Prediction of long-term clinical outcome in patients with lumbar spinal stenosis

PURPOSE

The natural course of lumbar spinal stenosis (LSS) fluctuates and is not necessarily progressive. The aim of this study was to explore the predictors of clinical outcome in patients with LSS that might eventually help to optimise the therapeutic choices.

METHODS

A group of 56 patients (27 men, 29 women, median age 55; range 31-72 years) with clinically symptomatic mild-to-moderate LSS were re-examined after a median period of 88 months and their clinical outcomes classified as satisfactory (34 patients, 60.7 % with stable or improved clinical status) or unsatisfactory (22 patients, 39.3 % for whom clinical status deteriorated). A wide range of demographical, clinical, imaging and electrophysiological entry parameters were evaluated as possible predictors of clinical outcome.

RESULTS

Unlike the demographical, clinical and imaging variables, certain electrophysiological parameters were significantly associated with unsatisfactory outcomes. There was a significantly higher prevalence of pluriradicular involvement detected by EMG in patients with unsatisfactory outcome than those with satisfactory outcome (68.2 vs. 32.3 %; p = 0.035). Patients with unsatisfactory outcome had more frequent bilateral abnormalities of the soleus H-reflex (50.0 vs. 14.7 %; p = 0.015) and lower mean H-reflex amplitude. Multivariate logistic regression proposed two variables as mutually independent predictors of unsatisfactory outcome: EMG signs of pluriradicular involvement (OR = 3.72) and averaged soleus H-reflex amplitude ≤ 2.8 mV (OR = 2.87).

CONCLUSIONS

Satisfactory outcomes were disclosed in about 61 % of the patients with mild-to-moderate LSS in a 7-year follow-up. Electrophysiological abnormalities, namely the presence of pluriradicular involvement and abnormalities of the soleus H-reflex, were predictive of deterioration of clinical status in these patients.

Low back pain: an assessment using positional MRI and MDT

Current guidelines advise against the use of routine imaging for low back pain. Positional MRI can provide enhanced assessment of the lumbar spine in functionally loaded positions which are often relevant to the presenting clinical symptoms. The purpose of this case report is to highlight the use of positional MRI in the assessment and classification of a subject with low back pain. A low back pain subject underwent a Mechanical Diagnosis and Therapy (MDT) assessment and positional MRI scan of the lumbar spine. The MDT assessment classified the subject as "other" since the subjective history indicated a possible posterior derangement whilst the objective assessment indicated a possible anterior derangement. Positional MRI scanning in flexed, upright and extended sitting postures confirmed the MDT assessment findings to reveal a dynamic spinal stenosis which reduced in flexion and increased in extension.

[Lumbar spinal stenosis: clinical course, pathophysiology and treatment]

The lumbar spinal stenosis is a radiological description of a pathology that can present clinically by a neurogenic intermittent claudication; its diagnosis is mainly clinical. After listing the main criteria allowing the clinician to make a diagnosis, a review of available treatments is proposed. There are few quality studies and an empirical approach is often necessary. In severe cases, very disabling despite correct treatment, a surgical approach may be considered and discussed with the patient to avoid failure, sometimes linked to excessive expectations.

[Treatment of lumbar spinal stenosis in the elder by micro-endoscopic discectomy]

OBJECTIVE

To explore the clinical effects of micro-endoscopic discectomy(MED) in treatment of lumbar spinal stenosis in the elder.

METHODS

The data of 376 cases of the lumbar spinal stenosis were treated by MED from December 2003 to December 2009, 47 cases of them aged above 60 years old. Of them, 43 old patients were followed up for 3 months to 6 years. There were 27 males and 16 females,with an average age of 68.3 years old ranging from 60 to 91 years. The average age was 68.3 years. The course was from 3 months to 15 years (averaged 3.5 years). The clinical effects of postoperation were observed and evaluated according to Nakai standard.

RESULTS

Forty-three patients were followed up for 3 months to 6 years. The incision of all the patients had no infection and achieved primary healing. The clinical effect of the patients were evaluated by Nakai standard. The results were excellent in 26 cases,good in 12,fair in 5.

CONCLUSION

MED has characteristics of less injury,fast recovery and thorough decompression to nerve roots. It is a kind of good method for treating lumbar spinal stenosis in the elder if the indication were grasped strictly.

[Spinal fusion combined with dynamic interspinous fixation with Coflex system for lumbar degenerative disease]

OBJECTIVE

To summarize the effect of the implantation of Coflex interspious stabilization device combined with pinal fusion for the treatment of lumbar degenerative disease. METHODS; From March 2008 to March 2010, 18 patients with two levels lumbar degenerative disease were treated with spinal fusion and dynamic interspinous fixation with Coflex system. There were 11 males and 7 females. The average age was 50.2 years (range 41 to 62 years). The VAS and the Oswestry Disability Index (ODI) were used to assess clinical symptoms preoperatively and postoperatively. All patients underwent flexion/extension radiographs examinations before surgery and at last follow-up. Range of motion (ROM) and disc height index (DHI) were recorded.

RESULTS

All patients were followed up for 12 months averagely (range 6-30 months). At final follow-up, leg VAS, back VAS and ODI functional score were significant improved than those of preoperation [back VAS: 1.50 +/- 0.90 vs 7.20 +/- 0.90; leg VAS: 1.10 +/- 0.80 vs 5.20 +/- 0.90; ODI functional score: (15.90 +/- 5.80)% vs (52.50 +/- 5.90)%]. The DHI increased from 0.23 +/- 0.05 preoperatively to 0.35 +/- 0.06 postoperatively and to 0.33 +/- 0.04 at final follow-up, the height of intervertebral space were not found significant loss. The ROM at the Coflex stabilized levels on the X-ray views was (8.90 +/- 1.80) degrees preoperatively, (8.30 +/- 1.90) degrees postoperatively, and (8.10 +/- 1.80) degrees at final follow-up. There was no significant difference between final follow-up and preoperative (P = 0.19). The ROM of the lumbar spine (L2-S1) was (20.20 +/- 5.60) degrees preoperatively, (14.40 +/- 5.70) degrees postoperatively, and (15.50 +/- 5.20) degrees at final follow-up. There was significant reduction of the [E-S, ROM at final follow-up (P = 0.01).

CONCLUSION

Posterior interspinous stabilization with Coflex system combined with spinal fusion can obtain satisfactory outcomes for patients with two levels lumbar degenerative disease in the short follow-up duration. Nevertheless,no overwhelming evidence suggested that the system is better than traditional fusion at present. The selection of surgical indication is important for the treatment of lumbar degenerative disease.

Lumbar spinal stenosis-diagnosis and management of the aging spine

Low back pain and lumbar spinal stenosis (LSS) is an extensive problem in the elderly presenting with pain, disability, fall risk and depression. The incidence of LSS is projected to continue to grow as the population ages. In light of the risks, costs and lack of long-term results associated with surgery, and the positive outcomes in studies utilizing physical therapy interventions for the LSS patient, a non-invasive approach is recommended as a first line of intervention. This Masterclass presents an overview of LSS in terms of clinical examination, diagnosis, and intervention. A focused management approach to the patient with LSS is put forward that emphasizes a defined four-fold approach of patient education, manual physical therapy, mobility and strengthening exercises, and aerobic conditioning.

Biomechanical comparison of an interspinous device and a rigid stabilization on lumbar adjacent segment range of motion

PURPOSE OF THE STUDY

Decompression surgery with or without fusion is the gold standard treatment of lumbar spinal stenosis, but adjacent segment degeneration has been reported as a long-term complication after fusion. This led to the development of dynamic implants like the interspinous devices. They are supposed to limit extension and expand the spinal canal at the symptomatic level, but with reduced effect on the range of motion of the adjacent segments. The aim of the present study is the evaluation of the biomechanical effects on the range of motion (ROM) of adjacent lumbar segments after decompression and instrumentation with an interspinous device compared to a rigid posterior stabilization device.

