比较退行性腰骶管狭窄犬手术与非手术治疗的临床结果

K. Goh
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They were prospective and retrospective studies.\nStrength of evidence\nWeak.\nOutcomes reported\nBesides the two studies, there are no other studies currently available that directly compare long-term clinical outcome of patients that have undergone nonsurgical and surgical treatment respectively.\nIn the study comparing clinical outcome of nonsurgical treatment by epidural steroid injection (ESI) and surgical treatment of degenerative lumbosacral stenosis, dogs were classified into clinical severity groups ranging from mild to moderate to severe. Mild cases demonstrated degenerative lumbosacral stenosis (DLSS) compatible clinical signs such as lumbosacral pain, reluctance to climb stairs / jump / raise up, lameness and muscle atrophy but no neurological deficits. Moderate cases presented DLSS compatible clinical signs in combination with neurological deficits such as reduced flexor withdrawal, proprioceptive deficits and nerve root signature. Severe cases demonstrated DLSS compatible clinical signs with more severe neurological deficits such as tail paresis and absent perineal reflex. Clinical outcomes were considered complete if clinical signs had resolved at follow-up consultations, partial if there was substantial but incomplete improvement in clinical signs and failed if the dog did not improve or deteriorated further. Improvements in patient condition were measured in terms of clinical outcome grading which is in relation to the initial clinical severity group assigned to each dog. Improvement after single dose of ESI was seen in 27/32 dogs, with 17/22 (after accounting for four dogs whose owners have refused further treatment, five dogs lost to follow-up after re-check as well as one dog whose owners have opted for repeated ESI instillations) relapsing within 6 months. All 17 of these dogs that suffered a relapse after single ESI subsequently underwent surgical treatment and demonstrated improvement in clinical signs, with a complete response seen in eight dogs and a partial response seen in nine dogs.\nIn the study comparing clinical outcome of conservative treatment of exercise restriction with phenylbutazone administration and surgical treatment of degenerative lumbosacral stenosis, outcomes were classified as good in dogs that regained preoperative activity levels; acceptable in dogs with persistent abnormality or requiring continued medication though otherwise active, and poor in all other cases. Out of 16 dogs treated surgically, 11 were treated by dorsal lumbosacral laminectomy and excision of the dorsal portion of the lumbosacral disc, while the other five had additional unilateral facetectomy to decompress the seventh lumbar nerve. Out of the 11 dogs treated with dorsal lumbosacral laminectomy and excision of the dorsal portion of the lumbosacral disc, 6/11 (54.5%) of dogs were deemed to have a good outcome, while 3/11 (27.3%) of dogs were deemed to have an acceptable outcome. Out of the five dogs treated with dorsal lumbosacral laminectomy and excision of the dorsal portion of the lumbosacral disc with additional unilateral facetectomy, 3/5 (60%) of dogs were deemed to have an acceptable outcome. The outcome of conservative treatment was deemed good in 8/16 (50%) of dogs in the conservative treatment group.\nConclusion\nThere is evidence suggesting that both nonsurgical and surgical treatments can improve clinical outcomes and reduce lower back pain and neurological deficits. However, based on the current limited literature, it cannot be ascertained whether surgical treatments are more effective than nonsurgical treatments in improving long-term clinical outcomes and vice versa. In the study that tested the efficacy of epidural steroid injection, only a single dose of steroids was given in this study, making it a potential reason for the high rate of relapse following nonsurgical treatment. For surgical treatment of DLSS, the type of surgical procedure chosen would also depend on the part of the lumbosacral region which fails and leads to compression. In conclusion, randomised controlled trials that compare different forms of nonsurgical treatment with surgical treatment for dogs with DLSS caused by different underlying factors need to be conducted to properly address the PICO question.