腰椎管狭窄症手术治疗进展

随着人口老龄化及影像诊断技术的飞速发展,退变性腰椎管狭窄症发病率明显升高,成为是老年人腿痛的重要原因,也是腰椎手术的常见病。在治疗上主要有手术和非手术治疗两大类。本文就退变性腰椎管狭窄症手术治疗的方法,如椎板减压、融合固定、非融合固定及微创MED等的应用进展加以综述。     

微创单侧入路双侧减压治疗腰椎椎管狭窄症早期疗效观察

目的评估微创单侧入路双侧减压经椎间孔椎体间融合术治疗腰椎椎管狭窄症的短期疗效？方法2010年6—10月,38例腰椎椎管狭窄症患者接受开放或微创手术治疗,微创组17例,开放组21例。记录手术时间、术中出血量和引流量、术后住院时间、并发症情况以及手术前后的腰痛视觉模拟量表（visualanalogscale,VAS）评分及日本骨科学会（Japanese Orthopaedic Association,JOA）评分。结果平均随访7．6个月。微创组平均出血量较少,手术时间较长,而术后住院时间较短。2组患者术后腰痛及功能均有显著改善,微创组末次随访时腰痛VAS评分低于开放组,微创组术后、随访时JOA评分及JOA改善率均明显高于开放组。微创组患者并发症发生率略高于开放组但差异无统计学意义（P〉0．05）。结论微创单侧入路双侧减压结合微创经椎间孔椎体间融合术治疗腰椎椎管狭窄症短期疗效满意,其长期疗效有待进一步随访明确。     

Spontaneous correction of sagittal spinopelvic malalignment after decompression surgery without corrective fusion procedure for lumbar spinal stenosis and its impact on clinical outcomes: A systematic review

BackgroundThe impact of a positive sagittal vertical axis (SVA) on the surgical outcome for lumbar spinal stenosis (LSS) remains unclear, because sagittal imbalance in LSS may partly result from the tendency of patients to lean forward to reduce symptoms. Such an abnormality could be normalized by decompression surgery alone without corrective fusion. As this spontaneous correction is not well known, some surgeons perform only neural decompression in patients with positive SVA and decreased lumbar lordosis (LL), unless flatback-related symptoms are present, whereas other surgeons add corrective fusion to restore spinopelvic alignment. We systematically reviewed previous studies on this issue.MethodsPubMed, Cochrane Library, and Embase were searched for English articles on the relationship between SVA and decompression surgery for LSS. The rates of spontaneous correction in spinopelvic parameters and the impact of SVA on clinical outcomes were analyzed.ResultsThe rate of spontaneous SVA correction from >40–50 mm to normal values following decompression surgery alone varied from 25% to 73%. Overall, the spinopelvic parameters tended to improve postoperatively, with statistically significant changes in some series. Postoperative residual sagittal imbalance, rather than preoperative imbalance, more consistently showed a negative impact on clinical outcomes, but not on leg symptoms. For predicting postoperative sagittal imbalance, 2 studies identified the cutoff of >20° for preoperative PI-LL mismatch. Another study suggested SVA >80 mm as a useful value for this purpose.ConclusionIn LSS treated with decompression surgery alone, postoperative rather than preoperative sagittal imbalance more consistently affects clinical outcomes, particularly low back pain. This is probably because decompression usually partly improves preoperative spinopelvic sagittal malalignment. Thus, LSS, if associated with preoperative PI-LL mismatch <20° and SVA <80 mm, may not require additional corrective fusion procedures.     

Clinical Evaluation of Surgery for Single‐Segment Lumbar Spinal Stenosis: A Systematic Review and Bayesian Network Meta‐Analysis

