Surgical management of lumbar stenosis: decompression and indications for fusion

Correlation Analysis for Selection of Microtitanium Plates with Different Specifications for Use in a Cervical Vertebral Dome Expansion Laminoplasty

Objective

To analyze correlations between the selection of microtitanium plates with different specifications for use in a cervical vertebral dome expansion laminoplasty.

Methods

Sixteen patients that underwent the cervical vertebral dome expansion laminoplasty with a cervical spinal stenosis angioplasty procedure for treatment of their cervical spinal cords were recruited at our hospital. From February 2017 to September 2018, medical records confirmed that all patients underwent cervical CT and MRI tests pre‐ and postsurgery. The anteroposterior diameter of the spinal canal, changes in the cross‐sectional area of the spinal canal, and the pre‐ and postsurgery distance of the cervical spinal cord after applying microtitanium plates with different lengths were measured by Mimics version 17.0 software (Materialise NV, Leuven, Belgium). A statistical regression and correlation analysis of relevant specification parameters of the microtitanium plate was then studied.

Results

As the size of the microtitanium plate increased, we found that the cross‐sectional area of cervical spinal canal and distance between the descendants of the lamina and the distance of cervical spinal cord concordantly increased, and these data changes linearly. The regression equation associated with sagittal diameter, cross‐sectional area, and posterior movement distance of the cervical spinal cord was obtained.

Conclusion

According to the correlation analysis of imaging data changes, the regression equation was obtained to guide the selection of microtitanium plates with appropriate specifications in a cervical vertebral dome expansion laminoplasty.

The biomechanical effect of single-level laminectomy and posterior instrumentation on spinal stability in degenerative lumbar scoliosis: a human cadaveric study

OBJECTIVEDegenerative lumbar scoliosis, or de novo degenerative lumbar scoliosis, can result in spinal canal stenosis, which is often accompanied by disabling symptoms. When surgically treated, a single-level laminectomy is performed and short-segment posterior instrumentation is placed to restore stability. However, the effects of laminectomy on spinal stability and the necessity of placing posterior instrumentation are unknown. Therefore, the aim of this study was to assess the stability of lumbar spines with degenerative scoliosis, characterized by the range of motion (ROM) and neutral zone (NZ) stiffness, after laminectomy and placement of posterior instrumentation.METHODSTen lumbar cadaveric spines (T12-L5) with a Cobb angle ≥ 10° and an apex on L3 were included. Three loading cycles were applied per direction, from -4 Nm to 4 Nm in flexion/extension (FE), lateral bending (LB), and axial rotation (AR). Biomechanical evaluation was performed on the native spines and after subsequent L3 laminectomy and the placement of posterior L2-4 titanium rods and pedicle screws. Nonparametric and parametric tests were used to analyze the effects of laminectomy and posterior instrumentation on NZ stiffness and ROM, respectively, both on an individual segment's motion and on the entire spine section. Spearman's rank correlation coefficient was used to study the correlation between disc degeneration and spinal stability.RESULTSThe laminectomy increased ROM by 9.5% in FE (p = 0.04) and 4.6% in LB (p = 0.01). For NZ stiffness, the laminectomy produced no significant effects. Posterior instrumentation resulted in a decrease in ROM in all loading directions (-22.2%, -24.4%, and -17.6% for FE, LB, and AR, respectively; all p < 0.05) and an increase in NZ stiffness (+44.7%, +51.7%, and +35.2% for FE, LB, and AR, respectively; all p < 0.05). The same changes were seen in the individual segments around the apex, while the adjacent, untreated segments were mostly unaffected. Intervertebral disc degeneration was found to be positively correlated to decreased ROM and increased NZ stiffness.CONCLUSIONSLaminectomy in lumbar spines with degenerative scoliosis did not result in severe spinal instability, whereas posterior instrumentation resulted in a rigid construct. Also, prior to surgery, the spines already had lower ROM and higher NZ stiffness in comparison to values shown in earlier studies on nonscoliotic spines of the same age. Hence, the authors question the clinical need for posterior instrumentation to avoid instability.

Navigated minimally invasive unilateral laminotomy with crossover for intraoperative prediction of outcome in degenerative lumbar stenosis

BACKGROUND

Different surgical techniques have been described for treatment of degenerative lumbar stenosis (DLS). Only postoperative measures have been identified as predictors of efficacy of decompression. The objective of this study is to assess the role of navigated unilateral laminotomy with crossover to achieve and predict a satisfying decompression and outcome in DLS.

MATERIALS AND METHODS

We enrolled patients with DLS who underwent navigation-assisted unilateral laminotomy with crossover. The extent of decompression was evaluated during surgery using neuronavigation. The outcome was assessed through the Oswestry disability index (ODI) and visual analog scale (VAS) for leg pain. Outcome correlation with the extent of the intraoperative bone decompression was analyzed. Finally, the outcome, surgical time, and in-hospital length-of-stay were compared with a control group treated through standard unilateral laminotomy.

