Spinal canal morphology and clinical outcomes of microsurgical bilateral decompression via a unilateral approach for lumbar spinal canal stenosis

"Short-segment lumbar fusion" vs."microsurgical bilateral decompression via unilateral approach" after removal of the spinal fixators in patients with adjacent segment disease: Clinical retrospective study

INTRODUCTION AND OBJECTIVES

In cases where adjacent segment disease (ASD) develops following lumbar fusion surgery, various surgical approaches can be employed. In such cases, removal of the instrumentation can positively impact lumbar pain syndrome. One frequently used method is short-segment fixation-decompression (SSFD). One of minimally invasive methods is microsurgical bilateral decompression via unilateral approach (MBDU). This study aims to determine which method is more effective and safe in cases that developed ASD following fusion surgery by comparing SSFD and MBDU after instrumentation removal.

METHODS

A retrospective analysis was conducted on 47 cases treated with SSFD and 29 cases treated with MBDU. The groups were analyzed for gender, age, preoperative symptom duration, duration of hospitalization, and Visual Analogue Scale (VAS) scores and Oswestry Disability Index (ODI) scores during the preoperative and postoperative intermittent follow-up periods.

RESULTS

Duration of hospitalization was higher in the SSFD group compared to the MBDU group (p = <0.001 CI = 56,42-76,24 and 22,04-25,13 respectively), mean transverse canal diameter ratio in the decompressed segment was lower in the SSFD group (p = 0,03 IC = 0,24-0,31 for SSFD y 0,40-0,47 for MBDU), and ODI indices were higher in the SSFD group in all follow-ups (p = <0.001). During the follow-up period, symptomatic ASD was observed in 3 of 47 patients in the SSFD group, whereas no symptomatic ASD was observed in the MBDU group.

CONCLUSION

In selected patients who develop ASD after fusion surgery MBDU after instrumentation removal can be considered as a minimally invasive option that does not exacerbate postoperative lumbar pain syndrome or lead to the development of new ASD. To the best of our knowledge, this is the first comparison of these two techniques in literature after removal of spinal fixators in lumbar ASD cases.

Effect of Different Interventions on Lumbar Spinal Stenosis: A Systematic Evaluation and Network Meta-Analysis

BACKGROUND

Surgery is the preferred option for lumbar spinal stenosis (LSS) when conservative methods cannot meet the needs. Recent advancements in surgical techniques have brought various new methods for treating LSS.

METHODS

Four databases, PubMed, Embase, the Cochrane Library, and Web of Science, were searched, covering the period from the establishment of the databases until May 2024. Randomized controlled trials were carried out to treat LSS using different surgical approaches. The outcome measures included the visual analog scale (VAS) score, Oswestry disability index score, surgical duration, intraoperative blood loss, and length of hospital stay of patients. Bayesian random-effects network meta-analysis was performed using R software (V4.4) and STATA17.0 software to analyze each surgical approach.

RESULTS

A total of 29 studies involving 4200 patients were included. Nine intervention methods, including laminotomy, decompression, decompression plus fusion, endoscopic decompression, interspinous process spacer device (IPSD), laminectomy, minimally invasive decompression, spinous process osteotomy, and lumbar interbody fusion, were analyzed. Network meta-analysis results indicated that endoscopic decompression (surface under the cumulative ranking curve [SUCRA = 88.70%) was the most effective in reducing short-term back VAS scores. IPSD (SUCRA = 98.00%) was the most effective in reducing long-term back VAS scores, surgical duration (SUCRA = 95.20%), and intraoperative blood loss (SUCRA = 100.00%). Endoscopic decompression (SUCRA = 83.60%) also showed the most significant effect in reducing hospital stays.

CONCLUSIONS

Endoscopic decompression can effectively improve short-term back VAS scores and reduce hospital stays, while IPSD is effective in reducing long-term back VAS scores with minimal surgical duration and blood loss.

Nonlaminotomy bilateral decompression: a novel approach in biportal endoscopic spine surgery for spinal stenosis

Biportal endoscopic spine surgery (BESS) is an emerging technique for lumbar spinal stenosis. Previous BESS techniques involve partial osteotomy for access to spinal canal such as partial laminotomy, partial facetectomy, and other forms to access the spinal canal for decompression. However, approaches that include osteotomy can cause bone bleeding intraoperatively, leading to obscured vision, and may be at risk of postoperative facet arthritis and segmental instability due to damage to the posterior stability structure. This study aimed to introduce a BESS technique, i.e., nonlaminotomy bilateral decompression (NLBD) that allows for decompression through the interlaminar space without damaging the posterior bony structures. For this, various sizes of curved curettes are mainly used than Kerrison rongeurs. The small tip of the curved curette allows it to reach any part of the spinal canal through the interlaminar space, and its rounded back reduces the risk of nerve damage during decompression. In addition, by changing the portals, decompression through the interlaminar space can be performed without osteotomy. Nine checkpoints were assessed for the complete decompression during surgery. In conclusion, NLBD is an alternative BESS approach that achieves adequate decompression while preserving the posterior structure as much as possible.