To compare the efficacy and safety of different surgical procedures for patients with single‐segment lumbar spinal stenosis (LSS), Bayesian network meta‐analysis (NMA) was conducted in this study. Randomized controlled trials (RCTs) which reported 2 years'' results after surgery were searched from PubMed, Embase, and Cochrane Register of Controlled Trials up to February 2021. Eligible RCTs that contained at least two of the following surgical procedures, bilateral decompression via the unilateral approach (BDUL), decompression with conventional laminectomy (CL), decompression with fusion (DF), endoscopic decompression (ED), interspinous process devices only (IPDs), decompression with interlaminar stabilization (DILS), decompression with lumbar spinal process‐splitting laminectomy (LSPSL), and minimally invasive tubular decompression (MTD), would be included after screening based on the inclusion and exclusion criteria. The primary outcome was Oswestry Disability Index (ODI). Twenty eligible RCTs were included, with a total of 2201 patients enrolled. The NMA showed that the following surgical procedures ranked first (surface under the cumulative ranking) when compared with CL and DF: DILS for ODI (SUCRA 87.8%); LSPSL for back pain (95%); and MTD for leg pain (95.6%). MTD ranked among the top three surgical procedures for most outcomes. The quality of the synthesized evidence was low according to the Grading of Recommendations Assessment, Development, and Evaluation criteria. DILS, LSPSL, MTD, IPDs, and ED are the most effective procedures for patients with single‐segment LSS. Because of combining efficacy and safety, MTD may be the most promising routine surgical option for treating single‐segment LSS.     

Minimally invasive decompression surgery for lumbar spinal stenosis with degenerative scoliosis: Predictive factors of radiographic and clinical outcomes

There is ongoing controversy regarding the most appropriate surgical treatment for lumbar spinal stenosis (LSS) with concurrent degenerative lumbar scoliosis (DLS): decompression alone, decompression with limited spinal fusion, or long spinal fusion for deformity correction. The coexistence of degenerative stenosis and deformity is a common scenario; Nonetheless, selecting the appropriate surgical intervention requires thorough understanding of the patients clinical symptomatology as well as radiographic parameters. Minimally invasive (MIS) decompression surgery was performed for LSS patients with DLS. The aims of this study were (1) to investigate the clinical outcomes of MIS decompression surgery in LSS patients with DLS, and (2) to identify the predictive factors for both radiographic and clinical outcomes after MIS surgery. 438 consecutive patients were enrolled in this study. Inclusion criteria was evidence of LSS and DLS with coronal curvature measuring greater than 10°. The Japanese Orthopaedic Association (JOA) score, JOA recovery rate, low back pain (LBP), and radiographic features were evaluated preoperatively and at over 2 years postoperatively. Of the 438 patients, 122 were included in final analysis, with a mean follow-up of 2.4 years. The JOA recovery rate was 47.6%. LBP was significantly improved at final follow-up. Cobb angle was maintained for 2 years postoperatively (p = 0.159). Clinical outcomes in foraminal stenosis patients were significantly related to sex, preoperative high Cobb angle and progression of scoliosis (p = 0.008). In the severe scoliosis patients, the JOA recovery was 44%, and was significantly depended on progression of scoliosis (Cobb angle: preoperation 29.6°, 2-years follow-up 36.9°) and mismatch between the pelvic incidence (PI) and the lumbar lordosis (LL) (preoperative PI–LL 35.5 ± 21.2°) (p = 0.028). This study investigated clinical outcomes of MIS decompression surgery in LSS patients with DLS. The predictive risk factors of clinical outcomes were severe scoliosis, foramina stenosis, progressive scoliosis and large mismatch of PI–LL.     

两种术式治疗双节段退变性腰椎管狭窄症的疗效比较

目的：比较显微内窥镜手术与传统开放手术治疗双节段退变性腰椎管狭窄症的临床疗效。方法2006-03-2012-06对186例双节段退变性腰椎管狭窄患者分别采用显微内窥镜开窗减压手术和传统开放减压融合内固定手术治疗,其中内窥镜减压组95例,开放减压融合内固定手术组91例,对两组病例手术时间、术中出血量、切口长度、术后并发症、末次随访时Oswestry功能障碍指数（Oswestry disability index ODI）及优良率进行比较。结果内窥镜组手术时间、术中出血量及切口长度均较开放组少（P＜0.05）,术后并发症少,两组术后ODI及优良率无显著性差异（P＞0.05）。结论显微内窥镜下椎管减压术治疗双节段退变性腰椎管狭窄症较开放手术创伤小、术中出血少、并发症少,并取得与开放手术相似的临床疗效。     

