A comprehensive study of patients with surgically treated lumbar spinal stenosis with neurogenic claudication

BACKGROUND: The relationship between objective measurements and subjective symptoms of patients with spinal stenosis and the degree of narrowing of the spinal canal is not clear. The purpose of this study was to evaluate patients undergoing surgery for lumbar spinal stenosis and intermittent neurogenic claudication with functional testing, quantitative imaging, and patient self-assessment. METHODS: Sixty-two patients with lumbar spinal stenosis and neurogenic claudication were prospectively enrolled in the study. All underwent preoperative magnetic resonance imaging and/or computed tomography myelography, and all were treated with decompressive surgery and were followed for a minimum of two years. The evaluation included treadmill and bicycle exercise tests as well as patient self-assessment with use of the Oswestry Disability Index and a visual analog pain scale preoperatively and postoperatively. RESULTS: Preoperatively fifty-eight (94%) of the patients had a positive result (provocation of symptoms) on the treadmill test and twenty-seven (44%) had a positive result on the bicycle test, whereas postoperatively six and twelve, respectively, had positive results. The mean preoperative scores on the Oswestry Disability Index and visual analog pain scale were 58.4 and 7.1, respectively. Postoperatively, these scores decreased to 21.1 and 2.3, respectively, and both decreases were significant (p < 0.05). Forty-seven (76%) of the patients were seen to have central stenosis on the preoperative imaging studies; forty-one of them had a cross-sectional area of the dural tube of <100 mm (2) at at least one level and twelve had a cross-sectional area of <100 mm (2) at at least two levels. CONCLUSIONS: A positive treadmill test was consistent with a diagnosis of spinal stenosis and neurogenic claudication in >90% of the patients preoperatively. Following surgical decompression of the lumbar spinal stenosis, more functional improvement was demonstrated by the treadmill test than by the bicycle test. The scores on the Oswestry Disability Index and visual analog pain scale also improved postoperatively. The severity of central canal narrowing at a single level does not appear to limit the postoperative improvement in either functional ability or patient self-assessment. Patients with multilevel central stenosis were, on the average, older and walked a shorter distance preoperatively and postoperatively, although the improvement in their postoperative self-assessment scores was similar to that of patients with single-level stenosis.     

Surgical management of lumbar degenerative spinal stenosis with spondylolisthesis via posterior reduction with minimal laminectomy

Degenerative lumbar spondylolisthesis with spinal stenosis is commonly treated with laminectomy. Recent reports have consistently supported the incremental clinical benefit of associated in situ arthrodesis with or without instrumentation. Resection of the lamina may result in intraoperative dural tear or epidural scar formation. Fifty-six consecutive patients with back pain, neuroclaudication, or both, in addition to degenerative spondylolisthesis with spinal stenosis, underwent a surgical procedure that incorporated fusion after reduction of the spondylolisthesis deformity with preservation of the lamina and the balance of the posterior elements. Clinical records were reviewed and patients interviewed at a mean of 33 months after surgery. Oswestry Disability Index scores were obtained independently at baseline and at a late review. Late imaging was available a mean of 28 months after operation. Clinical and imaging analyses and Oswestry scoring confirmed results comparable to the published outcomes of in situ fusion after formal laminectomy. Resection of the lamina may not be necessary in the treatment of degenerative lumbar spinal stenosis with spondylolisthesis.     

Psychometric properties of selected tests in patients with lumbar spinal stenosis

Background context

The psychometric properties of many outcome tools commonly used with patients with lumbar spinal stenosis have yet to be examined.

Purpose

Examine the test-retest reliability, responsiveness, and minimum levels of detectable and clinically important differences for several outcome measures in a cohort of patients with lumbar spinal stenosis.

Study design/setting

Cohort secondary analysis of a randomized clinical trial of patients with lumbar spinal stenosis receiving outpatient physical therapy.

Patient sample

Fifty-five patients (mean age, 69.5 years; standard deviation, ±7.9 years; 43.1% females) presenting with lumbar spinal stenosis to physical therapy.

Outcome measures

The Modified Oswestry Disability Index, Modified Swiss Spinal Stenosis Scale (SSS), Patient Specific Functional Scale, and Numeric Pain Rating Scale (NPRS).