MATERIALS AND METHODS

Eight fresh frozen human cadaver lumbar spines (L2-L5) were tested in a spinal testing device with a moment of 7.5 Nm in flexion/extension, lateral bending and rotation with and without a preload. The preload was applied as a follower load of 400N along the curvature of the spine. The range of motion (ROM) of the adjacent segments L2/L3 and L4/L5 was measured with the intact segment L3/L4, after decompression, consisting of resection of the interspinous ligament, flavectomy and bilateral medial facetecomy, and insertion of the Coflex® (Paradigm Spine, Wurmlingen) and after instrumentation with Click X® (Synthes, Umkirch) as well.

RESULTS

The interspinous and the rigid device caused a significant increase of ROM at both adjacent segments during all directions of motion and under follower load, without significant difference between these devices. The ROM of L2/L3 tends to increase more than the ROM of L4/L5 after instrumentation without statistical significance.

DISCUSSION

The "dynamic" Coflex device caused a significant increase of ROM at both adjacent lumbar segments comparable to the increase of ROM after instrumentation with the rigid Click X device. Other in vitro studies observed comparable biomechanical effects on the adjacent segments after fusion, but biomechanical spacer studies concentrated on the "noncompressible" X-Stop® and could not demonstrate a significant adjacent segment effect of this device.

CONCLUSIONS

The hypothesis, that an interspinous device would reduce the stress on adjacent segments compared to a rigid posterior stabilization device, could not be demonstrated with this biomechanical in vitro study. Therefore, the protection of adjacent segments after instrumentation with dynamic devices is still not completely achieved.

Case reports: Painful limbs/moving extremities: report of two cases

BACKGROUND

Painful limbs/moving extremities is a relatively rare condition characterized by aching pain in one limb and involuntary movement in the affected fingers or toes. Its pathomechanism is unknown. We report two patients with painful limbs/moving extremities. In one patient with a painful arm and moving fingers, the symptoms were resolved after surgery.

CASE DESCRIPTIONS

Patient 1 was a 36-year-old man with a painful arm and moving fingers. Treatment with administration of analgesics was not effective. Postmyelographic CT showed stenosis of the right C5/C6 foramen attributable to cervical spondylosis and a defect of the contrast material at the foramen. He was treated with cervical foraminotomy. Patient 2 was a 26-year-old woman with a painful leg and moving toes. The pain and involuntary movement appeared 2 weeks after discectomy at L5/S1. Lumbar MRI and myelography showed no indications of nerve root compression. She was treated with a lumbar nerve root block. The pain and involuntary movement completely disappeared in both patients after treatment.

LITERATURE REVIEW

Numerous studies report treatments for painful limbs/moving extremities, but few report successful treatment. Recently, botulinum toxin A injection and epidural spinal cord stimulation have been used and are thought to benefit this condition. Successful surgical treatment previously was reported for only one patient.

PURPOSES AND CLINICAL RELEVANCE

If imaging indicates compression of nerve tissue, we believe surgical decompression should be considered for patients with painful limbs/moving extremities who do not respond to nonoperative treatment.

Injection treatment and back pain associated with degenerative lumbar spinal stenosis in older adults

BACKGROUND

Lower back pain is one of the most common health-related complaints in the adult population. Thirty percent of Americans 65 years and older reported symptoms of lower back pain in 2004 (NCHS, 2006). Injection treatment is a commonly used non-surgical procedure to alleviate lower back pain in older adults. However, the effectiveness of injection treatment, particularly in older adults, has not been well documented.

OBJECTIVE

This study quantified the effectiveness of injection treatment on pain relief among adults 60 years and over who were diagnosed with degenerative lumbar spinal stenosis, a common cause of lower back pain in older adults. The variations of the effectiveness were examined by selected patient attributes.

STUDY DESIGN

Prospective, non-randomized, observational human study.

SETTING

Single institution spine clinic.

METHODS

Patients scheduled for lumbar injection treatment between January 1 and July 1, 2008 were prospectively selected from the study spine clinic. Selection criteria included patients age 60 and over, diagnosed with degenerative lumbar spinal stenosis and no previous lumbar injection within 6 months or lumbar surgery within 2 years. The pain sub-score of the SF-36 questionnaire was used to measure pain at baseline and at one and 3 months post injection. Variations in longitudinal changes in pain scores by patient characteristics were analyzed in both unadjusted (univariate) analyses using one-way analysis of variance (ANOVA), and adjusted (multiple regression) analyses using linear mixed effects models.

LIMITATIONS

This study is limited by its sample size and observational design.

RESULTS

Of 62 patients receiving epidural steroid injections, the mean Pain score at baseline was 27.4 (SD =13.6), 41.7 (SD = 22.0) at one month and 35.8 (SD = 19.0) at 3 months. Mean Pain scores improved significantly from baseline to one month (14.1 points), and from baseline to 3 months (8.3 points). Post injection changes in pain scores varied by body mass index (BMI) and baseline emotional health. Based on a linear mixed effects model analysis, higher baseline emotional health, as measured by the SF-36 Mental Component Score (MCS >/= 50), was associated with greater reduction in pain over 3 months when compared to lower emotional health (MCS), was associated with greater reduction in pain over 3 months when compared to lower emotional health (MCS <50). In patients with higher emotional health, pain scores improved by 14.1 (P < .05: 95% CI 6.9, 21.3). Patients who were obese also showed significant improvement in pain scores over 3 months compared to non-obese patients. In obese patients, pain scores increased by 7.9 (P <.05; 95% CI:1.0, 14.8) points.

CONCLUSION

Lower back pain in older adults with degenerative lumbar spinal stenosis might be clinically significantly alleviated after injection treatment. Pain relief varies by a patients personal and clinical characteristics. Healthier emotional status and obesity appears to be associated with more pain relief experienced over 3 months following injection.

The Felix-trial. Double-blind randomization of interspinous implant or bony decompression for treatment of spinal stenosis related intermittent neurogenic claudication

BACKGROUND

Decompressive laminotomy is the standard surgical procedure in the treatment of patients with canal stenosis related intermittent neurogenic claudication. New techniques, such as interspinous process implants, claim a shorter hospital stay, less post-operative pain and equal long-term functional outcome. A comparative (cost-) effectiveness study has not been performed yet. This protocol describes the design of a randomized controlled trial (RCT) on (cost-) effectiveness of the use of interspinous process implants versus conventional decompression surgery in patients with lumbar spinal stenosis.

METHODS/DESIGN

Patients (age 40-85) presenting with intermittent neurogenic claudication due to lumbar spinal stenosis lasting more than 3 months refractory to conservative treatment, are included. Randomization into interspinous implant surgery versus bony decompression surgery will take place in the operating room after induction of anesthesia. The primary outcome measure is the functional assessment of the patient measured by the Zurich Claudication Questionnaire (ZCQ), at 8 weeks and 1 year after surgery. Other outcome parameters include perceived recovery, leg and back pain, incidence of re-operations, complications, quality of life, medical consumption, absenteeism and costs. The study is a randomized multi-institutional trial, in which two surgical techniques are compared in a parallel group design. Patients and research nurses are kept blinded of the allocated treatment during the follow-up period of 1 year.

DISCUSSION

Currently decompressive laminotomy is the golden standard in the surgical treatment of lumbar spinal stenosis. Whether surgery with interspinous implants is a reasonable alternative can be determined by this trial.

TRIAL REGISTER

Dutch Trial register number: NTR1307.