腰椎管狭窄的治疗进展

随着我国人口老龄化加剧,以退行性改变为主的腰椎管狭窄症患者不断增多。腰椎管狭窄目前没有足够的证据推荐任何特定类型的非手术治疗,手术是治疗腰椎管狭窄的有效方法,腰椎管狭窄患者不经过保守治疗而采用手术改善临床症状具有最强的证据基础。单纯减压术后脊柱节段不稳促使融合技术的发展,融合后相邻节段退变加速、症状不缓解导致动态固定技术应运而生。患者在行椎管减压的同时是否需植骨融合至今仍存在较大争议,近年来我国治疗腰椎管狭窄的单纯减压手术明显下降,然而减压加融合手术却持续增加。椎管减压同时辅以腰椎融合,越来越多被应用于腰椎管狭窄来减少脊柱不稳和畸形的潜在风险。虽然减压手术治疗是有一定的临床效果,但目前尚不清楚是否减压附加融合手术的结果要优于单纯减压手术。本文对腰椎管狭窄患者是否需要融合进行综述研究,旨在进一步探讨腰椎管狭窄手术治疗的最佳选择,专注于以证据为基础的治疗方案。     

Less-invasive decompression procedures can reduce risk of reoperation for lumbar spinal stenosis with diffuse idiopathic skeletal hyperostosis extended to the lumbar segment: analysis of two retrospective cohorts

Purpose

Clinical outcomes after decompression procedures are reportedly worse for lumbar spinal stenosis (LSS) with diffuse idiopathic skeletal hyperostosis (DISH), especially DISH extended to the lumbar segment (L-DISH). However, no studies have compared the effect of less-invasive surgery versus conventional decompression techniques for LSS with DISH. The purpose of this study was to compare the long-term risk of reoperation after decompression surgery focusing on LSS with L-DISH.

Methods

This study compared open procedure cohort (open conventional fenestration) and less-invasive procedure cohort (bilateral decompression via a unilateral approach) with ≥ 5 years of follow-up. After stratified analysis by L-DISH, patients with L-DISH were propensity score-matched by age and sex.

Results

There were 57 patients with L-DISH among 489 patients in the open procedure cohort and 41 patients with L-DISH among 297 patients in the less-invasive procedure cohort. The reoperation rates in L-DISH were higher in the open than less-invasive procedure cohort for overall reoperations (25% and 7%, p = 0.026) and reoperations at index levels (18% and 5%, p = 0.059). Propensity score-matched analysis in L-DISH demonstrated that open procedures were significantly associated with increased overall reoperations (hazard ratio [HR], 6.18; 95% confidence interval [CI], 1.37–27.93) and reoperations at index levels (HR, 4.80; 95% CI, 1.04–22.23); there was no difference in reoperation at other lumbar levels.

Conclusions

Less-invasive procedures had a lower risk of reoperation, especially at index levels for LSS with L-DISH. Preserving midline-lumbar posterior elements could be desirable as a decompression procedure for LSS with L-DISH.

     

Comparison of techniques for decompressive lumbar laminectomy: the minimally invasive versus the "classic" open approach.

OBJECT: Decompressive laminectomy offers an effective surgical treatment of lumbar spinal stenosis. The purpose of this study was to compare the elements of treatment commonly associated with successful outcomes in the assessment of laminectomies - operating room times, estimated blood loss, length of stay, and complications - of the minimally invasive and open approach laminectomies. METHODS: We retrospectively reviewed the medical records and relevant imaging of 126 patients who underwent surgical decompression for lumbar stenosis. Thirty-eight patients underwent bilateral decompression via a unilateral minimally invasive technique, while 88 patients underwent bilateral decompression via a standard open technique. A chart review was performed to determine intraoperative blood loss, length of operative time, length of hospital stay, and number and nature of complications. RESULTS: The minimally invasive lumbar laminectomy (MID) patients had shorter operating room times, less estimated blood loss, shorter length of stay, and fewer complications. CONCLUSIONS: Bilateral decompression of lumbar spinal stenosis via a unilateral approach involves shorter operating times and less blood loss, less muscle dissection, fewer and less severe complications, and better mobility in the immediate postoperative period than open decompressive techniques. In addition, this technique is very similar to the commonly performed microendoscopic discectomy and is easily mastered over time.     