Methods

All patients completed the Oswestry Disability Index, SSS, Patient Specific Functional Scale, and NPRS at the baseline examination and at a follow-up. In addition, patients completed a 15-point Global Rating of Change at follow-up, which was used to categorize whether patients experienced clinically meaningful change. Changes in the Oswestry Disability Index, SSS, Patient Specific Functional Scale, and NPRS were then used to assess test-retest reliability, responsiveness, and minimum levels of detectable and clinically important differences.

Results

The Oswestry Disability Index was the only outcome measure to exhibit excellent test-retest reliability with an intraclass correlation coefficient of 0.86 (95% confidence interval, 0.63–0.93). All others ranged between fair and moderate. The Oswestry Disability Index, SSS, and Patient Specific Functional Scale exhibited varying levels of responsiveness, each of which was superior to the NPRS. The minimal clinically important difference for the Oswestry Disability Index was five points, the SSS was 0.36 and 0.10 for symptoms subscale and functional subscale, respectively, 1.3 for the Patient Specific Functional Scale, and for the NPRS, 1.25 for back/buttock symptoms and 1.5 for thigh/leg symptoms.

Conclusions

The results of our study indicate that the Oswestry Disability Index, SSS, and Patient Specific Functional Scale possess adequate psychometric properties to be used in the outcome assessment of patients with lumbar spinal stenosis. However, further investigation is needed to validate these findings in other samples of patients with lumbar spinal stenosis and nonspecific low back pain.     

The diagnostic value of a treadmill test in predicting lumbar spinal stenosis

Lumbar spinal stenosis is a frequent indication for spinal surgery. The predictive quality of treadmill testing and MRI for diagnostic verification is not yet clearly defined. Aim of the current study was to assess correlations between treadmill testing and MRI findings in the lumbar spine. Twenty-five patients with lumbar spinal stenosis were prospectively examined. Treadmill tests were performed and the area of the dural sac and neuroforamina was examined with MRI for the narrowest spinal segment. VAS and ODI were used for clinical assessment. The median age of the patients was 67 years. In the narrowest spinal segment the median area of the dural sac was 91 mm². The median ODI was 66 per cent. The median walking distance in the treadmill test was 70 m. The distance reached in the treadmill test correlated with the area of the dural sac (Spearman’s ρ = 0.53) and ODI (ρ = −0.51), but not with the area of the neuroforamina and VAS. The distance reached in the treadmill test predicts the grade of stenosis in MRI but has a limited diagnostic importance for the level of clinical symptoms in lumbar spinal stenosis.     

Decision-making in lumbar spinal stenosis: A survey on the influence of the morphology of the dural sac

Surgical decision-making in lumbar spinal stenosis involves assessment of clinical parameters and the severity of the radiological stenosis. We suspected that surgeons based surgical decisions more on dural sac cross-sectional area (DSCA) than on the morphology of the dural sac. We carried out a survey among members of three European spine societies. The axial T2-weighted MR images from ten patients with varying degrees of DSCA and morphological grades according to the recently described morphological classification of lumbar spinal stenosis, with DSCA values disclosed in half the assessed images, were used for evaluation. We provided a clinical scenario to accompany the images, which were shown to 142 responding physicians, mainly orthopaedic surgeons but also some neurosurgeons and others directly involved in treating patients with spinal disorders. As the primary outcome we used the number of respondents who would proceed to surgery for a given DSCA or morphological grade. Substantial agreement among the respondents was observed, with severe or extreme stenosis as defined by the morphological grade leading to surgery. This decision was not dependent on the number of years in practice, medical density or specialty. Disclosing the DSCA did not alter operative decision-making. In all, 40?respondents (29%) had prior knowledge of the morphological grading system, but their responses showed no difference from those who had not. This study suggests that the participants were less influenced by DSCA than by the morphological appearance of the dural sac. Classifying lumbar spinal stenosis according to morphology rather than surface measurements appears to be consistent with current clinical practice.     

