Functional outcome of surgical treatment for multilevel lumbar spinal stenosis

BACKGROUND: There is no consensus regarding the best treatment of patients with multilevel lumbar stenosis. We evaluated the clinical and radiological findings in 41 patients with complex degenerative spinal stenosis of the lumbar spine who were treated surgically. METHODS: Between 1997 and 2003, 41 patients suffering from degenerative lumbar spinal stenosis were included in a prospective clinical study. The spinal stenosis was multilevel in all patients and in 13 of them there was degenerative scoliosis, in 18 there was degenerative spondylolisthesis, and in 10 there was segmental instability. Plain radiographs, MRI and/or CT myelograms were obtained preoperatively. The patients were assessed clinically with the Oswestry disability index (ODI) and visual analog scale (VAS). Surgery included wide posterior decompression and fusion using a trans-pedicular instrumentation system and bone graft. RESULTS: After a mean follow-up of 3.7 (1-6) years, the patients' clinical improvement on the ODI and VAS was statistically significant. Recurrent stenosis was not observed, and 39 of 41 patients were satisfied with the outcome. 3 patients with improvement initially had later surgery because of instability. INTERPRETATION: The above-mentioned technique gives good and long lasting clinical results, when selection of patients is done carefully and when the spinal levels that are to be decompressed are selected accurately.     

多节段腰椎管狭窄症外科手术治疗的功能评价

[目的]本文通过对56例多节段腰椎管狭窄症患者的回顾性研究,探讨多节段腰椎管狭窄的发病特征、手术治疗方法及术后疗效评价。[方法]1998～2002年,56例多节段腰椎管狭窄病人,术前常规行临床神经功能检查,影像学检查包括标准的腰椎正侧位、左右斜位及前屈、后伸动力位X线片、腰椎CT及MRI检查。手术前后应用Beaujon功能评分法,Oswestry disability index（ODI）及visual analog scale（VAS）进行主客观评估。手术方法采用受累节段广泛椎板减压,椎弓根钉系统固定,后外侧植骨融合术式。[结果]经过平均2.2年的随访,病人在临床上Beaujon评分有提高（P〈0.05）,ODI和VAS评分有显著性差异。[结论]广泛椎板减压,椎弓根钉系统固定,后外侧植骨融合术是治疗多节段腰椎管狭窄的有效手段,只要准确地选取减压脊柱节段,该术式可以得到良好和持久的临床结果。     

老年多节段腰椎管狭窄症外科治疗进展

老年腰椎管狭窄症常为多节段病变,外科治疗受到广泛关注,外科治疗术式的选择仍存在争议。该文就术中如何在设计减压范围的同时保护脊柱的稳定性,是否行融合术、联合内固定术,骨质疏松置钉问题,以及是否在采用融合固定的同时采用非融合技术预防相邻节段退变等,作一综述。     

个体化手术治疗退变性腰椎管狭窄症

目的回顾性分析选择性减压和减压融合治疗退变性腰椎管狭窄症的临床疗效。方法对我科2008年10月-2010年10月81例行手术治疗的退变性腰椎管狭窄症的临床资料进行总结：其中男37例,女44例,年龄39~72岁,平均（59.4±6.3）岁;单节段狭窄48例,双节段狭窄25例,三个及其以上节段狭窄8例;7例伴L4椎体I°滑脱,5例伴腰椎退变性侧弯,26例存在节段性不稳。根据无或有不稳行减压（A组）或减压融合（B组）。A组43例,行经后路常规椎板开窗减压或后路椎间盘椎管探查减压;B组38例,行后路减压椎体间或横突间植骨融合及椎弓根钉棒内固定术。采用JOA评分、ODI量表评价临床疗效,比较两组的疗效。结果平均随访1.8年,总体临床优良率82.1%,A组82.1%,B组82.2%。结论在仔细分析病情的基础上,选择个体化手术方案治疗退变性腰椎管狭窄症可取得满意的临床疗效,提高生活质量。     

显微减压术治疗多平面腰椎管狭窄症

目的：总结显微减压术治疗多平面腰椎管狭窄症的临床应用结果。方法：2004年1月至2008年12月,对40例多平面腰椎管狭窄症患者采用显微减压术治疗,其中男28例,女12例;年龄55～80岁,平均58岁;病程18个月～12年,平均32个月。40例均经CT或MRI检查诊断为多平面腰椎管狭窄,其中2个平面狭窄（L4,5和L5S1）20例,3个平面狭窄（L3,4、L4,5和L5S1）15例,4个平面狭窄（L2,3、L3,4、L4,5和L5S1）5例。术后根据MacNab疗效评定标准,从疼痛、排尿功能障碍、腰部活动度、下肢肌力等方面对疗效进行评定。结果：40例患者术后无伤口感染及神经损伤并发症,伤口均Ⅰ期愈合。每侧手术时间50～90min,平均70min;每侧术中出血量90～200ml,平均150ml。所有病例均获随访,随访时间22～52个月,平均30个月。根据MacNab标准对疗效进行评定：优28例,良10例,差2例。结论：对腰椎管狭窄症的手术治疗重点应放在压迫引起症状的部位,而对无症状的部位不做预防性减压操作。显微减压术老年人更容易耐受,减轻了对腰椎后部结构的损伤,更容易进入椎管,有利于进行神经根减压。     

