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Zhu C, Xiao G. Efficacy and safety of interspinous process device compared with alone decompression for lumbar spinal stenosis: A systematic review and meta-analysis. Medicine (Baltimore) 2024; 103:e38370. [PMID: 38847722 PMCID: PMC11155552 DOI: 10.1097/md.0000000000038370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/03/2024] [Indexed: 06/10/2024] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. BACKGROUND Interspinous process devices (IPD) were used as a treatment in selected patients with lumbar spinal stenosis (LSS). However, the use of IPD was still debated that it had significantly higher reoperation rates compared to traditional decompression. Therefore, the purpose of the meta-analysis was to evaluate the effectiveness and safety of IPD treatment in comparison to traditional treatment. METHODS The databases were searched of PubMed, Embase and the Cochrane, Chinese National Knowledge Infrastructure, Chongqing VIP Database and Wan Fang Database up to January 2024. Relevant studies were identified by using specific eligibility criteria and data was extracted and analyzed based on primary and secondary endpoints. RESULTS A total of 13 studies were included (5 RCTs and 8 retrospective studies). There was no significant difference of Oswestey Disability Index (ODI) score in the last follow-up (MD = -3.81, 95% CI: -8.91-1.28, P = .14). There was significant difference of Visual Analog Scale (VAS) back pain scoring in the last follow-up (MD = -1.59, 95% CI: -3.09--0.09, P = .04), but there existed no significant difference of leg pain in the last follow-up (MD = -2.35, 95% CI: -6.15-1.45, P = .23). What's more, operation time, bleeding loss, total complications and reoperation rate had no significant difference. However, IPD had higher device problems (odds ratio [OR] = 9.00, 95% CI: 2.39-33.91, P = .001) and lesser dural tears (OR = 0.32, 95% CI: 0.15-0.67, P = .002) compared to traditional decompression. CONCLUSION Although IPD had lower back pain score and lower dural tears compared with traditional decompression, current evidence indicated no superiority for patient-reported outcomes for IPD compared with alone decompression treatment. However, these findings needed to be verified in further by multicenter, double-blind and large sample RCTs.
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Affiliation(s)
- Changjiu Zhu
- Department of Orthopedics, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Guiling Xiao
- Department of Orthopedics, Sichuan Provincial People’s Hospital, Chengdu, China
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Prod'homme M, Grasset D, Chalaron M, Boscherini D. Epidural abscess related to Streptococcus mitis in a 57-year-old immunocompetent patient. BMJ Case Rep 2021; 14:e239295. [PMID: 33837023 PMCID: PMC8043008 DOI: 10.1136/bcr-2020-239295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 11/04/2022] Open
Abstract
A 57-year-old immunocompetent male patient presented himself to our emergency department with lumbar pain for 10 days, after a lumbar torsion. He was neurologically intact, but showed signs of systemic inflammatory syndrome. A lumbar MRI found a spinal epidural abscess from L3-L4 to L5-S1 levels. The patient was operated early before occurrence of neurological deficit. The abscess cultures found a Streptococcus mitis infection. The patient made a good recovery after surgical decompression, washout with samples taken for cultures and targeted antibiotic therapy for 6 weeks.
