Iatrogenic spondylolisthesis following laminectomy for degenerative lumbar stenosis: systematic review and current concepts

The efficacy and safety of decompression with interspinous fixation for lumbar spondylolisthesis when compared with posterior lumbar interbody fusion: A pilot study

Posterior lumbar interbody fusion (PLIF) is widely used to treat degenerative spondylolisthesis because it provides definitive decompression and fixation. Although it has several advantages, it has some disadvantages and risks, such as paraspinal muscle injury, potential intraoperative bleeding, postoperative pain, hardware failure, subsidence, and medical comorbidity. Lumbar decompressive bilateral laminectomy with interspinous fixation (DLISF) is less invasive and can be used on some patients with PLIF, but this has not been reported. To compare the efficacy and safety of DLISF in the treatment of low-grade lumbar spondylolisthesis with that of PLIF. We retrospectively analyzed the medical records of 81 patients with grade I spondylolisthesis, who had undergone PLIF or DLISF and were followed up for more than 1 year. Surgical outcomes, visual analog scale, radiologic outcomes, including Cobb angle and difference in body translation, and postoperative complications were assessed. Forty-one patients underwent PLIF, whereas 40 underwent DLISF. The operative times were 271.0 ± 57.2 and 150.6 ± 29.3 minutes for the PLIF and DLISF groups, respectively. The estimated blood loss was significantly higher in the PLIF group versus the DLISF group (290.7 ± 232.6 vs 122.2 ± 82.7 mL, P < .001). Body translation did not differ significantly between the 2 groups. Overall pain improved during the 1-year follow-up when compared with baseline data. Medical complications were significantly lower in the DLISF group, whereas perioperative complications and hardware issues were higher in the PLIF group. The outcomes of DLISF, which is less invasive, were comparable to PLIF outcomes in patients with low-grade spondylolisthesis. As a salvage technique, DLISF may be a good option when compared with PLIF.

Full-endoscopic versus microscopic spinal decompression for lumbar spinal stenosis: a systematic review & meta-analysis

BACKGROUND CONTEXT

Symptomatic lumbar spinal stenosis is routinely treated with spinal decompression surgery, with an increasing trend towards minimally invasive techniques. Endoscopic decompression has emerged as a technique which minimizes approach-related morbidity while achieving similar clinical outcomes to conventional open or microscopic approaches.

PURPOSE

To assess the safety and efficacy of endoscopic versus microscopic decompression for treatment of lumbar spinal stenosis.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A systematic review on randomized and nonrandomized studies comparing endoscopic versus microscopic decompression was conducted, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Treatment effects were computed using pairwise random-effects meta-analysis. Risk of bias was assessed using the Cochrane Risk-of-bias and ROBINS-I tools for randomized and nonrandomized trials respectively. Quality of the overall body of evidence was appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

A total of 19 primary references comprising 1,997 patients and 2,132 spinal levels were included. Endoscopic decompression was associated with significantly reduced intraoperative blood-loss (weighted mean differences [WMD]=-33.29 mL, 95% CI:-51.80 to -14.78, p=.0032), shorter duration of hospital stay (WMD=-1.79 days, 95% CI: -2.63 to 0.95, p=.001), rates of incidental durotomy (RR = 0.63, 95% CI: 0.43 to 0.91, p=.0184) and surgical site infections (RR=0.23, 95% CI: 0.10 to-0.51, p=.001), and a nonsignificant trend towards less back pain, leg pain, and better functional outcomes compared to its microscopic counterpart up to 2-year follow up.

CONCLUSIONS

Endoscopic and microscopic decompression are safe and effective techniques for treatment of symptomatic lumbar spinal stenosis. Prospective studies of larger power considering medium to long-term outcomes and rates of iatrogenic instability are warranted to compare potential alignment changes and destabilization from either techniques.

Surgery for Spinal Stenosis in Achondroplasia: Causes of Reoperation and Reduction of Risks

BACKGROUND

Individuals with achondroplasia are prone to symptomatic spinal stenosis requiring surgery. Revision rates are thought to be high; however, the precise causes and rates of reoperation are unknown. The primary aim of this study is to investigate the causes of reoperation after initial surgical intervention in individuals with achondroplasia and spinal stenosis. In addition, we report on surgical techniques aimed at reducing the risks of these reoperations.

METHODS

A retrospective review was conducted over an 8-year period of all patients with achondroplasia at a single institution that serves as a large referral center for patients with skeletal dysplasias. Patients with achondroplasia who underwent spinal surgery for stenosis were identified and the need for revision surgery was studied. Data collected included demographic, surgical, and revision details. Fisher exact test was used to determine if an association existed between construct type and the need for revisions.

RESULTS

Thirty-three of the 130 (22%) patients with achondroplasia required spinal stenosis surgery. Twenty-four individuals who met the criteria were selected for analysis. The initial spine surgery was at an average age of 18.7 years (SD: 10.1 y). Nine patients (38%) required revision surgeries, and 3 required multiple revisions. Five of 9 (56%) of the revisions had primary surgery at an outside institution. Revision surgeries were due to caudal pseudarthrosis (the distal instrumented segment) (8), proximal junctional kyphosis (PJK) (7), and new neurological symptoms (7). There was a significant association found between construct type and the need for revision (P=0.0111). The pairwise comparison found that short fusions were significantly associated with the need for revision compared with the interbody group (P=0.0180). PJK was associated with short fusions when compared with the long fusion group (P=0.0294) and the interbody group (P=0.0300). Caudal pseudarthrosis was associated with short fusions when compared with the interbody group (P=0.0015). Multivariate logistic regression found long fusion with an interbody was predictive of and protective against the need for revision surgery (P=0.0246). To date, none of the initial cases that had long fusions with caudal interbody required a revision for distal pseudarthrosis.

CONCLUSIONS

In patients with achondroplasia, the rate of surgery for spinal stenosis is 22% and the risk of revision is 38% and is primarily due to pseudarthrosis, PJK, and recurrent neurological symptoms. Surgeons should consider discussing spinal surgery as part of the patient's life plan and should consider wide decompression of the stenotic levels and long fusion with the use of an interbody cage at the caudal level in all patients to reduce risks of revision.

LEVEL OF EVIDENCE

Level IV-Retrospective case series.

The Endoscopic Lumbar Interbody Fusion: A Narrative Review, and Future Perspective

Lumbar interbody fusion stands as a preferred surgical solution for degenerative lumbar spine diseases. The procedure primarily aims to establish lumbar segment stability, directly addressing patient symptoms associated with spinal complications. Traditional open surgery, though effective, is linked with notable morbidities and extended recovery time. To mitigate these concerns, minimally invasive surgery (MIS) has garnered significant popularity, presenting an appealing alternative with numerous benefits such as reduced soft tissue trauma, decreased blood loss, and expedited recovery. Among MIS procedures, full endoscopic spinal surgery, characterized by its minimal invasiveness, holds the potential to further minimize morbidities while enhancing surgical outcomes. Endoscopic lumbar interbody fusion, a novel procedure within this paradigm, has gained attention for offering advantages comparable to those of minimally invasive transforaminal lumbar interbody fusion. However, the safety, efficacy, and associated surgical techniques and instrument design of this method continue to be subjects of ongoing debate. This paper critically reviews current evidence on the safety, efficacy, and advantages of endoscopic lumbar spinal interbody fusion, examining whether it could indeed supersede existing mainstream techniques.

Comparison of full-endoscopic and tubular-based microscopic decompression in patients with lumbar spinal stenosis: a randomized controlled trial

PURPOSE

We aimed to demonstrate non-inferiority in terms of functional outcomes in patients with lumbar spinal stenosis who underwent full-endoscopic decompression compared with tubular-based microscopic decompression.

METHODS

This prospective, randomized controlled, non-inferiority trial included 60 patients with single-level lumbar spinal stenosis who required decompression surgery. The patients were randomly assigned in a 1:1 ratio to the full-endoscopic group (FE group) or the tubular-based microscopic group (TM group). Based on intention-to-treat analysis, the primary outcome was the Oswestry Disability Index score at 24 months postoperative. The secondary outcomes included the visual analog scale (VAS) score for back and leg pain, European Quality of Life-5 Dimensions (EQ-5D) score, walking time, and patient satisfaction rate according to the modified MacNab criteria. Surgery-related outcomes were also analyzed.

RESULTS

Of the total patients, 92% (n = 55) completed a 24-month follow-up. The primary outcomes were comparable between the two groups (p = 0.748). However, the FE group showed a statistically significant improvement in the mean VAS score for back pain at day 1 and at 6, 12, and 24 months after surgery (p < 0.05). No significant difference was observed in the VAS score for leg pain, EQ-5D score, or walking time (p > 0.05). Regarding the modified MacNab criteria, 86.7% of patients in the FE group and 83.3% in the TM group had excellent or good results at 24 months after surgery (p = 0.261). Despite the similar results in surgery-related outcomes, including operative time, radiation exposure, revision rate, and complication rate, between the two groups (p > 0.05), less blood loss and shorter length of hospital stay were observed in the FE group (p ≤ 0.001 and 0.011, respectively).

CONCLUSION

This study suggests that full-endoscopic decompression is an alternative treatment for patients with lumbar spinal stenosis because it provides non-inferior clinical efficacy and safety compared with tubular-based microscopic surgery. In addition, it offers advantages in terms of less invasive surgery. Trial registration number (TRN): TCTR20191217001.

Comparison of the results of open PLIF versus UBE PLIF in lumbar spinal stenosis: postoperative adjacent segment instability is lesser in UBE

OBJECTIVE

To compare the difference in efficacy between open PLIF and UBE for lumbar spinal stenosis and the effect on postoperative adjacent segment instability.

METHOD

The clinical data of 37 patients with PLIF and 32 patients with UBE for lumbar spinal stenosis were retrospectively analyzed to compare the differences in perioperative conditions and short- and medium-term outcomes.