DELTA内镜下单侧入路双侧减压治疗腰椎椎管狭窄症的疗效分析

目的 探讨DELTA内镜下单侧入路双侧减压治疗单节段腰椎管狭窄症的临床疗效.方法 选取广东省中医院骨科自2018年1月～2019年6月手术治疗的60例单节段腰椎管狭窄症患者,根据手术方式不同分为DELTA组和MIS-TLIF组,DELTA组采用DELTA内镜下单侧椎板间入路双侧减压术治疗,MIS-TLIF组采用微创管道...     

Endoscopic modified total laminoplasty for symptomatic lumbar spinal stenosis

Context/objective: At present, there is no consensus on the most effective surgical method for treating symptomatic lumbar spinal stenosis (LSS). Total laminectomy, which is frequently used at this time, destroys the posterior midline structure, causing many postoperative complications. We have designed a new surgical approach instead of total laminectomy. In this paper, we aimed to describe the surgical method of endoscopic modified total laminectomy for lumbar spinal stenosis as well as to explore its early efficacy.Participants: Patients with symptomatic LSS who underwent endoscopic modified total laminoplasty between August 2016 and August 2017 were eligible for our study.Outcome measures: Before surgery and one year after surgery, we measured lower limb pain and back pain by visual analog scale (VAS), disability via Oswestry Disability Index (ODI), and severity of back pain according to the Japanese Orthopedic Association Score for Back Pain (JOA), while any complications were also assessed.Results: Endoscopic modified total laminoplasty was performed on 22 LSS patients, including eight males and 14 females(mean age = 59.3 ± 9.6 years). We found statistically significant differences before and one year after surgery for VAS lower limb pain and back pain, ODI and JOA scores(P < 0.001). Complications included intraoperative dural tears(n = 1),and weak fusion between the lamina and the vertebral body (n = 1).Conclusion: Endoscopic modified total laminectomy is a promising surgical approach which reduces patient suffering and improves patient quality of life.     

Unilateral laminotomy for bilateral decompression of lumbar spinal stenosis part II: Clinical experiences

Summary The surgical aim in the treatment of symptomatic lumbar spinal stenosis is the relief of the patient's complaints by an adequate neural decompression. Unilateral laminotomy and bilateral spinal canal decompression represents such a safe, effective and minimally invasive surgical method. This technique has been successfully used in the operative treatment of 29 patients with symptomatic mono- or multisegmental lumbar stenosis. There was no surgically induced neurological deterioration. In one patient, an inadvertent dural tear occurred, and due to unchanged symptoms another patient with a multisegmental stenosis had to be re-operated on at an additional level. Postoperatively, 25 of the 27 patients with neurogenic claudication (93%) demonstrated a marked improvement of the walking distance. The follow-up of 25 patients (mean follow-up time was 18 months) demonstrated an excellent result without pain in 7 patients (28%); a good outcome with mild residual pain, but a normal working capacity in 15 patients (60%); and a fair outcome with unchanged postoperative low-back pain but markedly improved working capacity and walking distance in 3 patients (12%). Postoperative morphometric evaluation as well as the clinical improvement of the patient's symptoms clearly demonstrated that bilateral ligamentectomy and recess decompression were adequately and successfully achieved via unilateral approach.     

老年退行性腰椎管狭窄症手术治疗的疗效分析

目的探讨老年退行性腰椎管狭窄症患者手术治疗的疗效。方法1994年1月~2006年11月收治的247例65岁以上退行性腰椎管狭窄症患者中168例获得0.5~5年随访;把病例分为非固定组111例(全椎板切除减压或 横突间植骨、小开窗切除或半椎板减压)和固定组57例两组。将两组中各种术式的疗效进行回顾性分析。结果无死亡病例。发生并发症者30例。JOA评分优良率,非固定组为92.1%,固定组为94.3%。结论对于老年退行性腰椎管狭窄症的患者,没有明确证据证明腰椎不稳时,治疗以单纯减压为主,双侧小开窗或单侧小开窗 对侧半椎板减压可以满足绝大多数患者的要求,手术方法应人而异。内固定组与非固定组疗效经标准化处理无明显差异。但非固定组的治疗费用远远低于内固定组。     

The degree of decompressive relief and its relation to clinical outcome in patients undergoing surgery for lumbar spinal stenosis.