Lumbar spinal stenosis

Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. LSS is being more commonly diagnosed and may relate to better access to advanced imaging and to an ageing population. This review focusses on radicular symptoms related to degenerative central and lateral stenosis and updates knowledge of LSS pathophysiology, diagnosis and management. Since patients with anatomic LSS can range from asymptomatic to severely disabled, the clinical diagnosis focusses on symptoms and examination findings associated with LSS. Imaging findings are helpful for patients with persistent, bothersome symptoms in whom invasive treatments are being considered. There is limited information from high-quality studies about the relative merits and demerits of commonly used treatments. Interpreting and comparing results of available research are limited by a lack of consensus about the definition of LSS. Nevertheless, evidence supports decompressive laminectomy for patients with persistent and bothersome symptoms. Recommendations favour a shared decision-making approach due to important trade-offs between alternative therapies and differences among patients in their preferences and values.

[Surgical treatment of the old with degenerative lumbar spinal stenosis]

OBJECTIVE

To investigate the perioperative characteristics and surgical methods in treating the old with degenerative lumbar spinal stenosis.

METHODS

From January 2000 to October 2007, 36 patients with degenerative lumbar spinal stenosis with the age more than 60 years,including 16 males and 20 females, the age from 60 to 81 years with an average of 67.5 years. Of all patients, 6 cases were treated by simple surgical decompression, 16 cases by decompressive laminectomy, 20 cases by decompressive laminectomy combined with internal fixation and fusion.

RESULTS

No death cases occurred during perioperation and complication occurred in 14 cases, including cerebrospinal fluid leakage in 3 cases, incision late healed in 1 case, heart abnormal symptom in 1 case, respiratory infection in 1 case, gastrointestinal symptom in 4 cases, urinary system infection in 1 case, spirital symptom in 1 case. After symptomatic treatment, all complications improved. All the cases were followed up from 6 months to 5 years with an average of 2.5 years. Oswestry scoring improved from preoperative 45.66 +/- 7.12 to postoperative 16.80 +/- 5.75, there was significant difference between before and after operation (P < 0.05).

CONCLUSION

The age and heath condition are not operative absolute contraindication in treating old with degenerative lumbar spinal stenosis,with the proper operation modus after controlling concomitant diseases, the surgical treatment could guarantee the satisfactory therapeutic effect.

New image-guided ultra-minimally invasive lumbar decompression method: the mild procedure

BACKGROUND AND OBJECTIVES

Lumbar canal stenosis is a common source of chronic low back and leg pain. Minimally Invasive Lumbar Decompression (mild(R)) is a new minimally invasive treatment for pain relief from symptomatic central lumbar canal stenosis. The procedure involves limited percutaneous laminotomy and thinning of the ligamentum flavum in order to increase the critical diameter of the stenosed spinal canal. The objective of this technical report is to evaluate the acute safety of the mild procedure.

METHODS

Manual and electronic chart survey was conducted by 14 treating physicians located in 9 U.S. states on 90 consecutive patients who underwent the mild procedure. Patients within local geographical practice areas were selected in keeping with product Instructions For Use. Those patients requiring lumbar decompression via tissue resection at the perilaminar space, within the interlaminar space and at the ventral aspect of the lamina were treated. Data collected included any complications and/or adverse events occurring during or immediately following the procedure prior to discharge.

RESULTS

Of 90 procedures reviewed, there were no major adverse events or complications related to the devices or procedure. No incidents of dural puncture or tear, blood transfusion, nerve injury, epidural bleeding, or hematoma were observed.

LIMITATIONS

Data were not specifically collected; however, regardless of difficulty, in this series none of the procedures were aborted and none resulted in adverse events. Efficacy parameters were not collected in this safety survey.

CONCLUSIONS

This review demonstrates the acute safety of the mild procedure with no report of significant or unusual patient complications. To establish complication frequency and longer-term safety profile associated with the treatment, additional studies are currently being conducted. Survey data on file at Vertos Medical, Inc.

Floor activities and degenerative spinal diseases

BACKGROUND

The typical oriental life style in Thailand involves significant time spent on activities on the floor. This introduces an abnormal load against the spine and can cause the low back pain leading to the degenerative change of the lumbosacral region.

OBJECTIVE

To determine whether various floor activities in the early adult life could result in late degenerative lumbar stenosis in the elderly patients. A case-controlled study was conducted. The patients having undergone spinal surgery according to the degenerative spinal stenosis were the case subjects. The control group consisted of the subjects having no significant back pain. The cases and the controls were matched by age, gender, and residence location. The data were collected from their medical records, roentgenograms and the standardized questionnaire. A variety of floor activities categorized by common behaviors in the Thai life style was recorded.

RESULTS

There were 65 matches of cases and controls. Fifty-four patients were female performing floor activities for more than 28 times/week or more than 2 hours/week for longer than 10 years significantly increased the risk of degenerative spinal diseases by more than 15 times when being compared to the control. The most predictable activities related to the degenerative spinal diseases were occupational, cooking, and latrine use.

CONCLUSION

Floor activities increased the risk of symptomatic degenerative spinal diseases in the Thai population. The question whether the prolonged postures of these routine activities could result in lumbar spinal stenosis needs more investigation in further studies.

Instrumented open-door laminoplasty as treatment for cervical myelopathy in 104 patients

Treatment of multilevel cervical myelopathy remains a challenge. We report on a large series of cervical myelopathy patients treated with instrumented open-door laminoplasty. We retrospectively examined the medical records of 104 patients who had undergone instrumented open-door laminoplasty (titanium plate) for cervical myelopathy (minimum follow-up, 24 months). All patients had been myelopathic, 57 (54.8%) had stenosis, 39 (37.5%) had spondylosis, 66 (63.5%) reported gait disturbance, 18 (17.3%) had handwriting changes, 33 (31.7%) complained of deterioration of dexterity, 56 (53.8%) had grasp weakness, 7 (6.7%) had bowel and bladder complaints, 27 (26.0%) had a positive Hoffmann sign, 10 (9.6%) had sustained clonus, and 10 (9.6%) had a positive Babinski sign. Mean preoperative-to-postoperative improvement in Nurick grade was 1.47. Complications included 4 nerve root injuries (3.8%), 1 of which (at C5) was permanent, and 1 transient neurologic deterioration (<1%), 1 incidental durotomy (<1%), and 5 wound infections (4.8%). Four patients required anterior revision for persistent symptoms. Open-door laminoplasty with miniplate instrumentation is an effective, safe method for preventing progression of myelopathy with multilevel involvement while alleviating the need for multilevel fusion.

Continuous somatosensory evoked potentials monitoring is highly sensitive to intraoperative occlusion of iliac artery during anterior lumbar interbody fusion: case report

We report a case of thrombotic occlusion of the left common iliac artery during an L5-S1 anterior interbody fusion exposed via a retroperitoneal approach. The loss of distal blood flow was detected by loss of cortical and peripheral somatosensory evoked potentials on the left lower extremity. Restoration of the blood flow resulted in gradual return of evoked potentials of the involved extremity. The neurophysiological and pulse oximetry monitoring of the lower extremities are extremely sensitive for an early detection of thrombotic occlusions and vascular complications.

A prospective, masked 18-month minimum follow-up on neurophysiologic changes in persons with spinal stenosis, low back pain, and no symptoms

OBJECTIVES

To describe neurophysiologic changes over time in persons with and without spinal complaints and to assess whether paraspinal denervation predicts change in stenosis on magnetic resonance imaging (MRI) and clinical course.

DESIGN

Prospective, controlled, masked trial.

SETTING

University spine program.

PARTICIPANTS

Persons aged 55 to 80 years, screened for polyneuropathy and determined on clinical examination to have spinal stenosis, mechanical low back pain, or no spinal symptoms.

INTERVENTIONS

A comprehensive codified history was obtained and subjects underwent physical examination, ambulation testing, masked electrodiagnostic testing including paraspinal mapping, and MRI, repeated at greater than 18 months. This study presents detailed technical information and additional analyses not reported previously.