RESULTS

All 69 patients completed the surgery successfully. The operating time, number of intraoperative fluoroscopies and hospital days were higher in the UBE group than in the open PLIF group. Intraoperative bleeding and postoperative drainage were lower than in the open PLIF group (P < 0.05). The visual analogue scale (VAS) of low back pain was lower in the UBE group than in the open PLIF group at 1 month and 3 months postoperatively (P < 0.05), and there were no statistically significant VAS scores for low back pain in the two groups at 1 day and 6 months postoperatively (P > 0.05). Leg pain VAS scores were lower in the UBE group than in the open PLIF group at 1 month, 3 months and 6 months postoperatively (P < 0.05), and leg pain VAS scores were not statistically significant in both groups at 1 day postoperatively (P > 0.05). The ODI index was lower in the UBE group than in the open PLIF group at 1 day and 1 month postoperatively (P < 0.05) and was not statistically significant in the two groups at 3 months and 6 months postoperatively (P > 0.05). There was no statistically significant difference between the two groups in postoperative interbody height, sagittal diameter of the spinal canal, efficacy of modified MacNab and interbody fusion (P > 0.05). The open PLIF group was more prone to postoperative adjacent vertebral instability than the UBE group, and the difference was statistically significant (P < 0.05).

CONCLUSION

With appropriate indications, the open PLIF group and the UBE group had similar short- and medium-term clinical outcomes for the treatment of lumbar spinal stenosis, but patients in the UBE group had better symptomatic improvement than the open PLIF group at 3 months postoperatively, and the effect on postoperative adjacent vertebral instability was smaller in the endoscopic group than in the open PLIF group.

Does Tobacco Smoking Affect the Postoperative Outcome of MIS Lumbar Decompression Surgery?

BACKGROUND

Tobacco smoking is a major cause of morbidity and mortality worldwide. Several authors reported a significant negative impact of smoking on the outcome of spinal surgeries. However, comparative studies on the effect of smoking on the outcome of minimally invasive (MIS) spinal decompression are rare with conflicting results. In this study, we aimed to evaluate clinical outcomes and postoperative complications following MIS decompression in current and former smoking patients compared to those of non-smoking patients.

METHODS

We used our prospectively collected database to retrospectively analyse the records of 188 consecutive patients treated with MIS lumbar decompression at our institution between November 2013 and July 2017. Patients were divided into groups of smokers (S), previous smokers (PS) and non-smokers (N). The S group and the PS group comprised 31 and 40 patients, respectively. The N group included 117 patients. The outcome measures included perioperative complications, revision surgery and length of stay. Patient-reported outcome measures included a visual analogue scale (VAS) for back pain and leg pain, as well as the Oswestry disability index (ODI) for evaluating functional outcomes.

RESULTS

Demographic variables, comorbidity and other preoperative variables were comparable between the three groups. A comparison of perioperative complications and revision surgery rates showed no significant difference between the groups. All groups showed significant improvement in their ODI and VAS scores at 12 and 24 months following surgery. As shown by a multivariate analysis, current smokers had lower chances of improvement, exceeding the minimal clinical important difference (MCID) in ODI and VAS for leg pain at 12 months but not 24 months postoperatively.

CONCLUSIONS

Our findings show that except for a possible delay in improvement in leg pain and disability, tobacco smoking has no substantial adverse impact on complications and revision rates following MIS spinal decompressions.

Differentiating Lumbar Spinal Etiology from Peripheral Plexopathies

Clinicians have managed and treated lower back pain since the earliest days of practice. Historically, lower back pain and its accompanying symptoms of radiating leg pain and muscle weakness have been recognized to be due to any of the various lumbar spine pathologies that lead to the compression of the lumbar nerves at the root, the most common of which is the radiculopathy known as sciatica. More recently, however, with the increased rise in chronic diseases, the importance of differentially diagnosing a similarly presenting pathology, known as lumbosacral plexopathy, cannot be understated. Given the similar clinical presentation of lumbar spine pathologies and lumbosacral plexopathies, it can be difficult to differentiate these two diagnoses in the clinical setting. Resultingly, the inappropriate diagnosis of either pathology can result in ineffective clinical management. Thus, this review aims to aid in the clinical differentiation between lumbar spine pathology and lumbosacral plexopathy. Specifically, this paper delves into spine and plexus anatomy, delineates the clinical assessment of both pathologies, and highlights powerful diagnostic tools in the hopes of bolstering appropriate diagnosis and treatment. Lastly, this review will describe emerging treatment options for both pathologies in the preclinical and clinical realms, with a special emphasis on regenerative nerve therapies.

Radiological Definitions of Sagittal Plane Segmental Instability in the Degenerative Lumbar Spine - A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVE

To collect and group definitions of segmental instability, reported in surgical studies of patients with lumbar spinal stenosis (LSS) and/or lumbar degenerative spondylolisthesis (LDS). To report the frequencies of these definitions. To report on imaging measurement thresholds for instability in patients and compare these to those reported in biomechanical studies and studies of spine healthy individuals.To report on studies that include a reliability study.

METHODS

This review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies eligible for inclusion were clinical and biomechanical studies on adult patients with LDS and/or LSS who underwent surgical treatment and had data on diagnostic imaging. A systematic literature search was conducted in relevant literature databases. Full text screening inclusion criteria was definition of segmental instability or any synonym. Two reviewers independently screened articles in a two-step process. Data synthesis presented by tabulate form and narrative synthesis.

RESULTS

We included 118 studies for data extraction, 69% were surgical studies with decompression or fusion as interventions, 31% non-interventional studies. Grouping the definitions of segmental instability according similarities showed that 24% defined instability by dynamic sagittal translation, 26% dynamic translation and dynamic angulation, 8% used a narrative definition. Comparison showed that non-interventional studies with a healthy population more often had a narrative definition.

CONCLUSION

Despite a reputation of non-consensus, segmental instability in the degenerative lumbar spine can radiologically be defined as > 3 mm dynamic sagittal translation.

Factors associated with an increased risk of developing postoperative symptomatic lumbar spondylolisthesis after decompression surgery: an explorative two-centre international cohort study

PURPOSE

Symptomatic lumbar spinal stenosis can be treated with decompression surgery. A recent review reported that, after decompression surgery, 1.6-32.0% of patients develop postoperative symptomatic spondylolisthesis and may therefore be indicated for lumbar fusion surgery. The latter can be more challenging due to the altered anatomy and scar tissue. It remains unclear why some patients get recurrent neurological complaints due to postoperative symptomatic spondylolisthesis, though some associations have been suggested. This study explores the association between key demographic, biological and radiological factors and postoperative symptomatic spondylolisthesis after lumbar decompression.

METHODS

This retrospective cohort study included patients who had undergone lumbar spinal decompression surgery between January 2014 and December 2016 at one of two Spine Centres in the Netherlands or Switzerland and had a follow-up of two years. Patient characteristics, details of the surgical procedure and recurrent neurological complaints were retrieved from patient files. Preoperative MRI scans and conventional radiograms (CRs) of the lumbar spine were evaluated for multiple morphological characteristics. Postoperative spondylolisthesis was evaluated on postoperative MRI scans. For variables assessed on a whole patient basis, patients with and without postoperative symptomatic spondylolisthesis were compared. For variables assessed on the basis of the operated segment(s), surgical levels that did or did not develop postoperative spondylolisthesis were compared. Univariable and multivariable logistic regression analyses were used to identify associations with postoperative symptomatic spondylolisthesis.

RESULTS

Seven hundred and sixteen patients with 1094 surgical levels were included in the analyses. (In total, 300 patients had undergone multilevel surgery.) ICCs for intraobserver and interobserver reliability of CR and MRI variables ranged between 0.81 and 0.99 and 0.67 and 0.97, respectively. In total, 66 of 716 included patients suffered from postoperative symptomatic spondylolisthesis (9.2%). Multivariable regression analyses of patient-basis variables showed that being female [odds ratio (OR) 1.2, 95%CI 1.07-3.09] was associated with postoperative symptomatic spondylolisthesis. Higher BMI (OR 0.93, 95%CI 0.88-0.99) was associated with a lower probability of having postoperative symptomatic spondylolisthesis. Multivariable regression analyses of surgical level-basis variables showed that levels with preoperative spondylolisthesis (OR 17.30, 95%CI 10.27-29.07) and the level of surgery, most importantly level L4L5 compared with levels L1L3 (OR 2.80, 95%CI 0.78-10.08), were associated with postoperative symptomatic spondylolisthesis; greater facet joint angles (i.e. less sagittal-oriented facets) were associated with a lower probability of postoperative symptomatic spondylolisthesis (OR 0.97, 95%CI 0.95-0.99).

CONCLUSION

Being female was associated with a higher probability of having postoperative symptomatic spondylolisthesis, while having a higher BMI was associated with a lower probability. When looking at factors related to postoperative symptomatic spondylolisthesis at the surgical level, preoperative spondylolisthesis, more sagittal orientated facet angles and surgical level (most significantly level L4L5 compared to levels L1L3) showed significant associations. These associations could be used as a basis for devising patient selection criteria, stratifying patients or performing subgroup analyses in future studies regarding decompression surgery with or without fusion.

Efficacy of Repeat Percutaneous Endoscopic Lumbar Decompression for Reoperation of Lumbar Spinal Stenosis: A Retrospective Study

Purpose

To evaluate the efficacy of repeat percutaneous endoscopic lumbar decompression (PELD) in lumbar spinal stenosis (LSS) reoperation.

Patients and Methods

This study included patients with LSS who relapsed following treatment with PELD therapy between March 2017 and March 2020. Visual analog scale (VAS) scores and Oswestry Disability Index (ODI) were analyzed preoperatively, postoperatively at 3, 6, 12, and 24 months, and at final follow-up. The modified MacNab criteria were used to assess clinical effects. All complications were recorded.

Results

At a mean follow-up of 3 years, 24 patients with LSS who underwent repeat PELD were identified. The patients' mean operative time was 122.3±29.2 min, blood loss was 12.5±5.3 mL, and mean hospital stay was 7.0±1.9 days. VAS leg-pain score improved from 6.1±1.0 to 2.0±1.2 (P<0.001), VAS back-pain score improved from 6.2±0.8 to 2.1±1.1 (P<0.001), and ODI improved from 68.9±6.0 to 20.9±5.6 (P <0.001). According to the modified MacNab criteria, the good-to-excellent rate was 83.3%. Postoperative complications, including hematoma, nerve root injury, and dural injury, developed in four patients.

