Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Spinal Stenosis*†:

Relief of Low Back Pain After Posterior Decompression for Lumbar Spinal Stenosis

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to confirm that decompression for lumbar spinal stenosis (LSS) relieves low back pain (LBP) as adequately as it relieves leg pain and to identify predictors for inadequate LBP relief.

SUMMARY OF BACKGROUND DATA

Although decompression for LSS is generally thought to yield worse results for LBP than for leg pain, some studies have reported similar improvements in pain scores between LBP and leg pain. To treat LBP or take measures to prevent inadequate LBP relief, reliable predictors for LBP relief should be identified.

METHODS

We retrospectively reviewed 175 patients who underwent posterior element-preserving decompression and evaluated the relief of LBP and leg pain using numeric rating scales (NRSs). Associations between demographic, clinical, or imaging parameters and LBP relief at 1 and 4 years were analyzed by stepwise linear regression analyses. The imaging parameters included Modic change type 1, disc degeneration, foraminal stenosis, vertebral slipping (within Grade 1), scoliosis (<15°) and lordosis.

RESULTS

The mean improvements in LBP and leg pain NRS scores from baseline were 5.22 and 4.70 points (P = 0.064, paired t test) at 1 year and 5.12 and 4.62 points (P = 0.068) at 4 years, respectively. Poor LBP scores at 4 years were significantly associated with long-lasting LBP (beta = 0.31, P < 0.0001) and moderate or severe arm symptoms with cervical spinal cord compression or intramedullary hyperintense signal on T2-weighted MRI (beta = 0.22, P = 0.0014). The imaging parameters of the lumbar spine failed to show clear associations with poor LBP scores at 4 years, although Modic change type 1 showed a significant association with poor LBP scores at 1 year (beta = 0.28, P < 0.0001).

CONCLUSION

Posterior decompression relieves LBP as well as leg pain. Long-lasting LBP and concurrent symptomatic cervical myelopathy are important predictors for inadequate LBP relief. There were no reliable imaging parameters predictive of inadequate LBP relief.Level of Evidence: 4.

[Lumbar spinal canal stenosis : A historical perspective]

To know the history of a disease and its treatment is always instructive and helps us to understand the contexts better. It also shows what unbelievable preliminary work was necessary for us be able to treat patients today in the way we are used to. This article attempts to shed light on spinal canal stenosis from a historical perspective and to identify the pioneers who contributed to the understanding of the epidemiology, anatomy, pathogenesis, classification and diagnostic work-up of spinal canal stenosis. In addition, the efforts of scientists and clinicians who have participated in developing the treatment of lumbar spinal canal stenosis in the last seven decades should be recognized.

The MIST Guidelines: The Lumbar Spinal Stenosis Consensus Group Guidelines for Minimally Invasive Spine Treatment

BACKGROUND

Lumbar spinal stenosis (LSS) can lead to compression of neural elements and manifest as low back and leg pain. LSS has traditionally been treated with a variety of conservative (pain medications, physical therapy, epidural spinal injections) and invasive (surgical decompression) options. Recently, several minimally invasive procedures have expanded the treatment options.

METHODS

The Lumbar Spinal Stenosis Consensus Group convened to evaluate the peer-reviewed literature as the basis for making minimally invasive spine treatment (MIST) recommendations. Eleven consensus points were clearly defined with evidence strength, recommendation grade, and consensus level using U.S. Preventive Services Task Force criteria. The Consensus Group also created a treatment algorithm. Literature searches yielded 9 studies (2 randomized controlled trials [RCTs]; 7 observational studies, 4 prospective and 3 retrospective) of minimally invasive spine treatments, and 1 RCT for spacers.

RESULTS

The LSS treatment choice is dependent on the degree of stenosis; spinal or anatomic level; architecture of the stenosis; severity of the symptoms; failed, past, less invasive treatments; previous fusions or other open surgical approaches; and patient comorbidities. There is Level I evidence for percutaneous image-guided lumbar decompression as superior to lumbar epidural steroid injection, and 1 RCT supported spacer use in a noninferiority study comparing 2 spacer products currently available.

CONCLUSIONS

MISTs should be used in a judicious and algorithmic fashion to treat LSS, based on the evidence of efficacy and safety in the peer-reviewed literature. The MIST Consensus Group recommend that these procedures be used in a multimodal fashion as part of an evidence-based decision algorithm.