Predictors of treatment choice in lumbar spinal stenosis: a spine patient outcomes research trial study

STUDY DESIGN.: A retrospective cohort study. OBJECTIVE.: In this article, we examined the Spine Patient Outcomes Research Trial lumbar stenosis observational cohort to determine baseline patient characteristics that are predictive of the treatment patients chose. We also evaluated cutoff points on validated patient questionnaires that differentiate patients who chose surgery from those who chose nonsurgical management. SUMMARY OF BACKGROUND DATA.: Although the evidence from current studies suggests that surgical intervention is effective for lumbar spinal stenosis, the same studies show that nonoperative patients also improve. Thus, the reasons for patients choosing surgery versus nonoperative care are of continuing interest. METHODS.: Baseline patient and clinical characteristics between those who received operative intervention and those who received nonoperative care were compared to determine baseline predictors of lumbar spinal stenosis management. Also, an evaluation of responses to the 36-Item Short Form Health Survey Bodily Pain (BP), 36-Item Short Form Health Survey Physical Function (PF), and the modified Oswestry Disability Index (ODI) questionnaires was performed to determine the percentage of patients choosing surgical versus nonoperative care relative to their initial questionnaire values. RESULTS.: This analysis looked at the 356 patients in the observational spinal stenosis cohort of Spine Patient Outcomes Research Trial who completed at least 1 follow-up visit. Patients choosing surgery were younger (P = 0.022), had worse BP (P < 0.001), worse PF (P < 0.001), worse ODI (P < 0.001), worse Stenosis Bothersomeness Index (P < 0.001), were dissatisfied with their symptoms (P = 0.001), and had a worse self-assessed health trend (P < 0.001). Patients tended to choose surgery if they had lateral recess stenosis (P = 0.022). Kaplan-Meier curves demonstrate that patients with a BP score of 32 or less, PF score of 30 or less, and ODI greater than 29 chose surgery 75% of the time. CONCLUSION.: A greater understanding of baseline characteristics that influence patient choices in the treatment of lumbar spinal stenosis can aid the patient and the surgeon during the shared decision-making process.     

显微内窥镜下单侧入路双侧减压治疗腰椎椎管狭窄症

目的 探讨显微内窥镜下利用单侧入路双侧减压技术治疗腰椎椎管狭窄症的手术适应证及临床疗效.方法 2005年2月至2007年6月,采用显微内窥镜下单侧入路双侧减压技术治疗腰椎椎管狭窄症患者53例,男36例,女17例;年龄52～75岁,平均57岁.全部病例均有腰痛、单侧或双侧下肢疼痛、麻木及神经性间歇性跛行病史,其中有双下肢症状者均自觉一侧下肢症状较重.所有患者术前均行腰椎X线摄片、CT、MR等影像学检查确诊为单节段腰椎椎管狭窄症,并结合临床表现排除退变性腰椎失稳、多节段腰椎椎管狭窄.术后患者获得平均16个月(8～26个月)的随访,采用视觉模拟评分法(visual analogue scale,VAS)及腰椎功能障碍指数(Oswestry disability index,ODI)评定患者手术后的疗效.结果 术后无硬脊膜撕裂、神经根损伤等严重并发症发生.VAS及ODI评定结果显示患者手术前后的VAS及ODI分值改变有统计学意义(P<0.01).术后CT显示椎管得到有效扩大,解剖结构破坏较少.结论 显微内窥镜下单侧入路双侧减压技术减压效果良好,复发率低,适用于早期症状较轻的单节段腰椎椎管狭窄症患者.     

Stabilising effect of dynamic interspinous spacers in degenerative low-grade lumbar instability

The aim of the study was to investigate the stabilising effect of dynamic interspinous spacers (IS) in combination with interlaminar decompression in degenerative low-grade lumbar instability with lumbar spinal stenosis and to compare its clinical effect to patients with lumbar spinal stenosis in stable segments treated by interlaminar decompression only. Fifty consecutive patients with a minimum age of 60 years were scheduled for interlaminar decompression for clinically and radiologically confirmed lumbar spinal stenosis. Twenty-two of these patients (group DS) with concomitant degenerative low-grade lumbar instability up to 5 mm translational slip were treated by interlaminar decompression and additional dynamic IS implantation. The control group (D) with lumbar spinal stenosis in stable segments included 28 patients and underwent only interlaminar decompression. The mean follow-up was 46 months in group D and 44 months in group DS. A visual analogue scale (VAS), Oswestry Disability Index (ODI) and walking distance were evaluated pre- and postoperatively. The segmental instability was evaluated in flexion-extension X-rays. The implantation of an IS significantly reduced the lumbar instability on flexion-extension X-rays. At the time of follow-up walking distance, VAS and ODI showed a significant improvement in both groups, but no statistical significance between groups D and DS. Four patients each in groups D and DS had revision surgery during the period of evaluation. The stabilising effect of dynamic IS in combination with interlaminar decompression offers an opportunity for an effective treatment for degenerative low-grade lumbar instability with lumbar spinal stenosis.     

