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Bussieres A, Cancelliere C, Ammendolia C, et al. Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline. J Pain. 2021 Apr 12. pii: S1526-5900(21)00188-7. doi: 10.1016/j.jpain.2021.03.147. (Evidence-based guideline)
Abstract

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on nonsurgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. Clinical outcomes evaluated included pain, disability, quality of life, and walking capacity. The target audience for this guideline includes all clinicians, and the target patient population includes adults with LSS (congenital and/or acquired, lateral recess or central canal, with or without low back pain, with or without spondylolisthesis) causing NC. The guidelines panel developed 6 recommendations based on randomized controlled trials and 5 others based on professional consensus, summarized in 3 overarching recommendations: (Grade: statements are all conditional/weak recommendations) Recommendation 1. For patients with LSS causing NC, clinicians and patients may initially select multimodal care nonpharmacological therapies with education, advice and lifestyle changes, behavioral change techniques in conjunction with home exercise, manual therapy, and/or rehabilitation (moderate-quality evidence), traditional acupuncture on a trial basis (very low-quality evidence), and postoperative rehabilitation (supervised program of exercises and/or educational materials encouraging activity) with cognitive-behavioral therapy 12 weeks postsurgery (low-quality evidence). Recommendation 2. In patients LSS causing NC, clinicians and patients may consider a trial of serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants. (very low-quality evidence). Recommendation 3. For patients LSS causing NC, we recommend against the use of the following pharmacological therapies: nonsteroidal anti-inflammatory drugs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants, pregabalin (consensus-based), gabapentin (very low-quality), and epidural steroidal injections (high-quality evidence). PERSPECTIVE: This guideline, on the basis of a systematic review of the evidence on the nonsurgical management of lumbar spine stenosis, provides recommendations developed by a multidisciplinary expert panel. Safe and effective non-surgical management of lumbar spine stenosis should be on the basis of a plan of care tailored to the individual and the type of treatment involved, and multimodal care is recommended in most situations.

Ratings
Discipline Area Score
Rehab Clinician (OT/PT) 6 / 7
Physician 5 / 7
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Comments from MORE raters

Physician rater

Excellent review to keep.

Physician rater

The authors developed a guideline to provide clinical recommendations on nonsurgical management of patients with lumbar spinal stenosis (LSS) causing neurogenic claudication (NC). A multidisciplinary guidelines panel based recommendations on evidence from a systematic review of RCTs and systematic reviews. Recommendation 1: multimodal care nonpharmacologic therapies with education, advice, and lifestyle changes and/or rehabilitation. Recommendation 2: trial of serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants. Recommendation 3: don`t use these drugs: nonsteroidal anti-inflammatory drugs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants, pregabalin, gabapentin, and epidural steroidal injections. In conclusion, safe and effective nonsurgical management of LSS should be on the basis of a plan of care tailored to the individual and the type of treatment involved, and multimodal care is recommended in most situations.

Physician rater

The most important message is: for patients with LSS causing NC, we recommend against the use of the following pharmacologic therapies: nonsteroidal anti-inflammatory drugs, opioids, and epidural steroid injections.

Physician rater

Very interesting.

Rehab Clinician (OT/PT) rater

A robust article and discussion around the broad concepts for management of specific pathology that includes chronic pain management advice, but does not provide specific details/nuances of the best treatment in each area of recommendations.

Rehab Clinician (OT/PT) rater

It's interesting to have a breakdown of the evidence against the key research questions. The limitations of the study are well presented, allowing clinicians to make a balanced conclusion from the data presented.

Rehab Clinician (OT/PT) rater

Reinforces the value of a combined education, exercise and manual therapy approach to lumbar spinal stenosis (LSS), a valuable addition because it involves LSS with neurogenic claudication (not just back pain).

Rehab Clinician (OT/PT) rater

This gives a useful overview with the caveat through the lens of North American clinical practice.
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