The aging spine in sports

1. Masters athletes may experience low back pain from multiple sources. Masters athletes with discogenic back pain should avoid or modify sports with combined rotational and compressive forces; individuals with facet-mediated pain should avoid or modify sports with excessive extension and rotation. 2. Optimization of flexibility, strength, endurance, and core control is critical. Sports specific training, realistic goal setting, and counseling are of maximal importance. 3. Overall, the health benefits of continued sports and athletic participation outweigh the potential risks of spinal degeneration in middle-aged athletes. There is little correlation between radiographic appearance of the spine and symptoms; therefore, symptoms should serve as the primary guide when determining activity modifications. Overall, masters athletes should be encouraged to remain active and fit to enhance their quality of life and reduce the risk of cardiovascular disease.

Less invasive and less technically demanding decompressive procedure for lumbar spinal stenosis--appropriate for general orthopaedic surgeons?

This article presents the clinical and radiological results of the modified spinous process osteotomy decompressive procedure (MSPO), which affords excellent visualisation and provides wide access for Kerrison rongeur use and angulation while minimising destruction of tissues not directly involved in the pathological process. A total of 50 patients with degenerative lumbar spinal stenosis underwent MSPO between 2002 and 2005. The minimum follow-up period was five years. Patient's walking distance ability was 85.4 m (5-180 m) preoperatively and 2,560 m (1500-8000 m) at the last follow-up. Leg pain improved in 100% of the patients and back pain improved in 89% at the last follow-up. The overall results were good to excellent in 90% of the patients, fair in 16% and all patients were satisfied with the outcome at the last follow-up. The osteotomised spinous process eventually united with the retained laminar bridge in all patients within nine months after surgery. Degenerative lumbar spinal stenosis can be adequately decompressed with less violation of the integrity of the posterior elements using MSPO. The described technique of MSPO yielded promising results with few complications. The authors believe MSPO is less technically demanding and appropriate for general orthopaedic surgeons, occasional spine surgeons and chief residents.

Validation study of a clinical diagnosis support tool for lumbar spinal stenosis

BACKGROUND

A clinical diagnosis support tool for lumbar spinal stenosis was developed by the Japanese Society for Spine Surgery and Related Research. However, the use of this tool has not yet been validated.

METHODS

Patients with symptoms in the lower extremities and who visited the Department of Orthopedics initially were recruited to the study. Orthopedic physicians who were not spine specialists completed the support tools. Spine specialists examined the patients, made a diagnosis, and completed the lumbar spine examination sheet made for the study. The support tool and lumbar spine examination sheet were sent to a central panel comprising four panelists who then decided on a final diagnosis.

RESULTS

In total, 118 patients were evaluated, including 62 males and 56 females. Lumbar spinal stenosis was diagnosed in 58 and nonlumbar spinal stenosis in 60 patients. The mean score in the lumbar spinal stenosis group was 12.2 points (median 13 points). In the nonlumbar spinal stenosis group, the mean score was 7.5 points (median 7 points). Sensitivity was 0.948, and specificity was 0.40.

CONCLUSIONS

Patients with lumbar spinal stenosis with a very low score were diagnosed with mild lumbar spinal stenosis, whereas nonlumbar spinal stenosis patients with a very high score were diagnosed as suffering from spine disease and needing special treatment by spine surgeons. Our results validate the use of the support tool for the diagnosis of lumbar spinal stenosis. Although the specificity observed in the present study was lower than that reported at development, we conclude that this support tool is useful for screening patients with lumbar spinal stenosis.

Long-term outcome of decompressive surgery for lumbar spinal stenosis in octogenarians