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Affiliation(s)
- Marc Prod'homme
- Neuro Orthopedic Center, La Source College of Health, Lausanne, Vaud, Switzerland
| | - Didier Grasset
- Neuro Orthopedic Center, La Source College of Health, Lausanne, Vaud, Switzerland
| | - Marc Chalaron
- Radiology, La Source College of Health, Lausanne, Vaud, Switzerland
| | - Duccio Boscherini
- Neuro Orthopedic Center, La Source College of Health, Lausanne, Vaud, Switzerland
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Markman JD, Czerniecka-Foxx K, Khalsa PS, Hayek SM, Asher AL, Loeser JD, Chou R. AAPT Diagnostic Criteria for Chronic Low Back Pain. THE JOURNAL OF PAIN 2020; 21:1138-1148. [PMID: 32036046 DOI: 10.1016/j.jpain.2020.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 01/06/2020] [Accepted: 01/08/2020] [Indexed: 12/15/2022]
Abstract
Chronic low back pain (CLBP) conditions are highly prevalent and constitute the leading cause of disability worldwide. The Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION) public-private partnership with the US Food and Drug Administration and the American Pain Society (APS), have combined to create the ACTTION-APS Pain Taxonomy (AAPT). The AAPT initiative convened a working group to develop diagnostic criteria for CLBP. The working group identified 3 distinct low back pain conditions which result in a vast public health burden across the lifespan. This article focuses on: 1) the axial predominant syndrome of chronic musculoskeletal low back pain, 2) the lateralized, distally-radiating syndrome of chronic lumbosacral radicular pain 3) and neurogenic claudication associated with lumbar spinal stenosis. This classification of CLBP is organized according to the AAPT multidimensional framework, specifically 1) core diagnostic criteria; 2) common features; 3) common medical and psychiatric comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors. PERSPECTIVE: An evidence-based classification of CLBP conditions was constructed for the AAPT initiative. This multidimensional diagnostic framework includes: 1) core diagnostic criteria; 2) common features; 3) medical and psychiatric comorbidities; 4) neurobiological, psychosocial, and functional consequences; and 5) putative neurobiological and psychosocial mechanisms, risk factors, and protective factors.
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Affiliation(s)
- John D Markman
- Translational Pain Research Program, Department of Neurosurgery, University of Rochester, Rochester, New York.
| | | | - Partap S Khalsa
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, Maryland
| | - Salim Michel Hayek
- Division of Pain Medicine, Department of Anesthesiology, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Anthony L Asher
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates and Neuroscience Institute, Atrium Health, Charlotte, North Carolina
| | - John D Loeser
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Roger Chou
- Department of Medicine, Oregon Health & Science University, Portland, Oregon
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Hart R. Topping Phenomenon with Recurrent Spinal Stenosis and Epidural Fibrosis Prevented with Oxidized Cellulose - a Case Report. ACTA MEDICA (HRADEC KRÁLOVÉ) 2018; 61:69-73. [PMID: 30216187 DOI: 10.14712/18059694.2018.55] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Lumbar spinal stenosis is a condition where the neural structures are compressed in the narrowed spinal canal and often situated only within a single specific segment of the spine, most frequently in the lumbar spine. A case report demonstrates a surgical solution of lumbar spinal stenosis with using oxidized cellulose as a prevention of post-operative adhesions and failed back syndrome. A female patient (68) with a significant pain of the lumbar spine lasting for a number of months due to advanced spondylosis, failing to respond to conservative treatment underwent instrumented, posterolateral fusion of affected segments. The patient re-arrived with pain due to spinal stenosis in another segments after 4 and then after 3 years. We repeatedly performed spinal fusion of the affected segments and applied an antiadhesive gel to the dural sac and the decompressed nerve roots to prevent the development of post-operative adhesions and the "failed back syndrome". Last surgical solution included mobilisation of the simultaneously constricted dural sac through laminectomy. This time we covered the sac using a haemostat made of oxidized cellulose (Traumacel FAM). After this treatment, the patient was again without significant difficulties.
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Affiliation(s)
- Radek Hart
- Department of Orthopaedics and Traumatology, General Hospital Znojmo, Czech Republic.
