Degenerative spondylolisthesis: lumbar stenosis and instability.

Degenerative spondylolisthesis may manifest itself with different clinical pictures depending on the phase of the spondylotic disease. Based on pathophysiological criteria 24 patients affected with degenerative spondylolisthesis were divided into three groups: group I: those with spondylotic instability; group II: those with lumbar stenosis and current or potential segmental instability; group III: those with lumbar stenosis and naturally stabilized spondylolisthesis. Group I was treated by posterolateral fusion; group II by laminectomy, removal of the medial portion of the facets and posterolateral fusion; group III by laminectomy and removal of the medial portion of the facets. Long-term results were positive in 100% of the cases in group I, 90% in group II and 83% in group III, with no statistically significant differences between groups, because of the limited series of cases. The authors conclude that surgery for the treatment of degenerative spondylolisthesis must be based on age, symptoms, and the phase of the disease, and that when these indications suited to the clinical-radiographic picture are taken into account, good results may be obtained with different operations.     

Degenerative lumbar spinal stenosis

The aim of the study was to evaluate the long-term outcome of various surgical procedures for lumbar spinal stenosis. Operations were performed on 117 consecutive patients for lumbar spinal stenosis between 1987 and 1992. Pre- and intraoperative data were recorded in a standardized manner. Three treatment groups were distinguished: group I consisting of 39 patients submitted to undercutting decompression; group II, 51 patients, submitted to laminectomy and foraminal decompression alone; and group III, 27 patients, who underwent foraminal decompression and laminectomy with instrumented fusion. Eight years (5–10 years) after surgery a questionnaire was mailed to the patients containing the outcome scales according to Greenough and Fraser [6] and Turner et al. [22] together with questions about residual pain, necessity of treatment and satisfaction with the operative outcome. A total of 72 questionnaires (61.6%) gave enough information for analysis. After a mean follow-up of 8 years, walking capacity had increased significantly in all groups (P<0.001). Compared to preoperative values, pain had decreased significantly in all groups (P<0.01). In group I 36% had good-to-excellent outcomes, and 30.8% and 23.8% in groups II and III (P>0.05). Forty percent of group I patients were unsatisfied with the result, compared to 38.4% and 33.3% in the other groups (P>0.05). Overall, 25 of 72 patients (34.7%) had severe constant back and/or leg pain requiring daily administration of analgesics. We conclude that the long-term outcome of decompressive surgery of the lumbar spinal canal, without and with instrumented fusion, is less favourable than was previously reported. Received: 26 June 1998 / Accepted: 19 August 1998     

The outcome of decompression alone for lumbar spinal stenosis with degenerative spondylolisthesis

Purpose

Lumbar spinal stenosis in the presence of degenerative spondylolisthesis is generally treated by means of surgery. The role of lumbar decompression without fusion is not clear. Therefore, the aim of this study was to assess whether patients who undergo decompression alone have a favourable outcome without the need for a subsequent fusion.

Methods

This is a prospective cohort study with single blinding of 83 consecutive patients with lumbar stenosis and degenerative spondylolisthesis treated by decompression, without fusion, using a spinous process osteotomy. Blinded observers collected pre- and post-operative Oswestry Disability Index (ODI), EuroQol Five Dimensions (EQ-5D), and visual analogue scale (VAS) for back and leg pain scores prospectively. Failures for this study were those patients who required a subsequent lumbar fusion procedure at the decompressed levels. Statistical analysis was performed using paired t test and Mann–Whitney test.

Results

There were 36 males and 47 females with a mean age of 66 years (range 35–82). The mean follow-up was 36 months (range 19–48 months). The mean pre-operative ODI, EQ-5D, and VAS scores were 52 [standard deviation (SD) 18], 0.25 (SD 0.30), and 61 (SD 22), respectively. All mean scores improved post-operatively to 38 (SD 23), 0.54 (SD 0.34) and 36 (SD 27), respectively. There was a statistically significant improvement in all scores (p ≤ 0.0001). Nine patients (11 %) required a subsequent fusion procedure and five patients (6 %) required revision decompression surgery alone.

