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.     

Computed tomography findings 4 years after surgical management of lumbar spinal stenosis. No correlation with clinical outcome

STUDY DESIGN: A prospective, cross-sectional study of the correlation between postoperative computed tomography findings and patients' clinical outcomes approximately 4 years after laminectomy for lumbar spinal stenosis. OBJECTIVES: To evaluate clinical and radiologic characteristics and their relation to each other. SUMMARY OF BACKGROUND DATA: The goal of surgical management for lumbar spinal stenosis is to decompress the stenotic area determined in radiologic examinations to relieve pressure on the neurovascular structures. However, the success of this decompression very rarely has been confirmed by postoperative radiologic imaging or compared with clinical outcome. METHODS: Postoperative computed tomography was performed on 191 patients. The findings were classified as "no stenosis," "central stenosis," "lateral stenosis," or "central-lateral stenosis." Postoperative instability of the lumbar spine was investigated by functional radiography. Clinical status was assessed by clinical examination. Subjective disability was assessing using the Oswestry questionnaire, and severity of pain using the visual analog scale. Walking capacity was evaluated by the tread-mill test. RESULTS: Radiologic studies revealed postoperative stenosis in 123 patients (64%). Small differences between the computed tomography groups were shown for the Oswestry score, but not for walking distance. Clinical signs, severity of pain, and radiologic instability were very similar for all computed tomography groups. CONCLUSIONS: Postoperative radiologic stenosis was very common in patients operated on for lumbar spinal stenosis, but this did not correlate with clinical outcome. The clinician must be cautious when reconciling clinical symptoms and signs with postoperative computed tomography findings in patients operated on for lumbar spinal stenosis.     

Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR Imaging

Because neither the degree of constriction of the spinal canal considered to be symptomatic for lumbar spinal stenosis nor the relationship between the clinical appearance and the degree of a radiologically verified constriction is clear, a correlation of patient’s disability level and radiographic constriction of the lumbar spinal canal is of interest. The aim of this study was to establish a relationship between the degree of radiologically established anatomical stenosis and the severity of self-assessed Oswestry Disability Index in patients undergoing surgery for degenerative lumbar spinal stenosis. Sixty-three consecutive patients with degenerative lumbar spinal stenosis who were scheduled for elective surgery were enrolled in the study. All patients underwent preoperative magnetic resonance imaging and completed a self-assessment Oswestry Disability Index questionnaire. Quantitative image evaluation for lumbar spinal stenosis included the dural sac cross-sectional area, and qualitative evaluation of the lateral recess and foraminal stenosis were also performed. Every patient subsequently answered the national translation of the Oswestry Disability Index questionnaire and the percentage disability was calculated. Statistical analysis of the data was performed to seek a relationship between radiological stenosis and percentage disability recorded by the Oswestry Disability Index. Upon radiological assessment, 27 of the 63 patients evaluated had severe and 33 patients had moderate central dural sac stenosis; 11 had grade 3 and 27 had grade 2 nerve root compromise in the lateral recess; 22 had grade 3 and 37 had grade 2 foraminal stenosis. On the basis of the percentage disability score, of the 63 patients, 10 patients demonstrated mild disability, 13 patients moderate disability, 25 patients severe disability, 12 patients were crippled and three patients were bedridden. Radiologically, eight patients with severe central stenosis and nine patients with moderate lateral stenosis demonstrated only minimal disability on percentage Oswestry Disability Index scores. Statistical evaluation of central and lateral radiological stenosis versus Oswestry Disability Index percentage scores showed no significant correlation. In conclusion, lumbar spinal stenosis remains a clinico-radiological syndrome, and both the clinical picture and the magnetic resonance imaging findings are important when evaluating and discussing surgery with patients having this diagnosis. MR imaging has to be used to determine the levels to be decompressed.     

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.     

Factors influencing the outcome of degenerative lumbar spinal stenosis

The objective of this study was to evaluate the influence of decreased dural sac cross-sectional area and baseline clinical parameters on the outcome of patients treated surgically or conservatively for lumbar spinal stenosis. Computed tomography or magnetic resonance imaging scans of 37 patients were digitized and the dural sac cross-sectional area was calculated. This parameter and baseline clinical, socioeconomic, and anthropometric data of the patients were correlated with 1-year and 2-year follow-up data. The decrease in dural sac cross-sectional area negatively affected walking capacity on follow-up controls in patients treated conservatively, whereas such a relation was not observed among surgically treated patients. Female sex was the main parameter that worsened the global outcome of degenerative lumbar spinal stenosis, particularly after surgical treatment.     