Severity of degenerative lumbar spinal stenosis affects pelvic rigidity during walking

BACKGROUND CONTEXTTo understand the role of compensation mechanisms in the development and treatment of symptomatic degenerative lumbar spinal stenosis (DLSS), pelvic stability during walking should be objectively assessed in the context of clinical parameters.PURPOSETo determine the association among duration of symptoms, lumbar muscle atrophy, disease severity, pelvic stability during walking, and surgical outcome in patients with DLSS scheduled for decompression surgery.STUDY DESIGN/SETTINGProspective observational study with intervention.PATIENT SAMPLEPatients with symptomatic DLSS.OUTCOME MEASURESOswestry Disability Index score; duration of symptoms; lumbar muscle atrophy; severity grade; pelvis rigidity during walking.METHODSPatients with symptomatic DLSS were analyzed on the day before surgery and 10 weeks and 12 months postoperatively. Duration of symptoms was categorized as: <2years, <5years, and >5years. Muscle atrophy at the stenosis level was categorized according to Goutallier. Bilateral cross-sectional areas of the erector spinae and psoas muscles were quantified from magnetic resonance imaging. Stenosis grade was assessed using the Schizas classification. Pelvic tilt was measured in standing radiographs. Pelvic rigidity during walking was assessed as root mean square of the pelvic acceleration in each direction (anteroposterior, mediolateral, and vertical) normalized to walking speed measured using an inertial sensor attached to the skin between the posterior superior iliac spine.RESULTSBody mass index but not duration of symptoms, lumbar muscle atrophy, pelvic rigidity, and stenosis grade explained changes in Oswestry Disability Index from before to after surgery. Patients with greater stenosis grade had greater pelvic rigidity during walking. Lumbar muscle atrophy did not correlate with pelvic rigidity during walking. Patients with lower stenosis grade had greater muscle atrophy and patients with smaller erector spinae and psoas muscle cross-sectional areas had a greater pelvis tilt.CONCLUSIONSGreater pelvic rigidity during walking may represent a compensatory mechanism of adopting a protective body position to keep the spinal canal more open during walking and hence reduce pain. Pelvic rigidity during walking may be a useful screening parameter for identifying early compensating mechanisms. Whether it can be used as a parameter for personalized treatment planning or outcome prognosis necessitates further evaluation.     

Long-term clinical and magnetic resonance imaging follow-up assessment of patients with lumbar spinal stenosis after laminectomy.

STUDY DESIGN: A cross-sectional retrospective study to observe the correlation between postoperation findings shown on magnetic resonance imaging and clinical observations of 56 patients 10 years after laminectomy for lumbar spinal stenosis. OBJECTIVE: To evaluate the relation between postoperation findings on magnetic resonance imaging and surgical outcome in patients surgically treated for lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: Surgical management of lumbar spinal stenosis is based on the compression seen in radiologic imaging of neurovascular structures in the vertebral canal, but the success of surgical decompression and its correlation with clinical observations very seldom have been monitored by postoperation radiologic imaging. METHODS: In this study, 56 patients surgically treated for lumbar spinal stenosis were re-examined clinically by use of the Oswestry disability questionnaire. Their walking capacity was evaluated by the treadmill test. Severity of pain before and after the treadmill test was investigated using a visual analog scale. Patients' perception of improvement measured as the change in their condition during the preceding 5 years was elicited by a questionnaire. On the basis of the stenotic findings on magnetic resonance imaging, the patients were classified into no stenosis (NoSten, n = 15) and stenosis (Sten, n = 41) groups, and a summative degenerative scale also was constructed with the findings categorized as follows: disc degeneration, disc herniation, facet joint arthrosis, and degenerative spondylolisthesis. RESULTS: Whereas the patients' perception of improvement correlated very strongly with the Oswestry score and walking capacity, there was no statistical difference between the NoSten and Sten groups in the Oswestry score, walking capacity, perception of improvement, or severity of pain. The effect of the summative degenerative scale on the patients' walking capacity was 13 times greater than the effect of the minimum area of the dural sac. CONCLUSIONS: Patients' perception of improvement had a much stronger correlation with long-term surgical outcome than structural findings seen on postoperation magnetic resonance imaging. Moreover, degenerative findings had a greater effect on patients' walking capacity than stenotic findings.     