The purpose of our prospective study is to evaluate the surgical outcome among patients aged 80 years and above, who underwent surgery for lumbar spinal stenosis. We assessed patients' clinical and demographic data, procedures, perioperative complications, preoperative and postoperative pain intensity, basic activities of daily living (BADL), patients' satisfaction, the need for repeated surgery, and overall mortality. Thirty-nine patients more than 80 years of age were operated in our institution in the last decade. Twenty-five of them were followed-up with a mean 36.8 months after the operation. The Barthel index was used to evaluate pre and postsurgery ADL, and the visual analogue scale (VAS) was used to evaluate pain. The satisfaction rate of the patients before and after the operation and the complication rate were also evaluated. A significant reduction in VAS (P < 0.001) and a significant increase in the Barthel index (P < 0.001) were recorded. Seventy-six percent of the patients were very satisfied or somewhat satisfied with the operative results. Fifty-two percent of the patients had complications (0.9 complications per patients), however, about half of them were minor. No operative or perioperative mortality was noticed and the overall hospital stay for these elderly patients was 3.6 days on average. Surgery in very old elderly patients is safe and effective in the treatment of spinal stenosis, who did not respond well to the conservative treatment. The surgery did not increase the associated morbidity and mortality and most of the patients benefited from the surgery in terms of reduction in pain, increase in ADL and walking ability and overall increase in the satisfaction rate.

Clinical classification of patients with lumbar spinal stenosis based on their leg pain syndrome: its correlation with 2-year surgical outcome

STUDY DESIGN

Prospective follow-up and retrospective review of 174 patients surgically treated for degenerative lumbar spinal stenosis.

OBJECTIVE

To examine whether the type of leg pain syndrome associated with lumbar spinal stenosis is correlated with outcome.

SUMMARY OF BACKGROUND DATA

Although classifying patients based on their leg pain syndrome is useful in planning surgical decompression, there is no validated method of classification and its prognostic significance remains unknown.

METHODS

Based on the type of leg pain, the patients were classified into 2 groups: unilateral and bilateral. Improvement in functional status was evaluated using the Quebec Back Pain Disability Scale; the symptoms were rated on a visual analog scale and the change from baseline to 2-year evaluation was noted. Associations between score changes and baseline variables were examined using multivariate analysis.

RESULTS

The type of leg pain was independently associated with improvements in function and leg symptom scores but was not associated with improvement in the back pain score. After surgery, patients with unilateral leg pain had significantly greater improvements in function and leg symptoms than patients with bilateral leg pain.

CONCLUSION

In patients undergoing surgery for degenerative lumbar spinal stenosis, the preoperative type of leg pain predicts function and leg symptom outcomes.

Prevalence of symptoms of cervical and lumbar stenosis among participants in the Osteoporotic Fractures in Men Study

STUDY DESIGN

Cross-sectional.

OBJECTIVES

To determine the prevalence of symptoms typical of cervical and lumbar stenosis, evaluate the relationship between lumbar and cervical symptoms, and assess the impact of these symptoms on health status.

SUMMARY OF BACKGROUND DATA

Degenerative changes of the spine frequently associated with aging, may result in stenosis, a narrowing of the spinal canal. Little is known about the prevalence or health impact of symptoms associated with stenosis in older individuals.

METHODS

Between March 2000 and April 2002, 5995 men aged > or = 65 years participating in the Osteoporotic Fractures in Men Study completed a self-administered questionnaire and clinical examination. Information was collected on demographics, spinal/joint health, and general health status.

RESULTS

Overall, 14.4% of men had had clinically relevant neck pain during the previous year, and almost half this group (6.5%) had numbness/tingling/weakness (NTW) extending into the arm; 26.2% reported clinically relevant lower back pain, which in 12.2%, was accompanied by NTW extending into the leg. Men with spinal pain (neck or lower back) accompanied by NTW radiating into a limb had poorer health status than those with milder pain.

CONCLUSIONS

Symptoms suggestive of cervical and lumbar stenosis are relatively common among this cohort of older men, and generalized spinal stenosis may occur in as many as 4%.

F wave studies of neurogenic intermittent claudication in lumbar spinal stenosis

OBJECTIVE

Lumbar spinal stenosis (LSS) may result in neurogenic claudication (NC), which is thought to be a result of transient ischemia during exercise. In this study we evaluated the changes in F wave studies before and immediately after walking stress in patients with NC.

DESIGN

Twenty-six patients with LSS who had signs and symptoms of NC and 20 healthy volunteers were included in this study. Routine motor and sensory nerve conduction studies and tibial F wave studies were performed in both groups. Immediately after walking stress test, tibial F wave studies were repeated. Exercise treadmill protocol was used for ambulation. Time to first symptoms and total ambulation time were recorded.