MAIN OUTCOME MEASUREMENTS

Change in electrodiagnostic findings. Among persons with clinical stenosis, relationship of change in paraspinal mapping scores to MRI findings and clinical changes.

RESULTS

Of 149 initial subjects, 83 (79.3% of eligible subjects) repeated testing at 20 (+/-2 SDs) months. No significant change in limb muscle spontaneous activity or motor unit pathology was noted in any group. In 23 persons with initial diagnosis of stenosis, paraspinal mapping electromyography related to change in diagnosis over time (analysis of variance F = 3.77, P = .037), but not to most initial magnetic resonance imaging measurements or to change in spinal canal diameter.

CONCLUSIONS

Clinical spinal stenosis is neurophysiologically stable in most persons. Paraspinal electromyographic changes reflect large changes in clinical course, but neither neurophysiologic nor clinical changes relate to change in spinal geometry over 20 months.

[Study the degree of cervical spinal canal stenosis by MRI in flexion and extension of the cervical vertebrae]

OBJECTIVE

To study the degree and changes of cervical spinal canal stenosis by MRI scans in flexion and extension of the cervical vertebrae.

METHODS

Thirty cases of cervical stenosis included 13 male and 17 female with an average age of 39 years ranging from 28 to 66 years. The sagittal diameter of cervical spinal canal were below 10 mm (absolute stenosis) in 12 cases,within 10 to 12 mm (correspondence stenosis) in 18 cases. MRI scans in neutrality, flexion, extension performanced and the degree of cervical spinal canal stenosis and the changes of spinal cord compression were evaluated after MRI scans obtained.

RESULTS

Nineteen patients of extension occurrenced stenosis more serious, 8 patients of flexion occurrenced (P < 0.05).

CONCLUSION

For the cervical stenosis imaging diagnostic, flexion and extension of cervical MRI scan can be used to supplement conventional MRI examination neutral position, and the extension of MRI is more sensitivity than neutral position and flexion bit.

The pathophysiology and nonsurgical treatment of lumbar spinal stenosis

Lumbar spinal stenosis, which affects an ever-increasing number of patients, is best defined as a collection of clinical symptoms that includes low back pain, bilateral lower extremity pain, paresthesias, and other neurologic deficits that occur concomitantly with anatomic narrowing of the neural pathway through the spine. The narrowing may be centrally located in the spinal canal or more laterally in the lateral recesses or neuroforamina. Lumbar spinal stenosis can have a congenital or acquired etiology, and the origin of acquired lumbar stenosis is classified as degenerative, posttraumatic, or iatrogenic. In degenerative lumbar stenosis, the anatomic changes result from a cascade of events that includes intervertebral disk degeneration, facet joint arthrosis, and hypertrophy of the ligamentum flavum. The altered biomechanical characteristics of the spinal segment perpetuate a cycle of degenerative changes, and the resulting stenosis produces radicular pain through a combination of direct mechanical compression of nerve roots, restriction of microvascular circulation and axoplasmic flow, and inflammatory mediators. The initial treatment of lumbar spinal stenosis is nonsurgical. The most effective nonsurgical treatment is a comprehensive combination of oral anti-inflammatory drugs, physical therapy and conditioning, and epidural steroid injections. A significant number of patients improve after nonsurgical treatment, although most studies have found that patients treated surgically have better clinical results. Delaying surgical treatment until after a trial of nonsurgical treatment does not affect the outcome. Surgical intervention should be considered only if a comprehensive program of nonsurgical measures fails to improve the patient's quality of life.

Grading of degenerative disk disease and functional impairment: imaging versus patho-anatomical findings

Degenerative instability affecting the functional spinal unit is discussed as a cause of symptoms. The value of imaging signs for assessing the resulting functional impairment is still unclear. To determine the relationship between slight degrees of degeneration and function, we performed a biomechanical study with 18 multisegmental (L2-S2) human lumbar cadaveric specimens. The multidirectional spinal deformation was measured during the continuous application of pure moments of flexion/extension, bilateral bending and rotation in a spine tester. The three flexibility parameters neutral zone, range of motion and neutral zone ratio were evaluated. Different grading systems were used: (1) antero-posterior and lateral radiographs (degenerative disk disease) (2) oblique radiographs (facet joint degeneration) (3) macroscopic and (4) microscopic evaluation. The most reliable correlation was between the grading of microscopic findings and the flexibility parameters; the imaging evaluation was not as informative.

[Lumbar spinal stenosis--claudicatio spinalis. Pathophysiology, clinical aspects and treatment]

The lumbar spinal stenosis (LSS) is defined as a narrowing of the spinal canal together with neuronal and vascular structures via circumjacent bone and soft tissue. In patients aged over 65 years, the LSS is among the most frequent causes of lumbago, either with or without sciatica. The prevalence will continue to augment because of the increased life expectancy. The leading symptom is neurogenic claudicatio with lumbogluteal or sciatic pain, which occurs while walking and leads to a limitation of the walking distance. Its typical constellation of symptoms including subjective leg weakness is leading to the tentative diagnosis. Nowadays, the imaging technique of choice for the diagnosis is magnetic resonance imaging. A conservative treatment is initially sufficient in most cases. The indication for surgery is given, if the pain and limitation of walking distance are not tolerable any more. Additional fusion should be taken into account, when degenerative spondylolisthesis or other pathomorphological alterations result in an instability. Conservative and surgical therapeutic goals imply pain relief, amelioration of the physical functionality, mobility and general quality of life.

Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 4--Spinal stenosis

BACKGROUND

Spinal stenosis is one of the 3 most common diagnoses of low back and leg symptoms which also include disc herniation and degenerative spondylolisthesis. Spinal stenosis is a narrowing of the spinal canal with encroachment on the neural structures by surrounding the bone and soft tissue. In the United States, one of the most commonly performed interventions for managing chronic low back pain are epidural injections, including their use for spinal stenosis. However, there have not been any randomized trials and evidence is limited with regards to the effectiveness of epidural injections in managing chronic function-limiting low back and lower extremity pain secondary to lumbar spinal stenosis.

STUDY DESIGN

A randomized, double-blind, equivalence trial.

SETTING

An interventional pain management practice, a specialty referral center, a private practice setting in the United States.

OBJECTIVES

To evaluate the effectiveness of caudal epidural injections with or without steroids in providing effective and long-lasting pain relief in the management of chronic low back pain in spinal stenosis and to evaluate the differences between local anesthetic with or without steroids.

METHODS

Patients were randomly assigned to one of 2 groups, with Group I patients receiving caudal epidural injections of local anesthetic (lidocaine 0.5%), whereas Group II patients received caudal epidural injections with 0.5% lidocaine 9 mL mixed with 1 mL of steroid. Randomization is being performed by computer-generated random allocation sequence by simple randomization.

OUTCOMES ASSESSMENT

Multiple outcome measures were utilized which included the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3 months, 6 months, and 12 months post-treatment. Significant pain relief was defined as 50% or more, whereas significant improvement in disability score was defined as reduction of 40% or more.

RESULTS

Significant pain relief (> or =50%) was demonstrated in 55% to 65% of the patients and functional status improvement with 40% reduction in ODI scores in 55% to 80% of the patients. The overall average procedures per year were 3.4 +/- 1.27 in Group I and 2.6 +/- 1.35 in Group II with an average total relief per year of 30.3 +/- 19.49 weeks in Group I and 23.1 +/- 21.36 weeks in Group II over a period of 52 weeks.

LIMITATIONS

The results of this study are limited by the lack of a placebo group and a preliminary report of 20 patients in each group, even though sample was justified.

CONCLUSION

Caudal epidural injections with or without steroids may be effective in patients with chronic function-limiting low back and lower extremity pain with spinal stenosis in approximately 60% of the patients.