Correlation between clinical scoring systems and quantitative MRI parameters in degenerative lumbar spinal stenosis

BackgroundMany quantitative MRI parameters and clinical scores have been used patients with lumbar spinal stenosis (LSS). However, the correlation between clinical scores and MRI parameters is not very clear. The objective of the study was to find out the correlation between commonly used clinical scoring systems and quantitative MRI parameters.MethodsEighty two patients (more than 40 years) with clinical and radiological characteristics of degenerative LSS completed 10 clinical questionnaires which included Oswestry disability index (ODI), Swiss spinal stenosis (SSS) questionnaire, Quebec pain disability scale (QPD), Visual analogue scale (VAS), modified Japanese orthopaedic association scale (mJOA), Pain disability index (PDI), Short form health survey (SF-36), Self-paced walking test (SPWT), Euro quality of life-5D (EQ-5D) and Neurogenic claudication outcome score (NCOS). Lumbosacral MRIs were performed and 8 quantitative parameters namely transverse & AP diameter of dural sac (TDD, APDD), anteroposterior diameter of spinal canal (APDS), ligamentous interfacet distance (LID), mid-sagittal diameter of thecal sac (MSDT), cross-sectional area dural sac (CSAD), lateral recess depth and angle (LRD, LRA) were measured at the maximum stenotic level at the level of the disc. The clinical and radiological parameters were then statistically analysed.ResultsThere were 51 females and 31 males in the study with a mean age of 53.0253.02 ± 9.18 years. NCOS score had a moderate correlation with CSAD, LID and TDS (p<0.05,0.7>r ≥ 0.3). MSDT showed a moderate negative correlation with SSS, VAS, ODI and QPD (p<0.05,0.7>r ≥ 0.3). LRD had a moderate negative correlation with ODI and VAS score (p<0.05,0.7>r ≥ 0.3). LRA had a moderate correlation with the EQ-5D and ODI (p<0.05,0.7>r ≥ 0.3). The CSAD had a moderate negative correlation with PDI (r = −0.383, p = 0.000). For all other comparisons, there was poor or no correlation. MRI parameters showed poor or no correlation with most of components of SF-36 score.ConclusionsA poor correlation or no correlation was noted for most of the MRI parameters when compared to commonly used clinical scores. Hence, poor MRI's don't necessarily mean poor clinical scores in LSS. The role of MRI parameters should be supplementary and overreliance on them in LSS management should be avoided.     

微创极外侧入路腰椎椎间融合术治疗退行性腰椎椎管狭窄症的初步应用和早期疗效分析

目的 研究微创极外侧入路腰椎椎间融合术(extreme lateral interbody fusion,XLIF)治疗退行性腰椎椎管狭窄症的早期疗效和安全性。方法 2013年10月~2014年3月本院收治退行性腰椎椎管狭窄症患者14例,均在微创通道下采用XLIF治疗。分别测量并分析术前、末次随访时患者疼痛视觉模拟量表(visual analogue scale, VAS)评分及Oswestry功能障碍指数(Oswestry disability index, ODI),椎间高度,椎间孔高度,椎间孔面积和盘黄间隙(关节下间隙),并通过X线片、CT、MRI等影像学资料进行整体评价。结果 所有患者手术顺利,术后随访6~13个月,患者均有不同程度的症状改善。5例患者术后出现短暂的右大腿外侧皮肤感觉异常和轻度髂腰肌肌力下降,均在术后2个月内恢复;1例大体重患者术后下床活动时出现持续性腰痛,给予延长卧床休息时间后症状改善。术后影像学显示所有患者椎管及神经根管减压效果满意,滑脱得到一定程度的复位。腰、腿痛VAS评分及ODI均较术前明显改善。术后测量椎间高度增加109.2%;椎间孔高度增加33.8%,症状侧椎间孔面积扩大41.4%,盘黄间隙平均增加2.3 mm。多项影像学评价指标均优于术前,差异有统计学意义(P< 0.01)。结论 微创XLIF应用于退行性腰椎椎管狭窄症的治疗,可以使患者早期得到良好的症状缓解和满意的影像学改善,值得临床推广与应用。但其远期疗效还需经过大样本长期的随访和研究。     

