title: Arguments for the choice of surgical treatments in patients with lumbar spinal stenosis - a systematic appraisal of randomized controlled trials.
abstract: BACKGROUND
  Lumbar spinal stenosis is the most common reason for spinal surgery in elderly patients. However, the surgical management of spinal stenosis is controversial. The aim of this review was to list aspects a surgeon considers when choosing a specific type of treatment.
  
  
  METHODS
  Appraisal of arguments reported in randomized controlled trials (RCTs) included in systematic reviews published or indexed in the Cochrane library studying surgical treatments in patients with spinal stenosis.
  
  
  RESULTS
  Eight out of nine RCTs listed arguments for the choice of their treatments under investigation. The argument for decompression alone was the high success rate, the argument against was a potential increase in vertebral instability. The argument for decompression and fusion without instrumentation was that it is a well-established technique with a high fusion success rate, the argument against it was that the indication for fusion in spinal stenosis has remained unclear. The argument for decompression and fusion with instrumentation was an increased fusion rate compared to decompression and fusion without instrumentation, the argument against this was that the invasive procedure is associated with more complications.
  
  
  CONCLUSIONS
  The main argument identified in this appraisal for and against decompression alone in patient with lumbar spinal stenosis was whether or not instability should be treated with (instrumented) fusion procedures. However, there is disagreement on how instability should be defined. In a first step it is important that researchers and clinicians agree on definitions for important key concepts such as instability and reoperations.
authors.affiliation: Horten Centre for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland. jakob.burgstaller@usz.ch.
authors.forename: Jakob M
authors.initials: JM
authors.lastname: Burgstaller
authors.affiliation: Department of Neurosurgery, Spine Center, Schulthess Clinic, Zürich, Switzerland. francois.porchet@kws.ch.
authors.forename: François
authors.initials: F
authors.lastname: Porchet
authors.affiliation: Horten Centre for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland. johann.steurer@usz.ch.
authors.forename: Johann
authors.initials: J
authors.lastname: Steurer
authors.affiliation: Horten Centre for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland. maria.wertli@usz.ch.
authors.forename: Maria M
authors.initials: MM
authors.lastname: Wertli
mesh_terms: D019299:Decompression, Surgical / Q000009:adverse effects; D006801:Humans; D017116:Low Back Pain / Q000209:etiology / Q000601:surgery; D008159:Lumbar Vertebrae / Q000601:surgery*; D010149:Postoperative Pain / Q000209:etiology / Q000601:surgery; D018579:Patient Selection; D011474:Prosthesis Design; D016032:Randomized Controlled Trials as Topic; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D013123:Spinal Fusion / Q000009:adverse effects / Q000295:instrumentation; D013130:Spinal Stenosis / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D016896:Treatment Outcome