Mental state as a predictor of outcome in spinal stenosis surgery: Four quadrants model integrating patient satisfaction and functional outcome

Introduction

Mental status, characterised by anxiety and depression, significantly influences physical well-being, particularly in patients with spinal stenosis symptoms.

Research question

The prevalence of depression and anxiety in our cohort. The correlation between psychological distress and physical outcome after surgery, including postoperative recovery and satisfaction.

Materials and methods

Questionnaires evaluating anxiety and depression (HADS), functionality (ODI), quality of life (EQ-5D), and perceived recovery (Likert-scale) were sent to a randomly selected cohort of 450 lumbar spinal stenosis patients, with or without spondylolisthesis, who underwent surgery between 2007 and 2013. Results are presented, dichotomised by HADS score (score ≥8 indicating psychologically impaired) and in a Four Quadrants Model integrating functional outcomes and perceived recovery separately for psychologically impaired and non-impaired cases.

Results

Among the 147 included patients, 32 (22%) exhibited anxiety and/or depression (impaired cases). Satisfactory outcome (perceived recovery) was reported in 29.0% of the impaired cases and 78.3% of the non-impaired cases (p < 0.001). The mean postoperative functionality score of the impaired cases was 42.46 ± 16.24, in contrast to 18.48 ± 18.25 for the non-impaired cases (p < 0.001). In the impaired group, only 12.5% achieved both a good functional outcome (ODI ≤24) and satisfactory perceived recovery, compared with 58.4% in the non-impaired group.

Discussion and conclusion

Patients reporting anxiety and/or depression demonstrate an inferior long-term outcome after spinal stenosis surgery compared to non-impaired patients. This clinically relevant difference underscores the importance of addressing depression and anxiety in preoperative counselling to optimize patient satisfaction and functional outcomes.

Automatic segmentation of dura for quantitative analysis of lumbar stenosis: A deep learning study with 518 CT myelograms

BACKGROUND

The diagnosis of lumbar spinal stenosis (LSS) can be challenging because radicular pain is not often present in the culprit-level localization. Accurate segmentation and quantitative analysis of the lumbar dura on radiographic images are key to the accurate differential diagnosis of LSS. The aim of this study is to develop an automatic dura-contouring tool for radiographic quantification on computed tomography myelogram (CTM) for patients with LSS.

METHODS

A total of 518 CTM cases with or without lumbar stenosis were included in this study. A deep learning (DL) segmentation algorithm 3-dimensional (3D) U-Net was deployed. A total of 210 labeled cases were used to develop the dura-contouring tool, with the ratio of the training, independent testing, and external validation datasets being 150:30:30. The Dice score (DCS) was the primary measure to evaluate the segmentation performance of the 3D U-Net, which was subsequently developed as the dura-contouring tool to segment another unlabeled 308 CTM cases with LSS. Automatic masks of 446 slices on the stenotic levels were then meticulously reviewed and revised by human experts, and the cross-sectional area (CSA) of the dura was compared.

RESULTS

The mean DCS of the 3D U-Net were 0.905 ± 0.080, 0.933 ± 0.018, and 0.928 ± 0.034 in the five-fold cross-validation, the independent testing, and the external validation datasets, respectively. The segmentation performance of the dura-contouring tool was also comparable to that of the second observer (the human expert). With the dura-contouring tool, only 59.0% (263/446) of the automatic masks of the stenotic slices needed to be revised. In the revised cases, there were no significant differences in the dura CSA between automatic masks and corresponding revised masks (p = 0.652). Additionally, a strong correlation of dura CSA was found between the automatic masks and corresponding revised masks (r = 0.805).

CONCLUSIONS

A dura-contouring tool was developed that could automatically segment the dural sac on CTM, and it demonstrated high accuracy and generalization ability. Additionally, the dura-contouring tool has the potential to be applied in patients with LSS because it facilitates the quantification of the dural CSA on stenotic slices.

Establishment of the Lunar Phase Morphological Classification for Cervical Spinal Canal

STUDY DESIGN

Retrospective clinical trial.

PURPOSE

To establish a morphological classification of the cervical spinal canal using its parameters.

