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Chen L, Guan B, Anderson DB, Ferreira PH, Stanford R, Beckenkamp PR, Van Gelder JM, Bayartai ME, Radojčić MR, Fairbank JCT, Feng S, Zhou H, Ferreira ML. Surgical interventions for degenerative lumbar spinal stenosis: a systematic review with network meta-analysis. BMC Med 2024; 22:430. [PMID: 39379938 PMCID: PMC11463109 DOI: 10.1186/s12916-024-03653-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 09/24/2024] [Indexed: 10/10/2024] Open
Abstract
BACKGROUND Several surgical options for degenerative lumbar spinal stenosis (LSS) are available, but current guidelines do not recommend which one should be prioritized. Although previous network meta-analyses (NMAs) have been performed on this topic, they have major methodological problems and could not provide the convincing evidence and clinical practical information required. METHODS Randomized controlled trials (RCTs) comparing at least two surgical interventions were included by searching AMED, CINAHL, EMBASE, the Cochrane Library, and MEDLINE (inception to August 2023). A frequentist random-effects NMA was performed for physical function and adverse events due to any reason. For physical function, three follow-up time points were included: short-term (< 6 months post-intervention), mid-term (≥ 6 months but < 12 months), and long-term (≥ 12 months). Laminectomy was the reference comparison intervention. RESULTS A total of 43 RCTs involving 5017 participants were included in the systematic review and 28 RCTs encompassing 14 types of surgical interventions were included in the NMA. For improving physical function (scale 0-100), endoscopic-assisted laminotomy (mean difference: - 8.61, 95% confidence interval: - 10.52 to - 6.69; moderate-quality evidence), laminectomy combined with Coflex (- 8.41, - 13.21 to - 3.61; moderate quality evidence), and X-stop (- 6.65, - 8.60 to - 4.71; low-quality evidence) had small effects at short-term follow-up; no statistical difference was observed at mid-term follow-up (very low- to low-quality evidence); at long-term follow-up, endoscopic-assisted laminotomy (- 7.02, - 12.95 to - 1.08; very low-quality evidence) and X-stop (- 10.04, - 18.16 to - 1.93; very low-quality evidence) had a small and moderate effect, respectively. Compared with laminectomy, endoscopic-assisted laminotomy was associated with fewer adverse events due to any reason (odds ratio: 0.27, 0.09 to 0.86; low-quality evidence). CONCLUSIONS For adults with degenerative LSS, endoscopic-assisted laminotomy may be the safest and most effective intervention in improving physical function. However, the available data were insufficient to indicate whether the effect was sustainable after 6 months. TRIAL REGISTRATION PROSPERO (CRD42018094180).
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Affiliation(s)
- Lingxiao Chen
- Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, People's Republic of China
- Department of Biostatistics, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, People's Republic of China
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Bin Guan
- Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, People's Republic of China
| | - David B Anderson
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Paulo H Ferreira
- The University of Sydney, Sydney Musculoskeletal Health, Charles Perkins Centre, School of Health Sciences, Faculty of Medicine and Health, Sydney, NSW, Australia
| | - Ralph Stanford
- Prince of Wales Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Paula R Beckenkamp
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - James M Van Gelder
- Concord Repatriation General Hospital, Concord, Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Munkh-Erdene Bayartai
- Institute of Physiotherapy, School of Health Professions, Zurich University of Applied Sciences, (ZHAW), Winterthur, Switzerland
- Department of Physical and Occupational Therapy, School of Nursing, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Maja R Radojčić
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jeremy C T Fairbank
- Botnar Institute of Musculoskeletal Sciences, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Shiqing Feng
- Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, People's Republic of China.
- The Second Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250033, People's Republic of China.
| | - Hengxing Zhou
- Department of Orthopaedics, Qilu Hospital of Shandong University, Shandong University Centre for Orthopaedics, Advanced Medical Research Institute, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, People's Republic of China.
- The Second Hospital of Shandong University, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250033, People's Republic of China.
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, 250012, People's Republic of China.
| | - Manuela L Ferreira
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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Algarni N, Al-Amoodi M, Marwan Y, Bokhari R, Addar A, Alshammari A, Alaseem A, Albishi W, Alshaygy I, Alabdullatif F. Unilateral laminotomy with bilateral spinal canal decompression: systematic review of outcomes and complications. BMC Musculoskelet Disord 2023; 24:904. [PMID: 37990183 PMCID: PMC10662450 DOI: 10.1186/s12891-023-07033-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 11/10/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Unilateral laminotomy with bilateral spinal canal decompression has gained popularity recently. AIM To systematically review the literature of unilateral laminotomy with bilateral spinal canal decompression for lumbar spinal stenosis (LSS) aiming to assess outcomes and complications of the different techniques described in literature. METHODS On August 7, 2022, Pubmed and EMBASE were searched by 2 reviewers independently, and all the relevant studies published up to date were considered based on predetermined inclusion and exclusion criteria. The subject headings "unilateral laminotomy", "bilateral decompression" and their related key terms were used. The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles. RESULTS A total of seven studies including 371 patients were included. The mean age of the patients was 69.0 years (range: 55-83 years). The follow up duration ranged from 1 to 3 years. Rate of postoperative pain and functional improvement was favorable based on VAS, JOA, JOABPEQ, RMDW, ODI and SF-36, for example improved from a range of 4.2-7.5 preoperatively on the VAS score to a range of 1.4-3.0 postoperatively at the final follow up. Insufficient decompression was noted in 3% of the reported cases. The overall complication rate was reported at 18-20%, with dural tear at 3.6-9% and hematoma at 0-4%. CONCLUSION Unilateral laminotomy with bilateral decompression has favorable short- and mid-term pain and functional outcomes with low recurrence and complication rates. This, however, needs to be further confirmed in larger, long-term follow-up, prospective, comparative studies between open, and minimally invasive techniques.
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Affiliation(s)
- Nizar Algarni
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed Al-Amoodi
- Department of Orthopedics, University of British Columbia, Vancouver, BC, Canada
| | - Yousef Marwan
- Department of Surgery, Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
| | - Rakan Bokhari
- Division of Neurosurgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Abdullah Addar
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah Alshammari
- Department of Orthopedic Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Abdulrahman Alaseem
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Waleed Albishi
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ibrahim Alshaygy
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Fahad Alabdullatif
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Unilateral microscopic approach for lumbar spinal stenosis decompression: a scoping review. 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 2023; 32:475-487. [PMID: 36437434 DOI: 10.1007/s00586-022-07461-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 10/07/2022] [Accepted: 11/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Microscopic unilateral laminotomy for bilateral decompression (ULBD) is a minimally invasive technique used in the treatment of lumbar spinal stenosis and could limit spinal instability and be associated with better clinical outcomes. However, there is ongoing debate regarding its utility compared to conventional laminectomy (CL). The primary objective was to collate and describe the current evidence base for ULBD, including perioperative parameters, functional outcomes, and complications. The secondary objective was to identify operative techniques. METHODS A scoping review was conducted between January 1990 and August 2022 according to the PRISMA extension for scoping reviews (PRISMA-ScR) guidelines. Major databases were searched for full text English articles reporting on outcomes following microscopic unilateral laminotomy in patients with lumbar spinal stenosis. RESULTS Seventeen articles met the inclusion criteria. Two studies were randomised controlled trials. Two studies were prospective data collection and the rest were retrospective analysis. Three studies compared ULBD with CL. ULBD preserves the osteoligamentous complex and may be associated with shorter operative time, less blood loss, and similar clinical outcomes when compared to CL. CONCLUSION This review highlights that ULBD aims to minimise disruption to the normal posterior spinal anatomy and may have acceptable clinical outcomes. It also highlights that it is difficult to draw valid conclusions given there are limited data available as most studies identified were retrospective or did not have a comparator group.
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Kaya Ayvaz D, Kervancıoğlu P, Bahşi A, Bahşi İ. A Radiological Evaluation of Lumbar Spinous Processes and Interspinous Spaces, Including Clinical Implications. Cureus 2021; 13:e19454. [PMID: 34912602 PMCID: PMC8664751 DOI: 10.7759/cureus.19454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 11/16/2022] Open
Abstract
Background and objective The aim of this study was the examination of morphometry of the spinous process (SP) and interspinous space (ISS) of the lumbar region to help provide a basis for the design and implantation of interspinous devices. Methods Between 2017 and 2019, 215 individuals underwent magnetic resonance imaging of the lumbar region for various reasons. No pathology was detected in these images, and the participants' age, height, and weight information when available were included in the study. From these images, the height and length of the SP and ISS in the lumbar region were noted. The heights of the SP and ISS were measured at three levels as anterior, middle, and posterior (respectively, anterior height of the spinous process [AHSP], middle height of the spinous process [MHSP], as well as posterior height of the spinous process [PHSP] for the height of SP, and anterior ISS, middle ISS and posterior ISS for the height of ISS). All measurements were compared according to the gender, age, weight, height, and body mass index of the individuals. Results The level with the lowest SP height and length was L5 vertebra. The ISS height and length were lowest at L4-L5. In addition, we observed a statistically significant difference at multiple levels with age, weight, height, and body mass index of the reference ranges. Conclusion We think that these changes should be considered when designing and implanting interspinous devices. Since there are few studies examining all these correlations, we think that the results of this study will make a unique contribution to the literature.
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Konovalov NA, Nazarenko AG, Asyutin DS, Brinyuk ES, Kaprovoy SV, Zakirov BA. [Degenerative lumbar spine stenosis: minimally invasive microsurgical methods of treatment]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:87-95. [PMID: 34463455 DOI: 10.17116/neiro20218504187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Degenerative lumbar spine stenosis is one of the main causes of chronic pain and radiculopathy in advanced age people. Along with increase in average life expectancy, degenerative lumbar spine stenosis becomes the most common indication for spinal surgery. There is still no consensus regarding the most optimal surgical approach due to the variety of modern surgical methods. In recent years, minimally invasive spinal surgery has become a more advisable alternative to open surgery due to its advanced technical features combined with less soft tissue damage, lower risk of complications and shorter postoperative recovery.
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Affiliation(s)
| | | | - D S Asyutin
- Burdenko Neurosurgical Center, Moscow, Russia
| | - E S Brinyuk
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - B A Zakirov
- Burdenko Neurosurgical Center, Moscow, Russia
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Huang Y, Chen J, Gao P, Gu C, Fan J, Hu Z, Cao X, Yin G, Zhou W. A comparison of the bilateral decompression via unilateral approach versus conventional approach transforaminal lumbar interbody fusion for the treatment of lumbar degenerative disc disease in the elderly. BMC Musculoskelet Disord 2021; 22:156. [PMID: 33557804 PMCID: PMC7871543 DOI: 10.1186/s12891-021-04026-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 01/27/2021] [Indexed: 11/17/2022] Open
Abstract
Background Bilateral decompression via unilateral approach (BDUA) is an effective surgical approach for treating lumbar degenerative diseases. However, no studies of prognosis, especially the recovery of the soft tissue, have reported using BDUA in an elderly population. The aims of these research were to investigate the early efficacy of the bilateral decompression via unilateral approach versus conventional approach transforaminal lumbar interbody fusion (TLIF) for the treatment of lumbar degenerative disc disease in the patients over 65 years of age, especially in the perioperative factors and the recovery of the soft tissue. Methods The clinical data from 61 aging patients with lumbar degenerative disease who received surgical treatment were retrospectively analyzed. 31 cases who received the lumbar interbody fusion surgery with bilateral decompression via unilateral approach (BDUA) were compared with 30 cases who received conventional approach transforaminal lumbar interbody fusion. The radiographic parameters were measured using X-ray including lumbar lordosis angle and fusion rate. Japanese Orthopedic Association (JOA), Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores were used to evaluate the clinical outcomes at different time points. Fatty degeneration ratio and area of muscle/vertebral body were used to detect recovery of soft tissue. Results The BDUA approach group was found to have significantly less intraoperative blood loss(p < 0.05) and postoperative drainage(p < 0.05) compared to conventional approach transforaminal lumbar interbody fusion group. Symptoms of spinal canal stenosis and nerve compression were significantly relieved postoperatively, as compared with the preoperative state. However, the opposite side had a lower rate of fatty degeneration (9.42 ± 3.17%) comparing to decompression side (11.68 ± 3.08%) (P < 0.05) six months after surgery in the BDUA group. While there were no significant differences (P > 0.05) in two sides of conventional transforaminal lumbar interbody fusion approach group six months after surgery. Conclusions Bilateral decompression via unilateral approach (BDUA) is able to reduce the intraoperative and postoperative body fluid loss in the elderly. The opposite side of decompression in BDUA shows less fatty degeneration in 6 months, which indicates better recovery of the soft tissue of the aging patients.
