title: Effectiveness of surgery for lumbar spinal stenosis: a systematic review and meta-analysis.
abstract: BACKGROUND
  The management of spinal stenosis by surgery has increased rapidly in the past two decades, however, there is still controversy regarding the efficacy of surgery for this condition. Our aim was to investigate the efficacy and comparative effectiveness of surgery in the management of patients with lumbar spinal stenosis.
  
  
  METHODS
  Electronic searches were performed on MEDLINE, EMBASE, AMED, CINAHL, Web of Science, LILACS and Cochrane Library from inception to November 2014. Hand searches were conducted on included articles and relevant reviews. We included randomised controlled trials evaluating surgery compared to no treatment, placebo/sham, or to another surgical technique in patients with lumbar spinal stenosis. Primary outcome measures were pain, disability, recovery and quality of life. The PEDro scale was used for risk of bias assessment. Data were pooled with a random-effects model, and the GRADE approach was used to summarise conclusions.
  
  
  RESULTS
  Nineteen published reports (17 trials) were included. No trials were identified comparing surgery to no treatment or placebo/sham. Pooling revealed that decompression plus fusion is not superior to decompression alone for pain (mean difference -3.7, 95% confidence interval -15.6 to 8.1), disability (mean difference 9.8, 95% confidence interval -9.4 to 28.9), or walking ability (risk ratio 0.9, 95% confidence interval 0.4 to 1.9). Interspinous process spacer devices are slightly more effective than decompression plus fusion for disability (mean difference 5.7, 95% confidence interval 1.3 to 10.0), but they resulted in significantly higher reoperation rates when compared to decompression alone (28% v 7%, P < 0.001). There are no differences in the effectiveness between other surgical techniques for our main outcomes.
  
  
  CONCLUSIONS
  The relative efficacy of various surgical options for treatment of spinal stenosis remains uncertain. Decompression plus fusion is not more effective than decompression alone. Interspinous process spacer devices result in higher reoperation rates than bony decompression.
authors.affiliation: The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
authors.forename: Gustavo C
authors.initials: GC
authors.lastname: Machado
authors.affiliation: Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia.
authors.forename: Paulo H
authors.initials: PH
authors.lastname: Ferreira
authors.affiliation: South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, University of New South Wales, Sydney, NSW, Australia.
authors.forename: Ian A
authors.initials: IA
authors.lastname: Harris
authors.affiliation: Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia.
authors.forename: Marina B
authors.initials: MB
authors.lastname: Pinheiro
authors.affiliation: Department of General Practice, Erasmus Medical Centre, Rotterdam, The Netherlands.
authors.forename: Bart W
authors.initials: BW
authors.lastname: Koes
authors.affiliation: Department of Health Sciences, VU University, Amsterdam, The Netherlands.
authors.forename: Maurits
authors.initials: M
authors.lastname: van Tulder
authors.affiliation: The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
authors.forename: Magdalena
authors.initials: M
authors.lastname: Rzewuska
authors.affiliation: The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
authors.forename: Chris G
authors.initials: CG
authors.lastname: Maher
authors.affiliation: The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Institute of Bone and Joint Research, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
authors.forename: Manuela L
authors.initials: ML
authors.lastname: Ferreira
mesh_terms: D006801:Humans; D008159:Lumbar Vertebrae / Q000601:surgery*; D012086:Reoperation; D013130:Spinal Stenosis / Q000601:surgery*; D016896:Treatment Outcome
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