RESULTS

After completion of the baseline electrophysiological examination, a walking stress test was performed using a treadmill, and 16 patients (61.5%) experienced neurogenic claudication during the trial. The mean time to first symptoms was 2.0 +/- 3.5 mins (minimum = 0, maximum = 14). In the control group 18 subjects (90%) completed the trial without any symptoms, and 2 (10%) subjects had to stop at an average of 10 mins because of generalized fatigue. Within 5 mins after the walking stress test, tibial F wave studies were repeated in both groups. There were significant increases in F latency values bilaterally in the patient group (P = 0.001 for both sides) but not in control subjects (P = 0.435 for right side and P = 0.122 for left side).

CONCLUSION

Our data suggest that F wave studies after walking stress test provide more information for the diagnosis of NC.

Patients' expectations and satisfaction in lumbar spine surgery

STUDY DESIGN

Prospective consecutive series.

OBJECTIVE

To determine patient expectations in lumbar spine surgery and assess the level of fulfillment of those expectations.

SUMMARY OF BACKGROUND DATA

Little has been offered in the literature in specific regards to lumbar spine surgery.

METHODS

Ninety-eight patients, 49 patients who underwent discectomy for lumbar disc herniation (Group 1) and 49 patients who underwent laminotomy for lumbar spinal stenosis (Group 2), completed the self-report questionnaire. Preoperative expectations, reasons for surgery, and expected postoperative status were inquired before surgery and the satisfaction at 2 years after surgery.

RESULTS

Concerning patients' expectations, half of the patients expected to become completely leg pain free, and more than three fourths of the patients expected to become unlimited in their walking ability in both groups. More than half of the patients expected to have a 90% or greater chance of complete success of surgery. With regard to satisfaction, 42 of the 49 patients (86%) in Group 1 and 35 of the 49 patients (71%) in Group 2 chose "Surgery met my expectations" at the follow-up. The remaining patients selected "I did not improve as much as I had hoped." Positive expectations were associated with better satisfaction in Group 1 only. Of the patients who had achieved the expected postoperative status with respect to their no.1 reason for surgery, 2 of 34 patients in Group 1 (6%) and 5 of the 26 patients in Group 2 (19%) nonetheless reported "unfulfilled expectations." In patients whose no. 1 concern was further progression, 3 (38%) of the 8 patients in Group 1 and 2 (40%) of the 5 patients in Group 2 demonstrated unfulfilled expectations.

CONCLUSIONS

Even if the clinical expectations were met, some patients were still dissatisfied. Patients with spinal stenosis (Group 2) seem to have more unrealistic expectations than patients with disc herniation (Group 1).

Effects of laminectomy and facetectomy on the stability of the lumbar motion segment

A ligamentous, nonlinear, sliding contact, three-dimensional finite element (FE) model of L2-L3 complex was developed to investigate the biomechanical effect of laminectomy with and without facetectomy. The L2-L3 FE model was validated against experimental study under various physiological loadings and found to match well with the experimental data. Four iatrogenic models (unilateral laminectomy, unilateral laminectomy with unilateral facetectomy, unilateral laminectomy with bilateral facetectomy and total bilateral laminectomy) were evaluated under flexion, extension, torsion, lateral bending, anterior and posterior shear load vectors to determine alterations in kinematics and annulus stress. Results show that total laminectomy with facetectomy induces considerable increase in motion and annulus stress, except for lateral bending, whereas unilateral laminectomy shows the least increases.

Return to play after lumbar spine conditions and surgeries

Low back pain in athletes can result from a wide variety of conditions. A detailed history and physical examination supplemented by appropriate imaging studies can lead to an accurate diagnosis. The majority of cases will be self-limiting and resolve within 6 weeks regardless of treatment, but it is important to be able to identify conditions that require specific treatment. The decision of when an athlete can return to active competition is determined by the specific condition, associated symptoms, and treatment provided. Most athletes can return to full unrestricted play after sufficient resolution of pain and restoration of range of motion. Athletes undergoing spinal fusion are typically restricted from full-contact sports.

Posterior lumbar interbody fusion using local facet joint autograft and pedicle screw fixation

STUDY DESIGN

This is a retrospective study of 42 patients having lumbar degenerative disease or spondylolytic spondylolisthesis treated by posterior lumbar interbody fusion (PLIF) using local autogenous facet joint graft and pedicle screw fixation with an average follow-up time of 8.5 years.

OBJECTIVES

To evaluate the radiographic and clinical results of patients treated with PLIF using adjacent facet joint autograft and pedicle screw internal fixation.