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Affiliation(s)
- Yifan Huang
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Jian Chen
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Peng Gao
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Changjiang Gu
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Jin Fan
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Zhiyi Hu
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Xiaojian Cao
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China
| | - Guoyong Yin
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China.
| | - Wei Zhou
- Department of Orthopedics, The First Affiliated Hospital of Nanjing Medical University, No. 300 Guangzhou Road, Nanjing, 210029, People's Republic of China.
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Wang Y, Zhang Y, Chong F, Zhou Y, Huang B. Clinical outcomes of minimally invasive transforaminal lumbar interbody fusion via a novel tubular retractor. J Int Med Res 2021; 48:300060520920090. [PMID: 32367755 PMCID: PMC7218951 DOI: 10.1177/0300060520920090] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective To assess the feasibility and clinical results of microscopic minimally
invasive transforaminal lumbar interbody fusion (MIS-TLIF) using a novel
tapered tubular retractor that preserves the multifidus. Method A total of 122 patients underwent MIS-TLIF using a tapered tubular retractor
system from March 2016 to August 2017. Perioperative parameters and
follow-up outcomes were reviewed. Results The follow-up period was 23.95 ± 1.43 months. The operative time averaged
130.48 ± 34.44 minutes. The estimated blood loss was 114.10 ± 96.70 mL. The
mean time until ambulation was 16.33 ± 6.29 hours. The average visual
analogue scale (leg/waist) and Oswestry Disability Index scores
(preoperative to last follow-up) improved from 4.93 ± 2.68/3.74 ± 2.28 to
0.34 ± 0.77/0.64 ± 0.74 and from 59.09% ± 22.34 to 17.04% ± 8.49,
respectively. At the last follow-up, 98.36% of the patients achieved solid
fusion. Cerebrospinal fluid leakage occurred in two cases. The asymptote of
the surgeon’s learning curve occurred at the 25th case. There were no
significant differences between the preoperative qualitative and
quantitative analyses of multifidus muscle fatty infiltration and those at
the final follow-up. Conclusion MIS-TLIF can be performed safely and effectively using this tapered tubular
retractor system, which helps preserve the multifidus.
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Affiliation(s)
- Yan Wang
- Department of Orthopedics, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Yaqing Zhang
- Department of Orthopedics, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Fanli Chong
- Department of Orthopedics, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Yue Zhou
- Department of Orthopedics, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Bo Huang
- Department of Orthopedics, Xinqiao Hospital, Third Military Medical University, Chongqing, China
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Wu MH, Wu PC, Lee CY, Lin YK, Huang TJ, Lin CL, Lin CH, Huang YH. Outcome analysis of lumbar endoscopic unilateral laminotomy for bilateral decompression in patients with degenerative lumbar central canal stenosis. Spine J 2021; 21:122-133. [PMID: 32871276 DOI: 10.1016/j.spinee.2020.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has been reported as an alternative treatment for degenerative lumbar central canal stenosis (DLCS). PURPOSE To investigate the outcomes of LE-ULBD for different types of DLCS, including simple DLCS, DLCS with degenerative spondylolisthesis (DSL), and DLCS with degenerative scoliosis (DSC). STUDY DESIGN/SETTING Prospective cohort study. PATIENT SAMPLE One-hundred sixteen patients with DLCS who underwent LE-ULBD at a spine center from April 2015 to June 2017 were enrolled in this study. OUTCOME MEASURES Operative time, postoperative duration of hospitalization, and clinical outcomes (Oswestry disability index [ODI], visual analog scale [VAS], and modified Macnab outcome scale), and adverse events. METHODS A comparative analysis was performed evaluating medical records, radiological studies, and patient reported outcomes including ODI score, VAS scores and modified Macnab outcome scales in patients who underwent LE-ULBD. Data were prospectively collected at preoperative, postoperative 3-, 6-, 12-, 24-month to assess clinical and radiological outcomes and complications. RESULTS The study analyzed 106 patients (45 men and 61 women, with a mean age of 69.5 years); 40 (37.8%) had simple DLCS, 41 (38.7%) had DLCS with DSL, and 25 (23.5%) had DLCS with DSC. The mean follow-up period was 33.3 months. The mean preoperative and postoperative follow-up ODI score and VAS scores for leg and back pain showed significant improvement in all time points. No significant difference was found among different pathologies in terms of VAS scores for back and leg pain, ODI scores and modified Macnab outcome scales at all follow-up periods. CONCLUSIONS LE-ULBD is a feasible treatment method for DLCS. It did not result in worse outcomes in cases with DLCS with DSL or DLCS with DSC as compared with cases with simple DLCS.
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Affiliation(s)
- Meng-Huang Wu
- Department of Orthopedics, Taipei Medical University Hospital, Taipei 11031, Taiwan; Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Po-Chien Wu
- Department of Medical Education, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Ching-Yu Lee
- Department of Orthopedics, Taipei Medical University Hospital, Taipei 11031, Taiwan; Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Yen-Kuang Lin
- Research Center of Biostatistics, Taipei Medical University, Taipei 11031, Taiwan
| | - Tsung-Jen Huang
- Department of Orthopedics, Taipei Medical University Hospital, Taipei 11031, Taiwan; Department of Orthopaedics, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Cheng-Li Lin
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan; Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan; Medical Device Innovation Center (MDIC), National Cheng Kung University, Tainan 70101, Taiwan
| | - Chang-Hao Lin
- Department of Orthopaedics, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City 60002, Taiwan
| | - Yi-Hung Huang
- Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan; Department of Orthopaedics, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City 60002, Taiwan.
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Pang CY, Chen KY, Tseng KY, Hueng DY, Chang TS. Clinical outcome and multifidus muscle changes of transforaminal lumbar interbody fusion: Minimally invasive procedure versus conventional open approach. FORMOSAN JOURNAL OF SURGERY 2021. [DOI: 10.4103/fjs.fjs_112_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Salim AA, Yusof AH, Johari J, Yusof MI. Feasibility of Unilateral Approach for Bilateral Decompressive Endoscopic Spinal Surgery for Lumbar Stenosis to Improve Back and Leg Pain: A Consecutive Single-Center Series of 60 Patients. Front Surg 2020; 7:507954. [PMID: 33364252 PMCID: PMC7753151 DOI: 10.3389/fsurg.2020.507954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 09/25/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Endoscopic surgery is one of the methods that achieve the goal of decompression while minimizing collateral tissue damage. Its efficacy and safety have been supported by numerous studies. There is a plethora of studies on lumbar stenosis regarding the outcomes and related issues in endoscopic spine surgery. However, few studies evaluated the outcome of the decompressive lumbar spine surgery. The present study aims to analyze the outcome of a unilateral approach to endoscopic surgery for lumbar stenosis using the visual analog scale (VAS), the Oswestry Disability Index (ODI), and MacNab's criteria. Methods: This is a retrospective study (level IV) conducted between January 2009 and December 2013 on 60 patients who underwent endoscopic interlaminar decompressive spine surgery (Destandau method) for lumbar degenerative spinal stenosis in the Hospital Universiti Sains Malaysia. The clinical outcome was measured pre-operatively and post-operatively for VAS: for back and leg pain, motor and sensory grading, the ODI, and MacNab's criteria. A paired t-test was used for statistical analysis. Results: The mean age of patients was 60.82 years comprising 23 males (38.3%) and 37 females (61.7%). The mean follow-up period was 30.1 months (range = 17.2–43 months). The mean operation time was 183.6 min (ranging from 124.8 to 242.4 min), and the mean blood loss was 150.18 mL (ranging from 30.82 to 269.54 mL). Post-operatively, mean hospital stay was 2.45 days (ranging from 1.34 to 3.56 days). The most frequently involved level was L4/L5 in 51 patients (52.6%), followed by L3/L4 in 19 patients (19.6%), L5/S1 in 24 patients (24.7%), and L2/L3 in three patients (3.1%). Improvement in the post-operative VAS for back and leg pain and the ODI for pre-operation and post-operation was statistically significant (p < 0.001). Conversely, the reduction in neurological status was statistically insignificant. Based on MacNab's criteria, 88.4% showed excellent to good outcomes. Conclusion: To summarize, unilateral percutaneous endoscopic spine surgery to achieve the bilateral decompression in lumbar stenosis provides excellent yet safe and effective outcomes. It improves back and leg pain and patients' function significantly.
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Affiliation(s)
- Azizul Akram Salim
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kota Bharu, Malaysia.,Department of Orthopaedics, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Abdul Halim Yusof
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kota Bharu, Malaysia.,Department of Orthopaedics, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Joehaimey Johari
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kota Bharu, Malaysia.,Department of Orthopaedics, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Mohd Imran Yusof
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kota Bharu, Malaysia.,Department of Orthopaedics, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
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Yolcu YU, Helal A, Alexander AY, Bhatti AU, Alvi MA, Abode-Iyamah K, Bydon M. Minimally Invasive Versus Open Surgery for Degenerative Spine Disorders for Elderly Patients: Experiences from a Single Institution. World Neurosurg 2020; 146:e1262-e1269. [PMID: 33276177 DOI: 10.1016/j.wneu.2020.11.145] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) of the spine has been associated with lower complication rates and improved patient-reported outcomes in recent studies. In this study, we aimed to investigate operative and postoperative outcomes associated with both surgical techniques in elderly patients. METHODS Patients who are 65 years old or older underwent either minimally invasive or open surgery for lumbar degenerative conditions. Patients with a nondegenerative cause such as infection or trauma were excluded from the analysis. Patient characteristics such as demographics and associated comorbidities as well as perioperative and postoperative complications were collected. Outcomes of interest were operative time, estimated blood loss (EBL), length of stay (LOS), readmissions, reoperations, and any complications. RESULTS A total of 107 elderly patients were identified for this study, with a median age of 73.0 years. Demographics and comorbidities in both groups were similar in both groups. Univariate analysis yielded an MIS group with significantly lower EBL (P < 0.001), operative time (P < 0.001), and LOS (P < 0.001). In multivariable analysis, EBL and LOS were found to be significantly lower in the MIS group (P = 0.02 and 0.001, respectively). Rates of complications, readmissions (no readmissions in MIS group), reoperations, and pain improvement also favored the MIS group and although they were not found to be significantly different between the 2 groups on univariate and multivariable analysis, the results trended toward significance. CONCLUSIONS These findings suggest that minimally invasive spine surgery in the elderly is safe and may pose a lower risk of associated perioperative and postoperative complications with faster recovery time.
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Affiliation(s)
- Yagiz U Yolcu
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmed Helal
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Alex Y Alexander
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA; University of Minnesota, Minneapolis, Minnesota, USA
| | - Atiq U Bhatti
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammed A Alvi
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA.