OVERVIEW OF LITERATURE

Cervical spine computed tomography (CT) data of 200 healthy volunteers in 2 years were analyzed. The morphology of the spinal cord was also analyzed.

METHODS

The median sagittal diameter and transverse diameter of the spinal canal from C2 to C7 were measured on CT images. The ratio of the median sagittal diameter to the transverse diameter was calculated. Accordingly, the spinal canal shape of each segment was classified into four, and the specific criteria of lunar phase classification were determined through linear discriminant analysis based on the ratio of the median sagittal diameter to the transverse diameter. The inter-rater reliability of the classification was explored using Kappa coefficients. Finally, the morphology of the different segments of the cervical spinal canal in healthy volunteers was revised and compared.

RESULTS

According to the ratio of the median sagittal diameter and the transverse diameter of the cervical spinal canal, the lunar phase classification of the cervical bony spinal canal was determined as follows: full-moon >0.65, 0.55< convex-moon ≤0.65, 0.46≤ quarter-moon ≤0.55, and residual-moon <0.46. The Kappa values of C2-C7 were 0.851, 0.958, 0.823, 0.927, 0.793, and 0.946, and the Kappa value of all C2-C7 segments was 0.854 that mainly presented two forms of full-moon (76.5%) and convex-moon (23.0%). A quarter-moon spinal canal was mainly distributed in C3, C4, C5, and C6; a residual-moon spinal canal was mainly distributed in C4 and C5; and the morphological distribution of C4 and C5 were similar (p>0.05). The frequency of the spinal canal of the residual-moon type was the highest, and the full-moon (6.5%) and residual-moon (7.5%) types of C7 were rare.

CONCLUSIONS

The morphological classification of the cervical spinal canal was established to present anatomical variations. The classification showed good inter-rater reliability.

Effect of L5 spinal canal type on pedicle screw placement based on CT imaging: a retrospective clinical study

PURPOSE

The objective of this study was to investigate the optimal entry point and pedicle camber angle for L5 pedicle screws of different canal types.

METHODS

CT imaging data were processed by Mimics for simulated pedicle screw placement, and PD (Pedicle diameter), PCA (Pedicle camber angle), LD (Longitudinal distance), TD (Transverse distance), and PBG (Pedicle screw breach grade) were measured. Then they were divided into the Round group and Trefoil group according to the type of spinal canal. When comparing PD, PCA, LD, TD, and PBG, the two sides of the pedicle were compared separately, so they were first divided into the round-type pedicle group and the trefoil-type pedicle group.

RESULTS

In the round-type pedicle group (n = 134) and the trefoil-type pedicle group (n = 264), there was no significant difference in PD and LD, but there was a significant difference in PCA between the two groups (t = - 4.072, P < 0.05). A statistically significant difference in the distance of the Magerl point relative to the optimal entry point (t = - 3.792, P < 0.05), and the distance of the Magerl point relative to the optimal entry point was greater in the trefoil-type pedicle group than in the round-type pedicle group.

CONCLUSION

The optimal entry point for L5 is more outward than the Magerl point, and the Trefoil spinal canal L5 is more outwardly oriented than the Round spinal canal L5, with a greater angle of abduction during pedicle screw placement.

Preoperative Low Back Pain Affects Postoperative Patient Satisfaction Following Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery

STUDY DESIGN

A single-center retrospective study.

PURPOSE

To research the predictive factors associated with postoperative patient satisfaction 1 year after minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), a minimally invasive procedure for lumbar degenerative disease.

OVERVIEW OF LITERATURE

There have been reports of numerous variables influencing patient satisfaction with lumbar surgery; however, there have been few investigations on MIS are limited.

METHODS

This study included 229 patients (107 men and 122 women; mean age, 68.9 years) who received one or two levels of MISTLIF, and the patient's age, gender, disease, paralysis, preoperative physical functions, duration of symptom(s), and surgery-associated factors (waiting for surgery, number of surgical levels, surgical time, and intraoperative blood loss) were studied. Radiographic characteristics and clinical outcomes such as Oswestry Disability Index (ODI) scores and Visual Analog Scale (VAS; 0-100) ODI scores for low back pain, leg pain, and numbness were studied. One year following surgery, patient satisfaction (defined as satisfaction for surgery and for present condition; 0-100) was assessed using VAS and its relationships with investigation factors were examined.

RESULTS

The mean VAS scores of satisfaction for surgery and for present condition were 88.6 and 84.2, respectively. The results of multiple regression analysis showed that preoperative adverse factors of satisfaction for surgery were being elderly (β =-0.17, p =0.023), high preoperative low back pain VAS scores (β =-0.15, p =0.020), and postoperative adverse factors were high postoperative ODI scores (β =-0.43, p <0.001). In addition, the preoperative adverse factor of satisfaction for present condition was high preoperative low back pain VAS scores (β =-0.21, p =0.002), and postoperative adverse factors were high postoperative ODI scores (β =-0.45, p <0.001) and high postoperative low back pain VAS scores (β =-0.26, p =0.001).