Clinical study of lumbar spinal canal stenosis on 70 operated cases --clinical symptoms, pathogenesis, operative method, postoperative results

In surgical treatment of lumbar spinal canal stenosis, the stenotic area related to the clinical symptoms was determined and the stenotic form and stenotic factors in this stenotic area were estimated before operation. The most appropriate decompression of the stenotic area was performed taking the stenotic form into consideration and retaining the spinous process and interspinous ligament. In cases of stenosis of the spinal canal, posterolateral decompression of the dural sheath was performed by means of resection of the medial edge of the bilateral inferior articular processes and the yellow ligaments. In cases of stenosis of the spinal canal associated with stenosis of the lateral recess, the root was decompressed by unroofing the lateral recess in addition to posterolateral decompression of the dural sheath. And in cases with stenosis of the lateral recess, the root in an affected area was decompressed. Neither operation on the intervertebral disc nor incision of the dural sheath was performed. After operation as described above, symptoms, operative findings and postoperative results were investigated in 70 cases which could be directly examined. In this paper we discuss the relationship between the symptoms and the stenotic area, stenotic forms and stenotic factors. When our postoperative results were compared with those of cases with extensive laminectomy, it was seen that none of the patients we treated had low back pain nor recurrence of intermittent claudication and that lessening of paralysis was sufficient.     

Stabilization of the lumbar spine using the dynamic neutralization system

The records of 68 patients (42 men and 26 women) who underwent spine stabilization with a dynamic neutralization system were reviewed. Mean patient age at operation was 42.8 years. The primary indication for surgery was degenerative spine disease and instability with neurogenic or radicular pain and/or chronic back pain. Forty-one (60.2%) patients had degenerative diskopathy or disk herniation, and 27 (39.8%) patients had lumbar spine stenosis. One-motion segment spine stabilization was performed in 30 patients, 2-motion segment spine stabilization in 32 patients, and 3-motion segment spine stabilization in 6 patients. Within a mean follow-up of 36.2 months (range, 12.9-75.3 months), there were 2 re-operations, and 3 patients with screw loosening. Re-operations were for a deep infection in 1 patient and left leg pain in another patient. Both patients were managed with early implant removal and spinal arthrodesis. Self-assessment questionnaires showed improvement of patients' clinical and functional status. The Oswestry Disability Index and the Roland-Morris Disability Questionnaire score improved from a mean preoperative score of 55.4% (severe disability) and 52% respectively to a mean postoperative score of 22.9% (moderate disability) and 35% respectively. The overall results of this study are highly comparable to fusion procedures. The dynamic neutralization system can be a safe and effective alternative technique to spine arthrodesis in selected cases of degenerative lumbar spine instability.     

棘突截骨椎管成形术治疗腰椎黄韧带骨化症

目的 :观察棘突截骨椎管成形术治疗腰椎黄韧带骨化症的临床疗效和影像学。方法 :单侧椎板显露后行棘突基底截骨、中央椎管潜式扩大治疗 13例腰椎黄韧带骨化症患者 ,术前和术后进行腰椎功能Oswestry问卷调查和椎管直径测量。结果 :本组术后随访 2～ 4年 ,腰腿痛较术前平均改善 76 %～ 74% ,术后腰椎CT显示椎管中矢径平均增加2 1.6 % (P <0 .0 5 ) ,椎管横径平均增加 18.5 % (P <0 .0 5 )。结论 :棘突截骨椎管成形术治疗腰椎黄韧带骨化症 ,具有操作简单、椎管中央和侧方减压充分、对腰椎后方张力带结构影响小等优点 ,术后近期和中期临床疗效和影像学评估满意     