SUMMARY OF BACKGROUND DATA

Some goals of spinal surgery have been achieved by interbody arthrodesis using a posterior approach popularized by Cloward. However, significant problems including bone graft collapse, resorption, nonunion, persistent neurologic compression, and iliac crest donor complication using the classic PLIF remain. There are few reports describing the results of a PLIF by total facet joint excision.

METHODS

Forty-two patients (average, 53.2 years) treated at our institution with PLIF by total facetectomy were followed for an average period of 8.5 years. The changes in the Japanese Orthopedic Association score, the recovery rate, complications, and radiographic findings were evaluated.

RESULTS

Good radiographic fusion (92.9%) and clinical results (postoperative recovery rate of 76% in the Japanese Orthopedic Association score) were achieved by PLIF using local facet joint autograft and pedicle screw fixation in treating patients with debilitating lumbar degenerative disease. The complications related to the operative procedure occurred in three patients of delayed union.

CONCLUSIONS

For lumbar degenerative diseases with osteophytic changes of facet joints, PLIF using pedicle screw fixation and local autogenous bones obtained from facet excision may be justified as a treatment opinion. The procedure as described offers advantages for spinal surgery when PLIF is warranted.

Surgery of the lumbar spine for spinal stenosis in 118 patients 70 years of age or older

STUDY DESIGN

A consecutive case retrospective chart review and an outcome satisfaction questionnaire were used in this study.

OBJECTIVE

To provide a surgical reference for surgeons and elderly patients who may have concerns regarding the safety and outcome of lumbar spine surgery in their age population.

SUMMARY OF BACKGROUND DATA

Elderly patients scheduled for spine surgery have a major concern about the safety and outcome of the procedure in light of their advanced age. A review of the literature demonstrated conflicting results regarding the outcome of lumbar spine surgery for spinal stenosis in the elderly.

METHODS

A retrospective review evaluated 118 consecutive patients ages 70 to 101 years who were managed surgically for lumbar spinal stenosis. This patient population was analyzed for the operative procedure, postoperative morbidity and mortality, and long-term clinical outcome and satisfaction. All 118 patients had at least a 2-year follow-up evaluation, and 21 of these patients were older than 80 years. Clinical parameters were compiled and analyzed on the basis of chart review.

RESULTS

Overall morbidity occurred in 24 patients (20%). During the study period, the average length of hospitalization declined an average of 2 days. Of the 118 patients, 109 expressed satisfaction with the operation and resumed daily activities, whereas 9 had fair or poor results.

CONCLUSIONS

Advanced age did not increase the morbidity associated with this operation because the results reported in this study are comparable with those from other studies of a younger population, nor did advanced age decrease patient satisfaction or return to activities.

Surgical management of lumbar degenerative spinal stenosis with spondylolisthesis via posterior reduction with minimal laminectomy

Degenerative lumbar spondylolisthesis with spinal stenosis is commonly treated with laminectomy. Recent reports have consistently supported the incremental clinical benefit of associated in situ arthrodesis with or without instrumentation. Resection of the lamina may result in intraoperative dural tear or epidural scar formation. Fifty-six consecutive patients with back pain, neuroclaudication, or both, in addition to degenerative spondylolisthesis with spinal stenosis, underwent a surgical procedure that incorporated fusion after reduction of the spondylolisthesis deformity with preservation of the lamina and the balance of the posterior elements. Clinical records were reviewed and patients interviewed at a mean of 33 months after surgery. Oswestry Disability Index scores were obtained independently at baseline and at a late review. Late imaging was available a mean of 28 months after operation. Clinical and imaging analyses and Oswestry scoring confirmed results comparable to the published outcomes of in situ fusion after formal laminectomy. Resection of the lamina may not be necessary in the treatment of degenerative lumbar spinal stenosis with spondylolisthesis.

Distraction laminoplasty for decompression of lumbar spinal stenosis

Distraction laminoplasty is a technical modification of routine laminectomy that allows decompression of the lumbar spinal canal with maximal bone preservation. The technique involves the application of a distraction force, in conjunction with an undercutting laminoplasty technique. It is safe, easily applied, and allows excellent canal visualization and decompression with minimal bone resection. The purpose of the current study is to describe the technical aspects of the technique.