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Sun J, Liu YC, Yan SH, Wang SS, Lester DK, Zeng JZ, Miao J, Zhang K. Clinical Gait Evaluation of Patients with Lumbar Spine Stenosis. Orthop Surg 2018; 10:32-39. [PMID: 29430858 DOI: 10.1111/os.12367] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 12/01/2016] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE The third generation Intelligent Device for Energy Expenditure and Activity (IDEEA3, MiniSun, CA) has been developed for clinical gait evaluation, and this study was designed to evaluate the accuracy and reliability of IDEEA3 for the gait measurement of lumbar spinal stenosis (LSS) patients. METHODS Twelve healthy volunteers were recruited to compare gait cycle, cadence, step length, velocity, and number of steps between a motion analysis system and a high-speed video camera. Twenty hospitalized LSS patients were recruited for the comparison of the five parameters between the IDEEA3 and GoPro camera. Paired t-test, intraclass correlation coefficient, concordance correlation coefficient, and Bland-Altman plots were used for the data analysis. RESULTS The ratios of GoPro camera results to motion analysis system results, and the ratios of IDEEA3 results to GoPro camera results were all around 1.00. All P-values of paired t-tests for gait cycle, cadence, step length, and velocity were greater than 0.05, while all the ICC and CCC results were above 0.950 with P < 0.001. CONCLUSIONS The measurements for gait cycle, cadence, step length, velocity, and number of steps with the GoPro camera are highly consistent with the measurements with the motion analysis system. The measurements for IDEEA3 are consistent with those for the GoPro camera. IDEEA3 can be effectively used in the gait measurement of LSS patients.
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Affiliation(s)
- Jun Sun
- Department of School of Biomedical Engineering, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China.,Department of Radiology, Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Yan-Cheng Liu
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, China
| | - Song-Hua Yan
- Department of School of Biomedical Engineering, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
| | - Sha-Sha Wang
- Orthopaedic Private Practice, Fresno, California, USA
| | | | - Ji-Zhou Zeng
- Department of Orthopaedics, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jun Miao
- Department of Spinal Surgery, Tianjin Hospital, Tianjin, China
| | - Kuan Zhang
- Department of School of Biomedical Engineering, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Fundamental Research on Biomechanics in Clinical Application, Capital Medical University, Beijing, China
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Papanagiotou P, Boutchakova M. [Spinal canal stenosis]. Radiologe 2014; 54:1087-92. [PMID: 25398571 DOI: 10.1007/s00117-014-2729-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Spinal stenosis is a narrowing of the spinal canal by a combination of bone and soft tissues, which can lead to mechanical compression of spinal nerve roots or the dural sac. The lumbal spinal compression of these nerve roots can be symptomatic, resulting in weakness, reflex alterations, gait disturbances, bowel or bladder dysfunction, motor and sensory changes, radicular pain or atypical leg pain and neurogenic claudication. The anatomical presence of spinal canal stenosis is confirmed radiologically with computerized tomography, myelography or magnetic resonance imaging and play a decisive role in optimal patient-oriented therapy decision-making.
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Affiliation(s)
- P Papanagiotou
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Klinikum Bremen-Mitte/Bremen-Ost, St.-Jürgen-Str. 1, 28205, Bremen, Deutschland,
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Omidi-Kashani F, Hasankhani EG, Ashjazadeh A. Lumbar spinal stenosis: who should be fused? An updated review. Asian Spine J 2014; 8:521-30. [PMID: 25187873 PMCID: PMC4149999 DOI: 10.4184/asj.2014.8.4.521] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 12/30/2013] [Accepted: 02/04/2014] [Indexed: 12/22/2022] Open
Abstract
Lumbar spinal stenosis (LSS) is mostly caused by osteoarthritis (spondylosis). Clinically, the symptoms of patients with LSS can be categorized into two groups; regional (low back pain, stiffness, and so on) or radicular (spinal stenosis mainly presenting as neurogenic claudication). Both of these symptoms usually improve with appropriate conservative treatment, but in refractory cases, surgical intervention is occasionally indicated. In the patients who primarily complain of radiculopathy with an underlying biomechanically stable spine, a decompression surgery alone using a less invasive technique may be sufficient. Preoperatively, with the presence of indicators such as failed back surgery syndrome (revision surgery), degenerative instability, considerable essential deformity, symptomatic spondylolysis, refractory degenerative disc disease, and adjacent segment disease, lumbar fusion is probably recommended. Intraoperatively, in cases with extensive decompression associated with a wide disc space or insufficient bone stock, fusion is preferred. Instrumentation improves the fusion rate, but it is not necessarily associated with improved recovery rate and better functional outcome.