Identification and surgical treatment of primary thoracic spinal stenosis

We report the surgical treatment results for 7 patients (4 men, 3 women; mean age, 49 years) who presented with myelopathy caused exclusively by primary thoracic spinal stenosis, predominantly in the lower thoracic spine. (Patients with concurrent ascending lumbosacral degenerative disease were excluded.) All patients received extensive nonoperative treatment before referral to our center. Surgical treatment consisted of wide posterior decompression and instrumented fusion (5 cases), anterior vertebrectomy and fusion (1), and anterior vertebrectomy with autograft strut followed by wide posterior decompression and instrumented fusion (1). Mean operative time was 313 minutes, mean blood loss was 944 mL, and there were no major postoperative complications. Minimum follow-up was 2 years. Five patients had significant improvement in myelopathy and were ambulating normally, 1 had modest improvement in ambulation, and 1 remained wheelchair-bound. All patients achieved solid radiographic fusions. After presenting these case studies, we review the current literature on treatment effectiveness. Primary thoracic spinal stenosis should be considered in patients who present with isolated lower extremity myelopathy, particularly when no significant pathologic findings are identified in the cervical or lumbosacral spine. Expedient wide decompression with concurrent instrumented fusion is recommended to prevent late development of spinal instability and recurrent spinal stenosis.

[Basic and clinical studies on lumbar vertebral canal expansion with preservation of posterior ligaments complex]

OBJECTIVE

To investigate the clinical application and efficacy of lumbar vertebral canal expansion with preservation of posterior ligaments complex, and to study its biomechanical properties.

METHODS

Eight fresh lumbosacral cadaveric samples were divided into 3 groups. In group A, 8 intact lumbosacral cadaveric samples were used for biomechanical test. In group B, L3-5 laminectomy were, after the test in group A, performed and the posterior ligaments complex was preserved. In group C, the posterior ligaments complex was excised after the test in group B. In all 3 groups, the axial compression test, three-point bending test and torsional test were conducted. From June 2000 to June 2006, 309 patients (152 males and 157 females, aged 20-80 years with the average of 57.2 ) with lumbar canal stenosis received operation of the lumbar vertebral canal expansion with preservation of posterior ligaments complex. The course of disease was 3 months to 41 years. There were 55 patients suffering from pure lumbar canal stenosis, and 254 from lumbar canal stenosis combined with lumbar disc herniation, among which 105 were at L4,5 level, 56 at L4-S1 level, 86 at L5, S1 level, and 7 at L2,3 level. The therapeutic effect was assessed based on the JOA low back pain scoring system, the satisfaction degree of patient and radiographical observation.

RESULTS

The axial compression test was performed. In the position of forward bending, stress, strain and axial displacement were smaller in groups A, B than those in group C, and axial stiffness in groups A, B was higher than those in group C, and the difference was significant (P < 0.01). In the position of backward extension, there was no significant difference among 3 groups (P > 0.05). Concerning the three-point bending test, under the same bending moment, there was a significant difference in deflection, dip and bending rigidity between group A and group C, and also between group B and group C (P < 0.01), but no significant difference between group A and group B (P> 0.05). In the torsional test, under the same torsional angle, the torque in group B was bigger than that in group C (P < 0.01). Under the same torque, the torsional angle in group B was smaller than that in group C (P < 0.01), and the torsional stiffness in group B was higher than that in group C (P < 0.01). The complications included 7 cases of distraction of nerve root, 5 leakage of cerebrospinal fluid and 4 wound infection. All complications were treated and restored completely. All patients were followed up for 1-7 years. According to the JOA low back pain scoring system, the improvement rate averaged 86.0%. Of all the 309 cases, 163 were excellent, 112 good, 34 fair, and the choiceness rate was 89%. The satisfaction rate of patient was 87%. There was no radiographic vertebral instability postoperatively.

CONCLUSION

The lumbar vertebral canal expansion with preservation of posterior ligaments complex is conducive to maintaining the stability of lumbar spine and have good clinical outcomes.

Radiological features of lumbar spinal lesions in patients with rheumatoid arthritis with special reference to the changes around intervertebral discs

BACKGROUND CONTEXT

Compared with the cervical spine, little attention has been paid to rheumatoid arthritis (RA)-related lumbar disorders. Only a few articles have described the status of the lumbar spine affected by RA based on plain X-ray films and magnetic resonance imaging (MRI).

PURPOSE

To describe the features and prevalence of radiological changes of the lumbar spine of patients with RA and to clarify the correlations of such features with disease activity.

STUDY DESIGN

Transverse radiological study.

PATIENT SAMPLE

We radiographically examined 104 patients with RA whose age ranged from 21 to 78 years (mean, 51.0). In each, the duration of RA exceeded 10 years (mean, 17.7 years).

OUTCOME MEASURES

Clinical outcomes included Ochi's classification, Lansbury index, C-reactive protein (CRP) (mg/dL), rheumatoid factor (RF) (U/mL), and platelet (count/mm). Radiological outcomes included radiography and MRI.

METHODS

One hundred four RA patients were included in this study regardless of the presence/absence of low back pain. We examined discs from L1-2 to L5-S, including endplates, in each patient on plain X-ray films and magnetic resonance images and used a comprehensive grading system to evaluate each feature of the lumbar spine affected by RA based on the present findings and published reports. The correlations of these radiological features with RA activity and Ochi's classification were examined. To quantify disease activity, we determined the Lansbury index, serum CRP (mg/dL), RF (U/mL), and platelet count (count/mm) at the time of radiological examinations.

RESULTS

Of the 104 patients, 47 (45.2%) exhibited a lumbar lesion. There were two types of lumbar disc lesions related to RA: disc narrowing and disc ballooning. The Lansbury index of patients with the most severe lesions was significantly higher than that of patients with less severe lesions (p<.01). The frequency of lumbar involvement also increased as the number of affected peripheral joints increased, and Ochi's classification appeared to be useful in predicting the occurrence of lumbar lesions.

CONCLUSION

Of 104 patients, 47 (45.2%) exhibited abnormalities on X-ray films and MRI. There were two types of disorders, disc narrowing and disc ballooning. Both the Lansbury index and Ochi's classification reflected the severity of lumbar lesions in RA patients.

Lumbar spinal stenosis: can positional therapy alleviate pain?

METHODS

We analyzed a retrospective case series of 52 patients with spinal stenosis confirmed by spinal imaging and walking limitations treated with a wheeled walker set to induce lumbosacral flexion.

RESULTS

Of the 52 patients, improvement in ambulation was classified as excellent for 30 (58%), good for 7 (13%), moderate for 8 (16%), and poor for 7 (13%). Among 48 patients with neurogenic pain, pain relief was classified as excellent for 22 (46%), good for 11 (23%), moderate for 7 (14.5%), and poor for 8 (16.5%).

CONCLUSIONS

These retrospective data from a case series support the hypothesis that positional therapy with a wheeled walker set to induce lumbosacral flexion relieves lower extremity symptoms of spinal stenosis. However, an adequate test of this hypothesis will require randomized trials of sufficient size and duration that include objective clinical endpoints such as quality-of-life measures, immobility complications and need for drugs, physical therapy, procedures including epidural injections, and spinal surgery. In the meantime, this conservative strategy is an option for patients following the recommendations of the North American Spine Society, or for those who have contraindications (or aversions) to surgery or epidural injections, or who have found these options ineffective. Positional therapy with a wheeled walker offers the possibility of short-term benefits for ambulation and pain, with minimal risks and costs.