Predictors of surgical outcome in degenerative lumbar spinal stenosis

STUDY DESIGN: A prospective, observational study. OBJECTIVES: To identify outcome predictors of surgery for degenerative lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: Degenerative lumbar spinal stenosis is the most frequent indication for spine surgery in the elderly. More than 25% of surgical patients have a poor outcome, yet little is known about factors that predict the outcome of surgery. METHODS: Surgery was performed on 199 patients with degenerative lumbar spinal stenosis, and they were observed for 2 years after surgery in four referral centers. Surgery consisted of decompressive laminectomy with or without arthrodesis. Outcomes included validated measures of symptom severity, walking capacity, and satisfaction with the results of surgery. Potential predictors of outcome included sociodemographic factors and physical examination, as well as radiographic, psychological, social, and clinical history variables. RESULTS: The proportion of patients with severe pain decreased from 81% before surgery to 31% by 2 years afterward. The most powerful preoperation predictor of greater walking capacity, milder symptoms, and greater satisfaction was the patient's report of good or excellent health before surgery. Low cardiovascular comorbidity also predicted a favorable outcome. CONCLUSIONS: Patient's assessments of their own health and comorbidity are the most cogent outcome predictors of surgery for spinal stenosis.     

退变性腰椎侧凸合并多节段腰椎管狭窄的手术治疗

[目的]探讨多节段开窗椎管潜行扩大减压、椎体间及后外侧植骨融合内固定治疗退变性腰椎侧凸合并多节段腰椎管狭窄的临床疗效。[方法]回顾分析2003年4月~2013年6月收治的35例退变性腰椎侧凸合并多节段腰椎管狭窄患者施行多节段开窗椎管潜行扩大减压、椎体间及后外侧植骨融合内固定术,必要时辅助对侧椎板间小开窗减压。术前腰椎Cobb角24.2°±9.6°,腰椎侧凸角21.2°±8.8°,VAS评分(8.4±1.9)分,JOA评分(11.3±4.2)分。评价术前、末次随访时腰椎Cobb角及腰椎前凸角的矫正及维持情况,根据术前、末次随访时VAS评分、JOA评分评价临床疗效。[结果]本组患者未出现死亡、瘫痪、中枢神经系统感染等严重并发症,肺部感染、泌尿系统感染、术口愈合不良、术后神经症状等经积极处理后均得到治愈。35例患者均获得随访,术后随访12~60个月,平均19个月。末次随访时腰椎Cobb角减小至9.2°±4.5°,腰椎前凸角增加至33.8°±8.6°,矫正率分别为61.9%、37.2%,较术前相比差异均有统计学意义(P<0.05);末次随访时VAS、JOA评分分别为(2.8±1.5)分、(27.8±4.5)分,改善率分别为66.6%、93%,差异有统计学意义(P<0.05)。[结论]多节段开窗椎管潜行扩大减压、椎体间及后外侧植骨融合内固定术,必要时辅助对侧椎板间小开窗减压治疗退变性腰椎侧凸合并多节段腰椎管狭窄安全,脊柱畸形的矫正和维持以及临床症状的改善令人满意。     

A new surgical treatment for lumbar spinal canal stenosis

Using the method of Assessment of Treatment for Low Back Pain by the Japanese Orthopaedic Association, 159 cases of lumbar spinal canal stenosis treated between 1977 and 1988 were analyzed. Although walking ability was satisfactorily improved, low back pain, numbness, sensory disturbance, motor disturbance, and ability to lift heavy objects showed relatively poor improvement. Lumbar complaints remained in some of the cases radiographically evaluated as having worsened lumbar lordosis or an unbalanced range of motion. The improvement ratio was 82.6% on average, but it was 74.3% among cases that underwent wide laminectomy (non-fusion) due mainly to such nonspecific complaints as a feeling of heaviness in the lumbar region. The ratio increased to 88.5% after the introduction of wide fenestration with spinous process flap for conservation of the posterior component. Since this technique provides a wide operative field at a low risk for the occurrence of postoperative instability, it is strongly recommended for the treatment of degenerative multiple spinal canal stenosis.     

