: 10.1097/BRS.0b013e3182a314d0.
crossref
46. Finckh A, Zufferey P, Schurch MA, et al. Short-term efficacy of intravenous pulse glucocorticoids in acute disco-genic sciatica. A randomized controlled trial. Spine (Phila Pa 1976). 2006 Feb 15; 31(4):E377–81. DOI: 10.1097/01. brs.0000199917.04145.80.
crossref
47. Kasimcan O, Kaptan H. Efficacy of gabapentin for radiculopathy caused by lumbar spinal stenosis and lumbar disk hernia. Neurol Med Chir (Tokyo). 2010; 50(12):1070–3.
crossref
48. Keynan O, Mirovsky Y, Dekel S, et al. Safety and Efficacy of Dietary Agmatine Sulfate in Lumbar Disc-associated Radiculopathy. An Open-label, Dose-escalating Study Followed by a Randomized, Double-blind, Placebo-controlled Trial. Pain Med. 2010 Mar; 11(3):356–68. DOI: 10.1111/j.1526-4637.2010.00808.x.
crossref
49. Korhonen T, Karppinen J, Paimela L, et al. The treatment of disc herniation-induced sciatica with infliximab: results of a randomized, controlled, 3-month follow-up study. Spine (Phila Pa 1976). 2005 Dec 15; 30(24):E2724–8. DOI: 10.1097/01.brs.0000190815.13764.64.
50. Genevay S, Viatte S, Finckh A, et al. Adalimumab in severe and acute sciatica: a multicenter, randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2010 Aug; 62(8):2339–46. DOI: 10.1002/art.27499.
crossref
51. Thackeray A, Fritz JM, Brennan GP, et al. A pilot study ex-amining the effectiveness of physical therapy as an adjunct to selective nerve root block in the treatment of lumbar radicular pain from disk herniation: a randomized controlled trial. Phys Ther. 2010 Dec; 90(12):1717–29. DOI: 10.2522/ptj.20090260.
crossref
52. McMorland G, Suter E, Casha S, et al. Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. J Manipulative Physiol Ther. 2010 Oct; 33(8):576–84. DOI: 10.1016/j.jmpt.2010.08.013.
crossref
53. Unlu Z, Tasci S, Tarhan S, et al. Comparison of 3 physical therapy modalities for acute pain in lumbar disc herniation measured by clinical evaluation and magnetic resonance imaging. J Manipulative Physiol Ther. 2008 Mar; 31(3):191–8. DOI: 10.1016/j.jmpt.2008.02.001.
crossref
54. Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med. 2010 Aug; 11(8):1149–68. DOI: 10.1111/j.1526-4637.2010.00908.x.
crossref
55. Patel N, Re , Karppinen J, et al. Periradicular infiltration for sciatica. A randomized controlled trial. Spine 26, 1059–1067: 2001. Spine (Phila Pa 1976). 2002 Jul 15; 27(14):1588–9. author reply 1588-9. DOI: 10.1097/00007632-200207150-00025.
56. Vad VB, Bhat AL, Lutz GE, et al. Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine (Phila Pa 1976). 2002 Jan 1; 27(1):11–16. DOI: 10.1097/00007632-200201010-00005.
57. Manchkanti L, Singh V, Falco FJ, et al. Evaluation of the effectiveness of lumbar interlaminar epidural injections in managing chronic pain of lumbar disc herniation or ra-diculitis: a randomized, double-blind, controlled trial. Pain Physician. 2010 Jul-Aug; 13(4):343–55. DOI: 10.7150/ijms.7.124.
58. Ghahreman A, Bogduk N. Predictors of a favorable re-sponse to transforaminal injection of steroids in patients with lumbar radicular pain due to disc herniation. Pain Med. 2011 Jun; 12(6):871–9. DOI: 10.1111/j.1526-4637.2011.01116.x.
crossref
59. Choi SJ, Song JS, Kim C, et al. The use of magnetic resonance imaging to predict the clinical outcome of non-surgical treatment for lumbar intervertebral disc herniation. Korean J Radiol. 2007 Mar-Apr; 8(2):156–63. DOI: 10.3348/kjr.2007.8.2.156.