Epidural puncture can be confirmed by the Queckenstedt-test procedure in patients with cervical spinal canal stenosis

BACKGROUND

The loss-of-resistance test is the most popular method for identifying the epidural space, but it cannot confirm epidural puncture. Therefore, we developed a new method to confirm epidural puncture by assessing indirect changes in epidural pressure using the Queckenstedt-test procedure, which increases subarachnoid pressure by compressing the internal jugular veins. Because this new method depends on the dynamics of cerebrospinal fluid, blockade of cerebrospinal fluid flow, as with severe spinal stenosis, is predicted to reduce changes in epidural pressure. Thus, in this study, we examined the effect of spinal stenosis on the Queckenstedt-test procedure.

METHODS

Epidural puncture using the loss-of-resistance test was utilized to insert an electrode in patients undergoing cervical spine surgery. Epidural pressure was monitored during bilateral compression of the internal jugular veins to confirm epidural puncture. The insertion of the electrode into the epidural space was confirmed by observation of muscle twitch evoked by electric stimulation.

RESULTS

In 60 patients, epidural puncture was performed with the loss-of-resistance test; a second trial was required in 13 patients. Increased epidural pressure was observed in 57/73 trials. When increased epidural pressure was observed, epidural puncture was always successful. The sensitivity and specificity of this method was 92.0% and 100%, respectively. The positive and negative predictive values were 100% and 66.7%, respectively.

CONCLUSION

An increase in epidural pressure during bilateral compression of the internal jugular veins could offer a reliable method for confirming epidural puncture in combination with the loss-of-resistance test, even if patients have potential spinal canal narrowing.

Use of resorbable implants for symptomatic cervical spondylosis: experience on 16 consecutive patients

AIM

The aim of this study was to evaluate the results of a consecutive series of 16 patients affected by degenerative cervical spondylosis and operated on by anterior cervical discectomy and fusion (ACFD) by means of anterior bioresorbable plate and screws. Further, the authors compared the results in these patients with a series of 13 patients also affected by degenerative cervical spondylosis in whom arthrodesis was obtained by means of cages without plates.\

METHODS

The series included 8 males and 8 females aging from 37 to 69 years, operated from June 2003 to September 2004. They showed signs of cervical myelopathy, radiculopathy or both. The ACDF was performed with the insertion of dense cancellous allograft and application of anterior bioresorbable plate and screws (group A). The group B series included 9 males and 4 females aging from 50 to 77 years, all affected by the same pathology of group A patients and operated on in the same period of time. In these cases the ACDF was followed by the insertion of cages without anterior plates.

RESULTS

The retrospective analysis of our series showed lack of soft tissue reaction, with safeguarding of the vertebral body and disc space height. The degree of alignment of the cervical spine was also preserved, with a good rate of fusion and a good clinical outcome in both series of patients.

CONCLUSION

The use of a cervical plate increase stability and rate of fusion when added to the interbody device; while the use of a metallic plate may be responsible for several shortcomings, a resorbable plate may overcome these problems.

[Bilateral "over the top" decompression through unilateral laminotomy for lumbar and thoracic spinal canal stenosis]

OBJECTIVE

The standard surgical procedures used in degenerative thoracic and lumbar spinal canal stenosis allows decompression of the neural structures by unroofing the spinal canal, often resulted in destruction or insufficiency of facet joints, sacrifice the interspinosus/supraspinosus ligament complexes and stripping of the paraspinal muscles altering an already pathologic biomechanical milieu causing segmental instability. Various less invasive techniques exists to save the integrity and prevent the instability of the spine and allow decompression of neural structures located in the spinal canal. The authors discusses the experiences with technique of unilateral laminotomy for bilateral decompression.

METHODS

The unilateral laminotomy for bilateral decompression technique was performed at 60 levels in 51 patients to decompress the symptomatic degenerative stenosis of the thoracic and lumbar spinal canal. The inclusion criteria were used as follows: symptoms of neurogenic claudication and/or radiculopathy, myelopathy, neuroimaging evidence of degenerative stenosis and absence of instability. Symptoms were considered refractory to nonsurgical conservative management or myelopathy was detected.

RESULTS

The distribution of mostly affected segments were the L 4-5 (45%) and L3-4 (28.4%). Neurogenic claudication and walking distance improved during the follow up period in all patients. Seven patients (13.73%) reported excellent, 32 (62.74%) good, 12 (23.53%) fair outcome and no patient a poor overall outcome. The low back pain was the major residual postoperative complaint. 25 (49%) patients were very satisfied with their outcome, 23 (45.1%) were fairly satisfied, 2 (3.9%) were not very satisfied and 1 (2%) patients was dissatisfied.

CONCLUSION

The unilateral laminotomy for bilateral microdecompression technique minimizes resection of and injury to tissues not directly involved in the pathologic process, while affording a safe and through decompression of neural structures located in a degeneratively stenotic spinal canal.

Lumbosarcral radiculopathties--the importance of EDX information other than needle electromyography

OBJECTIVE

This study evaluates the importance of varying electrodiagnostic (EDX) parameters abnormalities in patients with possible lumbosacral radiculopathies (LSR).

METHODS

34 patients referred for EDX studies with clinical findings consistent with a LSR without other causes for their symptoms were evaluated. Studies included not only standard (Routine EDX) nerve conduction studies (NCS) including F-waves and needle electromyography (nEMG) but also a multiparameter automated analysis system using prefabricated nerve conduction electrodes without nEMG (NC-stat EDX).

RESULTS

Abnormal Routine EDX was present in 24 of the patients. Abnormal nEMG was present in only 14 of these patients, all of whom also had other relevant NCS abnormalities. Abnormal NC-stat EDX was found in 29 of the patients. In all but one patient there was agreement in the radicular localization between Routine and NC-stat EDX. In 30 patients, there was recent computed tomography or magnetic resonance imaging of the lumbosacral region. Comparable statistical agreements with the radiographic information were obtained for Routine EDX and NC-stat data. This was true including when the analyses were based on the neuroradiological evaluation of likely root injury.

CONCLUSION

This study emphasizes the importance of EDX studies other than nEMG in the evaluation of patients with possible LSR and supports the value of a computerized mutliparameter methodology in these patients.

Neurophysiological monitoring of lumbosacral spinal roots during spinal surgery: continuous intraoperative electromyography (EMG)

INTRODUCTION

Neurophysiological monitoring during spinal surgery reduces the associated neurological complications. Continuous EMG recording has developed an useful technique for spinal root monitoring

PATIENTS AND METHODS

Fifty four patients who underwent surgery for several lumbosacral spinal lesions (low and high degree spondylolisthesis, spinal stenosis, degenerated or herniated lumbar discs) were studied to evaluate the effectiveness of continuous EMG recording in monitoring spinal root function during surgery. Electrical root or screw stimulation was also performed in nine of them. To correlate surgical spinal root lesion with a precise EMG injury activity an animal study with 5 pigs was performed; lesion was produced by prolonged spinal root traction.

RESULTS

In the porcine group EMG discharges lasting longer than one minute after cessation of root traction was noted in 74% of spinal root levels (neurotonic discharges or pseudo-rhythmic activity in 70% of the cases). Spinal root lesion was demonstrated through EMG three weeks after surgery. In the patient group pathological-significant EMG activity was not recorded in any case during monitoring. Mechanical or chemical root stimulation during surgery produced brief lasting EMG bursts of no pathological significance. Only a patient developed a mild acute L5-S1 radiculopathy after surgery (1 false negative) and post-operative deficit was not observed in the rest. Electrical stimulation of spinal roots and screws allowed to identify root level and prove the adequate placement of screws.

CONCLUSION

Spontaneous and evoked EMG recordings are simple techniques that provide continuous information about lumbosacral spinal roots function throughout surgery.

