Lumbar Spinal Stenosis: Therapeutic Options Review

Lumbar spinal stenosis (LSS) functionally impacts significant numbers of Americans per year. Current estimates place the number of Americans suffering from senescent lumbar spinal stenosis at 400,000. The prevalence of this disorder in patients ranging from 60 to 69 years of age is very high. Forty‐seven percent of this age group have mild to moderate stenosis, and 19.7% have severe stenosis. As the baby boomer generation gets older, 10,000 individuals attain the age of 65 years every day in United States. LSS is becoming very common and will be a major healthcare issue as the population ages. Although LSS is not life threatening, it can cause substantial disability with limitations to performing daily activities, and thus, the associated negative impact on quality of life (QOL). This article reviews the pathophysiology and current treatment options for LSS, focusing on evidence‐based treatment options.     

Lumbar Spinal Stenosis

Questions from patients about pain conditions and analgesic pharmacotherapy and responses from authors are presented to help educate patients and make them more effective self-advocates. In reply to a question, lumbar spinal stenosis, commonly a multifactorial disease that can have profound functional consequences, is considered, along with a discussion of physical and pharmacologic treatments and quality of life.     

腰椎管狭窄症手术中应用大剂量甲基强的松龙对神经的保护作用

目的探讨腰椎管狭窄症手术治疗中大剂量甲基强的松龙（MP）对脊髓的保护作用。方法腰椎管狭窄症患者20例,均采用单纯后路腰椎板切除术。治疗组11例,于切开皮肤时静脉给予MP 30 mg/kg;术后静脉应用MP 40 mg/次,2次/d,共3 d。对照组9例,术中不使用MP,术后静脉给予MP 40 mg/次,2次/d,共3 d。应用JOA评分评价两组患者术前和术后神经功能情况。结果治疗组及对照组术前JOA评分分别为(9.25±2.12)分和(9.53±2.10)分（P>0.05）。术后1周时治疗组与对照组JOA评分分别为(13.43±2.01)分和(11.21±2.13)分;3个月时JOA评分分别为(14.62±2.15)分和(13.04±2.11),治疗组均优于对照组（P<0.05）。对照组出现神经症状加重患者1例。两组患者均未出现消化性溃疡、切口愈合不良等并发症。结论腰椎管狭窄症术中应用大剂量甲基强的松龙对脊髓神经功能有明显保护作用。     

老年退行性腰椎管狭窄症伴糖尿病患者手术的护理

退行性腰椎管狭窄症、糖尿病发病率逐年上升,而且两病伴发的情况日益增多。糖尿病的治疗常以运动治疗为基础,但患有退行性腰椎管狭窄症的老年患者的活动常被严重限制。因此,如上述两种疾病伴发,则患者的病情会不断加重,甚至丧失自理能力。脊柱外科手术技术的发展,给退行性腰椎管狭窄症伴糖尿病患者的治疗创造了条件。     

临床护理路径在腰椎管狭窄症患者围手术期中的应用

目的探讨临床护理路径应用于腰椎管狭窄患者围手术期的效果。方法成立临床护理路径管理小组,选择患者随机分组后制定出恰当的临床护理路径。对照组患者接受常规护理,观察组根据制定的临床护理路径进行护理。结果采用临床路径护理的观察组其输液期间输液通道重复建立和静脉炎的发生率低于对照组,并且卧床期间观察组患者并发症的发生率亦低于对照组。结论临床护理路径能显著提高腰椎椎管狭窄患者围术期的护理质量,较少并发症发生,使患者得到最佳的医疗护理服务。     

Effects of 2 Different Doses of Pregabalin on Morphine Consumption and Pain After Abdominal Hysterectomy: A Randomized, Double-Blind Clinical Trial

Background

Pregabalin has a similar pharmacologic profile to that of its developmental predecessor gabapentin but has shown greater analgesic activity in rodent models of neuropathic pain.

Objective

The objective of the study was to compare the effects of 2 different doses of pregabalin and placebo on postoperative pain and morphine consumption.

Methods

Ninety patients who underwent abdominal hysterectomy were included in the study and randomly divided into 3 groups in a doubled-blinded manner. They were given 150 mg of pregabalin (group P300, n = 30), 300 mg of pregabalin (group P600, n = 30), or placebo capsules (group C, n = 30) 4 hours before the induction of anesthesia; they received a second dose of the drug 12 hours postoperatively. Morphine consumption, nausea, and vomiting, visual analogue scale-pain intensity (VAS-PI), sedation scores, and dissatisfaction scores were recorded in the postanesthesia care unit (PACU) and at 2, 4, 6, and 24 hours after operation.

Results

Morphine consumption at 24 hours was 40.80 (3.42) mg, 33.79 (5.77) mg, and 46.97 (6.67) mg in groups P300, P600, and C, respectively (P < 0.001). VAS-PI scores at movement and at rest in the PACU and at 2, 4, and 6 hours decreased in group P600 (P < 0.01). In the PACU and at 2, 4, and 6 hours, the sedation scores were increased in group P600 compared with the scores in group C (P < 0.001, P < 0.001, P = 0.01, P = 0.006, respectively). Patient satisfaction was higher in group P600 than in group C for all time points (P < 0.001, P < 0.001, P < 0.001, P = 0.001, P < 0.001, respectively). There were no statistically significant differences between the groups for side effects such as nausea, vomiting, and dizziness (P = 0.58).