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Lim KT, Meceda EJA, Park CK. Inside-Out Approach of Lumbar Endoscopic Unilateral Laminotomy for Bilateral Decompression: A Detailed Technical Description, Rationale and Outcomes. Neurospine 2020; 17:S88-S98. [PMID: 32746522 PMCID: PMC7410386 DOI: 10.14245/ns.2040196.098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 05/21/2020] [Indexed: 11/19/2022] Open
Abstract
Although lumbar stenosis was recognized as a contraindication for endoscopic spine surgery in the past, the advancement in endoscopic system design and development of approach techniques and strategies now enabled the endoscopic spine surgeons to manage all types of lumbar stenosis safely and more effectively. A full-endoscopic lumbar technique for surgical management of spinal canal stenosis is now used today in many advanced spine centers around the world as one of their standard procedures which can be done under general, regional, local anesthesia with sedation. In this technical report, we described in detail the inside-out approach of performing lumbar endoscopic unilateral laminotomy with bilateral decompression (LE-ULBD) and retrospectively reviewed hospital records of 127 patients who underwent the approach from December 2018 to March 2019 to address 1 level lumbar spinal stenosis and determined its outcome after 12-month follow-up period. Perioperative outcomes, operation time, length of hospital stay, and surgical complications were recorded and analyzed. The cross-sectional area of the thecal sac at the operated level was measured. The visual analogue scale (VAS) was assessed preoperatively, 1 month, and 12 months as well as the Oswestry Disability Index (ODI). The data were statistically analyzed (using SPSS ver. 17.0). The inside-out approach LE-ULBD was shown to effect statistically significant improvement in the VAS of leg and back pain as well as the ODI. It is a familiar, safe, and effective way of performing spinal stenosis decompression with good reproducible outcomes.
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Affiliation(s)
| | - Elmer Jose Arevalo Meceda
- Department of Neurosciences, University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, the Philippines.,Department of Surgery, Section of Neurosurgery, Bicol Medical Center, Naga City, the Philippines
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Wu J, Guan T, Tian F, Liu X. Comparision of biportal endoscopic and microscopic decompression in treatment of lumbar spinal stenosis: A comparative study protocol. Medicine (Baltimore) 2020; 99:e21309. [PMID: 32791717 PMCID: PMC7387062 DOI: 10.1097/md.0000000000021309] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Microscopic bilateral decompression (MBD) has been suggested as an alternative to open laminectomy and fusion. Recently, percutaneous biportal endoscopic decompression (PBED) has begun to attract attention. The purpose of this retrospective study was to evaluate postoperative pain, functional disability, symptom reduction and satisfaction, and specific surgical parameters between the MBD and PBED techniques in patients with lumbar spinal stenosis (LSS). METHODS A retrospective review of LSS patients performed with MBD or PBED technique between May 2015 and June 2018 was conducted. Institutional review board approval in People's Hospital of Ningxia Hui Nationality Autonomous Region was obtained prior to conducting chart review and analysis. We received informed consent from all patients before surgery. The primary outcomes assessed were the preoperative to postoperative changes in leg/back pain and disability/function, patient satisfaction with the procedure, and postoperative quality of life. The secondary outcomes including duration of postoperative hospital stay, time to mobilization, postoperative analgesic use, complication rates, and baseline patient characteristics were prospectively collected. RESULTS The hypothesis was that the PBED technique would achieve better clinical outcomes as compared to the MBD technique in LSS.
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Kim HS, Choi SH, Shim DM, Lee IS, Oh YK, Woo YH. Advantages of New Endoscopic Unilateral Laminectomy for Bilateral Decompression (ULBD) over Conventional Microscopic ULBD. Clin Orthop Surg 2020; 12:330-336. [PMID: 32904063 PMCID: PMC7449863 DOI: 10.4055/cios19136] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 12/30/2019] [Indexed: 11/24/2022] Open
Abstract
Backgroud Biportal endoscopic unilateral laminectomy for bilateral decompression (ULBD) is an emerging minimally invasive procedure for spinal stenosis. However, reports of the results associated with this surgical method are still lacking. Methods We conducted a retrospective study of 60 patients who underwent bilateral decompression for lumbar central canal stenosis. The patients were divided into 2 groups according to the surgical method (endoscopic ULBD vs. microscopic ULBD). We compared the outcomes between the 2 groups in terms of postoperative segmental spinal instability, dura expansion, operation time, estimated blood loss, serum creatine kinase (CK), serum C-reactive protein (CRP), visual analog scale (VAS) score, Oswestry Disability Index (ODI), modified MacNab score, and the incidence of complications. Results The mean VAS, ODI, and modified MacNab score improved significantly from the preoperative period to the last follow-up in both groups and were better in the endoscopic ULBD group until the first day after treatment. The degree of horizontal displacement was lower in the endoscopic ULBD group than in the microscopic ULBD group at postoperative 12 months. Dura expansion, operation time, and estimated blood loss did not differ significantly between the 2 groups. Serum CK and CRP on the first day after treatment were lower in the endoscopic ULBD group than in the microscopic ULBD group. Conclusions This study shows that both endoscopic ULBD and microscopic ULBD can provide favorable outcomes for lumbar central canal stenosis. However, compared to microscopic ULBD, endoscopic ULBD has advantages in terms of postoperative segmental spinal instability, pain control, and serum CK and CRP.
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Affiliation(s)
- Hyeun-Sung Kim
- Department of Neurosurgery, Gangnam Nanoori Hospital, Seoul, Korea
| | - Sung-Hoon Choi
- Department of Orthopaedic Surgery, Busan Bumin Hospital, Busan, Korea
| | - Dae-Moo Shim
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - In-Seung Lee
- Department of Orthopaedic Surgery, Wonkwang University Hospital, Iksan, Korea
| | - Young-Kwang Oh
- Department of Orthopaedic Surgery, Daedong Hospital, Busan, Korea
| | - Young-Ha Woo
- Department of Orthopaedic Surgery, Daedong Hospital, Busan, Korea
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Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To report the feasibility, nuances, technical tips as well as outcomes of managing single-level grade D (extreme stenosis) and to compare the outcomes with nonextreme stenosis using the tubular retractor system. SUMMARY OF BACKGROUND DATA Minimally invasive decompression in extreme stenosis is a challenge due to technical difficulty, feasibility of adequate decompression, and a steep learning curve. METHODS Consecutive patients from January 2007 to January 2017 presenting with neurogenic claudication secondary to single-level spinal stenosis operated using tubular retractors were included in the study. The patients were divided into two groups; extreme-stenosis and nonextreme stenosis. The outcomes of surgery were evaluated and compared using visual analogue score (VAS) for leg and back pain, Oswestry disability index (ODI), and MacNab's criteria. RESULTS A total of 325 patients (out of 446 patients after excluding the multilevel cases) fulfilled the inclusion criteria. One hundred forty patients were cases of extreme stenosis and 185 were nonextreme stenosis. The mean VAS for back and leg pain for extreme stenosis improved from 3.23 ± 1.30 to 2.15 ± 0.91 and 7.33 ± 0.78 to 1.66 ± 1.03 respectively as compared with nonextreme stenosis where the mean VAS for back and leg pain improved from 3.01 ± 1.15 to 1.86 ± 1.10 and 6.57 ± 1.00 to 1.54 ± 1.12 respectively. The mean ODI changed from 66.47 ± 7.53 to 19.95 ± 2.90 in extreme stenosis as compared with nonextreme stenosis where mean ODI changed from 59.05 ± 5.08 to 19.88 ± 2.67. As per MacNab's criteria 102 (of 120 patients) and 139 (of 157 patients) reported excellent and good outcomes in extreme and nonextreme stenosis respectively. CONCLUSION Tubular decompression is feasible in patients with extreme-stenosis with no difference in the outcomes as well as complication rates when compared with a cohort of nonextreme stenosis. LEVEL OF EVIDENCE 3.
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Carrascosa-Granada A, Velazquez W, Wagner R, Saab Mazzei A, Vargas-Jimenez A, Jorquera M, Albacar JAB, Sallabanda K. Comparative Study Between Uniportal Full-Endoscopic Interlaminar and Tubular Approach in the Treatment of Lumbar Spinal Stenosis: A Pilot Study. Global Spine J 2020; 10:70S-78S. [PMID: 32528810 PMCID: PMC7263328 DOI: 10.1177/2192568219878419] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Multicenter, prospective, randomized, and double-blinded study. OBJECTIVES To compare tubular and endoscopic interlaminar approach. METHODS Patients with lumbar spinal stenosis and neurogenic claudication of were randomized to tubular or endoscopic technique. Enrollment period was 12 months. Clinical follow up at 1, 3, 6 months after surgery with visual analogue scale (VAS), Oswestry Disability Index (ODI), and Japanese Orthopedic Association (JOA) score. Radiologic evaluation with magnetic resonance pre- and postsurgery. RESULTS Twenty patients were enrolled: 10 in tubular approach (12 levels) and 10 in endoscopic approach (11 levels). The percentage of enlargement of the spinal canal was higher in endoscopic approach (202%) compared with tubular approach (189%) but was not statistically significant (P = .777). The enlargement of the dural sac was higher in endoscopic group (209%) compared with tubular group (203%) but no difference was found between the 2 groups (P = .628). A modest significant correlation was found between the percentage of spinal canal decompression and enlargement of the dural sac (r = 0.5, P = .023). Both groups reported a significant clinical improvement postsurgery. However, no significant association was found between the percentage of enlargement of the spinal canal or the dural sac and clinical improvement as determined by scales scores. Endoscopic group had lower intrasurgical bleeding (P < .001) and lower disability at 6 months of follow-up than tubular group (p=0.037). CONCLUSIONS In the treatment of lumbar spinal stenosis, endoscopic technique allows similar decompression of the spinal canal and the dural sac, lower intrasurgical bleeding, similar symptoms improvement, and lower disability at 6 months of follow-up, as compared with the tubular technique.
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Affiliation(s)
| | | | | | | | | | | | | | - Kita Sallabanda
- Hospital Clínico San Carlos, Madrid, Spain
- Complutense University of Madrid, Madrid, Spain
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Aydın Y, Yüce İ, Çavuşoğlu H. Letter: Contralateral Minimally Invasive Laminectomy for Resection of a Synovial Cyst: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 18:E258-E259. [DOI: 10.1093/ons/opaa046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Yunus Aydın
- Acıbadem Healthcare Group Fulya Hospital Istanbul, Turkey
| | - İsmail Yüce
- Vocational School of Health Services Acıbadem Mehmet Ali Aydınlar University Istanbul, Turkey
| | - Halit Çavuşoğlu
- Vocational School of Health Services Acıbadem Mehmet Ali Aydınlar University Istanbul, Turkey
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Kulkarni AG, Das S, Kunder TS. Are There Differences Between Patients with Extreme Stenosis and Non-extreme Stenosis in Terms of Pain, Function or Complications After Spinal Decompression Using a Tubular Retractor System? Clin Orthop Relat Res 2020; 478:348-356. [PMID: 31633587 PMCID: PMC7438131 DOI: 10.1097/corr.0000000000001004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 10/03/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Micro-tubular decompression in extreme lumbar spinal stenosis is challenging because it is technically difficult to achieve adequate decompression. Whether the results of micro-tubular decompression related to pain, function, and complications in lumbar spinal stenosis of the extreme and non-extreme varieties are different has not yet been conclusively established. QUESTIONS/PURPOSES Are there differences between patients with extreme stenosis and non-extreme stenosis in terms of (1) VAS back or leg pain, (2) Oswestry Disability Index (ODI), or (3) complications when they were treated with spinal decompression using a tubular retractor system? METHODS Between January 2007 and January 2017, one surgeon performed 325 single-level lumbar micro-tubular decompressions without fusion. Of those, 43% (140 of 325) had extreme stenosis (defined as the absence of cerebrospinal fluid signal and a grey homogeneous dural sac with unrecognizable rootlets and posterior epidural fat in T2 weighted axial MRI image) and the rest had non-extreme stenosis. During this time, we used tubular retractors for these procedures in patients with simple lumbar spinal stenosis who had persistent symptoms despite conservative treatment for neurogenic claudication. No alternate form of decompression was performed in the study period. Patients with complex lumbar spinal stenosis associated with a deformity or instability who were treated with instrumented fusion were excluded. A total of 14% (20 of 140) patients in the extreme stenosis group and 15% (28 of 185) patients in the non-extreme stenosis group were lost to follow-up before 2 years; the remaining 120 patients with extreme stenosis and 157 patients with non-extreme stenosis were analyzed at a mean follow-up of 33 ± 5 months in this retrospective, comparative study. The groups were not different at baseline in terms of preoperative VAS score for back pain, age, gender, BMI or the percentage who had diabetes or who smoked. However, patients with extreme stenosis had higher preoperative ODI scores and higher preoperative VAS score for leg pain compared with the non-extreme group. There was a higher proportion of men in the non-extreme stenosis group (56% [104 of 185] versus 50% [71 of 140]; p = 0.324). Study endpoints were VAS score for leg and back pain, ODI, and complications, all of which were ascertained by chart review. With the numbers available, we could detect with 80% power at p < 0.05 a difference of 0.93 cm of 10 cm on a 10-cm VAS scale for VAS leg pain; a difference of 1.00 cm of 10 cm on a 10-cm VAS scale for VAS back pain and a difference of 2.12 cm of 100 cm on a 100-cm ODI scale. RESULTS In terms of pain, both groups improved after surgery, but there was no between-group difference in terms of the VAS scores at the most recent follow-up. VAS back pain improved from a mean of 3 ± 1 to 2 ± 1 in the extreme stenosis group and from 3 ± 1 to 1 ± 1 in the non-extreme stenosis group (p = 0.904); VAS leg pain improved from 7 ± 1 to 1 ± 1 versus 6 ± 1 to 1 ± 1, respectively (p = 0.537). ODI scores likewise improved in both groups, with no between-group difference in the ODI scores at latest follow-up (66 ± 7 to 19 ± 2 in the extreme stenosis group versus 59 ± 5 to 19 ± 2 in the non-extreme stenosis group (p = 0.237). Complications in the group with extreme stenosis occurred in six patients (incidental dural tears in two patients, urinary retention in three patients, and Syndrome of Inappropriate Anti Diuretic Hormone secretion (SIADH) in one patient); complications in the non-extreme stenosis occurred in two patients (incidental dural tears in two patients). CONCLUSIONS The results in terms of improvement in VAS for leg and back pain and ODI scores were not different between patients with extreme and non-extreme stenosis. Micro-tubular decompression can be thus considered an alternative for patients with extreme stenosis. Future studies, ideally multicentre, comparative trials, are needed to confirm our preliminary results. LEVEL OF EVIDENCE LEVEL III, therapeutic study.