Novel biomechanical quantification methodology for lumbar intraforaminal spinal nerve adhesion in a laminectomy and disc injury rat model

Spinal nerve fibrosis following injury or surgical intervention may play an important role in the pathophysiology of chronic back pain. In this current study, we demonstrate the role of biomechanical quantification of lumbar intraforaminal spinal nerve adhesion and tethering in the analysis of the post-laminectomy condition and describe a direct methodology to make this measurement. Twenty age-matched Sprague-Dawley male rats were divided into operative and non-operative (control) groups. Operative animals underwent a bilateral L5-L6 laminectomy with right-side L5-6 disc injury, a post-laminectomy pain model previously published by this lab. At eight weeks, animals were sacrificed and the strength of adhesion of the L5 intraforaminal spinal nerve to surrounding structures was quantified using a novel biomechanical methodology. Operative animals were found to have a significantly greater load to displace the intact right L5 spinal nerve through the intervertebral foramen when compared to control animals. The findings show that the post-laminectomy condition creates quantifiable fibrosis of the spinal nerve to surrounding structures and supports the conclusion that this fibrosis may play a role in the post-laminectomy pain syndrome.

Construct validity of the physical function scale of the Swiss Spinal Stenosis Questionnaire for the measurement of walking capacity

STUDY DESIGN

Measurement (validity) study using data from a prospective longitudinal study of lumbar spinal stenosis.

OBJECTIVE

Provide convergent and divergent validity evidence for the use of the Physical Function Scale of the Swiss Spinal Stenosis Questionnaire for the measurement of walking capacity in persons with lumbar spinal stenosis. We were also interested in the association between the Physical Function Scale and the Oswestry Disability Index (ODI).

SUMMARY OF BACKGROUND DATA

The Physical Function Scale has been used to assess walking capacity in persons with lumbar spinal stenosis; however, there have been limited studies investigating its psychometric properties. No validity studies have compared the Physical Function Scale and the ODI head to head.

METHODS

The Physical Function Scale was correlated with the ODI, Health Utilities Index, Centres for Epidemiologic Studies Depression Scale, Medical Outcomes Survey Social Support Scale, and an additional item from the Oxford Claudication Score.

RESULTS

As hypothesized, the Physical Function Scale was correlated highly with those instruments and items intended to measure walking capacity and minimally with those instruments intended to measure different constructs. The correlation between the Physical Function Scale and the ODI was r = 0.719.

CONCLUSION

Results support construct validity of the Physical Function Scale for the measurement of walking in an lumbar spinal stenosis population. However, it cannot be ascertained from the current study that the construct being measured is, indeed, walking capacity. Further research is warranted to investigate criterion validity evidence for the use of the Physical Function Scale in the measurement of walking capacity in lumbar spinal stenosis, by examining the relationships between self-report and observational measures of walking.

Interspinous process devices in the lumbar spine

A growing number of interspinous process devices have been introduced to the lumbar spine implant market. Implant designs vary from static spacers to dynamized devices. Furthermore, they are composed of a range of different materials including bone allograft, titanium, polyetheretherketone, and elastomeric compounds. The common link between them is the mechanical goal of distracting the spinous processes to affect the intervertebral relationship. In contrast, the purported clinical goals are more variable, ranging from treatment of degenerative spinal stenosis, discogenic low back pain, facet syndrome, disk herniations, and instability. Though some clinical data exist for some of these devices, defining the indications for these minimally invasive procedures will be crucial. Indications should emerge from thoughtful consideration of data from randomized controlled studies.

Minimally invasive operative management for lumbar spinal stenosis: overview of early and long-term outcomes

Standard open posterior decompression is well established and familiar to virtually all spine surgeons. However, this traditional surgical treatment of lumbar spinal stenosis (LSS) is often associated with significant postoperative pain, disability, and dysfunction. This article reviews the use of a minimally invasive microendoscopic approach for bilateral decompression of lumbar stenosis by way of a unilateral approach. This technique has been shown to provide symptomatic relief equivalent to that of open discectomy, with significant reductions in operative blood loss, postoperative pain, hospital stay, and narcotic usage. Furthermore, the article explains the rationale, indications, and surgical techniques for minimally-invasive LSS surgery and presents the authors' 4-year outcomes data.

Treatment of Myelopathy Due to Cervicothoracic OPLL Via Open Door Laminoplasty

STUDY DESIGN

Postoperative long-term follow-up study of open door laminoplasty for the ossification of the posterior longitudinal ligament (OPLL) in the thoracic spine.

OBJECTIVES

Techniques and outcomes of open door laminoplasty were described. The efficacy of this procedure was discussed and compared with other surgical methods for thoracic OPLL reported in the literature.

SUMMARY OF BACKGROUND DATA

OPLL of the thoracic spine is often associated with cervical OPLL or ossification of the yellow ligament (OYL) of the thoracic spine; therefore, it is extremely difficult to determine the most appropriate surgical therapeutic procedure. There are very few detailed reports about extensive laminoplasty for OPLL of the thoracic spine.

METHODS

The subjects included in this study consisted of 13 consecutive patients of thoracic OPLL who were surgically treated between 1994 and 2003 by the open door laminoplasty using the spinal processes and ligament complex as spacers for the open side. The number of manipulated lamina, including the cervical spine, was from 7 to 14 (mean 10 laminae), the follow-up period was 75 months on average. We evaluated the clinical symptoms by the JOA scoring method and postoperative bone union and thoracic kyphosis by plain x-ray photograph and computed tomography.

RESULTS

Postoperatively, the JOA score improved from an average of 5.5 to 8.5 out of a maximum of 11 points and the mean recovery rate by Hirabayashi method was 54.5%. In all cases, bone union was seen at the hinge side between the opened lamina and the lateral mass. Neither restenosis of the opened lamina nor marked progression of kyphosis were seen on the final follow-up observation in any patient. There was no postoperative spinal cord injury.

CONCLUSIONS

Open door laminoplasty is a useful procedure for OPLL of the thoracic spine. This method enables wide-range posterior decompression, especially for the continuous type OPLL extending from the cervical spine to the thoracic spine, even if the apex of the thoracic kyphosis is included.

Esophageal perforation with a locking screw: a case report and review of the literature

STUDY DESIGN

A case report with a review of the literature.

OBJECTIVES

Anterior cervical spine surgery (ACS) has received widespread acceptance, and as a result, a variety of complications have been reported. Several cases of esophageal complications, arising from the use of various implants and grafts, have been described. The purpose of this article is to provide insight into the clinical presentation, diagnosis, types of involved implants, and the treatment of this entity.

SUMMARY OF BACKGROUND DATA

Previous reports of esophageal complications (esophageal perforation, diverticula, and stricture) after ACS are reviewed.

METHODS

Retrospective case study and literature review.

RESULTS

Redundant locking screws should be removed due to the potential for extrusion into the esophagus.

CONCLUSIONS

Regular, long-term follow-up of the patient undergoing anterior spine surgery is crucial. The wide range of possible complications mandates thorough workup. Early surgical treatment is imperative in the majority of esophageal complications.

Lumbar spine surgery in Israeli Arabs and Jews: a comparative study with emphasis on pain perception

BACKGROUND

Surgery for spinal stenosis is a frequent procedure in elderly patients. Presentation, hospital course, and outcome of disease including pain perception may vary among patients of different ethnic origin.

OBJECTIVES

To evaluate whether differences in various medical indicators can explain differences in pain perception between two ethnic groups.

METHODS

We conducted a case-control study on the experience of two spinal units treating a mixed Arab and Jewish population, and compared the data on 85 Arab and 189 Jewish patients undergoing spinal lumbar surgery.

RESULTS

Arab patients were younger (P = 0.027), less educated (P < 0.001), had a higher body mass index (P = 0.004) and included a higher proportion of diabetics (P = 0.013). Preoperative pain intensity (P = 0.023) and functional disability (P = 0.005) were more prominent, and factors associated with pre- or postoperative pain perception differed between the two ethnic groups. Despite these differences, results on follow-up were similar with respect to pain perception and level of disability.

