ebs footdrop surgery
TRANSCRIPT
EBS: Foot drop from lumbar spondylosis and outcomes after decompressive surgery
Anthony ChauAug 2015
Background
• ED referral: 44M electrician with 1 week of severe right-sided L5 radiculopathy after lifting, and 3/5 weakness ankle DF
• ED CT demonstrates L4/5 posterolateral disc protrusion
PICO question (1)
• P: adults with foot drop secondary to degenerative lumbar disc disease
• I: decompressive surgery• C: nil• O: improvement in neurological function
QUESTION:“What is the outcome of and how urgent is decompressive
surgery for patients with foot drop secondary to degenerative lumbar spondylosis”
Search Criteria
• Incl: RCTs, case series– Due to lumbar disc disease
• Excl: reviews, case reports– Foot drop from other surgical causes: e.g.
common peroneal nerve entrapment– Foot drop due to all medical causes
Strategy - Sources
• Databases– Medline (via OVID)– Cochrane CENTRAL
• Hand searching – Scopus bibliographies/ citation history check– Google screening
MeSH terms
CENTRAL database
Medline (1)
Medline (2)
Medline (3)
Medline (4)
PRISMA flow chartMedline 28 articlesCENTRAL 0 articles
Google 1 articleScopus cross reference 7 articles
36 abstracts reviewed
13 full text articles retrieved
Excluded: 23- Irrelevant: 22- Review article: 1
Excluded: 2-Irrelevant : 2
11 articles for qualitative review
0 articles for quantitative review
Results – Study summaries (2)Study, country Study Design Definition
foot dropIntervention
Knutsson 1962, Sweden Retrospective DF weakness Discectomy
Jonsson 1995, Sweden Prospective MRS<3/5 Discectomy; laminectomy
Guigui 1998France
Retrospective MRS <4/5 Decompression
Girardi 2002 USA Retrospective MRS <5/5 Microdiscectomy (HNP); laminectomy +/- fusion
Postacchini 2002, Italy Prospective MRS <5/5 Microdiscectomy
Aono 2007, Japan Retrospective MRS <3/5 Microdiscectomy; laminectomy
Ghahreman 2009, Australia
Retrospective MRS <3/5 Decompression
Iizuka 2009, Japan Retrospective MRS <4/5 Microdiscectomy (HNP); laminectomy +/- PLF (SCS)
Bhargava 2012, UK Retrospective MRS <4/5 Microdiscectomy; laminectomy
Liu 2013, China Retrospective MRS <4/5 Microdiscectomy; laminectomy
Aono 2014, Japan Retrospective MRS <3/5 Microdiscectomy; laminectomy
Results – Study summaries (1)Study, country
n Age (y)
Aetiology Duration preop Sx Mean (range)
F/u Postop Improve
Positive association for Improvement
No association for Improvement
Knutsson 1962 Sweden
123
NS HNP 1-10 mo 1 yr 74% Preop weakness -
Jonson 1995 Sweden
35 50 HNP, spinal canal stenosis
Not specified 24 mo 63% Aetiology HNP> lateral stenosis> central canal stenosis
Duration of preop sx, age
Guigui 1998 France
50 65 HNP, spinal canal stenosis
<3, 3-6, 6-12 >12 wks
38 80% Duration of preop sx, aetiology HNP> canal stenosis
Preop weakness, cauda equina, spondylolisthesis
Girardi 2002 USA
55 47 HNP, spinal canal stenosis
110 days (6 days – 2.5 yrs)
36 98% - Duration of preop sx, preop weakness, aetiology, age
Postacchini 2002, Italy
116
49 HNP Not specified >6 mo 84% Inverse relation to duration of preop sx and preop weakness
Age
Aono 2007Japan
46 57 HNP, spinal canal stenosis
97 days 2-9 yrs
61% Duration of preop sx, preop weakness
-
Ghahreman 2009 Australia
34 51 HNP, spinal canal stenosis
14 days (1-180)
24 mo 27% complete
Preop weakness, age Duration of preop sx
Iizuka 2009 Japan
28 55 HNP, spinal canal stenosis
3 wks (1-52) 6-60 mo
54% Preop weakness (p<0.05), and HNP aetiology (p=0.011)
Duration of preop sx
Bhargava 2012 UK
26 48 HNP, spinal canal stenosis
<4, 4-6, >6 wks >6 mo 88% Duration of preop sx (p=0.019) -
Liu 2013 China
135
55 HNP, spinal canal stenosis
186 days (14-365)
2-3 yrs
84% Duration of preop sx (p=0.04), preop weakness (p=0.003) and age (p=0.03)
-
Aono 2014 Japan
21 52 Painless foot drop from HNP, spinal canal stenosis
129 days (15-700)
2-9 yrs
65% Duration of preop sx main prognostic factor (p=0.03). No diff HNP for SCS, radiculopathy vs CES, single vs multilevel
-
Weaknesses of search strategy
• Only looked for foot drop studies– May have missed large lumbar surgery studies
with subset analysis of patients with foot drop• Only case series identified in the literature – Heterogeneous population and interventions
Conclusions
• Disagreement in the literature regarding the urgency of surgical decompression in lumbar spondylotic foot drop– But very heterogeneous population– Probably ‘case by case’ decision-making required
• Some form of neurological improvement can be expected in the majority of cases