40例多节段腰椎管狭窄症步行负荷试验及影像检查结果与手术疗效相关分析

[目的]探讨运用步行负荷试验检查对多节段退变性腰椎管狭窄症"责任节段"定位的价值.[方法]选择2008年1月一2009年10月收治的40例影像学表现为多节段退变件腰椎管狭窄症患者,运用步行负荷试验结合影像学检查,进行"责任节段"定位判断诊断,以便确定临床症状产生的责任区域,并与影像学检查对比分析.同时根据上述方法对确定的"责仟节段"运用"选择性椎板减压加神经根管扩大术"治疗;疗效则采用日本矫形外科协会JOA评分标准评定.[结果]加例患者步行后较静息时的临床体征均有不I司程度的加重或引发新的临床体征.步行后和静息时腰痛、下肢感觉障碍及下肢麻木、放射痛比较有显著性差异(P<0.01).MRI及CT检查显示受累168条神经根,经步行负荷试验定位诊断并经手术证实,实际累及110条神经根(X<'2>值=8.173),影像学检查与步行负荷试验检查阳性神经根的构成分布相同,狭窄节段以L<,4、5>为主,其次为;L<,5>S<,1>及L<,3、4>节段,而L<,1、2>及L<,2、3>,节段虽影像学有狭窄,但少见有临床症状及体征(但也可能与样本量过少有关).本组40例患者均针对"责任节段"行椎板减压及神经根管扩大手术,其结果显示:术前评分(7.02±0.42)分;术后评分(13.12±0.34)分;末次随访评分(12.96±0.65)分;术后与术前评分比较P=0.0000,提示有非常显著性差异.术后与术后最终随访时评分比较P=0.121 5,提示无显著性差异.[结论]对于多节段退变性腰椎管狭窄症,运用步行负荷试验结合影像检查,进行临床功能定位检查,可在术前明确本病的"责任节段",便于医牛选择手术减压的范围及部位,减少或避免了医源性腰椎不稳的发生.对仅有影像学狭窄征象而无临床症状的间隙无需进行"预防性手术".     

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.     

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.     

Electromyographic and magnetic resonance imaging to predict lumbar stenosis, low-back pain, and no back symptoms

BACKGROUND: Magnetic resonance imaging is commonly used to diagnose lumbar spinal stenosis. Some persons without symptoms have a small lumbar spinal canal. Electrodiagnosis has been used to diagnose spinal stenosis for over sixty years, but we are aware of no masked, controlled trials of the use of electrodiagnosis for that purpose. This study was performed to evaluate the relationships of magnetic resonance imaging measures and electrodiagnostic data with the clinical syndrome of spinal stenosis. METHODS: One hundred and fifty persons between the ages of fifty-five and eighty years old, including asymptomatic volunteers and persons referred for lumbar magnetic resonance imaging, underwent clinical examination, electrodiagnosis, and magnetic resonance imaging. Subjects were excluded if they had neuromuscular disease, sacral cancer, or inadequate test results, which left 126 subjects for the final analysis. The final cohort was divided into three groups--no back pain, mechanical back pain, and clinical spinal stenosis--on the basis of the impression of the examining physician, for whom the results of the magnetic resonance imaging and electrodiagnostic testing were masked. A spine surgeon also reviewed both the imaging and clinical examination data. RESULTS: The examining physician's diagnosis of clinical spinal stenosis was significantly related to the neurological findings on examination (p < 0.05) and to the spine surgeon's diagnosis (p < 0.001). The diagnosis of clinical spinal stenosis was also significantly related to the presence of fibrillations on electrodiagnostic testing (p < or = 0.003), the minimum anteroposterior diameter of the spinal canal on the magnetic resonance images (p = 0.016), and the average of the two smallest spinal canal diameters (p = 0.008) on the images. Measurements on magnetic resonance imaging did not differentiate subjects with clinical spinal stenosis from controls better than chance, whereas paraspinal mapping electrodiagnosis scores did. CONCLUSIONS: This prospective, controlled, masked study of electrodiagnosis and magnetic resonance imaging for older subjects showed that imaging does not differentiate symptomatic from asymptomatic persons, whereas electrodiagnosis does. We believe that radiographic findings alone are insufficient to justify treatment for spinal stenosis.     