CONCLUSIONS

A better understanding of ethnic differences is crucial for predicting surgery outcomes.

Is spinal stenosis better treated surgically or nonsurgically?

For patients with clinical and radiographic lumbar spinal stenosis, is surgery or continued nonsurgical treatment a better option for improvements in baseline disability scores; and what proportion of patients treated surgically and nonsurgically get better, worse, or remain the same with time? We prospectively evaluated 125 consecutive patients for this non-randomized cohort study. Of the patients choosing surgery, 54 underwent decompression only and 42 had decompression and fusion for preexisting spondylolisthesis; twenty-nine patients declined surgery. At 2 years followup, the average improvements in Roland-Morris questionnaire score in the decompression only, decompression with fusion, and nonsurgical groups were 6.9, 6.1, and 1.2, respectively. The percentages of patients who were better, worse, or the same were similar for those who had decompression only (63.3%, 4.1%, and 32.7%, respectively) and decompression with fusion (61.5%, 2.6%, and 35.9%, respectively) but different from those treated without surgery (25.0%, 12.5%, and 62.5%, respectively). We observed no occurrences of cauda equina syndrome or severe neurologic dysfunction in any of the groups after 2 years. A majority of patients declining surgery had persistent symptoms. The majority of patients who choose surgery will be improved but will have residual symptoms and therefore should be counseled about realistic expectations.

The efficiency of gabapentin therapy in patients with lumbar spinal stenosis

STUDY DESIGN

Randomized controlled study.

OBJECTIVES

To investigate the efficacy of treatment with gabapentin on the clinical symptoms and findings in patients with lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

LSS is a syndrome resulting from the narrowing of the lumbar nerve root canal, spinal canal, and intervertebral foramen, causing compression of the spinal cord. The most significant clinical symptom in patients with LSS is neurologic intermittent claudication (NIC). Gabapentin, which has been used in the treatment of neuropathic pain, may be effective in the treatment of symptoms associated with LSS.

METHODS

Fifty-five patients with LSS, who had NIC as the primary complaint, were randomized into 2 groups. All patients were treated with therapeutic exercises, lumbosacral corset with steel bracing, and nonsteroidal anti-inflammatory drugs. The treatment group received gabapentin orally in addition to the standard treatment.

RESULTS

Gabapentin treatment resulted in an increase in the walking distance better than what was obtained with standard treatment (P = 0.001). Gabapentin-treated patients also showed improvements in pain scores (P = 0.006) and recovery of sensory deficit (P = 0.04), better than could be attained with the standard treatment.

CONCLUSION

Based on the results of our pilot study, extensive clinical studies are warranted to investigate the role of gabapentin in the management of symptomatic LSS.

Surgical outcome of drop foot caused by degenerative lumbar diseases

STUDY DESIGN

A total of 46 patients undergoing lumbar spine surgery for degenerative lumbar disease and presenting with drop foot were included in this retrospective study.

OBJECTIVE

To determine which preoperative patients' symptoms were of statistical significance in their effect on surgical outcome.

SUMMARY OF BACKGROUND DATA

Drop foot is a neuromuscular condition that results in palsy of the ankle dorsiflexion and is a major problem in Japanese daily life. Few studies have described the effect of a surgical intervention on drop foot associated with degenerative lumbar disorders and the factors that affect the surgical outcome. The manual muscle test can be used to determine the muscular strength of the tibialis anterior. Drop foot is then defined as a score below 3 out of 5.

METHODS

Patient medical history, preoperative tibialis anterior strength, presence of leg pain, and duration of palsy were recorded and compared with surgical outcome.

RESULTS

Of patients, 61% recovered from drop foot after surgery. Patients with a tibialis anterior score of 2-3- and those suffering from palsy for a shorter duration of time showed better surgical results. Cases without leg pain were also shown to be treated effectively with surgery.

CONCLUSIONS

Palsy duration and preoperative strength were factors that most affected drop foot recovery following surgical intervention for spinal degeneration.

Lumbar spinal stenosis: Assessment of cauda equina involvement by electrophysiological recordings

The objective of this study was to investigate the relationship between electrophysiological recordings and clinical as well as radiological findings in patients suggestive to suffer from a lumbar spinal stenosis (LSS). We hypothesise that the electrophysiological recordings, especially SSEP, indicate a lumbar nerve involvement that is complementary to the neurological examination and can provide confirmatory information in less obvious clinical cases. In a prospective cohort study, 54 patients scheduled for surgery due to LSS were enrolled in an unmasked, uncontrolled trial. All patients were assessed by neurological examination, electrophysiological recordings, and magnetic resonance imaging (MRI) of the lumbar spine. The electrophysiological recordings focused on spinal lumbar nerve involvement.

RESULTS

About 88% suffered from a multisegmental LSS and 91% of patients respectively complained of chronic lower back pain and/or leg pain for more than 3 months, combined with a restriction in walking distance. The neurological examination revealed only a few patients with sensory and/or motor deficits while 87% of patients showed pathological electrophysiological recordings (abnormal tibial SSEP in 78% of patients, abnormal H-reflex in 52% of patients).

CONCLUSIONS

Whereas the clinical examination, even in severe LSS, showed no specific sensory-motor deficit, the electrophysiological recordings indicated that the majority of patients had a neurogenic disorder within the lumbar spine. By the pattern of bilateral pathological tibial SSEP and pathological reflexes associated with normal peripheral nerve conduction, LSS can be separated from a demyelinating polyneuropathy and mono-radiculopathy. The applied electrophysiological recordings, especially SSEP, can confirm a neurogenic claudication due to cauda equina involvement and help to differentiate neurogenic from vascular claudication or musculo-skeletal disorders of the lower limbs. Therefore, electro-physiological recordings provide additional information to the neurological examination when the clinical relevance of a radiologically-suspected LSS needs to be confirmed.

Low-back and neck pain diagnosis and treatment

Back and neck pain are symptoms, often complaints, and sometimes causes of disability, but they are not diseases. These distinctions are critical to understanding the personal and societal impact of back and neck pain and our opportunities to discover new ways to reduce their impact. This article briefly describes current diagnosis and treatment of spinal pain, the relationship between pain and disability, and the challenges in prioritizing our resource allocations between curing pain problems and reducing disability.

Use of small suture anchors in cervical laminoplasty to maintain canal expansion: a technical note

OBJECTIVE

Open door laminoplasty is a commonly performed procedure for the treatment of cervical spine pathology. One complication of this procedure is closure of the hinge and subsequent restenosis. A simple and effective method of using suture anchors to stabilize posterior elements has been previously described. The aim of this paper is to describe our experience using 2.0-mm suture anchors to maintain canal expansion.

METHODS

Results of 42-consecutive patients who were treated with a modified cervical open-door laminoplasty were reviewed. The modification involves the use of original Hirabayashi technique, but augmenting the canal expansion with 2.0-mm suture anchors at C3, C5, and C7 levels. Additionally, nonabsorbable sutures are placed at C4 and C6 levels as described by Hirabayashi. The technical issues and short-term radiographic outcomes were evaluated.

RESULTS

None of the 42 patients who had the door secured with 2.0-mm suture anchors had closure of the hinge. Additionally, the suture anchors maintained their position without loosening or "pull-outs" on postoperative follow-up radiographs. There were 3 short-term complications: 1 was a small dural-tear which was repaired intraoperatively without further sequelae, and the other 2 were both epidural hematomas that required emergent return to the operating room for evacuation. All 3 patients had an uneventful recovery without a new neurologic deficit.

CONCLUSIONS

This paper reviews a simple and effective method for maintaining canal expansion in open-door laminoplasty. Because of its technical simplicity, 2.0-mm suture anchors may be a safer alternative than other devices currently popular for this purpose.