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Affiliation(s)
- Farzad Omidi-Kashani
- Orthopedic Department, Orthopedic Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ebrahim Ghayem Hasankhani
- Orthopedic Department, Orthopedic Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Ashjazadeh
- Orthopedic Department, Orthopedic Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Kalff R, Ewald C, Waschke A, Gobisch L, Hopf C. Degenerative lumbar spinal stenosis in older people: current treatment options. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:613-23; quiz 624. [PMID: 24078855 DOI: 10.3238/arztebl.2013.0613] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 07/17/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Degenerative lumbar spinal stenosis is increasingly being diagnosed in persons over age 65. In 2011, 55 793 older people with this condition were treated as inpatients in German hospitals. Among physicians, there is much uncertainty about the appropriate treatment strategy. METHOD Selective literature review. RESULTS Lumbar spinal stenosis in older people is characterized by spinal claudication and neurological deficits. A precise clinical history and physical examination and ancillary radiological studies are the necessary prerequisites for treatment. Magnetic resonance imaging is the radiological study of choice. Conservative treatment consists of physiotherapy, drugs, and local injections; various surgical treatments can be considered, depending on the severity of the problem. The main purpose of surgery is to decompress the spinal canal. If the lumbar spine is demonstrably unstable, an instrumented fusion should be performed in addition. There is, however, only moderately good evidence supporting the superiority of surgery over conservative treatment. In a prospective study, the complication rate of purely decompressive surgery was found to be 18%. The utility of the current operative techniques cannot be definitively assessed, because they are applied to a wide variety of patients in different stages of the disease and at different degrees of severity, and the reported results are thus not comparable from one trial to another. CONCLUSION No evidence-based recommendation on the diagnosis and treatment of lumbar spinal stenosis in older people can be formulated at present because of the lack of pertinent randomized trials.
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Affiliation(s)
- Rolf Kalff
- Department of Neurosurgery, Jena University Hospital
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Landkammer Y, Bernecker R, Wicker A. ALTERG: AN INNOVATIVE TECHNOLOGY IN PHYSICAL ACTIVE REHABILITATION OF SPINAL STENOSIS. Br J Sports Med 2013. [DOI: 10.1136/bjsports-2013-092558.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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10
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Lakemeier S, Lind M, Schultz W, Fuchs-Winkelmann S, Timmesfeld N, Foelsch C, Peterlein CD. A comparison of intraarticular lumbar facet joint steroid injections and lumbar facet joint radiofrequency denervation in the treatment of low back pain: a randomized, controlled, double-blind trial. Anesth Analg 2013; 117:228-35. [PMID: 23632051 DOI: 10.1213/ane.0b013e3182910c4d] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Lumbar facet joint degeneration is a source of chronic low back pain, with an incidence of 15% to 45% among patients with low back pain. Various therapeutic techniques in the treatment of facet-related pain have been described in the literature, including intraarticular lumbar facet joint steroid injections and radiofrequency denervation. In this study, we compared the effectiveness of intraarticular facet joint steroid injections and radiofrequency denervation. METHODS Our randomized, double-blind, controlled study included patients who received intraarticular steroid infiltrations in the lumbar facet joints (L3/L4-L5/S1) and patients who underwent radiofrequency denervation of L3/L4-L5/S1 segments. The inclusion criteria were based first on magnetic resonance imaging findings showing hypertrophy of the facet joints L3/L4-L5/S1 and a positive response to an intraarticular test infiltration of the facet joints L3/L4-L5/S1 with local anesthetics. The primary end point was the Roland-Morris Questionnaire. Secondary end points were the visual analog scale and the Oswestry Disability Index. All outcome assessments were performed at baseline and at 6 months. RESULTS Fifty-six patients were randomized; 24 of 29 patients in the steroid injection group and 26 of 27 patients in the denervation group completed the 6-month follow-up. Pain relief and functional improvement were observed in both groups. There were no significant differences between the 2 groups for the primary end point (95% confidence interval [CI], -3 to 4) and for both secondary end points (95% CI for visual analog scale, -2 to 1; 95% CI for Oswestry Disability Index, -18 to 0). CONCLUSIONS Intraarticular steroid infiltration or radiofrequency denervation appear to be a managing option for chronic function-limiting low back pain of facet origin with favorable short- and midterm results in terms of pain relief and function improvement, but improvements were similar in both groups.