腰椎管狭窄症外科治疗进展

20世纪下半叶以来腰椎管狭窄症外科治疗发展很快,尽管手术方式各有不同,但手术原则仍离不开神经减压和脊柱稳定.与传统减压手术相比,内固定和融合手术的价值及其性价比一直存在争议,在不断积累经验,提高手术疗效的同时,其不良效应也逐渐得到认识.微创和非融合稳定技术的出现和发展,为克服减压和融合术带来的问题提供了希望.     

Functional outcome of surgical management of degenerative lumbar canal stenosis

Background:

The long term outcomes of decompressive surgery on relief of pain and disability in degenerative lumbar canal stenosis are unclear. The aim of our study was to evaluate the outcome of surgical management of secondary degenerative lumbar canal stenosis and to analyze the effect on outcome variables using Japanese Orthopaedic Association (JOA) score.

Materials and Methods:

Thirty-two patients of degenerative lumbar canal stenosis managed surgically were included in this study. Laminectomy (n=2), laminectomy with disectomy (n=23), laminectomy and disectomy with instrumental stabilization (n=5), and laminectomy, disectomy with posterior interbody fusion (n=2) were performed. JOA scoring system for low backache was used to assess the patients. The recovery rate was calculated as described by Hirabayashi et al. (1981). Surgical outcome was assessed based on the recovery rate and was classified using a four-grade scale: Excellent, improvement of >90%; good, 75–89% improvement; fair, 50–74% improvement; and poor, below 49% improvement. The patients were evaluated at 3 months, one year and at last followup.

Results:

At 3-month followup, 18.75% patients showed excellent outcome, 62.50% patients showed good outcome, and 18.75% showed fair outcome. At 1-year followup, 64% patients showed excellent outcome and 36% patients showed good outcome. At >1 year followup (average 34.2 months, range: 2–110 months), 64% patients showed excellent outcome, 28% showed good outcome, and 8% showed fair outcome. No patient had poor outcome. Outcome of the patients improved as the time after surgery increased till 1 year and was sustained thereafter till the last followup.

Conclusion:

Operative treatment in patients of degenerative lumbar canal stenosis yields excellent results as observed on the basis of JOA scoring system. No patient got recurrence of symptoms of nerve compression.     

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.     

腰椎管狭窄症手术治疗中应注意的几个问题

腰椎退行性改变是引起腰椎管狭窄症较常见的原因,其特点是：站立和行走时引起腰痛和下肢痛,腰部过伸时这种症状加重。随着影像学检查手段的发展和社会老龄化,腰椎管狭窄症的发病率呈逐年增高趋势,是中老年人腰腿痛的主要原因之一。经保守治疗未能取得满意效果时,手术是治疗腰椎管狭窄症的重要方法。本文阐述手术治疗中应注意的几个问题。     

责任节段融合术治疗高龄多节段腰椎管狭窄症

[目的]探讨责任节段腰椎融合术治疗高龄多节段腰椎管狭窄症的应用价值。[方法]回顾性分析2014年1月～2017年12月收治的160例高龄多节段退行性腰椎管狭窄症患者。其中,82例减压术后仅行责任节段融合,78例减压术后行常规长节段融合术。比较两组围手术期、随访和影像资料。[结果]两组患者均顺利完成手术。责任节段融合组手术时间、出血量、住院时间均少于多节段融合组,差异有统计学意义(P<0.05)。多节段融合组并发症发生率略高于责任节段融合组,差异无统计学差异(P>0.05)。两组患者术后平均随访(24.59±3.25)个月,随术后时间推移,两组患者的VAS评分、ODI指数均显著下降,而JOA评分明显增加,不同时间点间差异有统计学意义(P<0.05);相同时间点,两组间VAS、 ODI和JOA评分的差异均无统计学意义(P>0.05)。至末次随访时,两组患者疼痛、行走、弯腰活动、劳动能力较术前均得到明显改善,生活质量明显提高。影像检查显示随访过程中均未发生螺钉松动、断裂等现象,笼架未出现明显移位及下沉,所有患者均获得骨性融合。[结论]责任节段融合术治疗高龄多节段腰椎管狭窄症能有效地缩短手术时间,减少出血量,缩短住院时间,且能达到预期临床疗效,改善患者生活质量。     

Nonoperative treatment for lumbar spinal stenosis

The natural history of degenerative lumbar spinal stenosis is documented poorly. Little is known about the efficacy of nonoperative treatments. An aggressive nonoperative treatment consisting of therapeutic exercise, analgesics, and epidural steroid injections is proposed. The clinical evaluation of the patients is reviewed and the relevance to the selection of the nonoperative treatment plans is emphasized. Efficacy of nonoperative treatment may depend greatly on the nature and severity of the patient's symptomatic and radiographic presentation. Several studies on nonoperative treatment of patients with between 1 and 5 years of followup suggest that variably 15% to 43% of patients will have continued improvement after nonoperative treatment.     