60. Nygaard OP, Kloster R, Solberg T. Duration of leg pain as a predictor of outcome after surgery for lumbar disc herniation: a prospective cohort study with 1-year follow up. J Neurosurg. 2000 Apr; 92(2 Suppl):131–4.
crossref
61. Ng LC, Sell P. Predictive value of the duration of sciatica for lumbar discectomy. A prospective cohort study. J Bone Joint Surg Br. 2004 May; 86(4):546–9.
62. Lequin MB, Verbaan D, Jacobs WC, et al. Surgery versus prolonged conservative treatment for sciatica: 5-year results of a randomised controlled trial. BMJ Open. 2013 May 28; 3(5):). DOI: 10.1136/bmjopen-2012-002534.
crossref
63. Ghahreman A, Ferch RD, Rao P, et al. Recovery of ankle dorsiflexion weakness following lumbar decompressive surgery. J Clin Neurosci. 2009 Aug; 16(8):1024–7. DOI: 10.1016/j.jocn.2008.10.017.
crossref
64. Weber H. Lumbar disc herniation. A controlled, prospective study with ten years of observation. Spine (Phila Pa 1976). 1983 Mar; 8(2):131–40.
crossref
65. Atlas SJ, Keller RB, Chang Y, et al. Surgical and nonsurgical management of sciatica secondary to a lumbar disc herniation: five-year outcomes from the Maine Lumbar Spine Study. Spine (Phila Pa 1976). 2001 May 15; 26(10):117987. DOI: 10.1097/00007632-200105150-00017.
66. Peul WC, van Houwelingen HC, van den Hout WB, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007 May 31; 356(22):2245–56. DOI: 10.1056/NEJMoa064039.
crossref
67. Hakelius A. Prognosis in sciatica. A clinical follow-up of surgical and non-surgical treatment. Acta Orthop Scand Suppl. 1970; 129:1–76.
crossref
68. Atlas SJ, Keller RB, Wu YA, et al. Long-term outcomes of surgical and nonsurgical management of sci-atica secondary to a lumbar disc herniation: 10 year results from the maine lumbar spine study. Spine (Phila Pa 1976). 2005 Apr 15; 30(8):E927–35. DOI: 10.1097/01. brs.0000158954.68522.2a.
crossref
69. Cribb GL, Jaffray DC, Cassar-Pullicino VN. Observations on the natural history of massive lumbar disc herniation. J Bone Joint Surg Br. 2007 Jun; 89(6):782–4. DOI: 10.1302/0301-620X.89B6.18712.
crossref
70. Rhee JM, Schaufele M, Abdu WA. Radiculopathy and the herniated lumbar disc. Controversies regarding pathophysi-ology and management. J Bone Joint Surg Am. 2006 Sep; 88(9):2070–80. DOI: 10.2106/00004623-20060900000023.
71. Jordan J, Konstantinou K, O'Dowd J. Herniated lumbar disc. BMJ Clin Evid 2011 Jun 28. 2011. pii. 1118.
72. Lewis R, Williams N, Matar HE, et al. The clinical effectiveness and cost-effectiveness of management strategies for sciatica: systematic review and economic model. Health Technol Assess. 2011 Nov; 15(39):1–578. DOI: 10.3310/hta15390.
crossref
73. Aono H, Iwasaki M, Ohwada T, et al. Surgical outcome of drop foot caused by degenerative lumbar diseases. Spine (Phila Pa 1976). 2007 Apr 15; 32(8):E262–6. DOI: 10.1097/01.brs.0000259922.82413.72.
crossref
74. Pearson A, Lurie J, Tosteson T, et al. Who should have surgery for an intervertebral disc herniation? Comparative effectiveness evidence from the spine patient outcomes research trial. Spine (Phila Pa 1976). 2012 Jan 15; 37(2):E140–9. DOI: 10.1097/BRS.0b013e3182276b2b.
