Cost-effectiveness of Small Size Interarcuair Decompression Versus Extended Decompression in Patients With Intermittent Neurogenic Claudication (Size-study): a Multi-center, Double-blinded Randomized Controlled Trial
Trial Snapshot
- Phase
- Not Applicable
- Sponsor
- Erasmus Medical Center
- Enrollment
- 174
- Locations
- 1
- Primary Endpoint
- Change on the Modified Roland-Morris Disability Questionnaire
Study Overview
Brief Summary
Rationale: Minimally invasive techniques have gained popularity to decompress lumbar spinal stenosis in the elderly. However, high quality evidence based on randomised controlled trials are not available.
Objective: To investigate whether small size interarcuair decompression is more effective than conventional laminectomy in patients with intermittent neurogenic claudication caused by lumbar spinal stenosis. Study design: Double-blinded multi-centre randomised controlled trial Study population: In total 236 patients are to be included. The inclusion criteria are: subjects > 40 years of age with at least 12 weeks of complaints of intermittent neurogenic claudication based on MRI confirmed of LSS, with sufficient knowledge of the Dutch language.
Intervention: Small size interarcuair decompression versus conventional laminectomy.
Main study parameters/endpoints: Primary outcome is the Modified Roland Morris Questionnaire. Secondary outcomes are leg pain, back pain and a 6 minute walk test amongst others.
Nature and extent of the burden and risks associated with participation: based on available literature , it is believed that the risks associated with small size interarcuair decompression are no greater than that associated with a laminectomy, although these will be examined.
Detailed Description
Intermittent neurogenic claudication (INC) caused by a lumbar spinal canal stenosis (LSS) is the most frequent reason for spinal surgery in the elderly. Multiple, less invasive surgical techniques are applied without sufficient evidence for benefits for patients or society.
The classic symptoms of INC are leg pain, which can be exacerbated with prolonged walking and standing and/or lumbar extension, and is associated with back pain. Severe stenosis is common in the elderly spine with 30.4% of the population having severe stenosis. However, only 17.5% have complaints of INC.
Conservative treatment, such as physical therapy or pain medication, may give some relief of symptoms. However, surgical treatment is considered to be the gold standard for patients with INC caused by LSS. The first technique ever described to widen the lumbar spinal canal is the wide bony decompression (laminectomy), which is still a widely used technique. However, since INC is often accompanied by back pain, and this to post-operative back pain, it is hypothesized that a wide decompression is a ground for potential instability. Hence, less invasive techniques, such as interarcuair decompression, were developed and implemented.
Recent studies claim that a limited bony decompression is the new 'golden standard' therapy for patients with INC. Limited bony decompression is believed to give less muscle damage and thus a faster postoperative recovery. Furthermore, wide bony decompression (such as a laminectomy) is believed to result in lumbar instability and iatrogenic scoliosis. Performing a procedure with potential more complications in a - generally - elderly population could at least be described as doubtful. The assumption is often made that after a wide decompression recurrence of the complaints must be scarce. However, a (cost-) effectiveness study, which evaluates the effectiveness of small bony decompression compared to a 'classical' extensive bony decompression, has not been performed yet. The opinions on this matter are diverse. A laminectomy involves the removal of more bone and structures at the back of the spine which may result in longer hospitalization and loss of productivity, but it could also lead to spinal instability on the long term. However, the risk of an insufficient decompression may be higher, potentially leading to more reoperations.
By the means of this double-blinded, multi-center randomized controlled trial the investigators will determine the (cost-) effectiveness of a limited bony decompression compared to a wide bony decompression in patients with INC.
Study Design
- Study Type
- Interventional
- Allocation
- Randomized
- Intervention Model
- Parallel
- Primary Purpose
- Treatment
- Masking
- Triple (Participant, Investigator, Outcomes Assessor)
Eligibility Criteria
- Ages
- 40 Years to — (Adult, Older Adult)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •At least 12 weeks of complaints of INC
- •Magnetic resonance imaging showing LSS
- •Age >40 years of age
- •Sufficient knowledge of the Dutch language
- •Signed informed consent
Exclusion Criteria
- •History of lumbar spine surgery
- •>2 lumbar levels operation or needed discectomy
- •Degenerative spondylolisthesis > grade 1 (on a scale of 1 to 4), scoliosis or disc herniation
- •ASA-classification >3
- •Serious psychopathology
- •Pregnancy
- •Active malignancy
- •Plans to move abroad during study period
Arms & Interventions
Small size interarcuair decompression
Patients will undergo small size interarcuair decompression
Intervention: small size interarcuair decompression (Procedure)
Laminectomy
Patients will undergo laminectomy
Intervention: Laminectomy (Procedure)
Outcomes
Primary Outcomes
Change on the Modified Roland-Morris Disability Questionnaire
Time Frame: baseline, 3 weeks, 6 weeks, 12 weeks, 6 months, 12 months, 18 months, 24 months, 36 months and 48 months after surgery
This is a 24-point Dutch questionnaire that is designed to assess the physical disability in patients, due to lower back pain.
Secondary Outcomes
- Patient satisfaction(3 weeks, 6 weeks, 12 weeks, 6 months, 12 months, 18 months, 24 months, 36 months and 48 months after surgery)
- Changes on the Timed Chair-Stand-Test (TCST)(baseline, 6 months, 12 months, 24 months and 48 months after surgery)
- Change on the Numeric Rating Scale for leg pain(baseline, 3 weeks, 6 weeks, 12 weeks, 6 months, 12 months, 18 months, 24 months, 36 months and 48 months after surgery)
- Change on the Numeric Rating Scale for back pain(baseline, 3 weeks, 6 weeks, 12 weeks, 6 months, 12 months, 18 months, 24 months, 36 months and 48 months after surgery)
- Changes on the 6-minute walk test(baseline, 6 months, 12 months, 24 months and 48 months after surgery)
- Changes on the Oswestry Disability Index(baseline, 3 weeks, 6 weeks, 12 weeks, 6 months, 12 months, 18 months, 24 months, 36 months and 48 months after surgery)
- Changes on Neurological examination(baseline, 6 months, 12 months, 24 months and 48 months after surgery)
- Perceived recovery(3 weeks, 6 weeks, 12 weeks, 6 months, 12 months, 18 months, 24 months, 36 months and 48 months after surgery)
- Complications(3 weeks, 6 weeks, 12 weeks, 6 months, 12 months, 18 months, 24 months, 36 months and 48 months after surgery)
- Changes on the EuroQoL (EQ-5D)(Baseline, 3 weeks, 6 weeks, 12 weeks, 6 months, 12 months, 18 months, 24 months, 36 months and 48 months after surgery)
- Costs of treatment measured using cost questionnaires filled out by the patients(Baseline, 3 weeks, 6 weeks, 12 weeks, 6 months, 12 months, 18 months, 24 months, 36 months and 48 months after surgery)
- Changes on the SF-36(Baseline, 3 weeks, 6 weeks, 12 weeks, 6 months, 12 months, 18 months, 24 months, 36 months and 48 months after surgery)
- Changes on the timed-up and go test(baseline, 6 months, 12 months, 24 months and 48 months after surgery)
- Changes on Functional lumbar x-rays(baseline, 6 weeks)
Investigators
Pravesh S. Gadjradj
PhD-candidate
Erasmus Medical Center