RESULTS

Twenty-five patients were treated using the navigated technique (Group A), 25 using the standard unilateral laminotomy (Group B). In Group A, a cut-off value ≥0.9 cm for bone decompression revealed to be an intraoperative predictor of good outcome, both regarding the ODI and VAS scores (P = 0.0005; P = 0.002). As compared with Group B, patients operated using the navigated technique showed similar operative times, in-hospital length-of-stay, ODI scores, but improved VAS scores for leg pain (P = 0.04).

CONCLUSIONS

The intraoperative navigated evaluation of the bone decompression could predict the outcome allowing satisfactory results in unilateral laminotomy for DLS. The navigated technique also could lead to an improved decompression of lateral recesses resulting in better control of leg pain as compared to standard unilateral laminotomy.

Adequate cage placement for a satisfactory outcome after lumbar lateral interbody fusion with MRI and CT analysis

Introduction

Through an extreme lateral retroperitoneal and transpsoas approach to intervertebral disc and fusion surgery, a large lordosis cage can be placed for solid and stable intervertebral fusion and to provide strong anterior support, disc height restoration, favorable alignment, and indirect nerve decompression. However, appropriate placement of the interbody cage remains insufficiently researched. We sought to determine both appropriate cage placement as well as other factors affecting nerve decompression in extreme lateral interbody fusion (XLIF) surgery.

Methods

We included 53 consecutive patients suffering from lumbar degenerative diseases with an indication for XLIF. Radiographic analysis using a sagittal computed tomography (CT) and axial magnetic resonance imaging (MRI) views was conducted to determine intervertebral disc height and angle, degree of disc bulging and thickness of the flavum, the area of the dural tube, cage height, pre- and postoperative disc bulging, change of disc bulging after surgery, cage subsidence, and cage placement at the rostral and caudal endplates.

Results

Intervertebral disc height and angle were significantly increased at all levels (L2/3, 3/4, 4/5) (p < 0.05). The area of the dural tube was significantly increased (p < 0.05), whereas the degree of disc bulging and thickness of the flavum were significantly decreased at all disc levels (p < 0.05). The enlarged area of the dural tube showed significant correlation with increased disc height (p = 0.019), preoperative flavum thickness (p = 0.008), change of flavum thickness (p < 0.0001), and cage placement at the rostral endplate (p = 0.014).

Conclusions

A decrease in flavum buckling is more important than disc protrusion as a consideration for obtaining indirect decompression. Central placement may be advantageous for indirect decompression.

Perioperative Results and Complications after Posterior Lumbar Interbody Fusion for Spinal Stenosis in Geriatric Patients over than 70 Years Old

Objective

As increasing the size of the geriatric population, the number of elderly patients, who need the surgery for painful degenerative spinal stenosis has been increasing. The geriatric population may be relatively high complications, because of age and age-associated medical conditions. However, there is a lack of studies addressing the perioperative complications and outcomes in elderly patients with posterior lumbar inter body fusion with screw augmentation (PLIF).

Methods

We retrospectively reviewed the medical records and radiographic studies of geriatric patients who had spine surgery of PLIF due to spinal stenosis for 11 years. We divided into 2 groups (A; 70–75 years, B; over then 76 years) according to the age. Surgical level of each groups, hospital day and postoperative day, co-morbidities, complications, clinical outcomes were analyzed. Operative reports, hospital and outpatient clinic charts, and radiographic studies were reviewed.

Results

Group A was composed of 80 patients, their mean age was 72.21 and female dominant (n=46), and their mean surgically fused level was 1.52 level. Group B was 36 patients, their mean age was 78.83 and female dominant (n=20), and their mean surgically fused level was 1.36 level. Comparing between two groups, complications, postoperative hospital stay were slightly increase in group B and co-morbidity was statistically high in group B, however clinical outcomes were similar between two groups.

Conclusion

Increasing age might be an important risk factor for complications in patients undergoing PLIF, however, we would like to recommend that if the situation of spine of extreme geriatric patients need PLIF, it should be in the surgeon’s consideration after careful selection and clinical judgement.

Nursing review of diagnosis and treatment of lumbar degenerative spondylolisthesis

Background:

In the lumbar spine, degenerative spondylolisthesis or degenerative (not traumatic) slippage of one vertebral body over another is divided into 4 grades – grade I (25%), grade II (50%), grade III (75%), and grade IV (100%). Dynamic X-rays, magnetic resonance (MR), and computed tomography (CT) scans document the slip secondary to arthritic changes of the facet joint plus stenosis, ossification of the yellow ligament, disc herniations, and synovial cysts. MR best demonstrates soft tissue pathology whereas CT better delineates ossific/calcified disease.