CONCLUSIONS

According to this study, significant preoperative low back pain and high postoperative ODI score after surgery are linked to patient unhappiness.

Validating the predictive precision of the dialogue support tool on Danish patient cohorts

Background

Despite advances in surgical techniques and diagnostics, some patients remain unsatisfied with the result following spine surgery. One way to improve patient satisfaction may be found in better alignment of expectations. Prognostic tools might prove useful in strengthening surgeon-patient communication prior to surgery. The purpose of this study is to assess the predictive capabilities of the Swedish based Dialogue Support (DS) tool for spine surgery on a Danish population.

Methods

The study included the diagnoses lumbar disc herniation, lumbar spinal stenosis, and lumbar degenerative disc disease. A total of 5.954 patients were retrieved from the Danish national spine registry (DaneSpine). For each group, 200 random cases with complete preoperative and 1 year follow-up data were selected. Two outcome measures were used: Global assessment of pain (GA pain) and satisfaction with outcome. Predictions were produced by manual entry in the DS application. Goodness of fit tests were used to compare the predicted distribution of proportions with successful outcomes (GA pain) to the actual distribution in the three samples. Binomial tests were performed to evaluate the predicted proportion of satisfied patients. Furthermore, ROC-curves, calibration plots, and metrics were calculated to assess the predictive performance.

Results

ROC curves showed comparable AUC values with the values reported by the developing authors of the DS from 0.62 to 0.73 (GA pain) and 0.64 to 0.70 (satisfaction with outcome). The calibration plots, however, revealed a low degree of concordance. For GA pain sensitivity varied from 92.4% to 99.3%, and specificity from 1.5% to 13.4%. For satisfaction, sensitivity varied from 97.1% to 99.2% and specificity from 0.0% to 2.9%.

Conclusions

The predictive capabilities of the DS tool could not be generalized to the Danish sample cohorts. Further research on larger samples, provided full access to the underlying algorithms can be obtained, could produce a different result.

Early Readmission and Reoperation After Percutaneous Transforaminal Endoscopic Decompression for Degenerative Lumbar Spinal Stenosis: Incidence and Risk Factors

PURPOSE

To identify the incidence rates and risk factors for early readmission and reoperation after percutaneous transforaminal endoscopic decompression (PTED) for degenerative lumbar spinal stenosis (DLSS).

PATIENTS AND METHODS

A total of 1011 DLSS patients who underwent PTED were retrospectively evaluated. Of them, 58 were readmitted, and 31 underwent reoperation. The patients were matched with 174 control patients to perform case-control analyses. The clinical and preoperative imaging data of each patient were recorded. Univariate analyses were performed using independent sample t-tests and Fisher's exact tests. Furthermore, the risk factors for early readmission and reoperation were analyzed using multivariate logistic regression analyses.

RESULTS

The incidence rates of readmission and reoperation within 90 days after PTED were 5.7% and 3.1%, respectively. Age (odds ratio [OR]=1.054, p=0.001), BMI (OR=1.104, p=0.041), a history of lumbar surgery (OR=3.260, p=0.014), and the number of levels with radiological lumbar foraminal stenosis (LFS, OR=2.533, p<0.001) were independent risk factors for early readmission. The number of levels with radiological LFS (OR=5.049, p<0.001), the grade of surgical-level facet joint degeneration (OR=2.010, p=0.023), and a history of lumbar surgery (OR=10.091, p<0.001) were independent risk factors for early reoperation.

CONCLUSION

This study confirmed that aging, a higher BMI, a history of lumbar surgery, and more levels with radiological LFS were associated with a higher risk of early readmission. More levels with radiological LFS, a higher grade of surgical-level facet joint degeneration, and a history of lumbar surgery were predictors of early reoperation. These results are helpful in patient counseling and perioperative evaluation of PTED.

Microscopic Unilateral Approach for Bilateral Decompression of Lumbar Spinal Stenosis

BACKGROUND

This is a study based on single-surgeon data on spinal stenosis surgery via microscopic approach. The aim is to evaluate the effectiveness of the unilateral approach to bilateral decompression and the usage of Taylor retractors and brain spatula in patients with spinal stenosis.