75. Postacchini F, Giannicola G, Cinotti G. Recovery of motor deficits after microdiscectomy for lumbar disc herniation. J Bone Joint Surg Br. 2002 Sep; 84(7):1040–5.
crossref
76. Jansson KA, Nemeth G, Granath F, et al. Health-related quality of life in patients before and after surgery for a herniated lumbar disc. J Bone Joint Surg Br. 2005 Jul; 87(7):959–64. DOI: 10.1302/0301-620X.87B7.16240.
crossref
77. Macki M, Syeda S, Kerezoudis P, et al. Preoperative motor strength and time to surgery are the most important predictors of improvement in foot drop due to degenerative lumbar disease. J Neurol Sci. 2016 Feb 15; 361:133–6. DOI: 10.1016/j.jns.2015.12.035.
crossref
78. Sharma H, Lee SW, Cole AA. The management of weakness caused by lumbar and lumbosacral nerve root compression. J Bone Joint Surg Br. 2012 Nov; 94(11):1442–7. DOI: 10.1302/0301-620X.94B11.29148.
crossref
79. Nakagawa H, Kamimura M, Takahara K, et al. Optimal duration of conservative treatment for lumbar disc herniation depending on the type of herniation. J Clin Neurosci. 2007 Feb; 14(2):104–9. DOI: 10.1016/j.jocn.2006.08.001.
crossref
80. Bagley C, MacAllister M, Dosselman L, et al. Current con-cepts and recent advances in understanding and managing lumbar spine stenosis. F1000Res. 2019 Jan 31; 8:DOI: 10.12688/f1000research.16082.1.
crossref
81. Sahin F, Yilmaz F, Kotevoglu N, et al. The efficacy of physical therapy and physical therapy plus calcitonin in the treatment of lumbar spinal stenosis. Yonsei Med J. 2009 Oct 31; 50(5):683–8. DOI: 10.3349/ymj.2009.50.5.683.
crossref
82. Waikakul W, Waikakul S. Methylcobalamin as an adjuvant medication in conservative treatment of lumbar spinal stenosis. J Med Assoc Thai. 2000 Aug; 83(8):825–31.
83. Matsudaira K, Seichi A, Kunogi J, et al. The efficacy of prostaglandin E1 derivative in patients with lumbar spinal stenosis. Spine (Phila Pa 1976). 2009 Jan 15; 34(2):E115–120. DOI: 10.1097/BRS.0b013e31818f924d.
crossref
84. Goren A, Yildiz N, Topuz O, et al. Efficacy of exercise and ultrasound in patients with lumbar spinal stenosis: a prospective randomized controlled trial. Clin Rehabil. 2010 Jul; 24(7):623–31. DOI: 10.1177/0269215510367539.
crossref
85. Murphy DR, Hurwitz EL, Gregory AA, et al. A non-surgical approach to the management of lumbar spinal stenosis: a prospective observational cohort study. BMC Muscu-loskelet Disord. 2006 Feb 23; 7:16. DOI: 10.1186/1471-2474-7-16.
crossref
86. Papagelopoulos PJ, Petrou HG, Triantafyllidis PG, et al. Treatment of lumbosacral radicular pain with epidural steroid injections. Orthopedics. 2001 Feb; 24(2):145–9.
crossref
87. Cuckler JM, Bernini PA, Wiesel SW, et al. The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study. J Bone Joint Surg Am. 1986 Jun; 68(5):788–9.
crossref
88. Botwin KP, Gruber RD, Bouchlas CG, et al. Fluoroscopi-cally guided lumbar transformational epidural steroid injections in degenerative lumbar stenosis: an outcome study. Am J Phys Med Rehabil. 2002 Dec; 81(12):898–905. DOI: 10.1097/01.PHM.0000034953.43372.72.
89. Delport EG, Cucuzzella AR, Marley JK, et al. Treatment of lumbar spinal stenosis with epidural steroid injections: a retrospective outcome study. Arch Phys Med Rehabil. 2004 Mar; 85(3):479–84.
crossref
90. Hoogmartens M, Morelle P. Epidural injection in the treatment of spinal stenosis. Acta Orthop Belg. 1987; 53(3):409–11.
91. Prateepavanich P, Thanapipatsiri S, Santisatisakul P, et al. The effectiveness of lumbosacral corset in symptomatic degenerative lumbar spinal stenosis. J Med Assoc Thai. 2001 Apr; 84(4):572–6.