刺突截骨椎管成形术治疗退行性腰椎管狭窄症

目的：介绍刺突截骨椎管成形术及其应用,方法：采用该术式治疗37例退行性腰椎管狭窄症患者,术后进行疗效评分（Oswestry问卷）和腰椎管直径测量。方法：术后1年腰腿痛平均改善76％,术后4年平均改善74％,疗效下降不显著（P＞0．05）。术后CT显示腰椎管直径平均增加20％,刺突原位愈合率87％。结论：该术式操作简单,神经减压充分,手术并发症少,其治疗退行性腰椎管狭窄症术手近、中期疗效和影像学评估均满意。     

Relationship between alterations of the lumbar spine,visualized with magnetic resonance imaging,and occupational variables

Although the effect of physical workload on the occurrence of low back pain (LBP) has been extensively investigated, few quantitative studies have examined the morphological changes visualized via magnetic resonance imaging (MRI) in relation to occupational variables. The relationship between the severity of some abnormalities such as lumbar spinal stenosis or spondylolisthesis and physical or psychosocial occupational risk factors has not been investigated previously. In this cross-sectional study patients fulfilled the following inclusion criteria: (1) long-standing (minimum 1-year) LBP radiating down the leg (or not); (2) age more than 40 years; (3) willingness to undergo an MRI of the lumbar spine; and (4) ability to speak Italian. Primary objective of the study was to investigate the association between occupational exposure and morphological MRI findings, while controlling for the individual risk factors for LBP. Secondarily, we looked at the influence of this exposure and the degenerative changes in the lumbar spine on clinical symptoms and the related disability. Lumbar MRI scans from 120 symptomatic patients were supplemented by the results of structured interviews, which provided personal, medical, and occupational histories. All occupational factors were arranged on scales of increasing exposure, whereas pain and disability were assessed using ad hoc validated questionnaires. Evidence of intervertebral disc narrowing or herniation and the occurrence and severity of spinal stenosis and spondylolisthesis was obtained from the MRI scans and a summative degenerative score was then calculated. We detected a direct association between increasing age and the global amount of degenerative change, the severity of intervertebral disc height loss, the number of narrowed discs, stenosis, the number of stenotic levels, and spondylolisthesis. Physical occupational exposure was not associated with the presence of lumbar disc degeneration and narrowing per se, but a higher degree of such an exposure was directly associated with a higher degree of degeneration (P=0.017). Spondylolistesis and stenosis were positively related to heavy workload (P=0.014) and the manual handling of materials (P=0.023), respectively. Psychosocial occupational discomfort was directly associated to stenosis (P=0.041) and number of stenotic levels (P=0.019). A heavier job workload was the only occupational factor positively related to the degree of disability at the multivariate analysis (P=0.002). Total amount of degeneration in the lumbar spine directly influenced pain duration (P=0.011) and degree of disability (P=0.050). These results suggest that caution should be exercised when symptomatic subjects with evidence of degenerative changes on MRI scans engage in strenuous physical labor.     

Posterior dynamic stabilization of the lumbar spine with the Accuflex rod system as a stand-alone device: experience in 20 patients with 2-year follow-up

Decompression surgery for lumbar spinal stenosis is a common procedure. After surgery, segmental instability sometimes occurs, therefore, different methods for restabilization have been developed. Dynamic stabilization systems have been designed to improve segmental stability. In this study, clinical results of patients with lumbar spinal stenosis that underwent decompression and stabilization with the Accuflex dynamic system are presented; clinical, radiographic, and magnetic resonance imaging (MRI) findings are fully described. Improvements in all clinical measurements, including visual analog scale for back and leg pain, Oswestry disability index, and SF-36 health status survey were noticed. At a 2-year follow-up, 22.22% of patients required hardware removal due to fatigue while in 83% of them no progression of disk degeneration was observed after implantation of the Accuflex system. Additionally, as demonstrated by the MRI images at follow up, three patients (16%) showed disk rehydration with one grade higher on the Pfirmann classification. Although a relatively high hardware failure was observed (22.22%), the use of the dynamic stabilization system Accuflex posterior to decompression procedures, showed clinical benefits and stopped the degenerative process in 83% the patients.     