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Affiliation(s)
- Stefan Lakemeier
- Department of Orthopedics, University Hospital Goettingen, Robert-Koch-Straße 40, D-37075 Göttingen, Germany.
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Efficacy of an interspinous decompression device versus nonoperative treatment for lumbar spinal stenosis: an example for a randomized, controlled trial. ACTA ACUST UNITED AC 2012. [DOI: 10.4155/cli.12.128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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The interspinous spacer: a clinicoanatomical investigation using plastination. Minim Invasive Surg 2012; 2012:538697. [PMID: 22900164 PMCID: PMC3415215 DOI: 10.1155/2012/538697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 04/23/2012] [Indexed: 12/13/2022] Open
Abstract
Purpose. The relatively new and less-invasive therapeutic alternative "interspinous process decompression device (IPD)" is expected to result in improved symptoms of neurogenic intermittent claudication (NIC) caused by lumbar spinal stenosis. The aim of the study was to analyze IPD position particularly regarding damage originating from surgical implantation. Methods. Anatomic assessments were performed on a fresh human cadaver. For the anatomic examination, the lumbar spine was plastinated after implantation of the IPDs. After radiographic control, serial 4 mm thick sections of the block plastinate were cut in the sagittal (L1-L3) and horizontal (L3-L5) planes. The macroanatomical positioning of the implants was then analyzed. The insertion procedure caused only little injury to osteoligamentous or muscular structures. The supraspinous ligament was completely intact, and the interspinous ligaments were not torn as was initially presupposed. No osseous changes at the spinal processes were apparent. Contact of the IPD with the spinous processes was visible, so that sufficient biomechanical limitation of the spinal extension seems likely. Conclusions. Minimally invasive IPD implantation with accurate positioning in the anterior portion of the interspinous place is possible without severe surgical trauma.
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Richolt JA, Rauschmann MA, Schmidt S. [Interspinous spacers--technique of Coflex™ implantation]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2010; 22:536-44. [PMID: 21153011 DOI: 10.1007/s00064-010-9029-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This surgical procedure addresses the reduction of spinal stenoses as a short-term result. In the long run, prevention of recurrent narrowing of the spinal canal and the development of sciatic pain is the goal by taking load from the facet joint and indirect extension of the neuroforamina. This is achieved by interspinous distraction of the described spacer. In addition, this implant leads to a dynamic limitation of a spinal motion segment. INDICATIONS Spinal stenosis in conjunction with moderate spondylarthrosis without signs of spondylolisthesis (> Meyerding 1°). Other indications are revisions after nucleotomies and primary nucleotomies in cases of massive disk hernia. CONTRAINDICATIONS Segmental instabilities (degeneration or spondylolisthesis), advanced spondylarthrosis, dysraphia of the vertebral arc, scoliosis at the segment to treat, significant osteoporosis, tumor, infection. SURGICAL TECHNIQUE Interlaminar decompression and implantation of an interspinous spacer. POSTOPERATIVE MANAGEMENT Mobilization not before 2 h postoperatively. Wound drain removal after approximately 24 h. In case of treatment of more than one segment as as well as in cases of revision and obesity, a lumbar orthesis for 6 weeks is recommended. Physiotherapy to improve active lumbar stabilization especially by isometric exercises. Lifting of heavy loads (> 5 kg) and extensive flexion should be avoided. RESULTS So far, inconsistent results in currently available retrospective studies. Comparable short-term results in prospective studies of sole decompression without implantation of an interspinous spacer. Prospective randomized comparative studies are not yet available.