METHODS

This is a retrospective study on bilateral decompression for lumbar spinal stenosis using a microscopic unilateral approach by a single surgeon, between April 2015 and March 2018. In total, 50 patients were operated due to single level lumbar spinal stenosis. All patients were evaluated by preoperative and postoperative plain radiographs and magnetic resonance (MR) images. Walking distance (WD), visual analog scale (VAS) for pain and Odom's criteria were evaluated for follow-up.

RESULTS

One level of the lumbar spine was surgically decompressed in all patients. The median age of patients was 64.6 (51- 82). Of the patients, 72% (36) were women, and 28% (14) were men. Most patients had refractory low back pain (96%) after conservative treatment. The stenotic levels of the cases were as follows: L3-4, 23(46%); L4-5, 24(48%); and L5-S1, 3 (6%). VAS scores decreased in all patients after surgery. According to Odom's criteria, an excellent or good score was found in 43 patients at the 12th follow-up examination. WDs increased up to 1000 meters for 41 patients.

CONCLUSION

The microscopic unilateral approach to bilateral decompression is an effective method for decompression in spinal stenosis. Via this approach, surgical trauma is reduced and surgically induced instability is avoided as much as possible.

Long-Term Pain Characteristics and Management Following Minimally Invasive Spinal Decompression and Open Laminectomy and Fusion for Spinal Stenosis

Background and Objectives: To compare the long-term pain characteristics and its chronic management following minimally invasive spinal (MIS) decompression and open laminectomy with fusion for lumbar stenosis. Materials and Methods: The study cohort included patients with a minimum 5-year postoperative follow-up after undergoing either MIS decompression or laminectomy with fusion for spinal claudication. The primary outcome of interest was chronic back and leg pain intensity. Secondary outcome measures included pain frequency during the day, chronic use of non-opioid analgesics, narcotic medications, medical cannabinoids, and continuous interventional pain treatments. Results: A total of 95 patients with lumbar spinal stenosis underwent one- or two-level surgery for lumbar spinal stenosis between April 2009 and July 2013. Of these, 50 patients underwent MIS decompression and 45 patients underwent open laminectomy with instrumented fusion. In the fusion group, a higher percentage of patients experienced moderate-to-severe back pain with 48% compared to 21.8% of patients in the MIS decompression group (p < 0.01). In contrast, we found no significant difference in the reported leg pain in both groups. In the fusion group, 20% of the patients described their back and leg pain as persistent throughout the day compared to only 2.2% in the MIS decompression group (p < 0.05). A trend toward higher chronic dependence on analgesic medication and repetitive pain clinic treatments was found in the fusion group. Conclusions: MIS decompression for the treatment of degenerative spinal stenosis resulted in decreased long-term back pain and similar leg pain outcomes compared to open laminectomy and instrumented fusion surgery.

[Degenerative lumbar spine stenosis: minimally invasive microsurgical methods of treatment]

Degenerative lumbar spine stenosis is one of the main causes of chronic pain and radiculopathy in advanced age people. Along with increase in average life expectancy, degenerative lumbar spine stenosis becomes the most common indication for spinal surgery. There is still no consensus regarding the most optimal surgical approach due to the variety of modern surgical methods. In recent years, minimally invasive spinal surgery has become a more advisable alternative to open surgery due to its advanced technical features combined with less soft tissue damage, lower risk of complications and shorter postoperative recovery.

Comparing Ipsilateral and Contralateral Laminotomy with Bilateral Decompression in Cases with Far Lateral Disk Herniation and Lumbar Spinal Stenosis

Introduction The aim of this study was to compare clinical results of bilateral decompression and laminotomy and contralateral laminotomy following discectomy from the same side in patients who have far lateral disk herniation and lumbar spinal stenosis at the same level.

Materials and Methods Twenty-four patients with far lateral disk herniation have been divided into two groups: group 1 (n = 14), those who have been through bilateral canal decompression with far lateral discectomy and ipsilateral approach, and group 2 (n = 10), those who have been through far lateral discectomy and bilateral decompression with unilateral approach from contralateral side. Early postoperative, 1st month, and 12th month back and leg pain Visual Analogue Scale (VAS) scores of the patients have been retrospectively evaluated.

Results There is no significant difference between 1st month back and leg pain VAS scores of the groups. But 12th month back and leg pain VAS scores of group 1 are significantly higher than 1st month VAS scores. Also, 12th month back and leg pain VAS scores of group 1 are significantly higher than group 1. In the scanning carried out when the complaints of eight patients in group 1 continued, pars interarticularis fracture has been observed on the side where the surgery has been performed (57.1%). Six of these eight patients have been through stabilization surgery (42.8%).

Conclusion Long-term postoperative results are better in cases who have been performed bilateral decompression with unilateral approach from contralateral side with median incision following paramedian incision discectomy in patients with far lateral disk herniation and spinal stenosis.