92. Willner S. Effect of a rigid brace on back pain. Acta Orthop Scand. 1985 Feb; 56(1):40–2.
crossref
93. Inoue M, Kitakoji H, Yano T, et al. Acupuncture Treatment for Low Back Pain and Lower Limb Symptoms-The Relation between Acupuncture or Electroacupuncture Stimulation and Sciatic Nerve Blood Flow. Evid Based Complement Alternat Med. 2008 Jun; 5(2):133–43. DOI: 10.1093/ecam/nem050.
crossref
94. Lurie JD, Tosteson TD, Tosteson A, et al. Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2015 Jan 15; 40(2):E63–76. DOI: 10.1097/BRS.0000000000000731.
95. Guigui P, Benoist M, Delecourt C, et al. Motor deficit in lumbar spinal stenosis: a retrospective study of a series of 50 patients. J Spinal Disord. 1998 Aug; 11(4):283–8.
96. Cornefjord M, Sato K, Olmarker K, et al. A model for chronic nerve root compression studies. Presentation of a porcine model for controlled, slow-onset compression with analyses of anatomic aspects, compression on-set rate, and morphologic and neurophysiologic effects. Spine (Phila Pa 1976). 1997 May 1; 22(9):946–57. DOI: 10.1097/00007632-199705010-00003.
97. Schizas C, Kulik G. Decision-making in lumbar spinal stenosis: A survey on the influence of the morphology of the dural sac. J Bone Joint Surg Br. 2012 Jan; 94(1):98–101. DOI: 10.1302/0301-620X.94B1.27420.
98. Klessinger S. Radiofrequency neurotomy for treatment of low back pain in patients with minor degenerative spondylolisthesis. Pain Physician. 2012 Jan-Feb; 15(1):E71–8.
99. Abdu WA, Sacks OA, Tosteson ANA, et al. Long-Term Results of Surgery Compared With Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis in the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976). 2018 Dec 1; 43(23):E1619–30. DOI: 10.1097/BRS.0000000000002682.
crossref
100. Fredrickson BE, Baker D, McHolick WJ, et al. The natural history of spondylolysis and spondylolisthesis. J Bone Joint Surg Am. 1984 Jun; 66(5):699–707.
crossref
101. Beutler WJ, Fredrickson BE, Murtland A, et al. The natural history of spondylolysis and spondylolisthesis: 45-year follow-up evaluation. Spine (Phila Pa 1976). 2003 May 15; 28(10):E1027–35. discussion 1035. DOI: 10.1097/01. BRS.0000061992.98108.A0.
102. Ekman P, Moller H, Hedlund R. The long-term effect of posterolateral fusion in adult isthmic spondylolisthesis: a randomized controlled study. Spine J. 2005 Jan-Feb; 5(1):36–44.
crossref
103. Moller H, Hedlund R. Surgery versus conservative management in adult isthmic spondylolisthesis–a prospective randomized study: part 1. Spine (Phila Pa 1976). 2000 Jul 1; 25(13):1711–5. DOI: 10.1097/00007632-200007010-00016.
104. Miyamoto H, Sumi M, Uno K, et al. Clinical outcome of nonoperative treatment for lumbar spinal stenosis, and predictive factors relating to prognosis, in a 5-year minimum follow-up. J Spinal Disord Tech. 2008 Dec; 21(8):563–8. DOI: 10.1097/BSD.0b013e31815d896c.
crossref
105. Simotas AC, Dorey FJ, Hansraj KK, et al Jr. Nonoperative treatment for lumbar spinal stenosis. Clinical and outcome results and a 3-year survivorship analysis. Spine (Phila Pa 1976). 2000 Jan 15; 25(2):197–203. discussions 203-194. DOI: 10.1097/00007632-200001150-00009.
106. Swezey RL. Outcomes for lumbar stenosis. J Clin Rheumatol. 1996 Jun; 2(3):129–34.
crossref
107. Tsubosaka M, Kaneyama S, Yano T, et al. The factors of deterioration in long-term clinical course of lumbar spinal canal stenosis after successful conservative treatment. J Orthop Surg Res. 2018 Sep 18; 13(1):239. DOI: 10.1186/s13018-018-0947-2.
crossref
108. Fukushima M, Oka H, Hara N, et al. Prognostic factors associated with the surgical indication for lumbar spinal stenosis patients less responsive to conservative treatments: An investigator-initiated observational cohort study. J Orthop Sci. 2017 May; 22(3):411–4. DOI: 10.1016/j.jos.2017.01.021.