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Affiliation(s)
- Jens A Richolt
- Orthopädische Universitätsklinik Friedrichsheim GmbH, Frankfurt am Main, Germany
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Abstract
Background Lumbar spinal stenosis is the most frequent reason for spinal surgery in elderly people. For patients with moderate or severe symptoms different conservative and surgical treatment modalities are recommended, but knowledge about the effectiveness, in particular of the conservative treatments, is scarce. There is some evidence that surgery improves outcome in about two thirds of the patients. The aims of this study are to derive and validate a prognostic prediction aid to estimate the probability of clinically relevant improvement after surgery and to gain more knowledge about the future course of patients treated by conservative treatment modalities. Methods/Design This is a prospective, multi-centre cohort study within four hospitals of Zurich, Switzerland. We will enroll patients with neurogenic claudication and lumbar spinal stenosis verified by Computer Tomography or Magnetic Resonance Imaging. Participating in the study will have no influence on treatment modality. Clinical data, including relevant prognostic data, will be collected at baseline and the Swiss Spinal Stenosis Questionnaire will be used to quantify severity of symptoms, physical function characteristics, and patient's satisfaction after treatment (primary outcome). Data on outcome will be collected 6 weeks, and 6, 12, 24 and 36 months after inclusion in the study. Applying multivariable statistical methods, a prediction rule to estimate the course after surgery will be derived. Discussion The ultimate goal of the study is to facilitate optimal, knowledge based and individualized treatment recommendations for patients with symptomatic lumbar spinal stenosis.
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Winter CC, Brandes M, Müller C, Schubert T, Ringling M, Hillmann A, Rosenbaum D, Schulte TL. Walking ability during daily life in patients with osteoarthritis of the knee or the hip and lumbar spinal stenosis: a cross sectional study. BMC Musculoskelet Disord 2010; 11:233. [PMID: 20939866 PMCID: PMC2958990 DOI: 10.1186/1471-2474-11-233] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Accepted: 10/12/2010] [Indexed: 02/07/2023] Open
Abstract
Background Degenerative musculoskeletal disorders are among the most frequent diseases occurring in adulthood, often impairing patients' functional mobility and physical activity. The aim of the present study was to investigate and compare the impact of three frequent degenerative musculoskeletal disorders -- knee osteoarthritis (knee OA), hip osteoarthritis (hip OA) and lumbar spinal stenosis (LSS) -- on patients' walking ability. Methods The study included 120 participants, with 30 in each patient group and 30 healthy control individuals. A uniaxial accelerometer, the StepWatch™ Activity Monitor (Orthocare Innovations, Seattle, Washington, USA), was used to determine the volume (number of gait cycles per day) and intensity (gait cycles per minute) of walking ability. Non-parametric testing was used for all statistical analyses. Results Both the volume and the intensity of walking ability were significantly lower among the patients in comparison with the healthy control individuals (p < 0.001). Patients with LSS spent 0.4 (IQR 2.8) min/day doing moderately intense walking (>50 gait cycles/min), which was significantly lower in comparison with patients with knee and hip OA at 2.5 (IQR 4.4) and 3.4 (IQR 16.1) min/day, respectively (p < 0.001). No correlations between demographic or anthropometric data and walking ability were found. No technical problems or measuring errors occurred with any of the measurements. Conclusions Patients with degenerative musculoskeletal disorders suffer limitations in their walking ability. Objective assessment of walking ability appeared to be an easy and feasible tool for measuring such limitations as it provides baseline data and objective information that are more precise than the patients' own subjective estimates. In everyday practice, objective activity assessment can provide feedback for clinicians regarding patients' performance during everyday life and the extent to which this confirms the results of clinical investigations. The method can also be used as a way of encouraging patients to develop a more active lifestyle.
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Affiliation(s)
- Corinna C Winter
- Department of Orthopedics and Tumor Orthopedics, University Hospital Muenster, Albert-Schweitzer-Str, 33, 48149 Münster, Germany.