Conclusions

Pregabalin at a total dose of 600 mg, administered before operation and at 12 hours postoperatively after abdominal hysterectomy, reduced morphine consumption and pain intensity and increased patient satisfaction. No significant differences in side effects were observed between the study groups.     

腰椎管狭窄症并腰椎不稳的手术治疗

目的:探讨腰椎管狭窄症合并腰椎不稳的诊断和治疗。方法:52例腰椎管狭窄症合并腰椎不稳,男31例,女21例,平均年龄58.7岁,采用双侧半椎板有限元减压保留棘突韧带同时加椎弓根螺钉内固定植骨术治疗。结果:随访1.5～4.5年,平均2年7个月,植骨全部愈合,内固定位置正常,但有4例延迟愈合。术前JOA评分平均3.2分,术后平均13.8分,平均改善率89.83%,优良率94.23%。结论:在充分减压的同时保留棘突韧带,提供椎弓根螺钉内固定并植骨,能保持脊柱的稳定性,临床应用疗效肯定。     

腰椎管狭窄症的CT分型及临床评价

目的：探讨腰椎管狭窄症的CT分型并进行临床评价。材料与方法：对745例腰椎管狭窄症术前CT分型与手术结果进行对比分析。结果：CT分为三型,Ⅰ型：中心椎管狭窄型;Ⅱ型：脊神经根管狭窄型（即侧椎管狭窄型）;Ⅲ型：混合型,Ⅰ、Ⅱ型并存。其中Ⅰ型104例（13．96％）;Ⅱ型158例（21．21％）;Ⅲ型483例（64．83％）。CT分型与手术符合率为92．21％,不符合者多见于Ⅱ型。结论：CT分型对腰椎管狭窄症的手术治疗具有指导意义。     

Long‐Term Results of Percutaneous Lumbar Decompression mild® for Spinal Stenosis

Background: Lumbar spinal stenosis (LSS) generally occurs from a combination of degenerative changes occurring in the lumbar spine. These include hypertrophy of ligamentum flavum, facet joint arthritic changes and bulging of the intervertebral disk. Spinal stenosis leads to compression of the lumbar neural elements (cauda equina), which manifests as low back and leg pain especially on standing and walking known as “neurogenic claudication.” Current treatment options for LSS are varied. Conservative management, including physical therapy with/without epidural steroid injections, may be adequate for mild stenosis. Surgical decompression is reserved for severe cases and results in variable degrees of success. Patients with moderate‐to‐severe LSS having ligamentum flavum hypertrophy as a key contributor are generally inappropriately treated or undertreated. This is due to ineffectiveness of conservative therapy and possibility that major surgical compression might be too aggressive. Percutaneous decompression offers a possible solution for this patient population. Methods: One‐year follow‐up study was conducted at 11 U.S. sites. Study cohort included 58 mild^® percutaneous decompression patients who underwent 170 procedures, the majority treated bilaterally at one or two lumbar levels. Outcome measures included the visual analog scale (VAS), Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), and SF‐12v2^® Health Survey. Results: No major mild^® device or procedure‐related complications were reported. One‐year data showed significant reduction of pain as measured by VAS. Improvement in physical functionality, mobility, and disability was significant as measured by ZCQ, SF‐12v2, and ODI. Conclusions: At 1 year this 58‐patient cohort demonstrated continued excellent safety profile of the mild^® procedure and equally important, showed long‐term pain relief and improved functionality.     

Functional and Patient‐Reported Outcomes in Symptomatic Lumbar Spinal Stenosis Following Percutaneous Decompression

Background: Neurogenic claudication due to symptomatic lumbar spinal stenosis (LSS) is a painful condition causing significant functional disability. While the cause of LSS is multifactorial, thickened ligamentum flavum (LF) accounts for up to 85% of spinal canal narrowing. mild percutaneous lumbar decompression allows debulking of the hypertrophic LF while avoiding the morbidities frequently associated with more invasive surgical procedures. Methods: In this prospective case series study, consecutive LSS patients presenting with neurogenic claudication were treated with percutaneous lumbar decompression. Efficacy was evaluated using the Pain Disability Index (PDI) and Roland‐Morris Disability Questionnaire. Pre‐ and postprocedure Standing Time, Walking Distance, and Visual Analog Score (VAS) were also monitored. Significant device‐ or procedure‐related adverse events were reported. Results: The mild procedure was successfully performed on forty patients. At twelve months, both PDI and Roland‐Morris showed significant improvement of 22.6 points (ANOVA, P < 0.0001) and 7.7 points (ANOVA, P < 0.0001), respectively. Walking Distance, Standing Time, and VAS improvements were also statistically significant, increasing from 246 to 3,956 feet (ANOVA, P < 0.0001), 8 to 56 minutes (ANOVA, P < 0.0001), and 7.1 to 3.6 points (ANOVA, P < 0.0001), respectively. Tukey HSD test found improvement in all 5‐outcome measures to be significant from baseline at each follow‐up interval. No significant device‐ or procedure‐related adverse events were reported. Conclusion: This study demonstrated significant functional improvement as well as decreased disability secondary to neurogenic claudication after mild procedure. Safety, cost‐effectiveness, and quality‐of‐life outcomes are best compared with comprehensive medical management in a randomized controlled fashion and, where ethical, to open lumbar decompression surgery.     