109. Minamide A, Yoshida M, Maio K. The natural clinical course of lumbar spinal stenosis: a longitudinal cohort study over a minimum of 10 years. J Orthop Sci. 2013 Sep; 18(5):693–8. DOI: 10.1007/s00776-013-0435-9.
110. Tadokoro K, Miyamoto H, Sumi M, et al. The prognosis of conservative treatments for lumbar spinal stenosis: analysis of patients over 70 years of age. Spine (Phila Pa 1976). 2005 Nov 1; 30(21):E2458–63. DOI: 10.1097/01. brs.0000184692.71897.a2.
111. Kovacs FM, Urrutia G, Alarcon JD. Surgery versus conservative treatment for symptomatic lumbar spinal ste-nosis: a systematic review of randomized controlled trials. Spine (Phila Pa 1976). 2011 Sep 15; 36(20):E1335–1. DOI: 10.1097/BRS.0b013e31820c97b1.
112. Jain N, Brock JL, Phillips FM, et al. Chronic preoperative opioid use is a risk factor for increased complications, resource use, and costs after cervical fusion. Spine J. 2018 Nov; 18(11):1989–98. DOI: 10.1016/j.spinee.2018.03.015.
crossref
113. Jain N, Phillips FM, Weaver T, et al. Preoperative Chronic Opioid Therapy: A Risk Factor for Complications, Read-mission, Continued Opioid Use and Increased Costs After One- and Two-Level Posterior Lumbar Fusion. Spine (Phila Pa 1976). 2018 Oct; 43(19):1331–8. DOI: 10.1016/j.spinee.2018.03.015.
114. Bellini M, Barbieri M. Systemic effects of epidural ste-roid injections. Anaesthesiol Intensive Ther. 2013 Apr-Jun; 45(2):93–8. DOI: 10.5603/AIT.2013.0021.
crossref
115. Friedly JL, Comstock BA, Heagerty PJ, et al. Systemic effects of epidural steroid injections for spinal steno-sis. Pain. 2018 May; 159:876–83. DOI: 10.1097/j.pain.0000000000001158.
crossref
116. Gupta R, Shah M, Reese CM. Steroid induced spinal epi-dural lipomatosis–case report and review of the literature. W V Med J. 2011 Jul-Aug; 107(4):20–2.
117. Lee JW, Lee E, Lee GY, et al. Epidural steroid injection-related events requiring hospitalisation or emergency room visits among 52,935 procedures performed at a single centre. Eur Radiol. 2018 Jan; 28(1):418–27. DOI: 10.1007/s00330-017-4977-7. Epub 2017 Jul 19.
crossref
118. Shin WS, Ahn DK, Kim MJ, et al. Influence of Epidural Steroid Injection on Adrenal Function. Clin Orthop Surg. 2019 Jun; 11:183–6. DOI: 10.4055/cios.2019.11.2.183.
crossref
119. Stauber B, Ma L, Nazari R. Cardiopulmonary arrest following cervical epidural injection. Pain Physician. 2012 Mar-Apr; 15(2):147–52.
120. Parker SL, Anderson LH, Nelson T, et al. Cost-effectiveness of three treatment strategies for lumbar spinal stenosis: Conservative care, laminectomy, and the Superion interspinous spacer. Int J Spine Surg. 2015 Jul 9; 9:28. DOI: 10.14444/2028.
crossref
121. Beynon R, Hawkins J, Laing R, et al. The diagnostic utility and cost-effectiveness of selective nerve root blocks in patients considered for lumbar decompression surgery: a systematic review and economic model. Health Technol Assess. 2013 May; 17(19):1–88. v-vi. DOI: 10.3310/hta17190.
crossref

Table 1.
Level of evidence
Grade Description
A Good evidence (level I studies with consistent findings) for or against recommending intervention
B Fair evidence (level II or III studies with consistent findings) for or against recommending intervention
C Conflicting or poor quality evidence (level IV or V studies) not allowing a recommendation for or against intervention
I There is insufficient evidence to make a recommendation
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