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Abstract
Lumbar spinal stenosis (LSS) comprises narrowing of the spinal canal with subsequent neural compression, and is frequently associated with symptoms of neurogenic claudication. To establish a diagnosis of LSS, clinical history, physical examination results and radiological changes all need to be considered. Patients who exhibit mild to moderate symptoms of LSS should undergo multimodal conservative treatment, such as patient education, pain medication, delordosing physiotherapy and epidural injections. In patients with severe symptoms, surgery is indicated if conservative treatment proves ineffective after 3-6 months. Clinically relevant motor deficits or symptoms of cauda equina syndrome remain absolute indications for surgery. The first randomized, prospective studies have provided class I-II evidence that supports a more rapid and profound decline of LSS symptoms after decompressive surgery than with conservative therapy. In the absence of a valid paraclinical diagnostic marker, however, more evidence-based data are needed to identify those patients for whom the benefit of surgery would outweigh the risk of developing complications. In this Review, we briefly survey the underlying pathophysiology and clinical appearance of LSS, and explore the available diagnostic and therapeutic options, with particular emphasis on neuroradiological findings and outcome predictors.
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Schulte TL, Schubert T, Winter C, Brandes M, Hackenberg L, Wassmann H, Liem D, Rosenbaum D, Bullmann V. Step activity monitoring in lumbar stenosis patients undergoing decompressive surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 19:1855-64. [PMID: 20186442 DOI: 10.1007/s00586-010-1324-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Revised: 01/05/2010] [Accepted: 01/24/2010] [Indexed: 12/18/2022]
Abstract
Symptomatic degenerative central lumbar spinal stenosis (LSS) is a frequent indication for decompressive spinal surgery, to reduce spinal claudication. No data are as yet available on the effect of surgery on the level of activity measured with objective long-term monitoring. The aim of this prospective, controlled study was to objectively quantify the level of activity in central LSS patients before and after surgery, using a continuous measurement device. The objective data were correlated with subjective clinical results and the radiographic degree of stenosis. Forty-seven patients with central LSS and typical spinal claudication scheduled for surgery were included. The level of activity (number of gait cycles) was quantified for 7 consecutive days using the StepWatch Activity Monitor (SAM). Visual analogue scales (VAS) for back and leg pain, Oswestry disability index and Roland-Morris score were used to assess the patients' clinical status. The patients were investigated before surgery and 3 and 12 months after surgery. In addition, the radiographic extent of central LSS was measured digitally on preoperative magnetic resonance imaging or computed tomography. The following results were found preoperatively: 3,578 gait cycles/day, VAS for back pain 5.7 and for leg pain 6.5. Three months after surgery, the patients showed improvement: 4,145 gait cycles/day, VAS for back pain 4.0 and for leg pain 3.0. Twelve months after surgery, the improvement continued: 4,335 gait cycles/day, VAS for back pain 4.1 and for leg pain 3.3. The clinical results and SAM results showed significant improvement when preoperative data were compared with data 3 and 12 months after surgery. The results 12 months after surgery did not differ significantly from those 3 months after surgery. The level of activity correlated significantly with the degree of leg pain. The mean cross-sectional area of the spinal canal at the central LSS was 94 mm(2). The radiographic results did not correlate either with objective SAM results or with clinical outcome parameters. In conclusion, this study is the first to present objective data on continuous activity monitoring/measurements in patients with central LSS. The SAM could be an adequate tool for performing these measurements in spine patients. Except for leg pain, the objective SAM results did not correlate with the clinical results or with the radiographic extent of central LSS.
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Affiliation(s)
- Tobias L Schulte
- Department of Orthopaedics, Münster University Hospital, Albert-Schweitzer-Strasse 33, 48149, Münster, Germany.