STUDY DESIGN: A cross-sectional, clinical study to evaluate surgical decompression of the stenotic area monitored by computed tomographic scan and its relation to clinical variables in patients operated on for lumbar spinal stenosis. OBJECTIVE: To study in patients with lumbar spinal stenosis the influence of the degree of compressive relief on the patients' clinical outcome. SUMMARY OF BACKGROUND DATA: The goal of surgical treatment in lumbar spinal stenosis is to decompress the stenotic area. Although the decompression should be adequate, there are no clear guidelines to determine the extent of necessary decompression. In fact, there is clinical evidence that there is a discrepancy between the surgical outcome in the patient with lumbar spinal stenosis and postoperative radiologic findings. METHODS: In 92 patients with lumbar spinal stenosis who had had no prior back surgery, preoperative and postoperative computed tomographic scans were obtained to determine the degree of decompression. The postoperative scan findings were classified according to the degree of decompression into a no-stenosis group (n = 35), an adjacent-stenosis group (n = 27), and a residual-stenosis group (n = 30). The postoperative instability of the lumbar spine was investigated by functional radiography. The subjective disability of the patients was assessed using the Oswestry score and the severity of pain using the visual analog scale. Walking capacity was evaluated by a treadmill test. The patients' estimations of the results of surgery were classified into groups of satisfied patients and dissatisfied patients. RESULTS: The mean Oswestry score in all 92 patients was 27.1, and mean walking capacity was 630 m. In the satisfied patients, the Oswestry score was 18.8 and in the dissatisfied patients, 34.9 (P < 0.0000). Walking capacity was 690 m and 594 m, respectively. There were 30 patients with postoperative spinal instability, but it had no influence on surgical outcome. There were no differences in the Oswestry score, walking capacity, and patients' satisfaction among the postoperative CT groups. In the linear regression analysis, the satisfied patient corresponded significantly with the Oswestry score. CONCLUSIONS: The satisfaction of the patients with the results of surgery was more important in surgical outcome than the degree of decompression detected on computed tomographic scan.     

Delta大通道内镜下经皮单侧椎板间入路270°环形椎管减压治疗老年腰椎管狭窄症

目的:探讨Delta大通道内镜下经皮单侧椎板间入路270°环形减压治疗老年腰椎管狭窄症(lumbar spinal stenosis,LSS) 的临床疗效。方法:对2018年 12月至 2021年1月采用Delta大通道内镜下经皮单侧椎板间入路270°环形减压术治疗的29例LSS进行回顾性分析,其中男12例,女17例;年龄63~83(71.52±10.82)岁;患者均伴有明确的间歇性跛行,以双下肢神经源性症状为主;均为单节段椎管狭窄,L_3,4 5例,L_4,5 21例,L₅S₁ 3例。采用疼痛视觉模拟评分(visual analogue scale,VAS),Oswestry功能障碍指数(Oswestry disability index,ODI)和改良Macnab评定标准分别对疼痛,下腰痛功能障碍指数及临床疗效进行评价。结果:29例手术均顺利完成,且获得12个月以上的随访。手术时间(73.45±5.89) min,术中出血量(9.93±0.83) ml,住院时间(4.03±0.41) d。术前、术后1 d及术后1、3、12个月时腰痛VAS分别为(2.31±0.88)、(1.45±0.62)、(1.21±0.61)、(1.10±0.55)、(1.03±0.49)分:腿痛VAS分别为(6.48±0.56)、(1.97±0.61)、(1.31±0.59)、(1.17±0.59)、(1.10±0.55)分;ODI评分分别为(38.41±2.74),(18.14±1.17),(5.17±0.53),(5.07±0.45),(4.90±0.48)分;腰腿痛VAS、ODI评分术前与术后各随访时间节点比较,差异均有统计学意义(P<0.05)。术后1年按改良Macnab标准评定疗效,结果优22例,良5例,可2例。结论:Delta大通道内镜下经皮单侧椎板间入路270°环形椎管减压治疗老年腰椎管狭窄症临床疗效满意,具有创伤小、出血少、镜下操作空间大、减压充分、术后恢复理想等优点,同时最大程度地减少了对腰椎稳定结构的破坏,是一种治疗老年腰椎管狭窄症的理想术式。     

Can decompression surgery relieve low back pain in patients with lumbar spinal stenosis combined with degenerative lumbar scoliosis?