老年退变性腰椎管狭窄症的非手术治疗

[目的]探讨老年退变性腰椎管狭窄症患者非手术治疗的疗效。[方法]2000年11月～2005年10月收治的60岁以上退变性腰椎管狭窄症患者176例，随机分为中医组、西医组及中西医结合组，组间性别、年龄、病程及并发症比较差异无统计学意义（P〉0．05），具有可比性。分别予中医、西医及中西医结合非手术方法治疗并采用日本矫形外科协会JOA评分标准评定疗效。[结果]157例获2～7年随访，平均随访3．5年，三组患者治疗前JOA分值比较差异无统计学意义（P〉0．05），出院及随访时中医组与西医组患者JOA分值比较差异无统计学意义（P〉0．05），但中医组或西医组与中西医结合组间JOA分值以及疗效比较差异有统计学意义（P〈0．05），中西医结合组疗效优于中医组和西医组。[结论]对于无急诊手术指征老年退变性腰椎管狭窄症患者，在积极治疗并存内科疾病的同时，选择合理的非手术治疗，可取得较好疗效，但中西医结合疗法与单纯中医或西医疗法比较，疗效更持久及稳定。     

Spinaplasty following lumbar laminectomy for multilevel lumbar spinal stenosis to prevent iatrogenic instability

Background:

Iatrogenic instability following laminectomy occurs in patients with degenerative lumbar canal stenosis. Long segment fusions to obviate postoperative instability result in loss of motion of lumbar spine and predisposes to adjacent level degeneration. The best alternative would be an adequate decompressive laminectomy with a nonfusion technique of preserving the posterior ligament complex integrity. We report a retrospective analysis of multilevel lumbar canal stenosis that were operated for posterior decompression and underwent spinaplasty to preserve posterior ligament complex integrity for outcome of decompression and iatrogenic instability.

Materials and Methods:

610 patients of degenerative lumbar canal stenosis (n=520) and development spinal canal stenosis (n=90), with a mean age 58 years (33–85 years), underwent multilevel laminectomies and spinaplasty procedure. At followup, changes in the posture while walking, increase in the walking distance, improvement in the dysesthesia in lower limb, the motor power, capability to negotiate stairs and sphincter function were assessed. Forward excursion of vertebrae more than 4 mm in flexion–extension lateral X-ray of the spine as compared to the preoperative movements was considered as the iatrogenic instability. Clinical assessment was done in standing posture regarding active flexion–extension movement, lateral bending and rotations

Results:

All patients were followed up from 3 to 10 years. None of the patients had neurological deterioration or pain or catch while movement. Walking distance improved by 5–10 times, with marked relief (70–90%) in neurogenic claudication and preoperative stooping posture, with improvement in sensation and motor power. There was no significant difference in the sagittal alignment as well as anterior translation. Two patients with concomitant scoliosis and one with cauda equine syndrome had incomplete recovery. Two patients who developed disc protrusion, underwent a second operation for a symptomatic disc prolapse.

Conclusion:

Spinaplasty following posterior decompression for multilevel lumbar canal stenosis is a simple operation, without any serious complications, retaining median structures, maintaining the tension band and the strength with least disturbance of kinematics, mobility, stability and lordosis of the lumbar spine.     

Usefulness of Posner's definition of spinal instability for selection of surgical treatment for lumbar spinal stenosis

The aim of this study was to determine the usefulness of Posner's definition of spinal instability for selection of surgical therapy for lumbar spinal stenosis. Sixty patients with lumbar spinal stenosis were studied. Thirty-three patients were found to have instability, as defined using Posner's method. Nineteen of the 33 patients with instability underwent decompression and instrumented fusion. The 14 remaining patients with instability underwent decompression alone. Twenty-seven patients without instability were treated by decompression alone. Patients treated by decompression and fusion obtained the best results. Good results also could be obtained by decompression alone only if patients did not have instability. However, patients treated by decompression alone in the presence of instability had the worst results. The Posner's definition of instability proved useful for selecting patients with instability for fusion treatment.     

老年患者骨化性腰椎管狭窄的临床特点及手术

目的 探讨老年患者骨化性腰椎管狭窄症临床特点及手术的疗效。方法 对56例手术患者诊治结果进行回顾性分析。结果 腰椎间盘突出骨化、小关节突内聚增生和黄韧带肥厚骨化是造成狭窄的主要原因，2个以上致窄因素共同作用的临床征象较为普遍。53例获随访，随访时间4～24个月，平均10个月。优34例，良14例，优良率90．6％。结论 老年骨化性腰椎管狭窄有其特殊的临床特点，手术方式应因人而异，彻底减压兼顾保持脊柱稳定性的术式很重要。