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Schulte TL, Hurschler C, Haversath M, Liljenqvist U, Bullmann V, Filler TJ, Osada N, Fallenberg EM, Hackenberg L. The effect of dynamic, semi-rigid implants on the range of motion of lumbar motion segments after decompression. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2008; 17:1057-65. [PMID: 18493802 PMCID: PMC2518758 DOI: 10.1007/s00586-008-0667-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Revised: 03/02/2008] [Accepted: 04/01/2008] [Indexed: 12/18/2022]
Abstract
Undercutting decompression is a common surgical procedure for the therapy of lumbar spinal canal stenosis. Segmental instability, due to segmental degeneration or iatrogenic decompression is a typical problem that is clinically addressed by fusion, or more recently by semi-rigid stabilization devices. The objective of this experimental biomechanical study was to investigate the influence of spinal decompression alone, as well as in conjunction with two semi-rigid stabilizing implants (Wallis, Dynesys) on the range of motion (ROM) of lumbar spine segments. A total of 21 fresh-frozen human lumbar spine motion segments were obtained. Range of motion and neutral zone (NZ) were measured in flexion-extension (FE), lateral bending (LAT) and axial rotation (ROT) for each motion segment under four conditions: (1) with all stabilizing structures intact (PHY), (2) after bilateral undercutting decompression (UDC), (3) after additional implantation of Wallis (UDC-W) and (4) after removal of Wallis and subsequent implantation of Dynesys (UDC-D). Measurements were performed using a sensor-guided industrial robot in a pure-moment-loading mode. Range of motion was defined as the angle covered between loadings of -5 and +5 Nm during the last of three applied motion cycles. Untreated physiologic segments showed the following mean ROM: FE 6.6 degrees , LAT 7.4 degrees , ROT 3.9 degrees . After decompression, a significant increase of ROM was observed: 26% FE, 6% LAT, 12% ROT. After additional implantation of a semi-rigid device, a decrease in ROM compared to the situation after decompression alone was observed with a reduction of 66 and 75% in FE, 6 and 70% in LAT, and 5 and 22% in ROT being observed for the Wallis and Dynesys, respectively. When the flexion and extension contribution to ROM was separated, the Wallis implant restricted extension by 69% and flexion by 62%, the Dynesys by 73 and 75%, respectively. Compared to the intact status, instrumentation following decompression led to a ROM reduction of 58 and 68% in FE, 1 and 68% in LAT, -6 and 13% in ROT, 61 and 65% in extension and 54 and 70% in flexion for Wallis and Dynesys. The effect of the implants on NZ corresponded to that on ROM. In conclusion, implantation of the Wallis and Dynesys devices following decompression leads to a restriction of ROM in all motion planes investigated. Flexion-extension is most affected by both implants. The Dynesys implant leads to an additional strong restriction in lateral bending. Rotation is only mildly affected by both implants. Wallis and Dynesys restrict not only isolated extension, but also flexion. These biomechanical results support the hypothesis that postoperatively, the semi-rigid implants provide a primary stabilizing function directly. Whether they can improve the clinical outcome must still be verified in prospective clinical investigations.
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Affiliation(s)
- Tobias L Schulte
- Department of Orthopaedics, University Hospital Münster, Albert-Schweitzer-Strasse 33, 48149, Münster, Germany.
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Thomé C, Börm W, Meyer F. Degenerative lumbar spinal stenosis: current strategies in diagnosis and treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2008; 105:373-9. [PMID: 19626175 DOI: 10.3238/arztebl.2008.0373] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Accepted: 02/07/2008] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Although the aging of the population is causing a dramatic rise in the incidence of lumbar spinal stenosis, the indications and options for surgical treatment are not clearly defined. METHODS In an attempt to aid clinical decision making, a selective literature review was conducted, taking into account the guidelines of the Association of the Scientific Medical Societies in Germany (AWMF). RESULTS In degenerative lumbar spinal stenosis hypertrophy of the facet joints and yellow ligaments brings about constriction of the spinal canal, leading to back pain and activity-dependent lower limb symptoms (neurogenic claudication). If conservative treatment fails, an imaging study, usually magnetic resonance imaging, is required. In the case of severe symptoms the progressive underlying degeneration necessitates surgical treatment. Minimally invasive fenestration techniques are usually employed to decompress the spinal canal; in the presence of instability, fusion is indicated. DISCUSSION Despite the proven superiority of surgery in the management of refractory lumbar spinal stenosis, there is a lack of evidence-based data regarding the different surgical treatment options. The evaluation of modern, minimally invasive techniques is thus difficult.
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