Introduction

Decompression with fusion is usually recommended in patients with lumbar spinal stenosis (LSS) combined with degenerative lumbar scoliosis (DLS). However, elderly patients with LSS and DLS often have other comorbidities, and surgical treatment must be both safe and effective. The aim of this study was to investigate whether decompression surgery alone alleviates low back pain (LBP) in patients with LSS and DLS, and to identify the predictors of postoperative residual LBP.

Materials and methods

A total of 75 patients (33 males and 42 females) with a mean age of 71.8 years (range 53–86 years) who underwent decompression surgery for LSS with DLS (Cobb angle ≥ 10°) and had a minimum follow-up period of 1 year, were retrospectively reviewed using the Japanese Orthopaedic Association scoring system for the assessment of lumbar spinal diseases (JOA score). Radiographic measurements included coronal and sagittal Cobb angles, apical vertebral rotation (Nash-Moe method), and anteroposterior and lateral spondylolisthesis. Logistic regression analysis was performed to investigate the predictors of residual LBP after surgery.

Results

Forty-nine patients had preoperative LBP, of which 29 (59.1 %) experienced postoperative relief of LBP. Logistic regression analysis demonstrated that the degree of apical vertebral rotation on preoperative radiography was significantly associated with postoperative residual LBP (odds ratio, 8.16, 95 % confidence interval, 1.55–83.81, p = 0.011).

Conclusion

A higher degree of apical vertebral rotation may therefore be an indicator of mechanical LBP in patients with LSS and DLS. Decompression with fusion should be recommended in these patients.     

Functional outcome study of patients after surgical decompression for lumbar spinal stenosis: effects of concomitant pathology

The aim of this study is to identify factors associated with poor outcome in the medium (2-5 years) postoperative period following lumbar stenosis surgery. Fifty-six consecutive patients who underwent decompression for lumbar spinal stenosis were retrospectively analyzed using chart and radiologic review, questionnaire using American Association of Orthopaedic Surgeon's MODEM questionnaire containing disability, symptoms, and illness rating, as well as Short Form-36 questionnaires. Postoperatively, there was 98% partial or total relief in leg pain, 85% had partial or total relief in back pain, and 69% had partial or total recovery of neurologic deficit. Functional outcome according to the Short Form-36 was comparable with the age-adjusted population when other comorbidities were taken into account. We found a direct relationship between poor outcome and coexisting medical conditions (p <0.001). Accompanying comorbid conditions have a significant impact on outcome after surgical decompression for lumbar spinal stenosis.     

内镜下经单侧入路行双侧椎管减压治疗退变性腰椎管狭窄症

目的 报道内镜(METRx)辅助下经单侧椎板间隙入路,行双侧中央椎管和侧隐窝减压,治疗退变性腰椎管狭窄症患者的手术技巧与临床效果. 方法 透视下经单侧置入18 min的METRx工作通道,术中通过调整METRx工作通道和内窥镜角度,经单侧椎板间隙入路行双侧中央椎管和侧隐窝减压,从而可保留棘上、棘间韧带和对侧的骨性椎板,以及不影响对侧软组织,临床治疗56例. 结果 单节段METRx操作时间平均94 min.平均失血量为65 ml,双节段操作时间平均135 min,平均失血量为90 ml.平均卧床时间6.5 d.平均腰痛VAS指数从术前6.5降到术后平均3.1.平均腿痛VAS指数从术前7.2降到术后平均2.2,Oswestry功能指数(ODI)也从术前的平均46.8降到术后平均24.6,手术前后差异有统计学意义(P＜0.01).Nakai分级评定手术的优良率为84%. 结论 内窥镜(METRx)辅助下经单侧椎板间隙入路,行双侧椎管治疗退变性腰椎管狭窄症,不但手术创伤小,而且安全有效.     