Evaluation of Effectiveness of Treatment Strategies for Degenerative Lumbar Spinal Stenosis: A Systematic Review and Network Meta-Analysis of Clinical Studies

OBJECTIVE

Lumbar spinal stenosis (LSS) is a common disease in spinal surgery. Many related treatment methods have been reported, but their effectiveness still lacks a systematic comparison. We aimed to evaluate the clinical outcomes related to the efficacy and safety of these treatment strategies via a network meta-analysis.

METHODS

Relevant clinical studies were retrieved from the databases of PubMed, Embase, Web of Science, and Cochrane library updated to July 29, 2020. The data were extracted from the eligible literature and the results were presented as standardized mean differences with 95% confidence intervals (CIs). A network meta-analysis was executed using the netmeta, rjags, and gemtc packages in R software, and Begg and Egger tests were used to assess the publication bias within the included studies.

RESULTS

A total of 21 eligible studies based on 2890 patients with degenerative LSS were included. The newer microdecompression technique (bilateral decompression via unilateral laminotomy [BDUL]) performed better in decreasing the visual analog scale (VAS) score compared with conventional decompressive laminectomy (VAS score back pain, 1.22; 95% CI, 0.28-2.17; VAS score leg pain, 1.39; 95% CI, 0.82-1.96), but its Oswestry Disability Index improvement was slightly inferior to that of posterolateral fusion.

CONCLUSIONS

BDUL could effectively alleviate VAS pain of patients, and had a lower incidence of complications. Although BDUL was slightly inferior to posterolateral fusion in terms of Oswestry Disability Index improvement, the postoperative quality of life of patients treated with BDUL had been significantly improved compared with that before surgery.

Outcome analysis of lumbar endoscopic unilateral laminotomy for bilateral decompression in patients with degenerative lumbar central canal stenosis

BACKGROUND CONTEXT

Lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has been reported as an alternative treatment for degenerative lumbar central canal stenosis (DLCS).

PURPOSE

To investigate the outcomes of LE-ULBD for different types of DLCS, including simple DLCS, DLCS with degenerative spondylolisthesis (DSL), and DLCS with degenerative scoliosis (DSC).

STUDY DESIGN/SETTING

Prospective cohort study.

PATIENT SAMPLE

One-hundred sixteen patients with DLCS who underwent LE-ULBD at a spine center from April 2015 to June 2017 were enrolled in this study.

OUTCOME MEASURES

Operative time, postoperative duration of hospitalization, and clinical outcomes (Oswestry disability index [ODI], visual analog scale [VAS], and modified Macnab outcome scale), and adverse events.

METHODS

A comparative analysis was performed evaluating medical records, radiological studies, and patient reported outcomes including ODI score, VAS scores and modified Macnab outcome scales in patients who underwent LE-ULBD. Data were prospectively collected at preoperative, postoperative 3-, 6-, 12-, 24-month to assess clinical and radiological outcomes and complications.

RESULTS

The study analyzed 106 patients (45 men and 61 women, with a mean age of 69.5 years); 40 (37.8%) had simple DLCS, 41 (38.7%) had DLCS with DSL, and 25 (23.5%) had DLCS with DSC. The mean follow-up period was 33.3 months. The mean preoperative and postoperative follow-up ODI score and VAS scores for leg and back pain showed significant improvement in all time points. No significant difference was found among different pathologies in terms of VAS scores for back and leg pain, ODI scores and modified Macnab outcome scales at all follow-up periods.

CONCLUSIONS

LE-ULBD is a feasible treatment method for DLCS. It did not result in worse outcomes in cases with DLCS with DSL or DLCS with DSC as compared with cases with simple DLCS.

Accuracy of fluoroscopic guidance with the coaxial view of the pedicle for percutaneous insertion of lumbar pedicle screws and risk factors for pedicle breach

OBJECTIVE

In this study the authors aimed to evaluate the rate of malposition, including pedicle breach and superior facet violation, after percutaneous insertion of pedicle screws using the coaxial fluoroscopic view of the pedicle, and to assess the risk factors for pedicle breach.

METHODS

In total, 394 percutaneous screws placed in 85 patients using the coaxial fluoroscopic view of the pedicle between January 2014 and September 2017 were assessed, and 445 pedicle screws inserted in 116 patients using conventional open procedures were used for reference. Pedicle breach and superior facet violation were evaluated by postoperative 0.4-mm slice CT.