The 2‐Year Cost‐Effectiveness of 3 options to Treat Lumbar Spinal Stenosis Patients

Lumbar spinal stenosis (LSS) may result from degenerative changes of the spine, which lead to neural ischemia, neurogenic claudication, and a significant decrease in quality of life. Treatments for LSS range from conservative management including epidural steroid injections (ESI) to laminectomy surgery. Treatments vary greatly in cost and success. ESI is the least costly treatment may be successful for early stages of LSS but often must be repeated frequently. Laminectomy surgery is more costly and has higher complication rates. Minimally invasive lumbar decompression (mild^®) is an alternative. Using a decision‐analytic model from the Medicare perspective, a cost‐effectiveness analysis was performed comparing mild^® to ESI or laminectomy surgery. The analysis population included patients with LSS who have moderate to severe symptoms and have failed conservative therapy. Costs included initial procedure, complications, and repeat/revision or alternate procedure after failure. Effects measured as change in quality‐adjusted life years (QALY) from preprocedure to 2 years postprocedure. Incremental cost‐effectiveness ratios were determined, and sensitivity analysis conducted. The mild^® strategy appears to be the most cost‐effective ($43,760/QALY), with ESI the next best alternative at an additional $37,758/QALY. Laminectomy surgery was the least cost‐effective ($125,985/QALY).     

Pain Management Discussion Forum: Prevention of Chronic Postoperative Pain

ABSTRACT

A case of a 35-year-old woman scheduled for removal of a painful breast tumor is discussed. Ways to reduce risk of chronic pain developing postoperatively are described. Preoperative medications, nerve blocks, local anesthetics, and postoperative epidural pharmacotherapy are described.

This report is adapted from paineurope 2014; Issue 1, ©Haymarket Medical Publications Ltd., and is presented with permission. paineurope is provided as a service to pain management by Mundipharma International, Ltd., and is distributed free of charge to health care professionals in Europe. Archival issues can be accessed via the Web site: http://www.paineurope.com, at which European health professionals can register online to receive copies of the quarterly publication.     

A Double‐blind,Randomized, Prospective Study of Epidural Steroid Injection vs. The mild® Procedure in Patients with Symptomatic Lumbar Spinal Stenosis

Background: Epidural steroid injections (ESIs) are commonly used to treat low back pain, including symptomatic lumbar spinal stenosis (LSS). Reports on LSS treatment with ESIs have not differentiated between neurogenic claudication, which is believed to result from nerve root compression, and lumbar radicular pain, thought to be caused by inflammation. While there is overlap between these groups, the clinical relevance of ESI treatment cannot be generalized between these 2 distinct diseases with completely different pathophysiological causes. Methods: This was a double‐blind, randomized, prospective study of ESI vs. the mild procedure in patients with symptomatic LSS, conducted at a single pain management center. Patient reported outcome measures included Visual Analog Scale, Oswestry Disability Index, and Zurich Claudication Questionnaire (ZCQ) patient satisfaction. Results: Thirty‐eight patients were randomized into 2 treatment groups, 21 in mild and 17 in ESI. At 6‐ and 12‐week follow‐up, patients treated with mild reported significantly greater pain decrease over time (P < 0.0001), and significantly greater functional mobility improvement over time (P < 0.0018) than ESI patients. At week 6, mild ZCQ patient satisfaction score of 2.2 indicated a higher level of satisfaction than for ESI with a score of 2.8. In addition, 12‐week ZCQ satisfaction score was 1.8, demonstrating sustained near‐term satisfaction in the mild group. No major mild or ESI device or procedure‐related complications were reported. Conclusions: This study demonstrated that in LSS patients suffering with neurogenic claudication, mild provides statistically significantly better pain reduction and improved functional mobility vs. treatment with ESI.     

经皮激光椎间盘减压术治疗椎间盘源性腰痛

目的探讨经皮激光间盘减压术治疗椎间盘源性腰痛的疗效。方法使用Nd:YAG激光治疗机(波长1064nm)对56例椎间盘源性腰痛患者进行经皮激光间盘减压术,术后参考Macnab标准随访3个月以上。结果术后3个月时,优32例,良20例,可3例,差1例,优良率为92.9%,无神经损害、感染等并发症发生。结论经皮激光间盘减压术是治疗椎间盘源性腰痛安全、微创、有效的方法。