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Affiliation(s)
- Arvind G Kulkarni
- A. G. Kulkarni, S. Das, T. S. Kunder, Mumbai Spine Scoliosis and Disc Replacement Centre, Bombay Hospital and Medical Research Centre, Mumbai, India
| | - Swaroop Das
- A. G. Kulkarni, S. Das, T. S. Kunder, Mumbai Spine Scoliosis and Disc Replacement Centre, Bombay Hospital and Medical Research Centre, Mumbai, India
| | - Tushar S Kunder
- A. G. Kulkarni, S. Das, T. S. Kunder, Mumbai Spine Scoliosis and Disc Replacement Centre, Bombay Hospital and Medical Research Centre, Mumbai, India
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Refaat MI, Elsamman AK, Rabea A, Hewaidy MIA. Microsurgical unilateral laminotomy for bilateral decompression of degenerative lumbar canal stenosis: a comparative study. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2019. [DOI: 10.1186/s41983-019-0125-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The quest for better patient outcomes is driving to the development of minimally invasive spine surgical techniques. There are several evidences on the use of microsurgical decompression surgery for degenerative lumbar spine stenosis; however, few of these studies compared their outcomes with the traditional laminectomy technique.
Objectives
The aim of our study was to compare outcomes following microsurgical decompression via unilateral laminotomy for bilateral decompression (ULBD) of the spinal canal to the standard open laminectomy for cases with lumbar spinal stenosis.
Subjects and methods
Cases were divided in two groups. Group (A) cases were operated by conventional full laminectomy; Group (B) cases were operated by (ULBD) technique. Results from both groups were compared regarding duration of surgery, blood loss, perioperative complication, and postoperative outcome and patient satisfaction.
Results
There was no statistically significant difference between both groups regarding the improvement of visual pain analogue, while improvement of neurogenic claudication outcome score was significant in group (B) than group (A). Seventy-three percent of group (A) cases and 80% of group (B) stated that surgery met their expectations and were satisfied from the outcome.
Conclusion
Comparing ULBD with traditional laminectomy showed the efficacy of the minimally invasive technique in obtaining good surgical outcome and patient satisfaction. There was no statistically significant difference between both groups regarding the occurrence of complications The ULBD technique was found to respect the posterior spinal integrity and musculature, accompanied with less blood loss, shorter hospital stays, and shorter recovery periods than the open laminectomy technique.
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Park SM, Kim GU, Kim HJ, Choi JH, Chang BS, Lee CK, Yeom JS. Is the Use of a Unilateral Biportal Endoscopic Approach Associated with Rapid Recovery After Lumbar Decompressive Laminectomy? A Preliminary Analysis of a Prospective Randomized Controlled Trial. World Neurosurg 2019; 128:e709-e718. [DOI: 10.1016/j.wneu.2019.04.240] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/28/2019] [Accepted: 04/29/2019] [Indexed: 12/11/2022]
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Long-Term Clinical Outcome and Reoperation Rate for Microsurgical Bilateral Decompression via Unilateral Approach of Lumbar Spinal Stenosis. World Neurosurg 2019; 125:e465-e472. [DOI: 10.1016/j.wneu.2019.01.105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/19/2019] [Accepted: 01/21/2019] [Indexed: 11/19/2022]
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Takahashi H, Aoki Y, Saito J, Nakajima A, Sonobe M, Akatsu Y, Inoue M, Taniguchi S, Yamada M, Koyama K, Yamamoto K, Shiga Y, Inage K, Orita S, Maki S, Furuya T, Koda M, Yamazaki M, Ohtori S, Nakagawa K. Unilateral laminectomy for bilateral decompression improves low back pain while standing equally on both sides in patients with lumbar canal stenosis: analysis using a detailed visual analogue scale. BMC Musculoskelet Disord 2019; 20:100. [PMID: 30832643 PMCID: PMC6399850 DOI: 10.1186/s12891-019-2475-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 02/21/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Unilateral laminectomy for bilateral decompression (ULBD) for lumbar spinal stenosis (LSS) is a less invasive technique compared to conventional laminectomy. Recently, several authors have reported favorable results of low back pain (LBP) in patients of LSS treated with ULBD. However, the detailed changes and localization of LBP before and after ULBD for LSS remain unclear. Furthermore, unsymmetrical invasion to para-spinal muscle and facet joint may result in the residual unsymmetrical symptoms. To clarify these points, we conducted an observational study and used detailed visual analog scale (VAS) scores to evaluate the characteristics and bilateral changes of LBP and lower extremity symptoms. METHODS We included 50 patients with LSS treated with ULBD. A detailed visual analogue scale (VAS; 100 mm) score of LBP in three different postural positions: motion, standing, and sitting, and bilateral VAS score (approached side versus opposite side) of LBP, lower extremity pain (LEP), and lower extremity numbness (LEN) were measured. Oswestry Disability Index (ODI) was used to quantify the clinical improvement. RESULTS Detailed LBP VAS score before surgery was 51.5 ± 32.5 in motion, 63.0 ± 30.1 while standing, and 37.8 ± 31.8 while sitting; and showed LBP while standing was significantly greater than LBP while sitting (p < 0.01). After surgery, LBP while standing was significantly improved relative to that while sitting (p < 0.05), and levels of LBP in the three postures became almost the same with ODI improvement. Bilateral VAS scores showed significant improvement equally on both sides (p < 0.01). CONCLUSIONS ULBD improves LBP while standing equally on both sides in patients with LCS. The improvement of LBP by the ULBD surgery suggests radicular LBP improved because of decompression surgery. Furthermore, the symmetric improvement of LBP by the ULBD surgery suggests unsymmetrical invasion of the paraspinal muscles and facet joints is unrelated to residual LBP.
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Affiliation(s)
- Hiroshi Takahashi
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1, Shimoshizu, Sakura, Chiba 285-8741 Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan
| | - Junya Saito
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1, Shimoshizu, Sakura, Chiba 285-8741 Japan
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1, Shimoshizu, Sakura, Chiba 285-8741 Japan
| | - Masato Sonobe
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1, Shimoshizu, Sakura, Chiba 285-8741 Japan
| | - Yorikazu Akatsu
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1, Shimoshizu, Sakura, Chiba 285-8741 Japan
| | - Masahiro Inoue
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shinji Taniguchi
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1, Shimoshizu, Sakura, Chiba 285-8741 Japan
| | - Manabu Yamada
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1, Shimoshizu, Sakura, Chiba 285-8741 Japan
| | - Keita Koyama
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1, Shimoshizu, Sakura, Chiba 285-8741 Japan
| | - Keiichiro Yamamoto
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1, Shimoshizu, Sakura, Chiba 285-8741 Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kazuhide Inage
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sumihisa Orita
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoshi Maki
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masao Koda
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Koichi Nakagawa
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center, 564-1, Shimoshizu, Sakura, Chiba 285-8741 Japan
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Yüce İ, Kahyaoğlu O, Çavuşoğlu HA, Çavuşoğlu H, Aydın Y. Midterm outcome of thoracic disc herniations that were treated by microdiscectomy with bilateral decompression via unilateral approach. J Clin Neurosci 2018; 58:94-99. [DOI: 10.1016/j.jocn.2018.09.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 09/07/2018] [Accepted: 09/26/2018] [Indexed: 10/28/2022]
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Khalepa RV, Klimov VS, Rzaev JA, Vasilenko II, Konev EV, Amelina EV. SURGICAL TREATMENT OF ELDERLY AND SENILE PATIENTS WITH DEGENERATIVE CENTRAL LUMBAR SPINAL STENOSIS. HIRURGIÂ POZVONOČNIKA 2018. [DOI: 10.14531/ss2018.3.73-84] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective. To analyze the results of surgical treatment of patients of the older age group with central spinal stenosis at the lumbar level. Material and Methods. A total of 107 patients of elderly and senile age with clinically significant degenerative central stenosis of the spinal canal were treated. They were divided into two groups: patients in Group 1 underwent bilateral decompression of nerve roots through unilateral approach; those in Group 2 - nerve root decompression supplemented with interbody fusion and transpedicular fixation. Results. The surgery resulted in statistically significant reduction in pain, improvement of the quality of life, enlargement of spinal canal dimension parameters, and increase in the distance of walking. Statistical difference in the quality of life between Groups 1 and 2 was revealed for the indicator characterizing the psychological component of the SF-36 questionnaire (p = 0.03); there were no statistical differences for the remaining indicators. The key parameter for assessing central stenosis is the cross-sectional area of the dural sac. Conclusion. Preoperative examination of patients of the older age group should be comprehensive and include CT myelography with 3D reconstruction. The cause of nerve root compression in central stenosis is a combination of various factors in 41.9 % of cases. Differential surgical tactics provides an improvement in the quality of life in 80 % of cases. Excessive decompression does not improve the quality of life of patients. Instrumental fixation does not improve the outcome of surgical intervention and should be used only for clinically significant instability of the spinal motion segment.