\n \nHow to apply this evidence in practice\nThe application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.\nKnowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.","PeriodicalId":257905,"journal":{"name":"Veterinary Evidence","volume":"9 1","pages":"0"},"PeriodicalIF":0.0000,"publicationDate":"2023-06-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Comparing clinical outcomes of dogs suffering from degenerative lumbosacral stenosis upon surgical or nonsurgical treatment\",\"authors\":\"K. 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Severe cases demonstrated DLSS compatible clinical signs with more severe neurological deficits such as tail paresis and absent perineal reflex. Clinical outcomes were considered complete if clinical signs had resolved at follow-up consultations, partial if there was substantial but incomplete improvement in clinical signs and failed if the dog did not improve or deteriorated further. Improvements in patient condition were measured in terms of clinical outcome grading which is in relation to the initial clinical severity group assigned to each dog. Improvement after single dose of ESI was seen in 27/32 dogs, with 17/22 (after accounting for four dogs whose owners have refused further treatment, five dogs lost to follow-up after re-check as well as one dog whose owners have opted for repeated ESI instillations) relapsing within 6 months. 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引用次数: 0

摘要

对于患有退行性腰骶管狭窄(DLSS)的狗,手术治疗是否比非手术治疗更有效地减轻腰骶疼痛和长期神经功能障碍?临床底线研究类别治疗。审查的研究设计的数量和类型对两篇论文进行了严格审查。它们是前瞻性和回顾性研究。证据强度:弱。除了这两项研究外,目前还没有其他研究直接比较分别接受非手术和手术治疗的患者的长期临床结果。在比较非手术硬膜外类固醇注射(ESI)与手术治疗退行性腰骶管狭窄的临床效果的研究中,将犬的临床严重程度分为轻、中、重度。轻度病例表现为退行性腰骶管狭窄(DLSS)相容的临床症状,如腰骶疼痛,不愿爬楼梯/跳/上升,跛行和肌肉萎缩,但无神经功能障碍。中度病例表现为DLSS相容的临床症状,并伴有屈肌退缩减轻、本体感觉缺陷和神经根特征等神经功能缺陷。严重者表现出与DLSS相容的临床症状,并伴有更严重的神经功能缺陷,如尾瘫和会阴反射缺失。如果临床症状在随访中得到解决,则认为临床结果是完整的,如果临床症状有实质性但不完全的改善,则认为临床结果是部分的,如果狗没有改善或进一步恶化,则认为临床结果是失败的。根据临床结果分级来衡量患者病情的改善,这与分配给每只狗的初始临床严重程度组有关。单次注射ESI后,有27/32的狗出现改善,其中17/22(考虑到4只狗的主人拒绝进一步治疗,5只狗在复查后失去随访,1只狗的主人选择重复注射ESI)在6个月内复发。所有17只在单次ESI后复发的狗随后接受了手术治疗,并表现出临床症状的改善,其中8只狗完全缓解,9只狗部分缓解。在比较运动限制保守治疗与苯丁酮治疗与手术治疗退行性腰骶管狭窄的临床结果的研究中,恢复术前活动水平的狗的结果被分类为良好;对于持续异常或需要持续药物治疗的狗是可以接受的,但在其他情况下是活跃的,在所有其他情况下都很差。在16只接受手术治疗的狗中,11只接受腰骶背椎板切除术和切除腰骶椎间盘背侧部分,而其他5只接受额外的单侧面切除术以减压第七腰椎神经。在接受腰骶背部椎板切除术和切除腰骶椎间盘背部部分的11只狗中,6/11(54.5%)的狗被认为有良好的结果,而3/11(27.3%)的狗被认为有一个可接受的结果。在5只接受腰骶背部椎板切除术和切除腰骶椎间盘背部部分并附加单侧面部切除术的狗中,3/5(60%)的狗被认为有可接受的结果。保守治疗组8/16(50%)犬认为保守治疗效果良好。结论有证据表明非手术和手术治疗均可改善临床结果,减轻腰痛和神经功能障碍。然而,基于目前有限的文献,无法确定手术治疗是否比非手术治疗更有效地改善长期临床结果,反之亦然。在测试硬膜外类固醇注射疗效的研究中,本研究仅给予单剂量类固醇,这可能是非手术治疗后复发率高的潜在原因。对于DLSS的手术治疗,所选择的手术类型也取决于腰骶区失败并导致压迫的部分。总之,需要进行随机对照试验,比较不同形式的非手术治疗和手术治疗对不同潜在因素导致的DLSS犬的影响,以正确解决PICO问题。如何将证据应用于实践应考虑多种因素,不限于:个人临床专业知识、患者的情况和所有者的价值观、您工作的国家、地点或诊所、您面前的个案、治疗方法和资源的可用性。 知识摘要是帮助加强或告知决策的资源。他们不会凌驾于从业者的责任或判断之上,去做对他们照顾的动物最好的事情。
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Comparing clinical outcomes of dogs suffering from degenerative lumbosacral stenosis upon surgical or nonsurgical treatment
PICO question In dogs suffering from degenerative lumbosacral stenosis (DLSS), is surgical treatment more effective than nonsurgical therapy in reducing lumbosacral pain and neurological dysfunction in the long-term?   