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.     

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.     

Degenerative lumbar spinal stenosis and its imposters: three case studies

Degenerative lumbar spinal stenosis causing neurogenic claudicaton is a common condition impacting walking ability in older adults. There are other highly prevalent conditions in this patient population that have similar signs and symptoms and cause limited walking ability. The purpose of this study is to highlight the diagnostic challenges using three case studies of older adults who present with limited walking ability who have imaging evidence of degenerative lumbar spinal stenosis.     

动态中和固定系统治疗腰椎退变性疾病的临床观察

目的 探讨动态中和固定系统（Dynesys）在治疗腰椎退变性疾病的早期疗效及安全性.方法 回顾分析2008年5月至2010年8月因＂腰椎退变导致腰腿痛＂行Dynesys系统治疗的11例患者.腰椎间盘突出症8例;腰椎管狭窄2例,其中1例合并退变性滑脱（Ⅰ度）;多节段腰椎间盘退变合并腰椎不稳1例.随访6～28个月（平均18个月）,对患者术前及术后进行VAS疼痛评估以及用Oswestry功能障碍指数（ODI）进行临床疗效评估,复查腰椎X线片及MRI进行影像学评估.结果 VAS疼痛评分：术前6.5～9.2分（平均8.2分）;术后0～4.3分（平均2.4分）.Oswestry功能评分：术前38.0～85.0分（平均63.0分）,术后0～46.0分（平均30.0分）.影像学检查未发现椎弓根螺钉松动及断裂、手术节段复发及相邻节段退变.按中华医学会骨科学分会脊柱学组腰背痛手术评定标准评价：优10例,良1例.结论 Dynesys 动态稳定系统能保留被固定节段的相对稳定性,对腰椎间盘突出、椎管狭窄和轻度的腰椎不稳有很好的临床疗效和安全性.     

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.     

The distended facet sign: an indicator of position-dependent spinal stenosis and degenerative spondylolisthesis.

BACKGROUND CONTEXT: Symptoms of spinal stenosis are position-dependent. Stand up magnetic resonance imaging (MRI) and myelography can demonstrate further dynamic components of spinal stenosis that may go unrecognized on supine MRI. PURPOSE: To describe a radiographic finding seen on standard supine MRI that is an indicator for dynamic spinal stenosis and degenerative spondylolisthesis. STUDY DESIGN/SETTING: Case series. PATIENT SAMPLE: Six patients. OUTCOMES MEASURES: Radiographic observation. METHODS: Six patients with classic neurogenic claudication but equivocal supine MRI findings were evaluated with myelography. The imaging findings were reviewed and compared. RESULTS: All patients had severe position-dependent spinal stenosis upon upright myelographic imaging with grade I or II spondylolisthesis. The MRI showed very minimal to no spondylolisthesis. These dynamic slips reduced when supine, causing the vertebral bodies to appear aligned with adequate canal space, whereas the irregular facet joints became distended. Hypertrophic and fluid-filled facets at the dynamic slip level were seen in all patients, giving the appearance of a distended joint. CONCLUSIONS: MRI may not demonstrate significant stenosis in patients with neurogenic claudication caused by dynamic degenerative spondylolisthesis. However, the presence of large fluid-filled facet joints indicates the likelihood of positional translation at that level which could be further confirmed by upright imaging.     

Prospective functional evaluation of the surgical treatment of neurogenic claudication in patients with lumbar spinal stenosis

A prospective evaluation of patients with lumbar spinal stenosis undergoing operative treatment was performed using treadmill-bicycle functional testing as well as Oswestry and Visual Analog Pain scales for self-assessment. Thirty-two patients undergoing spinal stenosis decompression with and without a concomitant spinal fusion were prospectively evaluated, preoperatively and a minimum of 2 years postoperatively. Surgical treatment was demonstrated to produce significant improvement in walking ability, and to a lesser degree, in the ability to bicycle 2 years postoperatively. Improvement in patient function demonstrated on the Oswestry questionnaire correlated with decreased pain observed on the Visual Analog Pain scale. The treadmill-bicycle test appears to be a useful tool for the differential diagnosis of neurogenic claudication and may be used as an objective test of postoperative outcome.