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Affiliation(s)
| | | | | | | | | | - E. V. Amelina
- Institute of Computational Technologies of Siberian Branch of the Russian Academy of Sciences
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Kim JE, Choi DJ. Clinical and Radiological Outcomes of Unilateral Biportal Endoscopic Decompression by 30° Arthroscopy in Lumbar Spinal Stenosis: Minimum 2-Year Follow-up. Clin Orthop Surg 2018; 10:328-336. [PMID: 30174809 PMCID: PMC6107815 DOI: 10.4055/cios.2018.10.3.328] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 07/04/2018] [Indexed: 11/26/2022] Open
Abstract
Background Open microscopic laminectomy has been the standard surgical method for degenerative spinal stenosis without instability till now. However, it is associated with complications such as paraspinal muscle injury, excessive bleeding, and wound infection. Several surgical techniques, including microendoscopic decompression, have been introduced to solve these problems. Methods Authors analyzed retrospectively 55 patients presenting with neurological symptoms due to degenerative lumbar spinal stenosis refractory to conservative treatment. Patients with foraminal stenosis requiring foraminal decompression were excluded. Two or three portals were used for each level. One portal was used for viewing purpose and the others for instrument passage. Unilateral laminotomy was followed by bilateral decompression under the view of 30° arthroscopy. Clinical outcomes were evaluated using modified Macnab criteria, Oswestry disability index (ODI), and visual analogue scale (VAS). Postoperative complications were checked during the 2-year follow-up. Plain radiographs before and after surgery were compared to analyze the change of disc height decrement and alignment. Results ODI scores improved from 67.4 ± 11.5 preoperatively to 19.3 ± 12.1 at 2-year follow-up (p < 0.01). VAS scores of the leg decreased from 7.7 ± 1.5 to 1.7 ± 1.5 at the final follow-up (p < 0.01). Per the modified Macnab criteria, 81% of the patients improved to good/excellent. No cases of infection occurred. The intervertebral angle was significantly reduced from 6.26° ± 3.54° to 5.58° ± 3.23° at 2 years postoperatively (p = 0.027) and the dynamic intervertebral angle changed from 6.54° ± 3.71° to 6.76° ± 3.59°, which was not statistically significant (p = 0.562). No significant change in slippage was observed (3.76% ± 5.01% preoperatively vs. 3.81% ± 5.28% at the final follow-up [p = 0.531]). The dynamic percentage slip did not change significantly, from 2.65% ± 3.37% to 2.76% ± 3.71% (p = 0.985). However, intervertebral distance decreased significantly from 10.43 ± 2.23 mm to 10.0 ± 2.24 mm (p = 0.000). Conclusions Full endoscopic decompression using a 30° arthroscopy demonstrated a satisfactory clinical outcome at the 2-year follow-up. This technique reduces wound infection rate and did not bring about postoperative segmental spinal instability. It could be a feasible alternative to conventional open microscopic decompression or fusion surgery for degenerative lumbar spinal stenosis.
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Affiliation(s)
- Ju-Eun Kim
- Department of Orthopedic Surgery, Andong Hospital, Andong, Korea
| | - Dae-Jung Choi
- Department of Spine Surgery , Barun Hospital, Jinju, Korea
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Hatta Y, Tonomura H, Nagae M, Takatori R, Mikami Y, Kubo T. Clinical Outcome of Muscle-Preserving Interlaminar Decompression (MILD) for Lumbar Spinal Canal Stenosis: Minimum 5-Year Follow-Up Study. Spine Surg Relat Res 2018; 3:54-60. [PMID: 31435552 PMCID: PMC6690127 DOI: 10.22603/ssrr.2017-0097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 05/08/2018] [Indexed: 11/24/2022] Open
Abstract
Introduction Favorable short-term outcomes have been reported following muscle-preserving interlaminar decompression (MILD), a less invasive decompression surgery for lumbar spinal canal stenosis (LSCS). However, there are no reports of mid- to long-term outcomes. The purpose of this study was to evaluate the clinical outcomes five or more years after treatment of LSCS with MILD. Methods Subjects were 84 cases with LSCS (44 males; mean age, 68.7 years) examined five or more years after MILD. All patients had leg pain symptoms, with claudication and/or radicular pain. The patients were divided into three groups depending on the spinal deformity: 44 cases were without deformity (N group); 20 had degenerative spondylolisthesis (DS group); and 20 had degenerative scoliosis (DLS group). The clinical evaluation was performed using Japanese Orthopedic Association (JOA) scores, and revision surgeries were examined. Changes in lumbar alignment and stability were evaluated using plain radiographs. Results The overall JOA score recovery rate was 65.5% at final follow-up. The recovery rate was 69.5% in the N group, 65.2% in the DS group, and 54.0% in the DLS group, with the rate of the DLS group being significantly lower. There were 16 revision surgery cases (19.0%): seven in the N group (15.9%), three in the DS group (15.0%) and six in the DLS group (30.0%). There were no significant differences between pre- and postoperative total lumbar alignment or dynamic intervertebral angle in any of the groups, slip percentage in the DS group, or Cobb angle in the DLS group. Conclusions The mid-term clinical results of MILD were satisfactory, including in cases with deformity, and there was no major impact on radiologic lumbar alignment or stability. The clinical outcomes of cases with degenerative scoliosis were significantly less favorable and the revision rate was high. This should be taken into consideration when deciding on the surgical procedure.
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Affiliation(s)
- Yoichiro Hatta
- Department of Orthopaedics, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Hitoshi Tonomura
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masateru Nagae
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ryota Takatori
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasuo Mikami
- Department of Rehabilitation Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshikazu Kubo
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Akhavan-Sigari R, Rohde V, Prasad SK, Vahedi P. Uninstrumented Posterior Lumbar Interbody Fusion-Evidence Based or Matter of Habit? Perspective Statement. World Neurosurg 2018; 115:506-508. [PMID: 29775767 DOI: 10.1016/j.wneu.2018.05.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/03/2018] [Indexed: 10/16/2022]
Affiliation(s)
- Reza Akhavan-Sigari
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany.
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Srinivas K Prasad
- Department of Neurological Surgery, Division of Spine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Payman Vahedi
- Department of Neurological Surgery, Division of Spine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Minimally Invasive Lumbar Spinal Decompression in Elderly Patients with Magnetic Resonance Imaging Morphological Analysis. Asian Spine J 2018; 12:285-293. [PMID: 29713410 PMCID: PMC5913020 DOI: 10.4184/asj.2018.12.2.285] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/11/2017] [Accepted: 09/16/2017] [Indexed: 11/08/2022] Open
Abstract
Study Design Case-control study. Purpose In this study, we aimed to investigate clinical outcomes and morphological features in elderly patients with lumbar spinal stenosis (LSS) who were treated by minimally invasive surgery (MIS) unilateral laminectomy for bilateral decompression (ULBD) using a tubular retractor. Overview of Literature Numerous methods using imaging have been attempted to describe the severity of spinal stenosis. But the relationship between clinical symptoms and radiological features remains debatable. Objective In this study, we aimed to investigate clinical outcomes and morphological features in elderly patients with LSS who were treated by MIS-ULBD. Methods We methodically assessed 85 consecutive patients aged >65 years who were treated for LSS. The patients were retrospectively analyzed in two age groups: 66-75 years (group 1) and >75 years (group 2). Clinical outcomes were assessed using the Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and the modified MacNab criteria. Outcome parameters were compared between the groups at the 1-year follow-up. Core radiologic parameters for central and lateral stenosis were analyzed and clinical findings of the groups were compared. Results At the 1-year follow-up, patients in both groups 1 and 2 demonstrated significant improvement in their VAS and ODI scores. All clinical outcomes, except postoperative ODI, were not significantly difference between the groups. In addition, no significant difference was noted in the preoperative radiological parameters between the groups. There was no statistically significant correlation between radiological parameters and clinical symptoms or their outcomes. Moreover, no differences were noted in perioperative adverse events and in the need for repeat surgery at follow-ups between the groups. Conclusions MIS-ULBD by tubular approach is a safe and effective treatment option for elderly patients with LSS. Clinical outcomes in patients with LSS and aged >75 years were comparable with those in patients with LSS and aged 66-75 years. Moreover, we did not find any correlation between radiological parameters and clinical outcomes in either of the two patient groups.
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Schöller K, Alimi M, Cong GT, Christos P, Härtl R. Lumbar Spinal Stenosis Associated With Degenerative Lumbar Spondylolisthesis: A Systematic Review and Meta-analysis of Secondary Fusion Rates Following Open vs Minimally Invasive Decompression. Neurosurgery 2017; 80:355-367. [PMID: 28362963 DOI: 10.1093/neuros/nyw091] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 11/22/2016] [Indexed: 11/12/2022] Open
Abstract
Background Decompression without fusion is a treatment option in patients with lumbar spinal stenosis (LSS) associated with stable low-grade degenerative spondylolisthesis (DS). A minimally invasive unilateral laminotomy (MIL) for "over the top" decompression might be a less destabilizing alternative to traditional open laminectomy (OL). Objective To review secondary fusion rates after open vs minimally invasive decompression surgery. Methods We performed a literature search in Pubmed/MEDLINE using the keywords "lumbar spondylolisthesis" and "decompression surgery." All studies that separately reported the outcome of patients with LSS+DS that were treated by OL or MIL (transmuscular or subperiosteal route) were included in our systematic review and meta-analysis. The primary end point was secondary fusion rate. Secondary end points were total reoperation rate, postoperative progression of listhetic slip, and patient satisfaction. Results We identified 37 studies (19 with OL, 18 with MIL), with a total of 1156 patients, that were published between 1983 and 2015. The studies' evidence was mostly level 3 or 4. Secondary fusion rates were 12.8% after OL and 3.3% after MIL; the total reoperation rates were 16.3% after OL and 5.8% after MIL. In the OL cohort, 72% of the studies reported a slip progression compared to 0% in the MIL cohort, respectively. After OL, satisfactory outcome was 62.7% compared to 76% after MIL. Conclusion In patients with LSS and DS, minimally invasive decompression is associated with lower reoperation and fusion rates, less slip progression, and greater patient satisfaction than open surgery.
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Affiliation(s)
- Karsten Schöller
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA.,Department of Neurosurgery, Justus-Liebig University, Giessen, Germany
| | - Marjan Alimi
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Guang-Ting Cong
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Paul Christos
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York, USA
| | - Roger Härtl
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
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Minimally Invasive Computer Navigation-Assisted Endoscopic Transforaminal Interbody Fusion with Bilateral Decompression via a Unilateral Approach: Initial Clinical Experience at One-Year Follow-Up. World Neurosurg 2017; 106:291-299. [DOI: 10.1016/j.wneu.2017.06.174] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 06/25/2017] [Accepted: 06/28/2017] [Indexed: 11/20/2022]
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Kim JH, Kwon YJ. Long-term Clinical and Radiological Outcomes after Central Decompressive Laminoplasty for Lumbar Spinal Stenosis. KOREAN JOURNAL OF SPINE 2017; 14:71-76. [PMID: 29017300 PMCID: PMC5642091 DOI: 10.14245/kjs.2017.14.3.71] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/30/2017] [Accepted: 08/31/2017] [Indexed: 01/14/2023]
Abstract
OBJECTIVE There are many technical modifications of decompressive lumbar laminectomy. The purpose of this study was to report long-term clinical and radiological outcomes of central decompressive laminoplasty (CDL), the corresponding author's own modification of lumbar laminectomy for lumbar spinal stenosis (LSS). METHODS Among 100 patients who underwent CDL by a single surgeon between December 2010 and March 2014, 68 patients were included in this study. Mean follow-up time was 37.7 months. Clinical and radiological data were gathered prospectively and reviewed retrospectively. Clinical outcome was measured by using visual analog scale (VAS) for back/buttock and leg, and the Oswestry Disability Index (ODI). Radiological outcome was measured by neutral slippage percentage, dynamic slippage percentage, and dynamic intervertebral angel on sagittal X-ray. Outcomes after CDL were assessed by changes of clinical and radiological parameters from the baseline. Mixed effect model with random patients' effect as used to test for differences in the repeated measured clinical and radiological data. RESULTS The patients had no serious complications with an uneventful recovery during the early postoperative period. In the early postoperative period, VAS scores for back/buttock and leg improved significantly and were kept with time (p<0.001). ODI also improved significantly during the postoperative follow-up period (p<0.001). The radiologic parameters were well maintained and showed no progression of instability. During the follow-up, a case of herniated disc at same level recurrence was noted after lifting trauma, and 2 adjacent foraminal stenosis needed additional surgery. CONCLUSION CDL provides long-term pain relief and functional restoration without progression of radiological instability.