Methods:

Grade I degenerative spondylolisthesis, typically found at the L4–L5 level followed by L3–L4 and L5S1, is more common in females (ratio 2:1) over the age of 65. Symptoms include radiculopathy (root pain) and neurogenic claudication (e.g., pain with ambulation, requiring the patient to stop, rest, sit down). Symptoms/signs may include unilateral/bilateral radiculopathy and uni/multifocal motor, reflex, and sensory deficits in. Some may also present with a cauda equina syndrome (e.g., paraparesis/sphincter dysfunction).

Results:

Surgery for grade I-II spondylolisthesis may include laminectomy alone, laminectomy/noninstrumented fusion or with an instrumented fusion. Older patients with osteoporosis are more likely to have no fusion or a noninstrumented fusion. All fusions utilize autograft harvested from the laminectomy that may or may not be combined with a bone graft expander (to increase the fusion mass) combined with autogenous bone marrow aspirate. The fusion mass is placed over the transverse processes following decortication.

Conclusions:

Patients with multilevel spinal stenosis and degenerative spondylolisthesis may require decompressive lumbar laminectomies alone or in combination with noninstrumented or instrumented fusions.

Which functional outcome parameters correlate better with elderly patients' satisfaction after non-fusion lumbar spine surgery?

BACKGROUND

Elderly patients are increasingly operated for spinal degenerative diseases. The treatment objective is quality of life, which, in this population, is difficult to assess. Hence, patient satisfaction, although less objective, is of high importance. In this study, we have examined the relation of various functional parameters after non-fusion spinal surgery, with patient satisfaction.

METHODS

A 5-year follow-up after non-fusion lumbar spine surgery on 185 elderly patients was performed. Demographics, co-morbidity factors, type of lesion and operation performed were recorded. The Oswestry Disability Index (ODI) was calculated. Also, walking distance, use of analgesics, daily activities, social life and patient mobility were assessed by means of study-specific stratified pain-independent questionnaires. Finally, patient satisfaction was assessed by the single-item satisfaction question.

RESULTS

Postoperative ODI, and the improvement regarding ODI, analgesic use and walking distance indices were independent factors influencing patient satisfaction. The insertion of pain analog scale score into this model altered the results, and along with this score, only the walking distance improvement remained an independent statistically significant factor. When the independent from pain scales were used, the improvement of the walking distance score were independently related to the satisfaction of the elderly.

CONCLUSIONS

ODI is applicable in elderly patients, even with the exception of some of the categories assessed. Walking capacity should be assessed separately from other pain-dependent activities; its improvement should be an independent goal of lumbar spine surgery in the elderly. The level of the elderly patient subjectivity in auto-assessing the outcome of lumbar spine surgery is high, and objective outcome measurements remain important.

Thoracolumbar imbalance analysis for osteotomy planification using a new method: FBI technique

INTRODUCTION

Treatment of spine imbalance by posterior osteotomy is a valuable technique. Several surgical techniques have been developed and proposed to redress the vertebral column in harmonious kyphosis in order to recreate correct sagittal alignment. Although surgical techniques proved to be adequate, preoperative planning still is mediocre. Multiple suggestions have been proposed, from cutting tracing paper to ingenious mathematical formulas and computerised models. The analysis of the pelvic parameters to try to recover the initial shape of the spine before the spine imbalance occurred is very important to avoid mistakes during the osteotomy planification.

MATERIAL AND METHOD

The authors proposed their method for the osteotomy planning paying attention to the pelvic, and spine parameters and in accordance with Roussouly's classification. The pre operative planning is based on a full-body X-ray including the spine from C1 to the femoral head and the first 10 cm of the femur shaft. Using all the balance parameters provided, a formula name FBI is proposed. Calculation of the osteotomy is basic goniometry, the midpoint of the C7 inferior plateau (point a) is transposed horizontally on the projected future C7 plumb line (point b) crossing posterior S1 plateau on a sagittal X-ray. These are the first two reference points. A third reference point is made on the anterior wall of the selected vertebra for osteotomy at mid height of the pedicle (point c) mainly L4 vertebra. These three points form a triangle with the tip being the third reference point. The angle represented by this triangle is the theoretical angle of the osteotomy. Two more angles should be measured and eventually added. The femur angulation measured as the inclination of the femoral axis to the vertical. And a third angle named the compensatory pelvic tilt to integrate the type of pelvis. If the pelvic tilt is between 15 and 25° or is higher than 25° you must add 5 or 10°, respectively. This compensatory tilt is based on a clinical analysis of operated patients.

RESULTS

This planification was applied in a retrospective study of 18 patients and showed why in some cases improper correction was performed and prospectively in 8 cases with good clinical outcomes and correct spinal alignment. Sometimes it is necessary to find an acceptable compromise when rebalancing the spine paying attention to the general parameters of the patients like: age, osteoporosis, systemic disease etc.