Clinical bottom line Category of research Treatment. Number and type of study designs reviewed Two papers were critically reviewed. They were prospective and retrospective studies. Strength of evidence Weak. Outcomes reported Besides the two studies, there are no other studies currently available that directly compare long-term clinical outcome of patients that have undergone nonsurgical and surgical treatment respectively. In the study comparing clinical outcome of nonsurgical treatment by epidural steroid injection (ESI) and surgical treatment of degenerative lumbosacral stenosis, dogs were classified into clinical severity groups ranging from mild to moderate to severe. Mild cases demonstrated degenerative lumbosacral stenosis (DLSS) compatible clinical signs such as lumbosacral pain, reluctance to climb stairs / jump / raise up, lameness and muscle atrophy but no neurological deficits. Moderate cases presented DLSS compatible clinical signs in combination with neurological deficits such as reduced flexor withdrawal, proprioceptive deficits and nerve root signature. Severe cases demonstrated DLSS compatible clinical signs with more severe neurological deficits such as tail paresis and absent perineal reflex. Clinical outcomes were considered complete if clinical signs had resolved at follow-up consultations, partial if there was substantial but incomplete improvement in clinical signs and failed if the dog did not improve or deteriorated further. Improvements in patient condition were measured in terms of clinical outcome grading which is in relation to the initial clinical severity group assigned to each dog. Improvement after single dose of ESI was seen in 27/32 dogs, with 17/22 (after accounting for four dogs whose owners have refused further treatment, five dogs lost to follow-up after re-check as well as one dog whose owners have opted for repeated ESI instillations) relapsing within 6 months. All 17 of these dogs that suffered a relapse after single ESI subsequently underwent surgical treatment and demonstrated improvement in clinical signs, with a complete response seen in eight dogs and a partial response seen in nine dogs. In the study comparing clinical outcome of conservative treatment of exercise restriction with phenylbutazone administration and surgical treatment of degenerative lumbosacral stenosis, outcomes were classified as good in dogs that regained preoperative activity levels; acceptable in dogs with persistent abnormality or requiring continued medication though otherwise active, and poor in all other cases. Out of 16 dogs treated surgically, 11 were treated by dorsal lumbosacral laminectomy and excision of the dorsal portion of the lumbosacral disc, while the other five had additional unilateral facetectomy to decompress the seventh lumbar nerve. Out of the 11 dogs treated with dorsal lumbosacral laminectomy and excision of the dorsal portion of the lumbosacral disc, 6/11 (54.5%) of dogs were deemed to have a good outcome, while 3/11 (27.3%) of dogs were deemed to have an acceptable outcome. Out of the five dogs treated with dorsal lumbosacral laminectomy and excision of the dorsal portion of the lumbosacral disc with additional unilateral facetectomy, 3/5 (60%) of dogs were deemed to have an acceptable outcome. The outcome of conservative treatment was deemed good in 8/16 (50%) of dogs in the conservative treatment group. Conclusion There is evidence suggesting that both nonsurgical and surgical treatments can improve clinical outcomes and reduce lower back pain and neurological deficits. However, based on the current limited literature, it cannot be ascertained whether surgical treatments are more effective than nonsurgical treatments in improving long-term clinical outcomes and vice versa. In the study that tested the efficacy of epidural steroid injection, only a single dose of steroids was given in this study, making it a potential reason for the high rate of relapse following nonsurgical treatment. For surgical treatment of DLSS, the type of surgical procedure chosen would also depend on the part of the lumbosacral region which fails and leads to compression. In conclusion, randomised controlled trials that compare different forms of nonsurgical treatment with surgical treatment for dogs with DLSS caused by different underlying factors need to be conducted to properly address the PICO question.   How to apply this evidence in practice The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources. Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.
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