Conclusion

Our study’s results show that a lumbar decompression procedure without arthrodesis in a consecutive cohort of patients with lumbar spinal stenosis with degenerative spondylolisthesis had a significant post-operative improvement in ODI, EQ-5D, and VAS. The rate of post-operative instability and subsequent fusion is not high. Only one in 10 patients in this group ended up needing a subsequent fusion at a mean follow-up of 36 months, indicating that fusion is not always necessary in these patients.

     

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.     

Degenerative lumbar spinal stenosis and lumbar spine configuration

As life expectancy increases, degenerative lumbar spinal stenosis (DLSS) becomes a common health problem among the elderly. DLSS is usually caused by degenerative changes in bony and/or soft tissue elements. The poor correlation between radiological manifestations and the clinical picture emphasizes the fact that more studies are required to determine the natural course of this syndrome. Our aim was to reveal the association between lower lumbar spine configuration and DLSS. Two groups were studied: the first included 67 individuals with DLSS (mean age 66 ± 10) and the second 100 individuals (mean age 63.4 ± 13) without DLSS-related symptoms. Both groups underwent CT images (Philips Brilliance 64) and the following measurements were performed: a cross-section area of the dural sac, vertebral body dimensions (height, length and width), AP diameter of the bony spinal canal, lumbar lordosis and sacral slope angles. All measurements were taken at L3 to S1. Vertebral body lengths were significantly greater in the DLSS group at all levels compared to the control, whereas anterior vertebral body heights (L3, L4, L5) and middle vertebral heights (L3, L5) were significantly smaller in the LSS group. Lumbar lordosis, sacral slope and bony spinal canal were significantly smaller in the DLSS compared to the control. We conclude that the size and shape of vertebral bodies and canals significantly differed between the study groups. A tentative model is suggested to explain the association between these characteristics and the development of degenerative spinal stenosis.     

A prospective study of recovery from leg numbness following decompression surgery for lumbar spinal stenosis

Background

Residual leg numbness (LN) following lumbar surgery can lower patient satisfaction; however, prospective studies are sparse. The purpose of this study was to evaluate recovery from LN following decompression surgery for lumbar spinal stenosis (LSS).

A prospective study on CT scan outcomes after conservative decompression surgery for lumbar spinal stenosis

This is a prospective study analyzing CT scan imaging outcomes after conservative decompression in patients with lumbar spinal stenosis. Forty patients (18 males and 22 females) initially underwent a laminarthrectomy surgical procedure to decompress the central canal as well as the neuroforamina and nerve root canals while respecting the integrity of the neural arches, facet joints, and most muscle attachments. Morphologic features of preoperative CT scan images were compared with postoperative CT scans of the operative levels, obtained for 36 patients (17 males and 19 females) after a minimum follow-up of 1 year (mean 1.7 years). Successful surgical outcome was defined as an improvement in at least three of the following four criteria: self-reported pain on a visual analog scale, self-reported functional status measured by LBOS, reduction of pain while walking, and reduction of leg pain. Fifty-five percent of patients met the successful surgical outcome criteria, including 14 subjects who met all four success criteria. Overall, there was a statistically significant increase in the interfacet bony canal diameter of the operated levels (3.9 mm, p < 001). However, patients categorized as successful surgical outcomes had a substantially, but not significantly, lower interfacet canal diameter increase postsurgically (mean 3.41 mm) in comparison with patients categorized as failures (mean postoperative increase 4.52 mm). Midsagittal canal diameters remained unchanged in the failure group but increased in the success group. The CT scan canal measures used in this study cannot be advocated for evaluation of outcome in conservative lumbar spinal canal decompression.     