RESULTS

Superior facet violation was observed in 0.5% of the percutaneous screws and 1.8% of the conventionally inserted screws. Pedicle breach occurred more frequently with percutaneous screws (28.9%) than with conventionally inserted screws (11.9%). The breaches in percutaneous screws were minor and did not reduce the interbody fusion rate. The angle difference between the percutaneous and conventionally inserted screws was comparable. Insertion at the L3 or L4 level, right-sided insertion, placement around a trefoil canal, smaller pedicle angle, and a small difference between the screw and pedicle diameters were found to be risk factors for pedicle breach by percutaneous pedicle screws.

CONCLUSIONS

Percutaneous pedicle screw placement using the coaxial fluoroscopic view of the pedicle carries a low risk of superior facet violation. The screws should be placed carefully considering the level and side of insertion, canal shape, and pedicle angle.

Efficacy and safety of percutaneous endoscopic decompression via transforaminal and interlaminar approaches for lumbar spine stenosis: Protocol for a systematic review and meta-analysis

BACKGROUND

Lumbar spinal stenosis (LSS) is a common and frequently-occurring disease in the elderly. Percutaneous endoscopic decompression (PED) has become the first choice for the treatment of LSS because of its small wound, mild pain and rapid recovery. The surgical approaches are mainly divided into percutaneous interlaminar approach and transforaminal approach. However, these two surgical approaches have their own advantages, disadvantages and indications. Hence, the present study aims to synthesize the available direct and indirect evidence of transforaminal approach and interlaminar approach to prove their respective advantages and disadvantages.

METHODS

The following databases will be searched: Cochrane Library, PubMed, Web of Science, Embase, CNKI, Wanfang data, and China Biomedical Literature Database (CBM). The search dates will be set from the inception to November 2019. Two researchers independently screened the literature, extracted the data and assessed the risk of bias in the included studies. The efficacy outcomes including: Back and Leg Visual Analog Scale (VAS) score, the MacNab criteria, the Oswestry Disability Index (ODI) and Japanese Orthopedic Association (JOA) score. The safety outcomes including: incidence of complications (dura tear, incomplete decompression, reoperation, etc.). The meta-analysis will be conducted using Stata 12.0 software. Grading of Recommendations Assessment, Development and Evaluation (GRADE) will be used to assess evidence quality.

RESULTS

The results of this meta-analysis will be published in a peer-reviewed journal.

CONCLUSION

The meta-analysis will provide a comprehensive summary of the evidence for 2 approaches to PED in patients with LSS.

PROTOCOL REGISTRATION NUMBER

CRD42019128080.

Percutaneous endoscopic decompression for lumbar spinal stenosis: Protocol for a systematic review and network meta-analysis

BACKGROUND

Lumbar spinal stenosis (LSS) is a common and frequently-occurring disease in clinical practice. There are many interventions to treat it, and percutaneous endoscopic decompression (PED) is one of them, but their relative efficacy and safety remains unclear. Hence, the present study aims to synthesize the available direct and indirect evidence on the PED and other treatments for LSS.

METHODS

The following databases will be searched: Cochrane Library, PubMed, Web of Science, Embase and China Biomedical Literature Database (CBM). The search dates will be set from the inception to April 2019. All randomized controlled trials (RCTs) will be included in this network meta-analysis (NMA) and their risk of bias will be assessed using Cochrane handbook tool by 2 independent authors. The efficacy outcomes including: Back and Leg Visual Analog Scale (VAS) score, MacNab criteria, the Oswestry Disability Index (ODI), and Japanese Orthopedic Association (JOA) score. The safety outcomes including: incidence of complications (dura tear, incomplete decompression, reoperation, etc.). A network meta-analysis will be performed using R x64 3.5.1 software and pairwise meta-analysis will be conducted using Stata 12.0 software. Grading of recommendations assessment, development, and evaluation (GRADE) will be used to assess evidence quality.

RESULTS

The results of NMA will be submitted to a peer-reviewed journal.

CONCLUSION

The NMA will provide a comprehensive evidence summary on treatments for patients with LSS.

PROTOCOL REGISTRATION NUMBER

CRD42019120509.

Long-term clinical outcomes after bilateral laminotomy or total laminectomy for lumbar spinal stenosis: a single-institution experience

OBJECTIVE

Lumbar spinal stenosis (LSS) is the most common spinal disease in the geriatric population, and is characterized by a compression of the lumbosacral neural roots from a narrowing of the lumbar spinal canal. LSS can result in symptomatic compression of the neural elements, requiring surgical treatment if conservative management fails. Different surgical techniques with or without fusion are currently treatment options. The purpose of this study was to provide a description of the long-term clinical outcomes of patients who underwent bilateral laminotomy compared with total laminectomy for LSS.