Conclusion

Repeat PELD for reoperation in patients with LSS has a good clinical effect, and is recommended in routine clinical practice. Careful intraoperative manipulation is recommended to prevent complications.

Delta large-channel technique versus microscopy-assisted laminar fenestration decompression for lumbar spinal stenosis: a one-year prospective cohort study

PURPOSE

When it comes to treating lumbar spinal stenosis (LSS), a procedure known as microscope-assisted fenestration decompression has expediently become the gold standard. With the advancement of spinal endoscopy, the Delta large-channel approach has shown promising clinical outcomes in the management of lumbar spinal stenosis. However, case studies of this method being used to treat lumbar spinal stenosis are still uncommon. The purpose of this research was to examine how well microscopy-assisted laminectomy and the Delta large-channel approach work in treating LSS in the clinic.

METHODS

From May 2018 to June 2020, 149 patients diagnosed with LSS were divided into 80 patients in Delta large-channel technique groups (FE group) and 69 patients in microscope groups (Micro group). Lower back and lower limb pain were measured using the visual analogue scale (VAS-LBP and VAS-LP), while lower limb numbness was evaluated using the 11-point numerical rating scale (NRS-LN); modified Oswestry Disability Index (ODI) was used to evaluate the quality of life, and modified MacNab criteria were used to assess the clinical efficacy before surgery and at one week, three months, six months, and 12 months after surgery. All patients had single-level lumbar spinal stenosis, and clinical data such as hospital stay, operation time, intraoperative blood loss were statistically analyzed.

RESULTS

Finally, 111 patients (62 in FE group and 49 in Micro group) completed follow-up. Compared with preoperative results, postoperative VAS-LBP, VAS-LP, NRS-LN score and modified ODI score were significantly improved in 2 groups (P < 0.05), but there was no significant difference in postoperative follow-up at each time point (P > 0.05), Except 1 week after surgery, VAS-LBP in FE group was lower than that in Micro group (P < 0.05). It is noteworthy that the FE group had a shorter hospital stay, less intraoperative blood loss, and a quicker time of getting out of bed when compared with the microscope group，but the operation time was just the opposite (P < 0.05). The excellent and good rate was 83.87% in FE group and 85.71% in Micro group (P > 0.05).

CONCLUSIONS

Both microscope-assisted laminar fenestration decompression and Delta large-channel procedures provide satisfactory treatment outcomes, however the Delta large-channel approach has some potential advantages for the treatment of LSS, including quicker recovery and sooner reduced VAS-LBP. Long-term consequences, however, will necessitate additional follow-up and research.

Clinical efficacy and imaging outcomes of unilateral biportal endoscopy with unilateral laminotomy for bilateral decompression in the treatment of severe lumbar spinal stenosis

Objective

To investigate the clinical efficacy and imaging outcomes of unilateral biportal endoscopy (UBE) with unilateral laminotomy for bilateral decompression (ULBD) in the treatment of severe lumbar spinal stenosis (SLSS).

Methods

We retrospectively analyzed 50 patients with SLSS treated with UBE-ULBD from October 2018 to March 2021. Visual analog scale (VAS) for back and legs pain, Oswestry disability index (ODI), modified Macnab criteria, complications, hospital stay, preoperative and postoperative dural sac cross-sectional area (DSCA) and Schizas grade, mean angle of facetectomy and osseous lateral recess decompression rate were examined.

Results

The mean follow-up period was 10.7 months. The mean hospital stay was 2.76 ± 1.02 days. At the final follow-up, VAS for back pain and legs pain decreased from 7.22 ± 0.95 to 1.26 ± 0.44 and from 7.88 ± 0.69 to 1.18 ± 0.39, respectively; ODI decreased from 69.88 ± 6.32% to 14.96 ± 2.75%. According to the modified Macnab criteria, the results were excellent in 24 (48%), good in 22 (44%), and fair in 4 (8%). Excellent or good results (a satisfactory outcome) were obtained in 92% of the patients. There were 2 cases of complications of dural sac tear. The postoperative DSCA was significantly enlarged compared with that before surgery, from 44.74 ± 9.85 to 126.86 ± 14.81 mm². According to Schizas grade, the stenosis grade changes from preoperative grade C in 16 cases, grade D in 34 cases, to postoperative grade A in 40 cases, and grade B in 10 cases. The mean angle of facetectomy of the ipsilateral facet joint was 70.87 ± 5.68 ∘ , contralateral was 65.07 ± 4.98 ∘ . The decompression rate was 70.81 ± 4.43% (ipsilateral side) and 71.22 ± 3.68% (contralateral).

Conclusions

UBE-ULBD has a good clinical effect in the treatment of SLSS, and has achieved satisfactory results in spinal canal enlargement, undercutting of facet joints, and decompression effect. It is a safe and effective surgical for SLSS.

Minimally invasive surgery for spinal cerebrospinal fluid leaks in spontaneous intracranial hypotension

OBJECTIVE

Spinal CSF leaks cause spontaneous intracranial hypotension (SIH). Surgical closure of spinal CSF leaks is the treatment of choice for persisting leaks. Surgical approaches vary, and there are no studies in which minimally invasive techniques were used. In this study, the authors aimed to detail the safety and feasibility of minimally invasive microsurgical sealing of spinal CSF leaks using nonexpandable tubular retractors.

METHODS

Consecutive patients with SIH and a confirmed spinal CSF leak treated at a single institution between April 2019 and December 2020 were included in the study. Surgery was performed via a dorsal 2.5-cm skin incision using nonexpandable tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach. The primary outcome was successful sealing of the dura, and the secondary outcome was the occurrence of complications.

RESULTS

Fifty-eight patients, 65.5% of whom were female (median age 46 years [IQR 36-55 years]), with 38 ventral leaks, 17 lateral leaks, and 2 CSF venous fistulas were included. In 56 (96.6%) patients, the leak could be closed, and in 2 (3.4%) patients the leak was missed because of misinterpretation of the imaging studies. One of these patients underwent successful reoperation, and the other patient decided to undergo surgery at another institution. Two other patients had to undergo reoperation because of insufficient closure and a persisting leak. The rate of permanent neurological deficit was 1.7%, the revision rate for a persisting or recurring leak was 3.4%, and the overall revision rate was 10.3%. The rate of successful sealing during the primary closure attempt was 96.6% and 3.4% patients needed a secondary attempt. Clinical short-term outcome at discharge was unchanged in 14 patients and improved in 25 patients, and 19 patients had signs of rebound intracranial hypertension.

CONCLUSIONS

Minimally invasive surgery with tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach is safe and effective for the treatment of spinal CSF leaks. The authors suggest performing a minimally invasive closure of spinal CSF leaks in specialized centers.

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lumbar spinal stenosis, 2021 - Secondary publication

BACKGROUND

The Japanese Orthopaedic Association (JOA) guideline for the management of lumbar spinal stenosis (LSS) was first published in 2011. Since then, the medical care system for LSS has changed and many new articles regarding the epidemiology and diagnostics of LSS, conservative treatments such as new pharmacotherapy and physical therapy, and surgical treatments including minimally invasive surgery have been published. In addition, various issues need to be examined, such as verification of patient-reported outcome measures, and the economic effect of revised medical management of patients with lumbar spinal disorders. Accordingly, in 2019 the JOA clinical guidelines committee decided to update the guideline and consequently established a formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline, incorporating the recent advances of evidence-based medicine.

METHODS

The JOA LSS guideline formulation committee revised the previous guideline based on the method for preparing clinical guidelines in Japan proposed by the Medical Information Network Distribution Service in 2017. Background and clinical questions were determined followed by a literature search related to each question. Appropriate articles based on keywords were selected from all the searched literature. Using prepared structured abstracts, systematic reviews and meta-analyses were performed. The strength of evidence and recommendations for each clinical question was decided by the committee members.

RESULTS

Eight background and 15 clinical questions were determined. Answers and explanations were described for the background questions. For each clinical question, the strength of evidence and the recommendation were both decided, and an explanation was provided.

CONCLUSIONS

The 2021 clinical practice guideline for the management of LSS was completed according to the latest evidence-based medicine. We expect that this guideline will be useful for all medical providers as an index in daily medical care, as well as for patients with LSS.

Comparative Effects and Safety of Full-Endoscopic Versus Microscopic Spinal Decompression for Lumbar Spinal Stenosis: A Meta-Analysis and Statistical Power Analysis of 6 Randomized Controlled Trials

OBJECTIVE

This meta-analysis with statistical power analysis aimed to evaluate the difference between full-endoscopic and microscopic spinal decompression in treating spinal stenosis.

METHODS

We searched PubMed, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CNKI (China National Knowledge Infrastructure) for relevant randomized controlled trials (RCTs) regarding the comparison of full-endoscopic versus microscopic spinal decompression in treating lumbar spinal stenosis through February 28, 2022. Two independent investigators selected studies, extracted information, and appraised methodological quality. Meta-analysis was conducted using RevMan 5.4 and STATA 14.0, and statistical power analysis was performed using G*Power 3.1.

RESULTS

Six RCTs involving 646 patients met selection criteria. Meta-analysis suggested that, compared with microscopic decompression, full-endoscopic spinal decompression achieved more leg pain improvement (mean difference [MD], -0.20; 95% confidence interval [CI], -0.30 to -0.10; p = 0.001), shortened operative time (MD, -12.71; 95% CI, -18.27 to -7.15; p < 0.001), and decreased the incidence of complications (risk ratio, 0.43; 95% CI, 0.22-0.82; p = 0.01), which was supported by a statistical power of 98.57%, 99.97%, and 81.88%, respectively.

CONCLUSION

Full-endoscopic spinal decompression is a better treatment for lumbar spinal stenosis, showing more effective leg pain improvement, shorter operative time, and fewer complications than microscopic decompression.

Full Endoscopic Ligamentum Flavum Sparing Unilateral Laminotomy for Bilateral Recess Decompression: Surgical Technique and Clinical Results

OBJECTIVE

Interlaminar endoscopic spine surgery has been introduced and utilized for lumbar lateral recess decompression. We modified this technique and utilized it for bilateral lateral recess stenoses without significant central stenosis. Here we present the surgical details and clinical outcome of ligamentum flavum sparing unilateral laminotomy for bilateral recess decompression (ULBRD).