单纯减压治疗伴Ⅰ度退变滑脱的腰椎管狭窄症的中远期疗效分析

目的：探讨椎板节段开窗减压治疗伴Ⅰ度退变性滑脱的腰椎管狭窄症患者的中远期疗效及相关影响因素.方法：回顾分析28例采用单纯椎板减压术治疗的伴Ⅰ度退变性滑脱的腰椎管狭窄症患者,男10例,女18例,年龄45～75岁,平均62岁,病程4个月～14年,平均18个月;滑脱节段L4 25例,L3 2例,L5 1例.评估患者术后平均2年与6.8年时的临床疗效.结果：术后平均2年和6.8年的JOA评估优良率分别为89.8%和76%;术前腰痛VAS评分平均7.6分,术后2年及6.8年分别为3.8和5.6分（P＜0.05）,腿痛VAS评分分别由术前8.2分下降至2.4和2.7分（P＜0.01）.影像学检查示滑脱节段椎间高度降低,滑脱轻度增加,椎体间活动度减少,但均无统计学差异.并发症3例,二次手术3例.结论：椎板节段开窗、椎管潜行扩大减压是治疗伴Ⅰ度退变性滑脱的腰椎管狭窄症的一种有效手术方法,远期疗效与手术方法、自然病程进展、相邻节段退变及腰椎不稳等多种因素有关.     

Results of decompression for lumbar spinal stenosis.

Approximately 80% of patients with spinal stenosis return to their usual occupations following decompressive laminectomy. It is essential to recognize distinctive features of stenosis on myelography and in accordance with the individual patients' clinical problems, to carry out an adequate decompression.     

Endoscopic decompression combined with interspinous process implant fusion for lumbar spinal stenosis

Objective： To propose a new technique to treat lumbar spinal stenosis with median approach endoscopic decompression combined with interspinous process implant fusion and evaluate the initial clinical outcome.
Methods： This study involved 30 patients who had neurogenic commitment claudication over 2 years and were resistant to conservative therapy. All cases were treated using the median approach endoscopic decompression combined with interspinous process implant fusion in 2006. Clinical signs and radicular pain were noted and evaluated preoperatively and at the 1st month and 3rd month postoperatively. Japanese Orthopedic Association （JOA） score was used to evaluate leg and back pain. X-ray films at flexion and extension were applied to evaluate the range of motion at involved segments. Results： There was a significant increase in JOA score postoperatively, but no significant difference preoperatively or postoperatively between the two groups.The range of motion at involved segments was significantly higher in the control group.
Conclusions： The median approach endoscopic decompression is an ideal method for bilateral radiculopathy resulting from lumbar spinal canal stenosis. The combination with interspinous process implant fusion can stabilize the spine. The initial clinical outcome is exllent. Preservation of adjacent level disease can be assessed only in long-term follow-up.     

显微镜下手术治疗腰椎管狭窄症的前瞻性研究

[目的] 对比研究显微镜下与传统手术治疗腰椎管狭窄症的临床效果.[方法] 采取前瞻性研究,按同一标准选择180例病人,随机分为两组,A组采用显微镜,B组采用传统开放手术,比较两者在术中出血、住院日,医疗费用,并发症及疗效等方面的指标.[结果] 术中出血、住院日、医疗费用两组间差异均有统计学意义(P<0.01).两组各2例发生硬脊膜破裂,B组2例术后腰椎失稳.术后无神经根损伤、感染等并发症.175例获得11个月以上随访,根据中华医学会腰背痛手术评定标准评定疗效[1].A组优40例,良41例,可5例,差1例,优良率93.1%;B组优39例,良42例,可6例,差1例,优良率92.0%.两组之间差异无统计学意义(P>0.05).[结论] 两种方法疗效满意,但相比之下,显微镜下具有创伤小、术中出血少、住院日短、医疗费用少、并发症少,对腰椎后柱结构破坏小,不易造成腰椎失稳.是理想的微创手术方法.     

Degenerative lumbar spinal stenosis: evaluation and management

Degenerative lumbar spinal stenosis is caused by mechanical factors and/or biochemical alterations within the intervertebral disk that lead to disk space collapse, facet joint hypertrophy, soft-tissue infolding, and osteophyte formation, which narrows the space available for the thecal sac and exiting nerve roots. The clinical consequence of this compression is neurogenic claudication and varying degrees of leg and back pain. Degenerative lumbar spinal stenosis is a major cause of pain and impaired quality of life in the elderly. The natural history of this condition varies; however, it has not been shown to worsen progressively. Nonsurgical management consists of nonsteroidal anti-inflammatory drugs, physical therapy, and epidural steroid injections. If nonsurgical management is unsuccessful and neurologic decline persists or progresses, surgical treatment, most commonly laminectomy, is indicated. Recent prospective randomized studies have demonstrated that surgery is superior to nonsurgical management in terms of controlling pain and improving function in patients with lumbar spinal stenosis.     

