An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis†

Received 11 August 2008; accepted 20 March 2009. published online 18 May 2009.

Abstract

Background Context

The objective of the North American Spine Society (NASS) evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spondylolisthesis is to provide evidence-based recommendations on key clinical questions concerning the diagnosis and treatment of degenerative lumbar spondylolisthesis. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of January 2007. The goal of the guideline recommendations is to assist the practitioner in delivering optimum, efficacious treatment of and functional recovery from this common disorder.

Purpose

To provide an evidence-based, educational tool to assist spine care providers in improving the quality and efficiency of care delivered to patients with degenerative lumbar spondylolisthesis.

Study Design

Systematic review and evidence-based clinical guideline.

Methods

This report is from the Degenerative Lumbar Spondylolisthesis Work Group of the NASS Evidence-Based Clinical Guideline Development Committee. The work group was comprised of multidisciplinary spine care specialists, all of whom were trained in the principles of evidence-based analysis. Each member participated in the development of a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subject of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology) and four additional, evidence-based, databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answer to each clinical question were arrived at via face-to-face meetings among members of the work group using standardized grades of recommendation. When Level I–IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline.

Results

Nineteen clinical questions were formulated, addressing issues of prognosis, diagnosis, and treatment of degenerative lumbar spondylolisthesis. The answers to these 19 clinical questions are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence.

Conclusions

A clinical guideline for degenerative lumbar spondylolisthesis has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to aid practitioners involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.

Keywords: Degenerative lumbar spondylolisthesis definition, Diagnosis, Imaging, Medical/interventional treatment, Surgical treatment, Outcome measures

a Bone & Joint Clinic of Houston, 6624 Fannin Street, Suite 2600, Houston, TX 77030-2338, USA

b Department of Orthopaedic Surgery, Brigham & Women's Hospital, 75 Francis Street, Boston, MA 02115-6110, USA

c Center for Diagnostic Imaging, 5775 Wayzata Boulevard, Suite 140, Saint Louis Park, MN 55416-2660, USA

d Ahwatukee Sports & Spine, 4530 E. Muirwood Drive, Suite 110, Phoenix, AZ 85048-7639, USA

e Cleveland Clinic Spine Institute, 9500 Euclid Avenue, Cleveland, OH 44195-0001, USA

f University of Kentucky, 740 S. Limestone Street, Kentucky Clinic K-416, Lexington, KY 40536-0001, USA

g Department of Neurosurgery, Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI 53226-3522, USA

h Michigan Medical, PC, 12662 Riley Street, Suite 120, Holland, MI 49424-8023, USA

i North Jersey Medical Village, 516 Hamburg Turnpike, Wayne, NJ 07470-2062, USA

j Denver Spine, 7800 E. Orchard Road, Suite 100, Greenwood Village, CO 80111-2584, USA

k Orthopaedic Department, Baylor College of Medicine, 1709 Dryden Road, Suite 1230, Houston, TX 77030-2400, USA

l 122 Via Castilla, Jupiter, FL 33458-6919, USA

m San Francisco Spine Diagnostics, 2100 Webster Street, Suite 110, San Francisco, CA 94115-2374, USA

n Department of Neurosurgery, University of Wisconsin Medical School, 600 Highland, K4/834 Clinical Science Center, Madison, WI 53792-0001, USA

o Mississippi Pain Management, One Layfair Drive, #400, Jackson, MS 39232-9717, USA

p Comprehensive Pain Medicine, 510 Corday Street, Pensacola, FL 32503-2021, USA

q 1310 Prentice Drive, Suite G, Healdsburg, CA 95448-5005, USA

Corresponding author. Bone & Joint Clinic, 6624 Fannin Street, Suite 2600, Houston, TX 77030-2312, USA. Tel.: (713) 790-1818 ext 120; fax: (713) 790-7530.

FDA device/drug status: not applicable.

Author disclosures: WCW (consultant for Stryker; member of scientific advisory board at Intrinsic Therapeutics; receives remuneration from Blackstone Medical, Inc.); CMB (receives royalties from Life Spine; consultant for Depuy Spine and Medtronic Sofamor Danek; speaker for Depuy Spine and Stryker Spine; fellowship support from Depuy Spine; grant from Stryker Spine; member of board of directors at North American Spine Society; research support from Archus Orthopedics and Synthes Spine; receives financial support from Applied Spine); GG (receives royalties and consultant for Abbott Spine; stockholder at Allez Spine and DiFusion; speaker and travel support from Stryker Spine; member of scientific advisory board at DiFusion); MHH (royalties, stockholder, consultant, member of scientific advisory board at Relievant Medsystems; research support from Department of Defense); DSK (speaker and travel support from Smith & Nephew); CO (stockholder at Relievant and Nocimed; consultant for SpineView, ISTO, and Alleva; member of scientific advisory board at Relievant); DKR (consultant for medtronic); WOS (consultant for DePuy Spine; travel support from BrainLab; royalties from Depuy Spine).

† This review article summarizes a published evidence-based guideline, and as such it followed an expedited peer-review process. It was evaluated for format by the Special Features Editor and Editor-in-Chief before being accepted for publication in The Spine Journal.

PII: S1529-9430(09)00151-X

doi:10.1016/j.spinee.2009.03.016

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