METHODS

Prospectively collected registry for full-endoscopic surgeries was reviewed retrospectively. One hundred eighty-two consecutive cases from a single center between September 2015 and March 2021 were reviewed and 57 of them whom underwent ULBRD were enrolled for analysis. Basic patient demographic data, perioperative details, surgeryrelated complications, and clinical outcome were reviewed. The detailed surgical technique is presented as well.

RESULTS

Among the 57 patients enrolled, 37 were males while the other 20 were females. The mean age was 58.53 ± 14.51 years, and a bimodal age distribution at the age of mid-fifties and mid-sixties or older was noted. The later age-peak was related to coexistence of degenerative scoliosis. The average operative time per lamina was 70.34 ± 20.51 minutes and mean length of stay was 0.56 ± 0.85 days. Four perioperative complications were reported (7.0%) and the overall reoperation rate at the index level within 1 year was 8.8%. The preoperative back/leg visual analogue scale scores and functional outcome scales including EuroQol-5 dimension questionnaire, Oswestry Disability Index presented significant improvement immediately after surgery and were maintained until final follow-up.

CONCLUSION

ULBRD for bilateral lateral recess stenoses without significant central stenosis resulted in good clinical outcomes with acceptably low perioperative complications rates. Sufficient decompression was achieved with the central ligamentum flavum being preserved.

Full-endoscopic versus microscopic unilateral laminotomy for bilateral decompression of lumbar spinal stenosis at L4-L5: comparative study

PURPOSE

Full-endoscopic spine surgery for degenerative lumbar diseases is growing in popularity and has shown favourable outcomes. Lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has been used to treat lumbar spinal stenosis (LSS). However, studies comparing LE-ULBD to microscopic ULBD are lacking. This study compared the clinical efficacy and radiological outcomes between the LE-ULBD and microscopic ULBD.

METHODS

The study retrospectively enrolled patients undergoing either LE-ULBD or microscopic ULBD for spinal stenosis at the L4-L5 level. The demographic data, operative details, radiological images, clinical outcomes, and complications of patients from the two groups were compared through matched-pairs analysis. The minimum follow-up duration was 24 months.

RESULTS

There were 93 patients undergoing either LE-ULBD (n = 42) or microscopic ULBD (n = 51). The patient demographics were similar between the two groups. The LE-ULBD group had significantly less estimated blood loss, less analgesic use, and shorter hospitalization duration (P < .05). The endoscopic group had a significantly lower visual analog scale for back pain at all follow-up intervals compared with the microscopic group (P < .05). There were no significant differences in leg pain or Oswestry Disability Index. The cross-section area of the spinal canal was significantly wider after microscopic ULBD. There were no significant differences in post-operative degenerative changes in disc height, translational motion, or facet preservation rate.

CONCLUSIONS

LE-ULBD is comparable in clinical and radiological outcomes with enhanced recovery for single-level LSS. The endoscopic approach might further minimize tissue injury and enhance post-operative recovery.

Mobility-Maintaining Facet Arthroplasty of the Lumbar Spine With the Second-Generation TOPS System: A Case Series

BACKGROUND

Lumbar spinal stenosis results from spinal canal narrowing and can lead to pain and dysfunction. Until recently, surgical treatment for lumbar spinal stenosis requiring an extensive decompression, with or without spondylolisthesis, had to balance pain relief with the long-term risks of spinal instability after decompression and adjacent segment disease (ASD) after spinal fusion. Spinal motion-preserving devices aim to reduce the incidence of ASD after posterolateral fusion and consequent need for revision surgery.

OBJECTIVE

To present a single-center experience with a facet replacement implant (TOPS System [TOtal Posterior Spine System], Premia Spine) designed to stabilize the spine and prevent further degeneration while maintaining a normal range of motion (ROM).

METHODS

Seventeen patients received the implant after a laminotomy. Clinical assessments included surgery duration, complication rates, and visual analog score for back pain. Radiographs were used to measure ROM changes from flexion to extension and assess for any repositioning of a degenerative spondylolisthesis and segment lordosis.

RESULTS

The average operative time was 102 minutes. The average visual analog score reduction was 7.5 at 3 months, 6.8 at 12 months, and 6.7 at the longest follow-up (average: 51 months, range: 26-77), demonstrating an average improvement of 81%. The preoperative and postoperative average ROMs were 8.2° and 7.4°, respectively.

CONCLUSION

This series shows that the TOPS System has the potential to relieve back pain and maintain close-to-normal ROM over longer time periods without inducing ASD. The TOPS System is the first to allow the patient to settle into physiological lordosis adjustment thus presenting new treatment possibilities with mobility-maintaining dorsal instrumentation.

Lumbar spinal stenosis - surgical outcome and the odds of revision-surgery: Is it all due to the surgeon?

BACKGROUND

Surgical decompression is the intervention of choice for lumbar spinal stenosis (LSS) when non-operative treatment has failed. Apart from acute complications such as hematoma and infections, same-level recurrent lumbar stenosis and adjacent-segment disease (ASD) are factors that can occur after index lumbar spine surgery.

OBJECTIVE

The aim of this retrospective case series was to evaluate the outcome of surgery and the odds of necessary revisions.

METHODS

Patients who had undergone either decompressive lumbar laminotomy or laminotomy and spinal fusion due to lumbar spinal stenosis (LSS) between 2000 and 2011 were included in this analysis. Demographic, perioperative and radiographic data were collected. Clinical outcome was evaluated using numeric rating scale (NRS), the symptom subscale of the adapted version of the german Spinal Stenosis Measure (SSM) and patient-sreported ability to walk.

RESULTS

Within the LSS- cohort of 438 patients, 338 patients underwent decompression surgery only, while instrumentation in addition to decompression was performed in 100 cases (22.3%). 38 patients had prior spinal operations (decompression, disc herniation, fusion) either at our hospital or elsewhere. Thirty-five intraoperative complications were documented with dural tear with CSF leak being the most common (33/35; 94.3%). Postoperative complications were defined as complications that needed surgery and differentiated between immediate postoperative complications (⩽ 3 weeks post operation) and complications that needed revisions surgery at a later date. Within all patients 51 revisions were classified as immediate complications of the index operation with infections, neurological deficits and hematoma being the most common. Within this group only 22 patients had fusion surgery in the first place, while 29 were treated by decompression. Revision surgery was indicated by 53 patients at a later date. While 4 patients decided against surgery, 49 revision surgeries were planned. 28 were performed at the same level, 10 at the same level plus an adjacent level, and 10 were executed at index level with indications of adjacent level spinal stenosis, adjacent level spinal stenosis plus instability and stand-alone instability. Pre- operative VAS score and ability to walk improved significantly in all patients.

CONCLUSIONS

While looking for predictors of revision surgery due to re-stenosis, instability or same/adjacent segment disease none of these were found. Within our cohort no significant differences concerning demographic, peri-operative and radiographic data of patients with or without revision wer noted. Patients, who needed revision surgery were older but slightly healthier while more likely to be male and smoking. Surprisingly, significant differences were noted regarding the distribution of intraoperative and early postoperative complications among the 6 main surgeons while these weren't obious within the intial index group of late revisions.

Long-Term Outcomes After Minimally Invasive Bilateral or Unilateral Laminotomy for Degenerative Lumbar Spinal Stenosis: A Minimum 10-Year Follow-Up Study

OBJECTIVE

The optimal surgical procedure for minimal surgical intervention in symptomatic degenerative lumbar spinal stenosis (DLSS) is unknown. This article presents a method of minimally invasive decompression alone and reports the long-term outcomes and complications of patients treated with minimally invasive bilateral or unilateral laminotomy decompression performed by one surgeon.

METHODS

Patients with DLSS who underwent minimally invasive laminotomy decompression alone from March 2008 to October 2010 were included in the study, and 106 patients were followed up for at least 10 years. Clinical outcomes were assessed by Japanese Orthopedic Association, Oswestry Disability Index, and visual analog scale for back pain scores, and changes in walking tolerance and leg numbness were evaluated. Complications were recorded.

RESULTS

A total of 106 patients who met the inclusion and exclusion criteria were included in the study (mean age = 64 years, range = 43-83). The Japanese Orthopedic Association, Oswestry Disability Index, and visual analog scale back pain scores of patients significantly changed between before surgery and at subsequent follow-up (P < 0.001). The walking tolerance and leg numbness of patients significantly improved (P < 0.001), and these functions were well maintained during follow-up. Complications included intraoperative dural tears (n = 5), a wound infection (n = 1), deep vein thrombosis (n = 1), and nerve root lesions on the asymptomatic side (n = 2), all of which recovered within 3 months.

CONCLUSIONS

Minimally invasive laminotomy decompression is an effective procedure and achieves beneficial long-term clinical results for DLSS.

The lateral entry point S2 alar-iliac (L-S2AI) screw: a preoperative computed tomography analysis of adult spinal deformity patients

PURPOSE

To radiographically compare lateral entry point S2-alar-iliac (L-S2AI) screw with conventional S2AI (C-S2AI) and conventional iliac screw (CIS) lengths and trajectories.

METHODS

Twenty-five preoperative CT scans of consecutive patients undergoing adult spinal deformity realignment surgery over a random 2-year period were analysed. Maximum in-bone length, caudal and lateral trajectories of CIS, C-S2AI, and L-S2AI screws were measured and compared using One-way ANOVA with Tukey's post hoc tests. Multivariate logistic regression was performed to identify predictors of high screw length discrepancy between C-S2AI and L-S2AI.

RESULTS

Potential screw length was longest for CIS, followed by L-S2AI, then C-S2AI (114.5 ± 8.3 mm vs 101.4 ± 9.6 mm vs 80.6 ± 5.9 mm, respectively) in all patients (p < 0.001). Actual screw lengths found both CIS and L-S2AI to be longer than C-S2AI (95.3 ± 8.5 mm and 93.4 ± 7.5 mm vs 82.1 ± 7.3 mm; p = 0.008 and 0.003). Potential lateral angulation was smallest for CIS, followed by L-S2AI, then C-S2AI (21.9 ± 7.0° vs 31.9 ± 7.1° vs 40.9 ± 6.7°, respectively) in all patients (p < 0.001). L-S2AI and C-S2AI had the same caudal angulation (24.9 ± 6.8°), which was smaller than CIS (30.8 ± 5.8°) in all patients (p < 0.001). Univariate, but not multivariate analysis, revealed that lumbar lordosis > 40° (OR 7.2, p = 0.041), diagnosis of degenerative spondylolisthesis (OR 10.5, p = 0.017), and > 7 instrumented levels (OR 2.6, p = 0.049) were significantly associated with high screw discrepancies.