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Affiliation(s)
- Jun-Hwan Kim
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Joon Kwon
- Department of Neurosurgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Stand-alone Lateral Recess Decompression Without Discectomy in Patients Presenting With Claudicant Radicular Pain and MRI Evidence of Lumbar Disc Herniation: A Prospective Study. Spine (Phila Pa 1976) 2017; 42:984-991. [PMID: 27792115 DOI: 10.1097/brs.0000000000001944] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective study. OBJECTIVE The aim of this study was to analyze the outcomes of stand-alone lateral recess decompression without discectomy in patients with claudicant radicular pain and magnetic resonance imaging (MRI) showing LRS (lateral recess stenosis) with lumbar disc herniation. SUMMARY OF BACKGROUND DATA Discectomy is the gold standard treatment for symptomatic lumbar disc herniations refractory to conservative care. Typically, patients with positive SLR (Straight leg raising test) and flexion dominant leg pain are the ideal candidates who can be benefited from discectomy. There is a subset of patients with morphological features of lumbar disc herniation with LRS on MRI and presenting with diametrically opposite symptoms such as claudicant leg pain, extension dominant leg pain, relief on flexion, and a negative SLR. Until now, no focused prospective study in the literature highlights stand-alone lateral recess decompression in this group of patients. METHODS From January 2007 to June 2013, 55 patients having unilateral claudicant radicular pain were selected to undergo stand-alone lateral recess decompression with tubular retractors. Intraoperatively, disc consistency and presence of sequestrated fragments were analyzed. Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) score, and Macnab criteria were used to measure outcomes. RESULTS Out of 55 patients, stand-alone lateral recess decompression was successfully executed in 51 patients and remaining four patients had sequestrated discs that required removal. Mean age at presentation was 54.5 years (41-67 years), male:female ratio was 1.12:1, and mean follow-up was 3.8 years (3-5.8 years). Significant improvement (P < 0.0001) was noticed between preoperative and postoperative VAS score (8.39 ± 0.84 vs. 2.5 ± 0.48) and ODI score (46.79 ± 1.85 vs. 18.71 ± 2.41). As per Macnab criteria, 94% patients were satisfied with surgery. CONCLUSION Stand-alone lateral recess decompression without discectomy is clinically effective for a large majority of patients with claudicant radicular pain and MRI evidence of LRS with associated lumbar disc herniation. The ability to perform it with minimal invasive techniques makes it focused and targeted with minimal morbidity. LEVEL OF EVIDENCE 4.
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Lønne G, Cha TD. Minimally Invasive Decompression in Lumbar Spinal Stenosis. JBJS Essent Surg Tech 2016; 6:e41. [PMID: 30233934 DOI: 10.2106/jbjs.st.16.00029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction Unlike traditional open laminectomy, minimally invasive decompression (MID) spares the important midline structures of the spine (i.e., the spinous process and the supraspinous and interspinous ligaments). Indications & Contraindications Step 1 Preoperative Planning Determine the levels and laterality for the decompression on the basis of the symptoms and findings on the MRI scan. Step 2 Operating Room Setup Ensure the correct positioning of the patient and the proper setup of the equipment. Step 3 Marking the Levels Use fluoroscopy to localize the level(s) of the stenosis. Step 4 Skin Incision and Tube Positioning Ensure the correct placement of the tube. Step 5 Resection of the Lower Part of the Lamina Use a high-speed drill and Kerrison rongeur to enter the spinal canal. Step 6 Resection of the Medial Part of the Facet Joint Proceed cautiously at the point where the spinal canal is usually narrowest. Step 7 Resection of the Ligamentum Flavum Resect the ligamentum flavum piecemeal with a Kerrison rongeur. Step 8 Crossover Technique Optional Use the crossover technique to reach across the midline and decompress the contralateral lateral recess (Video 3). Step 9 Closing the Wound Perform a check to be certain that all steps have been completed before closing the skin. Results In the study by Lønne et al., the 41 patients managed with MID had significant improvement at 6 weeks and throughout the 2-year observation period7. Pitfalls & Challenges
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Affiliation(s)
- Greger Lønne
- Department of Orthopaedic Surgery, Innlandet Hospital Trust, Lillehammer, Norway.,Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas D Cha
- Department of Orthopaedics, Massachusetts General Hospital, Boston, Massachusetts
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Clinical Outcomes of Posterior Lumbar Interbody Fusion versus Minimally Invasive Transforaminal Lumbar Interbody Fusion in Three-Level Degenerative Lumbar Spinal Stenosis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9540298. [PMID: 27747244 PMCID: PMC5056235 DOI: 10.1155/2016/9540298] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 09/05/2016] [Indexed: 12/25/2022]
Abstract
The aim of this study was to directly compare the clinical outcomes of posterior lumbar interbody fusion (PLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in three-level lumbar spinal stenosis. This retrospective study involved a total of 60 patients with three-level degenerative lumbar spinal stenosis who underwent MIS-TLIF or PLIF from January 2010 to February 2012. Back and leg visual analog scale (VAS), Oswestry Disability Index (ODI), and Short Form-36 (SF-36) scale were used to assess the pain, disability, and health status before surgery and postoperatively. In addition, the operating time, estimated blood loss, and hospital stay were also recorded. There were no significant differences in back VAS, leg VAS, ODI, SF-36, fusion condition, and complications at 12-month follow-up between the two groups (P > 0.05). However, significantly less blood loss and shorter hospital stay were observed in MIS-TLIF group (P < 0.05). Moreover, patients undergoing MIS-TLIF had significantly lower back VAS than those in PLIF group at 6-month follow-up (P < 0.05). Compared with PLIF, MIS-TLIF might be a prior option because of noninferior efficacy as well as merits of less blood loss and quicker recovery in treating three-level lumbar spinal stenosis.
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Antoniadis A, Ulrich NH, Schmid S, Farshad M, Min K. Decompression surgery for lumbar spinal canal stenosis in octogenarians; a single center experience of 121 consecutive patients. Br J Neurosurg 2016; 31:67-71. [DOI: 10.1080/02688697.2016.1233316] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Alexander Antoniadis
- Department of Orthopedics, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Nils H. Ulrich
- Department of Orthopedics, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Samuel Schmid
- Department of Orthopedics, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Kan Min
- Department of Orthopedics, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
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Alimi M, Hofstetter CP, Torres-Campa JM, Navarro-Ramirez R, Cong GT, Njoku I, Härtl R. Unilateral tubular approach for bilateral laminotomy: effect on ipsilateral and contralateral buttock and leg pain. 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 2016; 26:389-396. [PMID: 27272621 DOI: 10.1007/s00586-016-4594-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 04/28/2016] [Accepted: 04/29/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Tubular laminotomy is an effective procedure for treatment of lumbar spinal stenosis (LSS) and lateral recesses stenosis. Most surgeons familiar with the procedure agree that the tubular approach appears to afford a more complete decompression of the contralateral thecal sac and nerve root, as compared to the ipsilateral approach. With this study we sought to answer the question whether this is reflected in clinically significant differences between the ipsilateral and contralateral side pain improvements. METHODS In a retrospective case study, patients with LSS and lateral recesses stenosis who started out with VAS scores that were similar on the right and left side were included. All patients underwent a tubular (MIS) "over the top" laminotomy from a unilateral approach and through one incision. Surgeries were performed by a single surgeon in a single center. At the last follow-up, the extent of VAS score improvement on the approach (ipsilateral) side was compared to that of the contralateral side. RESULTS Thirty-three patients were included in. At the latest follow-up of 25.8 ± 3.4 months, there were statistically significant improvements in ODI and back VAS scores (p = 0.002 and p < 0.0001, respectively). In addition, buttock VAS scores were significantly improved both on the ipsilateral and the contralateral side (p < 0.001, and p = 0.001, respectively). Similarly, leg VAS scores were improved significantly on both sides (p < 0.001, and p = 0.001, respectively). There were no statistically significant differences between the extent of pain improvement on the ipsilateral and the contralateral side. CONCLUSIONS MIS tubular laminotomy through a unilateral approach results in clinically effective bilateral decompression of LSS and lateral recesses, regardless of the approach side.
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Affiliation(s)
- Marjan Alimi
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, Weill Cornell Brain and Spine Center, 525 East 68th Street, Box 99, New York, NY, 10065, USA
| | - Christoph P Hofstetter
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, Weill Cornell Brain and Spine Center, 525 East 68th Street, Box 99, New York, NY, 10065, USA
| | - Jose M Torres-Campa
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, Weill Cornell Brain and Spine Center, 525 East 68th Street, Box 99, New York, NY, 10065, USA
| | - Rodrigo Navarro-Ramirez
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, Weill Cornell Brain and Spine Center, 525 East 68th Street, Box 99, New York, NY, 10065, USA
| | | | | | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, Weill Cornell Brain and Spine Center, 525 East 68th Street, Box 99, New York, NY, 10065, USA.
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Schöller K, Steingrüber T, Stein M, Vogt N, Müller T, Pons-Kühnemann J, Uhl E. Microsurgical unilateral laminotomy for decompression of lumbar spinal stenosis: long-term results and predictive factors. Acta Neurochir (Wien) 2016; 158:1103-13. [PMID: 27084380 DOI: 10.1007/s00701-016-2804-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 04/04/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND The microsurgical unilateral laminotomy (MUL) technique for bilateral decompression of lumbar spinal stenosis (LSS) is a less destabilizing alternative to laminectomy and leads to good short-term outcomes. However, little is known about the long-term results including predictive factors. METHODS Medical records of patients who underwent MUL for LSS decompression between 2005 and 2010 were reviewed, and a questionnaire was distributed to complement the long-term outcome data. The study population consisted of 176 patients including 17 patients with stable grade I spondylolisthesis. Complications and reoperations were meticulously analyzed. Clinical outcome was measured using a modified Prolo scale and was further dichotomized in good vs. poor outcome. Predictive factors were obtained from uni- and multivariate analyses. RESULTS The median age of the cohort was 70.0 years and the follow-up 71.7 months. Complications occurred in 5.1 % of the patients. The overall reoperation rate was 17.0 %, including surgery, which was exclusively performed at other levels in 4.0 %. The reoperation rate for fusion was 4.5 %. Good neurogenic claudication outcome faded from 98.3 % at hospital discharge to 47.2 % at 6 years. Multivariate analysis identified previous lumbar operation as a potential independent predictor of a reoperation; potential independent predictors of poor long-term claudication outcome were older age, female gender, higher body mass index (BMI) and tobacco smoking. CONCLUSIONS In our experience, the long-term reoperation rate after MUL for LSS is not negligible and higher in previously operated patients. It seems like the good initial clinical results after MUL may fade over time, and several patient-related predictive factors including potentially modifiable obesity and tobacco smoking seem to play an important role.