Predictors of residual symptoms in lower extremities after decompression surgery on lumbar spinal stenosis

Leg pain/numbness and gait disturbance, two major symptoms in the lower extremities of lumbar spinal stenosis (LSS), are generally expected to be alleviated by decompression surgery. However, the paucity of information available to patients before surgery about specific predictors has resulted in some of them being dissatisfied with the surgical outcome when the major symptoms remain after the procedure. This prospective, observational study sought to identify the predictors of the outcome of a decompression surgery: modified fenestration with restorative spinoplasty. Of 109 consecutive LSS patients who underwent the decompression surgery, 89 (56 males and 33 females) completed the 2 year follow-up. Both leg pain/numbness and gait disturbance determined by the Japanese Orthopedic Association scoring system were significantly improved at 2 years after surgery compared to those preoperative, regardless of potential predictors including gender, preoperative presence of resting numbness in the leg, drop foot, cauda equina syndrome, degenerative spinal deformity or myelographic filling defect, or the number of decompressed levels. However, 27 (30.3%) and 13 (14.6%) patients showed residual leg pain/numbness and gait disturbance, respectively. Among the variables examined, the preoperative resting numbness was associated with residual leg pain/numbness and gait disturbance, and the preoperative drop foot was associated with residual gait disturbance, which was confirmed by logistic regression analysis after adjustment for age and gender. This is the first study to identify specific predictors for these two remaining major symptoms of LSS after decompression surgery, and consideration could be given to including this in the informed consent.     

Mid-term changes in spinopelvic sagittal alignment in lumbar spinal stenosis with coexisting degenerative spondylolisthesis or scoliosis after minimally invasive lumbar decompression surgery: minimum five-year follow-up

BACKGROUND CONTEXTRecently, the number of patients with lumbar spinal stenosis (LSS) who present with a coexisting spinal deformity such as degenerative spondylolisthesis (DS) and scoliosis (DLS) has been increasing. Lumbar decompression without fusion can lead to a reactive improvement in the lumbar and sagittal spinopelvic alignment, even if a sagittal imbalance exists preoperatively. However, the mid- to long-term impact of the coexistence of DS and DLS on the change in sagittal spinopelvic alignment and clinical outcomes after decompression surgery remains unknown.PURPOSEThis study aimed to investigate whether the coexistence of DS or DLS in patients with LSS is associated with differences in radiological and clinical outcomes after minimally invasive lumbar decompression surgery.STUDY DESIGN/SETTINGA retrospective analysis of prospectively collected data.PATIENT SAMPLEA total of 169 patients who underwent minimally invasive lumbar decompression surgery and follow-up >5 years postoperatively.OUTCOME MEASURESSelf-report measures: Low back pain (LBP) and/or leg pain and/or leg numbness visual analog scale (VAS) scores and the Japanese Orthopedic Association scores.PHYSIOLOGIC MEASURESStanding sagittal spinopelvic alignment.METHODSIn total, 81 patients with LSS, 50 patients with LSS and DS (≥3 mm anterior slippage), and 38 patients with LSS and DLS (≥15° coronal Cobb angle) were included in the current study. Clinical and radiological outcome results before surgery and at 2 and 5 years after surgery were compared among the groups.RESULTSIn patients with LSS with coexisting DS, the clinical outcomes at 2, and 5 years after surgery were similar to those of patients with only LSS. In patients with LSS with coexisting DLS, the VAS LBP and leg pain at 2 years after surgery was significantly higher (34.7 vs. 27.8, p=0.014; 27.8 vs. 14.7, p=0.028) and the achievement rate of the minimal clinically important difference in VAS LBP and leg pain was significantly lower than that of the LSS group (36.1% vs. 54.2%, p=0.036; 58.3% vs. 69.9%, p=0.10). The clinical outcomes except VAS leg numbness at 5 years after surgery were similar to those of patients with only LSS. The reoperation rate of the DS group was significantly lower than that of the LSS group (4.0% vs. 14.8%; p=0.01); however, the reoperation rate of the DLS group was comparable to that of the LSS group (15.8% vs. 14.8%; p=0.493). Lumbar lordosis (LL), sacral slope, pelvic tilt, and pelvic incidence-LL had significantly improved and been maintained for 5 years after the surgery in both the DS and the DLS groups. The sagittal vertical axis had improved at two-year follow-up; however, no significant difference was observed at the 5-year follow-up in both the DS, and the DLS groups.CONCLUSIONSMid-term clinical outcomes in patients with LSS with and without deformity were comparable. Lumbar decompression without fusion can result in a reactive improvement in the lumbar and sagittal spinopelvic alignment, even with coexisting DS or DLS. Minimally invasive surgery could be considered for most patients with LSS.