CONCLUSION

The L-S2AI screw combines advantages of CIS and C-S2AI screws, which includes increased screw length, reduced lateral angulation, a low-profile screw head, ease of connection to proximal hardware, and the biomechanical advantage of a quadcortical purchase.

Radiological Analysis of Minimally Invasive Microscopic Laminectomy for Lumbar Canal Stenosis with a Focus on Multilevel Stenosis and Spondylolisthesis

OBJECTIVE

We retrospectively compared the radiological and clinical outcomes of two different surgical techniques (lumbar spinous process splitting laminectomy [LSPSL] and unilateral laminotomy for bilateral decompression [ULBD]) to treat lumbar spinal canal stenosis (LCS).

METHODS

We performed a retrospective comparative study of 141 consecutive patients with an average age of 70.8 ± 9.4 years who had undergone LSPSL or ULBD for LCS between April 2015 and April 2019. None of the patients had developed remote fractures of the spinous processes using either technique. These cases were divided into 2 groups: group L, 73 patients who had undergone LSPSL from April 2015 to April 2017; and group U, 68 patients who had undergone ULBD from May 2017 to April 2019. The clinical and radiological outcomes and surgical complications at the 1-year postoperative follow-up period were evaluated.

RESULTS

We found no significant differences in the operative time between the 2 groups. However, group U had had significantly less blood loss than group L. The facet joints were significantly well preserved in group U. We examined the multilevel and spondylolisthesis cases separately and found that both surgical procedures were equally effective and that the visual analog scale scores for back or leg pain and Japanese Orthopaedic Association scores had significantly improved postoperatively in each group. Group U showed better outcomes in terms of LCS recurrence, with 3 patients in the group L requiring repeat surgery.

CONCLUSIONS

We found both ULBD and LSPSL to be safe and effective techniques for LCS, even for patients with spondylolisthesis and multilevel disease. ULBD was superior in terms of recurrence prevention, preservation of the facet joints, and less blood loss.

Endoscopic decompression for the treatment of lumbar spinal stenosis: an updated systematic review and meta-analysis

OBJECTIVE

Lumbar stenosis treatment has evolved with the introduction of minimally invasive surgery (MIS) techniques. Endoscopic methods take the concepts applied to MIS a step further, with multiple studies showing that endoscopic techniques have outcomes that are similar to those of more traditional approaches. The aim of this study was to perform an updated meta-analysis and systematic review of studies comparing the outcomes between endoscopic (uni- and biportal) and microscopic techniques for the treatment of lumbar stenosis.

METHODS

Following PRISMA guidelines, a systematic search was performed using the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Ovid Embase, and PubMed databases from their dates of inception to December 14, 2020. All identified articles were then systematically screened against the following inclusion criteria: 1) studies comparing endoscopic (either uniportal or biportal) with minimally invasive approaches, 2) patient age ≥ 18 years, and 3) diagnosis of lumbar spinal stenosis. Bias was assessed using quality assessment criteria and funnel plots. Meta-analysis using a random-effects model was used to synthesize the metadata.

RESULTS

From a total of 470 studies, 14 underwent full-text assessment. Of these 14 studies, 13 comparative studies were included for quantitative analysis, totaling 1406 procedures satisfying all criteria for selection. Regarding postoperative back pain, 9 studies showed that endoscopic methods resulted in significantly lower pain scores compared with MIS (mean difference [MD] -1.0, 95% CI -1.6 to -0.4, p < 0.01). The length of stay data were reported by 7 studies, with endoscopic methods associated with a significantly shorter length of stay versus the MIS technique (MD -2.1 days, 95% CI -2.7 to -1.4, p < 0.01). There was no significant difference with respect to leg visual analog scale scores, Oswestry Disability Index scores, blood loss, surgical time, and complications, and there were not any significant quality or bias concerns.

CONCLUSIONS

Both endoscopic and MIS techniques are safe and effective methods for treating patients with symptomatic lumbar stenosis. Patients who undergo endoscopic surgery seem to report less postoperative low-back pain and significantly reduced hospital stay with a trend toward less perioperative blood loss. Future large prospective randomized trials are needed to confirm the findings in this study.

Comparison of 3 Different Minimally Invasive Surgical Techniques for Lumbar Spinal Stenosis: A Randomized Clinical Trial

IMPORTANCE

Operations for lumbar spinal stenosis is the most often performed surgical procedure in the adult lumbar spine. This study reports the clinical outcome of the 3 most commonly used minimally invasive posterior decompression techniques.

OBJECTIVE

To compare the effectiveness of 3 minimally invasive posterior decompression techniques for lumbar spinal stenosis.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial used a parallel group design and included patients with symptomatic and radiologically verified lumbar spinal stenosis without degenerative spondylolisthesis. Patients were enrolled between February 2014 and October 2018 at the orthopedic and neurosurgical departments of 16 Norwegian public hospitals. Statistical analysis was performed in the period from May to June 2021.

INTERVENTIONS

Patients were randomized to undergo 1 of the 3 minimally invasive posterior decompression techniques: unilateral laminotomy with crossover, bilateral laminotomy, and spinous process osteotomy.

MAIN OUTCOMES AND MEASURES

Primary outcome was change in disability measured with Oswestry Disability Index (ODI; range 0-100), presented as mean change from baseline to 2-year follow-up and proportions of patients classified as success (>30% reduction in ODI). Secondary outcomes were mean change in quality of life, disease-specific symptom severity measured with Zurich Claudication Questionnaire (ZCQ), back pain and leg pain on a 10-point numeric rating score (NRS), patient perceived benefit of the surgical procedure, duration of the surgical procedure, blood loss, perioperative complications, number of reoperations, and length of hospital stay.

RESULTS

In total, 437 patients were included with a median (IQR) age of 68 (62-73) years and 230 men (53%). Of the included patients, 146 were randomized to unilateral laminotomy with crossover, 142 to bilateral laminotomy, and 149 to spinous process osteotomy. The unilateral laminotomy with crossover group had a mean change of -17.9 ODI points (95% CI, -20.8 to -14.9), the bilateral laminotomy group had a mean change of -19.7 ODI points (95% CI, -22.7 to -16.8), and the spinous process osteotomy group had a mean change of -19.9 ODI points (95% CI, -22.8 to -17.0). There were no significant differences in primary or secondary outcomes among the 3 surgical procedures, except a longer duration of the surgical procedure in the bilateral laminotomy group.

CONCLUSIONS AND RELEVANCE

No differences in clinical outcomes or complication rates were found among the 3 minimally invasive posterior decompression techniques used to treat patients with lumbar spinal stenosis.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02007083.

Minimally invasive bilateral decompressive lumbar laminectomy with unilateral approach: patient series

BACKGROUND

Minimally invasive bilateral decompressive lumbar laminectomy with a unilateral approach is a less destructive procedure compared to the traditional open bilateral laminectomy. The objective of this study is to report the authors’ experience with this technique. The first 26 cases performed using the unilateral approach for bilateral decompression are described. Baseline characteristics, operative time, blood loss, and intraoperative complications were collected retrospectively. No specific surgical equipment is needed for this technique.

OBSERVATIONS

Twenty-six patients and a total of 40 lumbar levels were treated. Mean operative time was 82 minutes per level and mean estimated blood loss was 40.4 mL per level. Mean length of hospitalization was 1.65 days. Cerebrospinal fluid leak occurred in 1 of 26 (3.85%) cases.

LESSONS

Although improved stabilization needs to be proven in future long-term studies to clearly show a decrease in need for fusion, the initial experience with a unilateral approach is positive and continued use in minimally invasive spine surgery seems promising.

Treatment of restenosis after lumbar decompression surgery: decompression versus decompression and fusion

OBJECTIVE

The aim of this study was to compare perioperative complications and postoperative outcomes between patients with lumbar recurrent stenosis without lumbar instability and radiculopathy who underwent decompression surgery and those who underwent decompression with fusion surgery.

METHODS

For this retrospective study, the authors identified 2606 consecutive patients who underwent posterior surgery for lumbar spinal canal stenosis at eight affiliated hospitals between April 2017 and June 2019. Among these patients, those with a history of prior decompression surgery and central canal restenosis with cauda equina syndrome were included in the study. Those patients with instability or radiculopathy were excluded. The patients were divided between the decompression group and decompression with fusion group. The demographic characteristics, numerical rating scale score for low-back pain, incidence rates of lower-extremity pain and lower-extremity numbness, Oswestry Disability Index score, 3-level EQ-5D score, and patient satisfaction rate were compared between the two groups using the Fisher's exact probability test for nominal variables and the Student t-test for continuous variables, with p < 0.05 as the level of statistical significance.

RESULTS

Forty-six patients met the inclusion criteria (35 males and 11 females; 19 patients underwent decompression and 27 decompression and fusion; mean ± SD age 72.5 ± 8.8 years; mean ± SD follow-up 18.8 ± 6.0 months). Demographic data and perioperative complication rates were similar. The percentages of patients who achieved the minimal clinically important differences for patient-reported outcomes or satisfaction rate at 1 year were similar.

CONCLUSIONS

Among patients with central canal stenosis who underwent revision, the short-term outcomes of the patients who underwent decompression were comparable to those of the patients who underwent decompression and fusion. Decompression surgery may be effective for patients without instability or radiculopathy.

Minimally invasive microsurgical decompression in patients with monosegmental lumbar spinal stenosis

Surgical treatment of degenerative lumbar spinal stenosis is an actual problem of modern spinal surgery and orthopedics.

OBJECTIVE

To analyze the results of minimally invasive microsurgical decompression (MI-MD) in patients with monosegmental lumbar spinal stenosis.