CONCLUSION

This FBI technique can be used even for small lordosis restoration: it gave a good evaluation of the amount of correction needed and then the surgeon had the choice to use the appropriate technique to obtain a good balance.

Degenerative lumbar scoliosis associated with spinal stenosis

BACKGROUND CONTEXT

Degenerative de novo scoliosis is commonly present in older adult patients with spinal pain. The degenerative process including disc bulging, facet arthritis, and ligamentum flavum hypertrophy contributes to the appearance of symptoms of spinal stenosis in these patients.

PURPOSE

The etiology, prevalence, biomechanics, classification, symptomatology, and treatment of degenerative lumbar scoliosis in association with spinal stenosis are reviewed.

STUDY DESIGN

Review study.

METHODS

Retrospective analysis of studies focused on all parameters concerning degenerative scoliosis associated with stenosis.

RESULTS

There is a variety of treatment methods of degenerative scoliosis based on symptomatology and radiologic measurements of scoliosis and stenosis. Satisfactory clinical results reported in relevant retrospective studies after operative treatment range from 83% to 96% but with increased percentage of complications. An algorithm for operative treatment corresponding to a newly proposed classification system of degenerative lumbar scoliosis with associated canal stenosis is presented.

CONCLUSIONS

There is an increasing prevalence of degenerative scoliosis in the aged population. Even though the exact percentage of patients with symptomatology of spinal stenosis is not known, the main goal is to provide pain relief and improved functional lifestyle with minimum intervention.

Juvenile degenerative disc disease: a report of 76 cases identified by magnetic resonance imaging

BACKGROUND

Persistent low back pain in the young remains a significant diagnostic and treatment challenge for clinicians. Traditionally, chronic low back pain in this population has been attributed to either serious undetected pathology or psychosocial etiologies. This assumption may be incorrect because patients in this population may have underlying juvenile degenerative disc disease (JDDD), an important pathological diagnosis in the adult population.

PURPOSE

The purpose of this study is to report the presentation, radiographic findings, diagnosis, and treatment modalities of juvenile patients presenting with persistent low back pain for greater then 6 months.

STUDY DESIGN

This is a retrospective review of patients less than 21 years old referred to a spine specialty practice with persistent low back pain.

PATIENT SAMPLE

The charts of 1,877 patients less than 21 years old referred to a spine specialty practice for the evaluation of spinal problems.

OUTCOME MEASURES

Magnetic resonance images (MRI) were obtained and reviewed by a neuroradiologist and two orthopedic surgeons.

METHODS

Patients younger than 21 years old with persistent low back pain for greater that 6 months were identified. Patients with scoliosis, Scheuermann's kyphosis, spondylolisthesis, fracture, tumor, and metabolic bone disease were excluded. Standard demographic information, relevant medical history and physical examination findings were collected. Patients were evaluated with an MRI of their spines to detect any potential underlying pathology. The success of various treatment modalities used was reviewed. The findings of this study were correlated to those of the available literature following a thorough review.

RESULTS

Seventy-six patients (34 males, 42 females) with degenerative disc disease were identified on MRI. The mean age was 17.1 years (range 11.5-21.0) with a mean body mass index (BMI) of 24.5 (range 17.7-35.4). Thirty-one had associated radiculopathy. There was 11 smokers, 20 involved in athletics, 17 with co-morbidities, and 9 with a BMI greater than 30. A distinct subgroup of 13 patients with multilevel concurrent spinal stenosis was documented. Four of this subgroup required surgical intervention for severe radicular or claudication symptoms. The majority of JDDD patients were successfully treated with nonoperative modalities.

CONCLUSION

The findings of this study question whether lumbosacral degenerative disc disease, commonly thought to exist only in an older population, in fact begins earlier in selected patients. Our study confirms the findings of others that there is a definite population of juveniles that present with chronic low back pain who have degenerative disc disease identified on MRI. Within this population is a subgroup of patients with concurrent congenital spinal stenosis. Most patients with JDDD appear to be well managed by traditional nonoperative treatment modalities.

Minimally invasive lumbar decompression

With the increasing elderly population, the number of patients presenting with symptoms secondary to lumbar stenosis can be expected to increase accordingly. Therefore, treatment of this disease process should become more prevalent, and the minimally invasive techniques offer another treatment option. As surgeons become more experienced in minimally invasive techniques, the reported advantages of the minimal access surgery, including reduction in soft tissue injury, less blood loss, shorter hospitalization, and faster recovery, should make this an attractive alternative to traditional open surgery. Continuing efforts in the minimally invasive field can be expected to yield new and potentially less invasive as well as possibly more efficacious treatment options in the future.