Semi-Circumferential Decompression: Microsurgical Total en-bloc Ligamentum Flavectomy to Treat Lumbar Spinal Stenosis with Grade I Degenerative Spondylolisthesis

Background

To describe and assess clinical outcomes of the semi-circumferential decompression technique for microsurgical en-bloc total ligamentum flavectomy with preservation of the facet joint to treat the patients who have a lumbar spinal stenosis with degenerative spondylolisthesis.

Methods

We retrospectively analyzed the clinical and radiologic outcomes of 19 patients who have a spinal stenosis with Meyerding grade I degenerative spondylolisthesis. They were treated using the "semi-circumferential decompression" method. We evaluated improvements in back and radiating pain using a visual analogue scale (VAS) and the Oswestry Disability Index (ODI). We also evaluated occurrence of spinal instability on radiological exam using percentage slip and slip angle.

Results

The mean VAS score for back pain decreased significantly from 6.3 to 4.3, although some patients had residual back pain. The mean VAS for radiating pain decreased significantly from 8.3 to 2.5. The ODI score improved significantly from 25.3 preoperatively to 10.8 postoperatively. No significant change in percentage slip was observed (10% preoperatively vs. 12.2% at the last follow-up). The dynamic percentage slip (gap in percentage slip between flexion and extension X-ray exams) did not change significantly (5.2% vs. 5.8%). Slip angle and dynamic slip angle did not change (3.2° and 8.2° vs. 3.6° and 9.2°, respectively).

Conclusions

The results suggested that semi-circumferential decompression is a clinically recommendable procedure that can improve pain. This procedure does not cause spinal instability when treating patients who have a spinal stenosis with degenerative spondylolisthesis.     

"开窗技术"治疗退行性腰椎管狭窄症融合指征

目的 探讨初次"开窗技术"治疗退行性腰椎管狭窄症融合的指征.方法 对1999年12月至2005年12月收治的145例退行性腰椎管狭窄症患者进行回顾性研究.按术前腰椎条件及手术方法分三组:A组39例,术前合并腰椎失稳运动、退变性滑脱或侧弯,行融合术;B组31例,术前合并腰椎失稳运动、退变性滑脱或侧弯,行非融合术;c组75例,术前无腰椎失稳运动、退变性滑脱或侧 弯,行非融合术.对患者住院天数、手术时间、估计出血量复发、再手术及并发症情况等进行统计分析;采用Oswestry 功能障碍指数(ODI)和疼痛视觉模拟评分(VAS)及满意率等进行疗效评估,并进行统计学分析.结果 所有患者随访时间均在3年以上.C组的住院时间少于A组和B组(P<0.05);A组的手术时间和估计出血量均大于B组和c组,差异均有统计学意义(P<0.05);A、C组长 期疗效优于B组(P<0.05),而A、c两组间差异无统计学意义;三组间的复发或残余症状恶化、再手术及并发症等方面差异没有统计学意义.结论 对于术前合并腰椎失稳、滑脱或侧凸的退变性腰椎管狭窄症患者,即使初次行"开窗技术"减压,也应融合;单纯狭窄患者初次手术则无需融合.     

脊柱内镜减压治疗高龄腰椎退变性脊柱侧凸合并神经根管狭窄

目的探讨局麻下脊柱内镜减压治疗高龄腰椎退变性脊柱侧凸合并神经根管狭窄的疗效。方法局部麻醉下经椎间孔入路,从背侧和腹侧减压受压神经根。术后症状改善采用下肢痛视觉疼痛模拟评分(Visual Analogue Scale,VAS)和Oswestry功能障碍指数(Oswestry Disability Index,ODI)评估,手术疗效采用改良MacNab标准评估。结果术中1例硬膜撕裂,术后出现随体位变化的疼痛不适感,3周后症状改善。12例侧凸腰椎冠状面Cobb角39.3°±6.8°。12例随访(19.4±3.4)月。下肢痛VAS评分从术前(6.5±1.2)分,改善为末次随访(1.2±0.9)分(P=0.000)。ODI从术前(67.5±6.1)%,改善为末次随访(29.0±6.6)%(P=0.000)。末次随访改良MacNab标准优良率为83.3%(10/12)。结论高龄退变性腰椎侧凸合并神经根管狭窄的处理需要考虑患者自身条件,局麻脊柱内镜下减压能够有效缓解神经压迫症状,改善生活质量,是一种可供选择且安全有效的方法。     