MATERIAL AND METHODS

A retrospective observational cohort study was performed. We analyzed medical records of patients who underwent MI-MD for monosegmental degenerative lumbar spinal stenosis. Clinical and objective results of MI-MD, as well as the types and prevalence of adverse clinical events were studied.

RESULTS

The study included 96 medical records (50 (52%) males and 46 (48%) females aged 18-84 years). Analysis of pain in lower back and lower extremities in 3, 6, 9, 12 and 24 months after MI-MD showed a significant decrease of this indicator (p<0.001). There was significant improvement of capacity according to ODI score up to 5-12% in 72.9% of patients in early postoperative period (p=0.055). In delayed postoperative period, we also observed significant improvement of working capacity according to ODI score and gradual decrease in disability index (p<0.001). Adverse clinical events occurred in 6 (6.2%) patients.

CONCLUSION

MI-MD is a highly effective surgical method for monosegmental lumbar spinal stenosis with minimal incidence of adverse clinical events.

Clinical outcome following decompression and short or long instrumented fusion in lumbar degenerative spinal stenosis. A prospective case-control analysis

OBJECTIVES

There is limited data on the direct clinical comparison between short and long fusion following surgery for lumbar spinal stenosis. The hypothesis that regardless their baseline characteristics and morbidity, clinical outcome is similar in patients with lumbar stenosis treated with decompression plus posterior instrumented fusion in one or two versus three to five levels was tested.

METHODS

Subjects were divided into Group A and Group B corresponding to stenotic pathology and instrumented fusion in one or two levels and three to five levels, respectively. Primary outcome measures at one year were the change in SF-36 physical component (PCS) and Oswestry Disability Index (ODI). Secondary outcome measures included the EuroQol-5D (EQ-5D), the Visual Analog Scale (VAS), the mental component (MCS) of SF-36 scale and the Zung Self-Rating Depression Scale.

RESULTS

Seventy seven (77) patients were included (Group A, n = 42; Group B, n = 35). Patients in Group B were older, surgery lasted longer and intraoperative blood loss was greater than patients in Group A (p < 0.05). A significant clinical improvement was noted in both Groups on all scales (p < 0.01). Clinical outcome at one year was equally favorable in both Groups (p > 0.05). The evaluation of depression for Group A showed a significant improvement at one year (p = 0.02) compared to the preoperative status.

CONCLUSIONS

Older individuals are more likely to have multilevel stenosis and more co-morbidities and they were associated with longer instrumentation. However, complications are similar and clinical outcome is equally favorable compared to short instrumented fusion for fewer levels of disease.

Stable Low-Grade Degenerative Spondylolisthesis Does Not Compromise Clinical Outcome of Minimally Invasive Tubular Decompression in Patients with Spinal Stenosis

Background and Objectives: In recent literature, the routine addition of arthrodesis to decompression for lumbar spinal stenosis (LSS) with concomitant stable low-grade degenerative spondylolisthesis remains controversial. The purpose of this study is to compare the clinical outcome, complication and re-operation rates following minimally invasive (MIS) tubular decompression without arthrodesis in patients suffering from LSS with or without concomitant stable low-grade degenerative spondylolisthesis. Materials and Methods: This study is a retrospective review of prospectively collected data. Ninety-six consecutive patients who underwent elective MIS lumbar decompression with a mean follow-up of 27.5 months were included in the study. The spondylolisthesis (S) group comprised 53 patients who suffered from LSS with stable degenerative spondylolisthesis, and the control (N) group included 43 patients suffering from LSS without spondylolisthesis. Outcome measures included complications and revision surgery rates. Pre- and post-operative visual analog scale (VAS) for both back and leg pain was analyzed, and the Oswestry Disability Index (ODI) was used to evaluate functional outcome. Results: The two groups were comparable in most demographic and preoperative variables. VAS for back and leg pain improved significantly following surgery in both groups. Both groups showed significant improvement in their ODI scores, at one and two years postoperatively. The average length of hospital stay was significantly higher in patients with spondylolisthesis (p-value< 0.01). There was no significant difference between the groups in terms of post-operative complications rates or re-operation rates. Conclusions: Our results indicate that MIS tubular decompression may be an effective and safe procedure for patients suffering from LSS, with or without degenerative stable spondylolisthesis.

Wide Laminectomy, Segmental Bilateral Laminotomies, or Unilateral Hemi-Laminectomy for Lumbar Spinal Stenosis: Five-year Patient-reported Outcomes in Propensity-matched Cohorts

STUDY DESIGN

Propensity-matched retrospective study of patients prospectively enrolled in Danespine.

OBJECTIVE

The aim of this study was to report 5-year patient reported outcome in lumbar spinal stenosis (LSS) patients who underwent wide laminectomy (WL), segmental bilateral laminotomies (SBL), or unilateral hemilaminectomy (UHL) with bilateral decompression.

SUMMARY OF BACKGROUND DATA

The optimal procedure for LSS remains controversial. Studies have shown no difference in short term outcomes among micro-laminectomy, hemi-laminotomies, broad laminectomy, and laminectomy with instrumented fusion.

METHODS

Patients with spinal stenosis who were enrolled in DaneSpine at two spine centers from January 2010 until May 2014 and underwent WL0, SBL, or UHL with bilateral decompression were identified. Patients completed standard questionnaires preoperatively and 1, 2, and 5 years after surgery. Patients in the three cohorts were propensity-matched using age, sex, body mass index (BMI), smoking status, number of surgical levels, American Society of Anesthesiologists (ASA) score, and patient-reported outcome measures (PROMs).

RESULTS

Propensity matching produced 62 cases in each group. There were no differences in PROM among the three cohorts at five years follow up. Twelve patients were re-operated at the index level. The most frequent indication of reoperation was repeat decompression after SBL. Regression analysis revealed no statistical significant associations between the incidence of reoperation and age, sex, number of operated levels, ASA score, BMI, center, smoking status, or having a dural tear at index operation.

CONCLUSION

This study revealed no significant difference PROMs, reoperation rates or time to reoperation at five years follow up between SBLs, UHL, or WL in patients operated for central LSS.Level of Evidence: 4.

Application of the IntraSPINE® interlaminar device in patients with osteoporosis and spinal stenosis: two case reports

Osteoporosis is a rising concern in the aging population and should be considered before performing spinal surgery for older patients. Nonfusion surgery using interlaminar or interspinous devices is gradually gaining acceptance because adjacent segment disease seldom occurs postoperatively; however, other complications may occur. This report discusses the surgical outcomes of two women with osteoporosis treated by laminectomy and interlaminar device (IntraSPINE®) placement. Both patients had experienced low back pain for several years and had developed vertebral compression fractures. Several conservative treatments, including rehabilitation and local injections, were ineffective. Their bone mineral density levels were −3.0 and −2.8, indicating severe osteoporosis according to the definition established by the World Health Organization. They chose to undergo nonfusion surgery with IntraSPINE® interlaminar device placement. Their pain significantly decreased postoperatively, and their visual analog scale scores decreased from 8 to 2 and 3. Their extremity numbness and back pain resolved within 3 months. Both patients were satisfied with the surgical outcomes. No complications had occurred by 1 year postoperatively. These cases indicate that osteoporosis may not be an absolute contraindication for nonfusion spinal surgery. This report suggests a possible alternative surgical treatment for patients with osteoporosis that is refractory to conservative treatments.

Fully endoscopic lumbar spinal surgery: Is it time to change?

Spinal surgery is becoming safer and progressively less invasive with advances in optical and instrument technology. The amount of decompression achievable with endoscopic approaches is now comparable to open approaches with the advantage of much less tissue trauma. This review aims at examining the status of endoscopic approaches in lumbar decompressive surgery.

Clinical Outcomes of Minimally Invasive Posterior Decompression for Lumbar Spinal Stenosis with Degenerative Spondylolisthesis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare the clinical outcomes 5 years after minimally invasive posterior decompression for lumber spinal stenosis (LSS) between patients with and without degenerative spondylolisthesis (DS).

SUMMARY OF BACKGROUND DATA

Indications for surgical procedures for patients with LSS and DS are still under investigation. Since minimally invasive surgery does not affect most anatomical structures, preoperative DS may not negatively affect the clinical outcomes of minimally invasive posterior decompression.

METHODS

Overall, 198 patients with LSS who underwent microendoscopic or microscopic decompression and were followed up for more than 5 years postoperatively were included in the present study. Patients who showed a segmental kyphosis >5° at the surgical level during flexion were treated with fusion surgery. However, other patients, including those with DS, were treated with posterior decompression. The patients were divided into two groups: the DS group included 82 patients with >3-mm slip and the non-DS group included 112 patients with ≤3-mm slip or without slip. A mixed-effects model adjusted for age and sex was used to compare the improvements in the visual analog scale score for low-back pain and the Japanese Orthopaedic Association score of the two groups. For subgroup analysis (n = 53), the changes in the preoperative physical component summary and the mental component summary of Short Form-36 of the two groups at 5 years after surgery were evaluated.

RESULTS

There was no significant difference in the improvement of preoperative low-back pain visual analog scale score and Japanese Orthopaedic Association score 5 years after surgery between the two groups. Subgroup analysis showed no significant difference between the two groups in the improvement of preoperative physical component summary and mental component summary 5 years after surgery.

CONCLUSION

After carefully eliminating patients with segmental instability, DS did not affect the clinical outcomes of minimally invasive decompression surgery.Level of Evidence: 3.

Incidence of Iatrogenic Lumbar Spinal Instability after Laminectomy, Discectomy or Facetectomy

OBJECTIVE: This thesis aim to report the incidence of iatrogenic spinal instability that occurs after laminectomy, discectomy or facetectomy in Lumbar spine surgery. METHODS: This is a prospective study of 50 cases of degenerative lumbar spondylosis complaining of various symptoms of claudication, sciatica and back pain which were surgically managed by laminectomy according to the level of stenosis in the period between October 2018 and October 2020 in the neurosurgery department at Cairo university hospitals. Mesial facetectomy was added according to the degree of stenosis if needed. Some patients needed discectomy if sciatica was an eminent symptom. RESULTS: Out of 50 patients included: 9 patients (18%) developed postoperative instability. The number of levels operated on and the degree of mesial facetectomy were found to be variables that may affect postoperative stability. CONCLUSION: Iatrogenic instability may result from large laminectomy and extensive facetectomy for lumbar stenosis in patients who do not have obvious pre-existing instability. Key words: Iatrogenic spinal instability - Laminectomy - conventional open discectomy - Mesial facetectomy.