Indirect spinal decompression for lumbar stenosis

Lumbar spinal stenosis continues to be an important cause of low back pain and neurogenic claudication. As the population ages and life expectancy increases, both the incidence and prevalence of spinal stenosis will present a significant challenge to spine surgeons. Both interspinous and interbody fusion techniques have demonstrated the ability to decrease low back pain and provide clinically significant pain relief from neurogenic claudication through indirect means. While direct decompression of the spine has been well documented in the literature and the gold standard, new interest in minimally invasive techniques and indirect decompression has led to new devices and clinical studies with promising results.     

A comparative study of gait characteristics associated with and without degenerative lumbar spondylolisthesis in patients with lumbar spinal stenosis

BackgroundReported characteristics of DS include forward slippage of the superior lumbar relative to the inferior lumbar, lumbar instability, increased lumbar lordotic angle, and high body mass index (BMI). However, to our knowledge, only static measurements were conducted in previous studies, and no dynamic observations exist. In this crosssectional study, the gait of patients with and without DS in LSS was compared, and their characteristics were examined using a three-dimensional motion analysis system.MethodsIn total, 42 patients with LSS were included. Lumbar lordosis angle, sacral tilt angle, lumbar slip rate determined from X-ray images, the Zurich Claudication Questionnaire (ZCQ), the visual analog scale (VAS), and BMI were evaluated. U-COM length was the distance between the upper center of mass (COM) and the body's COM, while L-COM length was the distance between the lower COM and the COM. Each DS and Non-DS group evaluation was compared using the Mann–Whitney U-test. Additionally, multivariate analysis was performed using factors with significant differences as explanatory variables and with or without DS as the target variable.ResultsLumbar lordotic angle was significantly higher in the DS group and there was a significant difference between U-COM and L-COM lengths in the sagittal planes at heel contact (HC) and toe-off (TO). L-COM length at HC and TO was a significant variable when the lumbar lordotic angle was adjusted as a confounding factor in multivariate analysis.ConclusionsThe U-COM and L-COM lengths in the DS group were both extended and the line connecting each COM was inclined backward on the sagittal plane at HC and TO during gait. Our study showed that L-COM length was associated with or without DS.     

Mini-open versus open decompression and fusion for lumbar degenerative spondylolisthesis with stenosis

The outcome of less invasive surgical techniques in comparison to traditional surgical techniques has been the source of debate. In this retrospective study, 51 patients who had undergone posterior lumbar fusion along with bilateral decompression were enrolled. Twenty-one patients underwent fusion using a standard, midline open technique (open group) and 30 patients underwent fusion using a mini-open technique, with a small, central incision for the decompression and bilateral paramedian incisions for the posterolateral fusion and placement of cannulated pedicle screws (mini-open group). Surgical variables were compared between the 2 groups. Patients in both groups experienced significant improvements in leg pain at 12 months, with a reduction in visual analog scale scores from 7.6 to 2.4 in the open group, and 7.8 to 2.3 in the mini-open group. There were no statistical differences between the groups in the magnitude of improvement of either the visual analog scale or Oswestry Disability Index scores. Operative times, blood loss, and length of hospitalization failed to show statistically significant differences between the groups, although there was a trend toward less blood loss and shorter hospitalization in the mini-open group. Fusion results and complications were similar between the 2 groups. Both techniques resulted in similarly statistically significant improvements in pain and clinical function.     

Technique for lumbar decompression of spinal stenosis

This article presents a technique for lumbar laminectomy and decompression in patients suffering from acquiredlumbar spinal stenosis. The technique is discussed in detail and illustrated accordingly. The discussion reviewed a “typical” L3 to S1 (ie, L3-4, L4-5, and L5-S1) lumbar laminectomy without fusion.