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Affiliation(s)
- Karsten Schöller
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstr. 33, 35392, Giessen, Germany.
| | - Thomas Steingrüber
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstr. 33, 35392, Giessen, Germany
| | - Marco Stein
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstr. 33, 35392, Giessen, Germany
| | - Nina Vogt
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstr. 33, 35392, Giessen, Germany
| | - Tilman Müller
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstr. 33, 35392, Giessen, Germany
| | - Jörn Pons-Kühnemann
- Institute for Medical Informatics, Medical Statistics Study Group, Justus-Liebig-University, Giessen, Germany
| | - Eberhard Uhl
- Department of Neurosurgery, Justus-Liebig-University Giessen, Klinikstr. 33, 35392, Giessen, Germany
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Haddadi K, Ganjeh Qazvini HR. Outcome after Surgery of Lumbar Spinal Stenosis: A Randomized Comparison of Bilateral Laminotomy, Trumpet Laminectomy, and Conventional Laminectomy. Front Surg 2016; 3:19. [PMID: 27092304 PMCID: PMC4824790 DOI: 10.3389/fsurg.2016.00019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 03/15/2016] [Indexed: 11/15/2022] Open
Abstract
Background Laminectomy is the traditional operating method for the decompression of spinal canal stenosis. New partial decompression processes have been suggested in the treatment of lumbar stenosis. The benefit of a micro surgical approach is the chance of an extensive bilateral decompression of the spinal canal or foramen at one or numerous levels, through a minimal para-spinal muscular separation. Purpose To match the safety and the clinical consequences after a bilateral laminotomy, laminectomy and trumpet laminectomy in patients with lumbar spinal stenosis who were randomized to one of three treatment groups. Study design Prospective study. Methods One hundred twenty consecutive patients with 227 levels of lumbar stenosis without significant herniated discs or instability were randomized to three treatment groups [bilateral laminotomy (Group 1), laminectomy (Group 2), and trumpet laminectomy (Group 3)]. Perioperative parameters and complications were documented. Symptoms and scores, such as a visual analog scale (VAS), Oswestry Disability Index, and patient satisfaction, were assessed preoperatively at 3, 6, and 12 months after surgery. Adequate decompression was achieved in all patients on the basis of surgeon satisfaction. Results The global complication rate was lowest in patients who had undertaken bilateral laminotomy (Group 1). The minimum follow-up of 12 months was achieved in 100% of patients. Matched with that experience in Group 1, but, with more remaining back and leg pain was found in Group 2, 3.85 ± 0.28 and 1.60 ± 0.44, respectively and 3.24 ± 0.22 and 2.44 ± 0.26 in Group 3, respectively compared with 1.84 ± 0.28 and 1.25 ± 0.12 (Group 1) at the 1-year follow-up assessment (p < 0.05). It was the same for the ODI scores, which reached 14 ± 8% (Group 1), 28 ± 12% (Group 2), and 26 ± 16 after 12 months of surgery (Group 3) (significant, p < 0.01 compared with preoperative scores). Patient satisfaction was higher in Group 1, with 7.5, 20, and 25% of patients displeased (in Groups 1, 2, and 3, respectively; p < 0.01). Conclusion Bilateral Laminotomy is certified acceptable and harmless in decompression of lumbar stenosis, causing a highly significant decrease of symptoms and disability.
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Affiliation(s)
- Kaveh Haddadi
- Department of Neurosurgery, Diabetes Research Center, Emam Hospital, Mazandaran University of Medical Sciences , Sari , Iran
| | - Hamid Reza Ganjeh Qazvini
- Department of Neurosurgery, Faculty of Medicine, Mazandaran University of Medical Sciences , Sari , Iran
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Phan K, Mobbs RJ. Minimally Invasive Versus Open Laminectomy for Lumbar Stenosis: A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976) 2016; 41:E91-E100. [PMID: 26555839 DOI: 10.1097/brs.0000000000001161] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review with meta-analysis. OBJECTIVE To assess the relative merits of minimally invasive unilateral laminectomy for bilateral decompression (ULBD) versus open laminectomy, a systematic review and meta-analysis of all available evidence was performed. SUMMARY OF BACKGROUND DATA Lumbar spinal stenosis is one of the most common pathologies in the increasingly elderly population that results in claudication, back and leg pain, and disability. The conventional approach for decompression is open laminectomy. In recent years, there has been a surge in microendoscopic procedures, which aim to minimize invasiveness. Despite the increasing use of these minimally invasive techniques, few studies have directly compared the safety, efficacy, and outcomes of these procedures with conventional laminectomy. There is a lack of robust clinical evidence, with most reports limited to single-center, inadequately powered, noncomparative studies. METHODS Relevant articles were identified from six electronic databases. Predefined endpoints were extracted and meta-analyzed from the identified studies. RESULTS Satisfaction rates were significantly higher in the minimally invasive group (84% vs. 75.4%; P = 0.03), whereas back pain Visual Analog Scale scores were lower (P < 0.00001). Minimally invasive laminectomy operative duration was 11 minutes longer than the open approach (P = 0.001), however this may not have clinical significance. However, there was less blood loss (P < 0.00001) and shorter hospital stay (2.1 days; P < 0.0001). Dural injuries and cerebrospinal fluid leaks were comparable, but reoperation rates were lower in the minimally invasive cohort (1.6% vs. 5.8%; P = 0.02); however this was not significant when only randomized evidence was considered. CONCLUSION The pooled evidence suggests ULBD may be associated with less blood loss and shorter stay, with similar complication profiles to the open approach. These findings warrant verification in large prospective registries and randomized trials. LEVEL OF EVIDENCE 1.
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Affiliation(s)
- Kevin Phan
- *Department of Neurosurgery, University of New South Wales, High Street, Randwick, New South Wales, Australia†Neuro Spine Clinic, Prince of Wales Private Hospital, Randwick, New South Wales, Australia‡Neuro Spine Surgery Research Group, Sydney, Australia
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Takenaka S, Tateishi K, Hosono N, Mukai Y, Fuji T. Preoperative retrolisthesis as a risk factor of postdecompression lumbar disc herniation. J Neurosurg Spine 2015; 24:592-601. [PMID: 26654340 DOI: 10.3171/2015.6.spine15288] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this study, the authors aimed to identify specific risk factors for postdecompression lumbar disc herniation (PDLDH) in patients who have not undergone discectomy and/or fusion. METHODS Between 2007 and 2012, 493 patients with lumbar spinal stenosis underwent bilateral partial laminectomy without discectomy and/or fusion in a single hospital. Eighteen patients (herniation group [H group]: 15 men, 3 women; mean age 65.1 years) developed acute sciatica as a result of PDLDH within 2 years after surgery. Ninety patients who did not develop postoperative acute sciatica were selected as a control group (C group: 75 men, 15 women; mean age 65.4 years). Patients in the C group were age and sex matched with those in the H group. The patients in the groups were also matched for decompression level, number of decompression levels, and surgery date. The radiographic variables measured included percentage of slippage, intervertebral angle, range of motion, lumbar lordosis, disc height, facet angle, extent of facet removal, facet degeneration, disc degeneration, and vertebral endplate degeneration. The threshold for PDLDH risk factors was evaluated using a continuous numerical variable and receiver operating characteristic curve analysis. The area under the curve was used to determine the diagnostic performance, and values greater than 0.75 were considered to represent good performance. RESULTS Multivariate analysis revealed that preoperative retrolisthesis during extension was the sole significant independent risk factor for PDLDH. The area under the curve for preoperative retrolisthesis during extension was 0.849; the cutoff value was estimated to be a retrolisthesis of 7.2% during extension. CONCLUSIONS The authors observed that bilateral partial laminectomy, performed along with the removal of the posterior support ligament, may not be suitable for lumbar spinal stenosis patients with preoperative retrolisthesis greater than 7.2% during extension.
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Affiliation(s)
- Shota Takenaka
- Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Kosuke Tateishi
- Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Noboru Hosono
- Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Yoshihiro Mukai
- Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Takeshi Fuji
- Orthopaedic Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
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Soliman HM. Irrigation endoscopic decompressive laminotomy. A new endoscopic approach for spinal stenosis decompression. Spine J 2015; 15:2282-9. [PMID: 26165475 DOI: 10.1016/j.spinee.2015.07.009] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 06/07/2015] [Accepted: 07/01/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The classic surgical treatment of spinal stenosis involves bilateral dissection of paraspinal muscles to expose all the involved levels, wide laminectomy, and medial facetectomy and foraminotomy. The surgical morbidity of the procedure is further magnified by being more common in elderly with associated medical comorbidities and being usually global involving multiple levels. To address this problem, several less invasive techniques have been introduced over the past decade including the microendoscopic decompression. PURPOSE The aim was to describe and evaluate a new endoscopic technique for lumbar spinal canal decompression named irrigation endoscopic decompressive laminotomy. STUDY DESIGN This was a technical report. PATIENT SAMPLE One hundred four consecutive patients suffering from neurogenic claudication and resistant to 3 months of conservative management were included in the study. Grade I degenerative spondylolisthesis and degenerative scoliosis were not considered a contraindication. Patients with segmental instability and predominant low back pain were excluded. OUTCOME MEASURES Primary outcome measures included the final functional outcome using modified Macnab criteria and the Oswestry Disability Index (ODI). In addition, the operative time and complication rate have been evaluated. Secondary outcome measures included the evaluation of the early postoperative course using visual analog scale for postoperative incisional pain, time for ambulation, and length of hospital stay. METHODS Two 0.5-cm portals were used, one for the endoscope and the other for instruments. For every additional level, one portal is added. The endoscope and instruments are directly placed over the surface of lamina without any dissection, and saline under pump pressure is used to open a potential working space. Unilateral laminotomy/laminectomy is performed according to the severity of stenosis, followed by bilateral decompression beneath the midline structures. RESULTS Mean follow-up period was 28 months. The final outcome was excellent in 63%, good in 24%, fair in 9%, and poor in 4%. The preoperative ODI dropped from a mean of 64.2±10.0 to 23.1±20.8 postoperatively. Complications were limited to six cases of dural tear, which required no open conversion. CONCLUSIONS Irrigation endoscopic decompressive laminotomy allows the surgeon to safely perform effective central and foraminal decompression resulting in satisfactory midterm clinical results. Substituting long surgical incisions with 0.5-cm stabs and direct placement of instruments without dissection or dilatation could result in an improved postoperative course, shortened time for hospitalization, and reduced infection rate. However, still multicenter studies and randomized trials are needed before making final conclusions.
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Affiliation(s)
- Hesham Magdi Soliman
- Department of Orthopedic Surgery, Faculty of Medicine, Cairo University, 21A Abdelaziz Al Seoud, Manial-EL Roda, Cairo, Egypt.
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den Boogert HF, Keers JC, Marinus Oterdoom DL, Kuijlen JMA. Bilateral versus unilateral interlaminar approach for bilateral decompression in patients with single-level degenerative lumbar spinal stenosis: a multicenter retrospective study of 175 patients on postoperative pain, functional disability, and patient satisfaction. J Neurosurg Spine 2015; 23:326-35. [DOI: 10.3171/2014.12.spine13994] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The bilateral and unilateral interlaminar techniques for bilateral decompression both demonstrate good results for the treatment of degenerative lumbar spinal stenosis (DLSS). Although there is some discussion about which approach is more effective, studies that directly compare these two popular techniques are rare. To address this shortcoming, this study compares postoperative functional disability, pain, and patient satisfaction among patients with single-level DLSS who underwent bilateral decompression using either a bilateral or unilateral approach.
METHODS
This retrospective study included patients who underwent operations between November 1, 2009, and October 1, 2011. These patients underwent single-level bilateral decompressive surgery using either the bilateral or unilateral interlaminar approach at one of 5 participating hospitals. Exclusion criteria included previous lumbar surgery, additional disc surgery, and spondylolisthesis requiring fusion surgery. Primary outcome measures included bodily pain (as reported using the visual analog scale [VAS]), the Roland-Morris Disability Questionnaire (RMDQ), and the Oswestry Disability Index (ODI). In addition, reductions in leg and back symptoms and the patient’s general evaluation of the procedure were queried. Finally, patient satisfaction and surgical parameters were evaluated. Questionnaires were sent to each patient’s home, and electronic patient files were used to collect the data.
RESULTS
One hundred and seventy-five patients returned the questionnaire (74.4% response rate; 68 and 107 patients who underwent the bilateral or unilateral approach, respectively). Mean age at surgery was 68 years (range 34–89 years), and the mean follow-up period was 14.2 months (range 3.3–27.4 years). There were no significant differences in ODI (20.3 vs 22.6 for the bilateral and unilateral approaches, respectively), RMDQ (3.99 vs 4.8, respectively), or pain scores between treatment groups. Back symptoms were reduced in 74.8% (bilateral: 74.6% vs unilateral: 75%; not significant), and leg symptoms in 80.6% of the patients (bilateral: 73.1% vs unilateral: 85.4%; p = 0.048). In total, 72.1% (bilateral) and 80.0% (unilateral) of patients reported good overall treatment results (p = 0.226). Significantly more patients in the unilateral group reported a better overall satisfaction with the procedure (82.1% vs 69.1%; p = 0.047).