MIS-TLIF versus O-TLIF for single-level degenerative stenosis: study protocol for randomised controlled trial

INTRODUCTION

Patients with symptomatic single-level combination of degenerative stenosis and low-grade spondylolisthesis are often treated by nerve root decompression and spinal fusion. The gold standard is traditional open decompression and fusion, but minimally invasive method is more and more prevailing. However, there is lack of high-quality studies comparing these two techniques in order to obtain the advantages and certain indications to use one of these methods. The current study includes clinical, safety and radiological endpoints to determine the effectiveness of minimally invasive decompression and fusion (MIS-TLIF) over the traditional open one (O-TLIF).

METHODS AND ANALYSIS

All patients aged 40-75 years with neurogenic claudication or bilateral radiculopathy caused by single-level combination of degenerative stenosis and low-grade spondylolisthesis, confirmed by MRI with these symptoms persisting for at least 3 months prior to surgery, are eligible. Patients will be randomised into MIS-TLIF or traditional O-TLIF. The primary outcome measure is Oswestry Disability Index at 3-month follow-up term. The secondary outcomes are patient-reported outcome measures by the number of clinical scales, radiological parameters including sagittal balance parameters, safety endpoints and cost-effectiveness of each method. All patients will be analysed preoperatively, as well as on the 14th day of hospital stay (or on the day of hospital discharge), 3 months, 6 months, 12 months and 24 months postoperatively. The study has the design of a parallel group to demonstrate the non-inferior clinical results of MIS-TLIF compared with the traditional O-TLIF.

ETHICS AND DISSEMINATION

The study will be performed according to Helsinki Declaration. The study protocol was approved by the Local Ethical Committee of Priorov National Medical Research Center of Traumatology and Orthopedics in August 2020. Preliminary and final results will be presented in peer-reviewed journals, especially orthopaedic and spine surgery journals, at national and international congresses.

TRIAL REGISTRATION NUMBER

NCT04594980.

Clinical Efficacy and Rehabilitation of Microscopic "Over the Top" for Bilateral Decompression in Degenerative Lumbar Stenosis: A Retrospective Study

Background

Recently, “over the top” (also called ULBD; microscopic unilateral laminotomy for bilateral decompression) is a less invasive technique for symptomatic degenerative lumbar spinal stenosis (LSS), and this minimally invasive surgical technique has demonstrated favorable therapeutic outcomes. However, the risk of postoperative complications remains controversial.

Objective

This study is aimed at determining the clinical efficacy and complication and rehabilitation of the microscopic “over the top” for degenerative LSS in geriatric patients. Study Design. This was a retrospective study. Setting. All data were obtained from the People's Hospital of a University.

Methods

A retrospective analysis of 39 consecutive elderly patients treated for LSS by microscopic “over the top” between January 2016 and January 2018 was performed. A postoperative rehabilitation program for geriatric patients with restricted weight-bearing was instituted after the microscopic “over the top” treatment. Estimated blood loss, duration of operation, length of hospitalization, and total complications were also evaluated. The CT and MRI examinations of the lumbar spine were collected to evaluate the completeness of the nerve decompression. Clinical data were assessed at 6 months and 12 months after operation utilizing the visual analog scale (VAS), Oswestry Disability Index (ODI), and 36-Item Short-Form Health Survey (SF-36). Preoperative comorbidities, complications, and revision surgery were also recorded.

Results

We enrolled a total of 39 degenerative LSS patients (27 male and 12 female patients, mean age of 75.8 ± 9.2 years). Twenty patients had one-level of degenerative LSS; thirteen patients had two-level of LSS; six patients had three-level of LSS. The average follow-up time in our study was 14.6 ± 7.8 months (range, 6-24 months). The overall complication rate was 10.2% (4/39), and the reoperation rates at one year were 2.5% (1/39). VAS back and leg pain score at 6 months were decreased to 1.8 ± 0.7 and 1.4 ± 0.6, respectively, and remained at 1.9 ± 0.3 and 1.2 ± 0.2 at 12 months, respectively. ODI scores improved significantly from 32.26 ± 6.82 to 11.44 ± 2.50 at 6 months and 10.56 ± 2.29 at 12 months. 36-Item Short-Form Health Survey scores revealed a significant improvement throughout follow-up. Postoperative complications included dural tear (n = 2), neurologic deficit (n = 1), and reoperation (n = 1). No infections or hematomas were reported. Limitation. Multicenter research is recommended to confirm our results and investigate the factors related to clinical and radiographic results.

Conclusions

Microscopic “over the top” technique is a safe, effective option in the therapy of degenerative LSS and obtained satisfactory functional outcomes when coupled with aggressive rehabilitation, with a long recurrence-free recovery.

Facet Arthrodesis with the FFX Device: One-Year Results from a Prospective Multicenter Study

BACKGROUND

Facet osteosynthesis can be performed to treat facet syndrome (FS) and reduce spinal instability following laminectomy in patients with lumbar spinal stenosis (LSS). The present study evaluated clinical and radiological outcomes following facet osteosynthesis with the FFX device.

METHODS

Patients with FS or LSS were prospectively enrolled in a single-arm, multicenter study. The device was placed at affected levels with or without concomitant posterior lumbar interbody fusion (PLIF) procedures. The visual analog scale (VAS) for back and leg pain and Oswestry Disability Index (ODI) were evaluated preoperatively and postoperatively. Computed tomography scans to assess fusion and migration were performed 1 year following surgery.

RESULTS

Fifty-three patients (26 men/27 women) with a mean age of 65.0 ± 9.6 years (range: 37-83 years) were enrolled. A total of 205 FFX devices were implanted with 15 patients undergoing concurrent PLIF procedures. There were no intraoperative or postoperative surgical complication reported, and no patient required revision surgery. Mean VAS leg and back pain scores significantly improved from 5.57 to 2.09 (P < .001) and 5.74 to 3.13 (P < .001), respectively, between the preoperative and 1 year follow-up assessments. Mean ODI scores also significantly improved from 44.7% to 24.0% (P < .001) during the same time period. Facet fusion occurred with 86.3% of device placements after 12 months. There was 1 (0.5%) asymptomatic device migration. Eight devices (3.9%) were considered misplaced.

CONCLUSIONS

The use of the FFX device is associated with a significant reduction in both pain and disability following surgery with a high facet joint fusion rate.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

This is the first study reporting clinical experience using the FFX device to facilitate facet osteosynthesis. The ability of the device to relieve pain, reduce disability, and enhance lumbar facet fusion with a low rate of device misplacement and migration was demonstrated.

Psoas hematoma as a rare complication of posterior lumbar interbody fusion: a case report

Background

Psoas hematoma rarely occurs in patients with spondylolisthesis who undergo posterior lumbar interbody fusion (PLIF) surgery.

Case presentation

Here we reported a case of a 57-year-old male patient diagnosed with spondylolisthesis who underwent PLIF at the local hospital. Seven days post-surgery, abdominal pain occurred, and the pain in the right lower limb gradually increased. The computerized tomography (CT) indicated a formation of hematoma around the psoas muscle. Digital-subtraction angiography (DSA) suggested a vascular injury, a rupture of the right segmental artery of the lumbar vertebral level 4. The patient then received DSA vascular embolization, after which the lower lumbar segmental artery active bleeding was stopped. One month after discharge, the abdominal hematoma was gradually absorbed, and the pain in the waist, leg, and abdomen disappeared.

Conclusion

Symptoms such as abdominal pain, abdominal distension, and exacerbation of lower limb pain, may suggest the occurrence of psoas hematoma after PLIF. DSA vascular embolization is suggested as the first treatment approach for this type of complication.

Development of a Machine-Learning Model of Short-Term Prognostic Prediction for Spinal Stenosis Surgery in Korean Patients

Background: In this study, based on machine-learning technology, we aim to develop a predictive model of the short-term prognosis of Korean patients who received spinal stenosis surgery. Methods: Using the data obtained from 112 patients with spinal stenosis admitted at N hospital from February to November, 2019, a predictive analysis was conducted for the pain index, reoperation, and surgery time. Results: Results show that the predicted area under the curve was 0.803, 0.887, and 0.896 for the pain index, reoperation, and surgery time, respectively, thereby indicating the accuracy of the model. Conclusion: This study verified that the individual characteristics of the patient and treatment characteristics during surgery enable a prediction of the patient prognosis and validate the accuracy of the approach. Further studies should be conducted to extend the scope of this research by incorporating a larger and more accurate dataset.

Consent for spine surgery: an observational study

BACKGROUND

The tension between the ideal of informed consent and the reality of the process is under-investigated in spine surgery. Guidelines around consent imply a logical, plain-speaking process with a clear endpoint, agreement and signature yet surgeons' surveys and patient interviews suggest that surgeons' explanation is anecdotally variable and patient understanding remains poor. To obtain a more authentic reflection of practice, spine surgeons obtaining 'informed consent' for non-instrumented spine surgery were studied via video recording and risk/benefit discussions were analysed.

METHODS

A prospective observational study was conducted at a single neurosurgical institution. Twelve video recordings involving six surgeons obtaining an informed consent for non-instrumented spine surgery were transcribed verbatim and blindly analysed using descriptive quantification and linguistic ethnography.

RESULTS

Ten (83%) consultations discussed surgical benefit but less than half (41%) quantified the likelihood of benefit from surgery. The most discussed risks were nerve damage or paralysis (92%), bleeding (92%), infection (92%), cerebrospinal fluid leak (83%) and bowel and bladder dysfunction (75%). Surgeons commonly used a quantitative statement of risk (58%) but only half of the risks were explained in words patients were likely to understand.

CONCLUSIONS

This study highlights inconsistencies in the way spine surgeons explain risks and obtain informed consent for 'simple' spine procedures in a real-world setting. There are wide disparities in the provision of informed consent, which may be encountered in other surgical fields. Direct observation and qualitative analysis can provide insights into the limitations of current informed consent practice and help guide future practice.