Does pre-operative magnetic resonance imaging of the lumbar multifidus muscle predict clinical outcomes following lumbar spinal decompression for symptomatic spinal stenosis?

Purpose

To investigate whether pre-operative magnetic resonance imaging (MRI) of the lumbar multifidus muscle (LMM) would predict clinical outcomes following lumbar spinal decompression for symptomatic spinal stenosis.

Methods

A prospective cohort of patients with symptomatic neurogenic claudication, documented spinal stenosis on pre-operative MRI underwent spinal decompression. All subjects completed standardised outcome measures (Core Outcome Measures Index (COMI), Oswestry Disability Index (ODI v2.1) pre-operatively, 1 and 2 years post-surgery. Surgery was performed using a standardised lumbar spinous process osteotomy for access, followed by a decompression of the central canal, lateral recess and foraminal zones as indicated by the pre-operative MRI. Lumbar MRI scans were evaluated by two independent observers who assessed the axial CSA of the LMM bilaterally and the degree of muscle atrophy according to the Kader classification (2000). Changes in COMI and ODI scores at 1 and 2 years were investigated for statistically significant correlations with CSA of LMM and Kader grading. Statistical analyses utilised Student’s t test, kappa coefficient for inter-observer agreement and Bland–Altman Limits of Agreement (BALOA).

Results

66 patients (41 female) aged between 29 and 86 years underwent single-level decompression in 44, two-level decompression in 16 and three-level decompression in 6 cases. No significant correlation was observed between improvements in ODI and COMI relative to age, degree of stenosis, posterior fat thickness or psoas CSA. Those subjects with the greatest LMM atrophy relative to psoas CSA and L5 vertebral body area on pre-operative MRI had the least absolute improvement in both ODI and COMI scores (p = 0.006).

Conclusions

Reduced LMM CSA (<8.5 cm²) and muscle atrophy were associated with less favourable outcomes following lumbar spinal decompression. Pre-operative CSA of LMM appeared to be a more reliable predictor of post-operative clinical outcomes compared to the Kader Grading Score. This is the first study to investigate the prognostic value of pre-operative MRI appearance and CSA of LMM with respect to post-operative outcome following lumbar decompression surgery. Healthy pre-operative LMM is associated with better outcomes following lumbar spinal decompression.

     

经皮全脊柱内镜经椎板间隙入路治疗中央型腰椎管狭窄症

目的探讨经皮全脊柱内镜经椎板间隙入路治疗单节段中央型腰椎管狭窄症的临床疗效。方法2016年1月~2017年12月我科对腰椎中央管狭窄在连续硬膜外麻醉下行经皮全脊柱内镜椎板间隙入路椎管扩大减压术,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MacNab标准评价疗效。结果26例均顺利完成手术。1例术中损伤撕裂硬膜囊,保守治疗后痊愈。1例术后出现单侧下肢一过性肌力下降,1例术后出现腰背部及双下肢疼痛症状。住院时间(6.4±2.1)d。腰痛术前VAS评分(7.5±0.8)分,显著高于术后第1天(3.4±0.6)分和术后12个月(1.7±0.7)分(P均=0.000)。腿痛VAS评分术前(7.3±0.8)分,显著高于术后第1天(4.0±0.7)分和术后12个月(1.7±0.7)分(P均=0.000)。术前ODI(77.8±4.6)%,显著高于术后1个月(45.4±4.6)%和术后12个月(8.8±2.9)%(P均=0.000)。术后12个月采用MacNab进行疗效评定:优14例,良10例,可2例,优良率92.3%(24/26)。结论经皮全脊柱内镜经椎板间隙入路治疗单节段腰椎中央管狭窄症,手术风险低,临床疗效满意。