CONCLUSIONS
There were no differences in postoperative functional disability and pain between the surgical techniques. The significant differences in patient satisfaction and reduction in leg symptoms were unrelated to surgical technique. The overall treatment results were satisfactory. Both techniques are safe and effective options for treating patients with single-level DLSS.
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Affiliation(s)
| | | | - D. L. Marinus Oterdoom
- 1Department of Neurosurgery, University Medical Center Groningen; and
- 3Department of Neurosurgery, Martini Hospital Groningen, The Netherlands
| | - Jos M. A. Kuijlen
- 1Department of Neurosurgery, University Medical Center Groningen; and
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Overdevest G, Vleggeert-Lankamp C, Jacobs W, Thomé C, Gunzburg R, Peul W. Effectiveness of posterior decompression techniques compared with conventional laminectomy for lumbar stenosis. 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 2015; 24:2244-63. [PMID: 26184719 DOI: 10.1007/s00586-015-4098-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 06/27/2015] [Accepted: 06/27/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To compare the effectiveness of techniques of posterior decompression that limit the extent of bony decompression or to avoid removal of posterior midline structures of the lumbar spine versus conventional facet-preserving laminectomy for the treatment of patients with degenerative lumbar stenosis. METHODS A comprehensive electronic search of the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, and the clinical trials registries ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform was conducted for relevant literature up to June 2014. RESULTS A total of four high-quality RCTs and six low-quality RCTs met the search criteria of this review. These studies included a total of 733 participants. Three different techniques that avoid removal of posterior midline structures are compared to conventional laminectomy; unilateral laminotomy for bilateral decompression, bilateral laminotomy and split-spinous process laminotomy. Evidence of low or very low quality suggests that different techniques of posterior decompression and conventional laminectomy have similar effects on functional disability and leg pain. Only perceived recovery at final follow-up was better in patients that underwent bilateral laminotomy compared with conventional laminectomy. Unilateral laminotomy for bilateral decompression and bilateral laminotomy resulted in numerically fewer cases of iatrogenic instability, although in both cases, the incidence of instability was low. The difference in severity of postoperative low back pain following bilateral laminotomy and split-spinous process laminotomy was significantly less, but was too small to be clinically important. We found no evidence to show that the incidence of complications, length of the procedure, length of hospital stay and postoperative walking distance differed between techniques of posterior decompression. CONCLUSION The evidence provided by this systematic review for the effects of unilateral laminotomy for bilateral decompression, bilateral laminotomy and split-spinous process laminotomy compared with conventional laminectomy on functional disability, perceived recovery and leg pain is of low or very low quality. Therefore, further research is necessary to establish whether these techniques provide a safe and effective alternative for conventional laminectomy. Proposed advantages of these techniques regarding the incidence of iatrogenic instability and postoperative back pain are plausible, but definitive conclusions are limited by poor methodology and poor reporting of outcome measures among included studies.
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Affiliation(s)
- Gijsbert Overdevest
- Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands.
| | - Carmen Vleggeert-Lankamp
- Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
| | - Wilco Jacobs
- Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
| | - Claudius Thomé
- Department of Neurosurgery, Innsbruck Medical University, Innsbruck, Austria
| | - Robert Gunzburg
- Department of Orthopaedics, Brugmann University Hospital, Free University of Brussels, Brussels, Belgium
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, PO Box 9600, 2300RC, Leiden, The Netherlands
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Parker SL, Anderson LH, Nelson T, Patel VV. Cost-effectiveness of three treatment strategies for lumbar spinal stenosis: Conservative care, laminectomy, and the Superion interspinous spacer. Int J Spine Surg 2015; 9:28. [PMID: 26273546 DOI: 10.14444/2028] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Lumbar spinal stenosis is a painful and debilitating condition resulting in healthcare costs totaling tens of billions of dollars annually. Initial treatment consists of conservative care modalities such as physical therapy, NSAIDs, opioids, and steroid injections. Patients refractory to these therapies can undergo decompressive surgery, which has good long-term efficacy but is more traumatic and can be associated with high post-operative adverse event (AE) rates. Interspinous spacers have been developed to offer a less-invasive alternative. The objective of this study was to compare the costs and quality adjusted life years (QALYs) gained of conservative care (CC) and decompressive surgery (DS) to a new minimally-invasive interspinous spacer. METHODS A Markov model was developed evaluating 3 strategies of care for lumbar spinal stenosis. If initial therapies failed, the model moved patients to more invasive therapies. Data from the Superion FDA clinical trial, a prospective spinal registry, and the literature were used to populate the model. Direct medical care costs were modeled from 2014 Medicare reimbursements for healthcare services. QALYs came from the SF-12 PCS and MCS components. The analysis used a 2-year time horizon with a 3% discount rate. RESULTS CC had the lowest cost at $10,540, while Spacers and DS were nearly identical at about $13,950. CC also had the lowest QALY increase (0.06), while Spacers and DS were again nearly identical (.28). The incremental cost-effectiveness ratios (ICER) for Spacers compared to CC was $16,300 and for DS was $15,200. CONCLUSIONS Both the Spacer and DS strategies are far below the commonly cited $50,000/QALY threshold and produced several times the QALY increase versus CC, suggesting that surgical care provides superior value (cost / effectiveness) versus sustained conservative care in the treatment of lumbar spinal stenosis.
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Affiliation(s)
- Scott L Parker
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville TN
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Rahman HASA, Iacob G. Treatment of lumbar spinal stenosis (LSS) and outcome. ROMANIAN NEUROSURGERY 2015. [DOI: 10.1515/romneu-2015-0030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Patient outcomes for a minimally invasive approach to treat lumbar spinal canal stenosis: Is microendoscopic or microscopic decompressive laminotomy the less invasive surgery? Clin Neurol Neurosurg 2015; 131:21-5. [DOI: 10.1016/j.clineuro.2015.01.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 12/08/2014] [Accepted: 01/17/2015] [Indexed: 11/22/2022]
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Yusof MI, Shif M, Abdullah MS. The Morphometric Study of Degenerative Lateral Canal Stenosis at L4-L5 and L5-S1 Using Magnetic Resonance Imaging (MRI): Feasibility Analysis for Posterior Surgical Decompression. Malays Orthop J 2015; 9:4-10. [PMID: 28435587 PMCID: PMC5349339 DOI: 10.5704/moj.1503.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This study was to evaluate the morphological features of degenerative spinal stenosis and adequacy of lateral canal stenosis decompression via unilateral and bilateral laminectomy. Measurements of facet joint angulation (FJA), mid facet point (MFP), mid facet point distance (MFPD), the narrowest point of the lateral spinal canal (NPLC) and the narrowest point of the lateral spinal canal distance (NPLCD) were performed. At L4L5 of the right and left side, the mean distance between the lateral border of the dura and MFP was 1.0 ± 0.2 cm and 1.0 ± 0.3cm respectively. The mean NPLC was seen at 0.7 ± 0.3 and 0.7 ± 0.3 cm cm from the dura. At L5S1 of the right and left side, the mean distance between the lateral border of the dura and MFP was 1.2± 0.2 and 1.3 ± 0.2 cm respectively. The mean NPLC was seen at 0.8 ± 0.4 and 0.9 ± 0.5 cm from the dura. Unilateral laminectomy may result in incomplete decompression.
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Affiliation(s)
- M I Yusof
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Msm Shif
- Department of Orthopaedics, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - M S Abdullah
- Department of Radiology, Universiti Sains, Malaysia, Kubang Kerian, Malaysia
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Alimi M, Hofstetter CP, Pyo SY, Paulo D, Härtl R. Minimally invasive laminectomy for lumbar spinal stenosis in patients with and without preoperative spondylolisthesis: clinical outcome and reoperation rates. J Neurosurg Spine 2015; 22:339-52. [PMID: 25635635 DOI: 10.3171/2014.11.spine13597] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Surgical decompression is the intervention of choice for lumbar spinal stenosis (LSS) when nonoperative treatment has failed. Standard open laminectomy is an effective procedure, but minimally invasive laminectomy through tubular retractors is an alternative. The aim of this retrospective case series was to evaluate the clinical and radiographic outcomes of this procedure in patients who underwent LSS and to compare outcomes in patients with and without preoperative spondylolisthesis. METHODS Patients with LSS without spondylolisthesis and with stable Grade I spondylolisthesis who had undergone minimally invasive tubular laminectomy between 2004 and 2011 were included in this analysis. Demographic, perioperative, and radiographic data were collected. Clinical outcome was evaluated using the Oswestry Disability Index (ODI) and visual analog scale (VAS) scores, as well as Macnab's criteria. RESULTS Among 110 patients, preoperative spondylolisthesis at the level of spinal stenosis was present in 52.5%. At a mean follow-up of 28.8 months, scoring revealed a median improvement of 16% on the ODI, 2.75 on the VAS back, and 3 on the VAS leg, compared with the preoperative baseline (p < 0.0001). The reoperation rate requiring fusion at the same level was 3.5%. Patients with and without preoperative spondylolisthesis had no significant differences in their clinical outcome or reoperation rate. CONCLUSIONS Minimally invasive laminectomy is an effective procedure for the treatment of LSS. Reoperation rates for instability are lower than those reported after open laminectomy. Functional improvement is similar in patients with and without preoperative spondylolisthesis. This procedure can be an alternative to open laminectomy. Routine fusion may not be indicated in all patients with LSS and spondylolisthesis.
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Affiliation(s)
- Marjan Alimi
- Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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Chung SW, Kang MS, Shin YH, Baek OK, Lee SH. Postoperative expansion of dural sac cross-sectional area after unilateral laminotomy for bilateral decompression: correlation with clinical symptoms. KOREAN JOURNAL OF SPINE 2015; 11:227-31. [PMID: 25620982 PMCID: PMC4303278 DOI: 10.14245/kjs.2014.11.4.227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 08/10/2014] [Accepted: 08/13/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Dural sac cross-sectional area (DSCSA) is a way to measure the degree of central spinal canal compression. The objective was to investigate the correlation between the expansion ratio of DSCSA after unilateral laminotomy for bilateral decompression (ULBD) and the clinical results for lumbar spinal stenosis. METHODS We retrospectively reviewed the clinical data and radiographs of 103 patients who underwent ULBD for symptomatic spinal stenosis in one year. We compared preoperative and postoperative clinical data and DSCSA and evaluated the correlation between clinical and radiographic measurements. RESULTS There was a significant increase of DSCSA after ULBD (p=0.000) and mean expansion ratio of DSCSA was 203.7±147.2%(range -32.9-826.1%). Clinical outcomes, measured by VAS and ODI were improved significantly not only in early postoperative period, but also in the last follow-up. However, there were no statistically significant correlations between the preoperative DSCSA and clinical symptoms, Perioperative expansion ratio of DSCSA and clinical parameters were also not correlated to the improvement of clinical symptoms significantly in both early postoperative phase and last follow-up. CONCLUSION Our result indicates that the DSCSA itself has a definite limitation to be correlated to the clinical symptoms, and thus meticulous correlation between the clinical presentation and MRI imaging is essential in determination of surgical treatment.
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Affiliation(s)
- Seok-Won Chung
- Department of Neurosurgery, Daegu Wooridul Spine Hospital, Daegu, Korea
| | - Min-Soo Kang
- Department of Neurosurgery, Daegu Wooridul Spine Hospital, Daegu, Korea
| | - Yong-Hwan Shin
- Department of Neurosurgery, Daegu Wooridul Spine Hospital, Daegu, Korea
| | - Oon-Ki Baek
- Department of Neurosurgery, Daegu Wooridul Spine Hospital, Daegu, Korea
| | - Sang-Ho Lee
- Department of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea
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Lin JH, Chiang YH. Unilateral Approach for Bilateral Foramen Decompression in Minimally Invasive Transforaminal Interbody Fusion. World Neurosurg 2014; 82:891-6. [DOI: 10.1016/j.wneu.2014.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 02/04/2014] [Accepted: 06/07/2014] [Indexed: 11/27/2022]
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