Machine learning-based preoperative predictive analytics for lumbar spinal stenosis

OBJECTIVEPatient-reported outcome measures (PROMs) following decompression surgery for lumbar spinal stenosis (LSS) demonstrate considerable heterogeneity. Individualized prediction tools can provide valuable insights for shared decision-making. The authors aim to evaluate the feasibility of predicting short- and long-term PROMs, reoperations, and perioperative parameters by machine learning (ML) methods.METHODSData were derived from a prospective registry. All patients had undergone single- or multilevel mini-open facet-sparing decompression for LSS. The prediction models were trained using various ML-based algorithms to predict the endpoints of interest. Models were selected by area under the receiver operating characteristic curve (AUC). The endpoints were dichotomized by minimum clinically important difference (MCID) and included 6-week and 12-month numeric rating scales for back pain (NRS-BP) and leg pain (NRS-LP) severity and the Oswestry Disability Index (ODI), as well as prolonged surgery (> 45 minutes), extended length of hospital stay (> 28 hours), and reoperations.RESULTSA total of 635 patients were included. The average age was 62 ± 10 years, and 333 patients (52%) were male. At 6 weeks, MCID was seen in 63%, 76%, and 61% of patients for ODI, NRS-LP, and NRS-BP, respectively. At internal validation, the models predicted MCID in these variables with accuracies of 69%, 76%, and 85%, and with AUCs of 0.75, 0.79, and 0.92. At 12 months, 66%, 63%, and 51% of patients reported MCID; the observed accuracies were 62%, 74%, and 66%, with AUCs of 0.68, 0.72, and 0.79. Reoperations occurred in 60 patients (9.5%), of which 27 (4.3%) occurred at the index level. Overall and index-level reoperations were predicted with 69% and 63% accuracy, respectively, and with AUCs of 0.66 and 0.61. In 15%, a length of surgery greater than 45 minutes was observed and predicted with 78% accuracy and AUC of 0.54. Only 15% of patients were admitted to the hospital for longer than 28 hours. The developed ML-based model enabled prediction of extended hospital stay with an accuracy of 77% and AUC of 0.58.CONCLUSIONSPreoperative prediction of a range of clinically relevant endpoints in decompression surgery for LSS using ML is feasible, and may enable enhanced informed patient consent and personalized shared decision-making. Access to individualized preoperative predictive analytics for outcome and treatment risks may represent a further step in the evolution of surgical care for patients with LSS.

Contralateral Keyhole Biportal Endoscopic Surgery for Ruptured Lumbar Herniated Disc: A Technical Feasibility and Early Clinical Outcomes

OBJECTIVE

Spinal endoscopic surgery is increasingly adapted as a minimal invasive technique, however, significant facet joint violation may be developed after ipsilateral laminectomy. The aim of this study is to introduce surgical technique of contralateral keyhole biportal endoscopic surgery (CKES) for ruptured lumbar disc and report it is early surgical outcomes with facet joint violation.

METHODS

Between January to December 2019, 27 patients with ruptured lumbar disc were underwent CKES. Simple radiographs were obtained to investigate development of iatrogenic instability or spondylolisthesis. Magnetic resonance imaging scan was checked about 8 hours after surgery to evaluate successful removal of ruptured disc and existence of facet joint violation. Clinical outcomes were assessed by modified MacNab criteria, visual analogue scale (VAS) scores of back and radicular pain.

RESULTS

The mean age of the patients was 62.8 ± 12.48 years. The average operative time and mean follow-up period were 57.1 ± 21.36 minutes and 8.1 ± 3.78 months, respectively. Compared to preoperative scores, the VAS scores of back and radicular pain were significantly improved. Modified MacNab outcome grade was good to excellent in 96.3% (26 out of 27 patients) of patients. The reduction rate of facet joint plane was about 4.9% after contralateral approach.

CONCLUSION

CKES may be considered as an excellent surgical option to treat ruptured lumbar disc without the development of iatrogenic instability. Low rate of facet joint reduction, good visualization of lateral recess, and identification of accurate midline of central spinal canal are advantages of the procedure.

Clinical Comparison of Full-Endoscopic and Microscopic Unilateral Laminotomy for Bilateral Decompression in the Treatment of Elderly Lumbar Spinal stenosis: A Retrospective Study with 12-Month Follow-Up

Purpose

Although lumbar spinal stenosis (LSS) is the most common spinal disease in the elderly, there is still a confusion about the appropriate surgical treatment strategy. The aim of this study was to compare the safety and efficacy of full-endoscopic and microscopic unilateral laminotomy for bilateral decompression (ULBD) for LSS in elderly patients.

Patients and Methods

A retrospective analysis of 61 consecutive elderly patients with LSS who underwent either full-endoscopic (FE group) or microscopic (Micro group) unilateral laminotomy for bilateral decompression was performed. Clinical data were assessed before 2 weeks, 3 months, 6 months and 12 months after surgery using the Visual Analog Scale (VAS), the Oswestry Disability Index (ODI) and the modified MacNab criteria.

Results

There are no significant differences in VAS (back and leg) and ODI between the two groups. However, the VAS back pain in the FE group was significantly improved compared to the Micro group at 2 weeks. The rate of excellent or good outcomes was 87.88% and 85.71% in the FE and Micro group, respectively (P>0.05). The hospital stay and early ambulation in FE group were shorter than those in Micro group, but the operation time was longer (P<0.05). The complications between the FE group (18.18%) and the Micro group (17.86%) were minor (P>0.05).

Conclusion

Both full-endoscopic and microscopic decompression have achieved favorable clinical results in treating elderly lumbar spinal stenosis, and the complications are minor. Full-endoscopic decompression has the advantages of small incision and rapid recovery, which can be used as an alternative for the treatment of lumbar spinal stenosis, especially the elderly with comorbidities.

Unilateral biportal endoscopic decompression for degenerative lumbar canal stenosis

Background

Unilateral biportal endoscopic (UBE) decompression is a minimally invasive (MI) approach to treat degenerative lumbar canal stenosis (DLCS). Decompression can be performed in a clear and magnified surgical field with proper control of normal saline inflow and outflow.

Methods

Clinical and radiographic data of 81 consecutive patients of DLCS treated between July 2018 and Feb 2019 using UBE techniques were reviewed. They were 38 males and 43 females with an average age of 70.2. Sixty-nine had pure canal stenosis and 12 patients had associated spondylolisthesis. Bilateral decompression via unilateral laminotomy was performed from the side on patients with more severe neurological symptoms. This is a retrospective study from chart review and image analysis. Therefore, we don't have formal ethical information for this study, and it is not mandatory in our hospital.

Results

At the final follow-up, the mean VAS for low back pain was improved from 4.3±3.0 to 1.2±1.0 and the VAS for leg symptoms was improved from 7.3±2.2 to 0.9±0.7. The mean JOA score and ODI was significantly improved from 13.3±7.9 to 25.3±5.0 and from 54.6±16.9 to 14.6±12.6, respectively. Modified Macnab criteria were excellent in 47 patients (58.0%), good in 29 (35.8%), fair in 5 (6.2%). The average hospital stay was 3.6±2.4 days. MRI before and after the operation showed the cross-sectional dural area (CSDA) was significantly increased from 71.4±36.5 to 177.3±59.2 mm², corresponding to a 201.9%±188.0% increase. The percentage of facet joint preservation was 84.2% on the approach side and 92.9% on the contralateral side. Complications included 4 dural tears, 1 transient motor weakness, 1 inadequate decompression, and 1 epidural hematoma.

Conclusions

With UBE techniques, decompression for DLCS can be performed safely and effectively. The soft tissue and facet joint destruction are minimized; therefore, it is possible to avoid spinal fusion as well as to preserve the segmental stability.

Lumbar stability following graded unilateral and bilateral facetectomy: A finite element model study

BACKGROUND

Excision of excessive amount of facet joint during lumbar discectomy or decompression can cause segmental instability of the lumbar spine. This study was performed to assess the segmental instability, facet joint loading and intradiscal pressure following graded lumbar facetectomy. This biomechanical study was performed using a verified and validated L3-S1 finite element model.

METHODS

Nine scenarios were analysed. Intact model as control, 30%, 45%, 60% and complete facet joint excision in unilateral and bilateral setting. The effect of progressive graded facetectomy of L4-L5 on the segmental mobility, facet loading and intradiscal pressure was assessed.

FINDINGS

In comparison with control 30% excision of the facet joint mainly caused increase in mediolateral mobility. With 45% excision of the facet joint there was increase in both anteroposterior and mediolateral mobility, this was worse in bilateral and unilateral models respectively. This worsened with larger facet excision scenarios. Facet load increased significantly on extension with excision of 45% & 60% unilaterally and 100% bilaterally. Flexion produced rise in intradiscal pressure in all scenarios.

INTERPRETATION

The increased spinal mobility, facet loading and intradiscal pressure with more than 30% facetectomy highlights the importance of preserving the facets during decompression thereby safeguarding accelerated degeneration of these segments and iatrogenic segmental instability. The findings from this study could also potentially explain the correlation between spinal instability, disc degeneration and facet joint arthrosis as noted in clinical studies.

Fusion Surgery for Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations

Lumbar spine stenosis represents a complex degenerative pathology that has been a subject of significant dispute when it comes to fusion. A review of the literature from 2008 to 2019 was performed on the role of fusion in the treatment of lumbar spinal stenosis using PubMed, Ovid Medline, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Using the key words "lumbar spinal stenosis," "lumbar fusion," "lumbar decompression," and "lumbar pedicle screw fixation," the search revealed 490 papers. Of these, only Level 1 or Level 2 evidence papers were selected, leading to only 3 randomized controlled trials (RCTs) that were analyzed. None of the good-quality studies (RCTs) performed so far have proven any clinical benefit of adding fusion to degenerative lumbar spine decompression. The effect of spinal instability on the outcome following decompression remains controversial. At present, no unanimous criteria exist among the RCTs to identify what constitutes true instability. Fusion for instability or stenosis alone remains controversial, and the results are unconvincing. At this point, the issue expands to not only lumbar degenerative diseases but spinal fractures and lumbar isthmic spondylolisthesis. We thereby present the consensus of the World Federation of Neurosurgical Societies Spine Committee, which formulated the indications for lumbar spine fusion in degenerative lumbar stenosis.