METHODS

The authors retrospectively reviewed all the patients treated surgically by the senior author for LSS with total laminectomy and bilateral laminotomy with a minimum of 10 years of follow-up. Patients were divided into 2 treatment groups (total laminectomy, group 1; and bilateral laminotomy, group 2) according to the type of surgical decompression. Clinical outcomes measures included the visual analog scale (VAS), the 36-Item Short-Form Health Survey (SF-36) scores, and the Oswestry Disability Index (ODI). In addition, surgical parameters, reoperation rate, and complications were evaluated in both groups.

RESULTS

Two hundred fourteen patients met the inclusion and exclusion criteria (105 and 109 patients in groups 1 and 2, respectively). The mean age at surgery was 69.5 years (range 58–77 years). Comparing pre- and postoperative values, both groups showed improvement in ODI and SF-36 scores; at final follow-up, a slightly better improvement was noted in the laminotomy group (mean ODI value 22.8, mean SF-36 value 70.2), considering the worse preoperative scores in this group (mean ODI value 70, mean SF-36 value 38.4) with respect to the laminectomy group (mean ODI 68.7 vs mean SF-36 value 36.3), but there were no statistically significant differences between the 2 groups. Significantly, in group 2 there was a lower incidence of reoperations (15.2% vs 3.7%, p = 0.0075).

CONCLUSIONS

Bilateral laminotomy allows adequate and safe decompression of the spinal canal in patients with LSS; this technique ensures a significant improvement in patients’ symptoms, disability, and quality of life. Clinical outcomes are similar in both groups, but a lower incidence of complications and iatrogenic instability has been shown in the long term in the bilateral laminotomy group.

Unilateral laminectomy for bilateral decompression improves low back pain while standing equally on both sides in patients with lumbar canal stenosis: analysis using a detailed visual analogue scale

BACKGROUND

Unilateral laminectomy for bilateral decompression (ULBD) for lumbar spinal stenosis (LSS) is a less invasive technique compared to conventional laminectomy. Recently, several authors have reported favorable results of low back pain (LBP) in patients of LSS treated with ULBD. However, the detailed changes and localization of LBP before and after ULBD for LSS remain unclear. Furthermore, unsymmetrical invasion to para-spinal muscle and facet joint may result in the residual unsymmetrical symptoms. To clarify these points, we conducted an observational study and used detailed visual analog scale (VAS) scores to evaluate the characteristics and bilateral changes of LBP and lower extremity symptoms.

METHODS

We included 50 patients with LSS treated with ULBD. A detailed visual analogue scale (VAS; 100 mm) score of LBP in three different postural positions: motion, standing, and sitting, and bilateral VAS score (approached side versus opposite side) of LBP, lower extremity pain (LEP), and lower extremity numbness (LEN) were measured. Oswestry Disability Index (ODI) was used to quantify the clinical improvement.

RESULTS

Detailed LBP VAS score before surgery was 51.5 ± 32.5 in motion, 63.0 ± 30.1 while standing, and 37.8 ± 31.8 while sitting; and showed LBP while standing was significantly greater than LBP while sitting (p < 0.01). After surgery, LBP while standing was significantly improved relative to that while sitting (p < 0.05), and levels of LBP in the three postures became almost the same with ODI improvement. Bilateral VAS scores showed significant improvement equally on both sides (p < 0.01).

CONCLUSIONS

ULBD improves LBP while standing equally on both sides in patients with LCS. The improvement of LBP by the ULBD surgery suggests radicular LBP improved because of decompression surgery. Furthermore, the symmetric improvement of LBP by the ULBD surgery suggests unsymmetrical invasion of the paraspinal muscles and facet joints is unrelated to residual LBP.

[Operative treatment of degenerative diseases of the lumbar spine]

BACKGROUND

Degenerative diseases of the lumbar spine and associated lower back pain represent a major epidemiological and health-related economic challenge. A distinction is made between specific and unspecific lower back pain. In specific lower back pain lumbar disc herniation and spinal canal stenosis with or without associated segment instability are among the most frequent pathologies. Diverse conservative and operative strategies for treatment of these diseases are available.

OBJECTIVES

The aim of this article is to present an overview of current data and an evidence-based assessment of the possible forms of treatment.

MATERIAL AND METHODS

An extensive literature search was carried out via Medline plus an additional evaluation of the authors' personal experiences.

RESULTS

Conservative and surgical treatment represent efficient treatment options for degenerative diseases of the lumbar spine. Surgical treatment of lumbar disc herniation shows slight advantages compared to conservative treatment consisting of faster recovery of neurological deficits and a faster restitution of pain control. Surgical decompression is superior to conservative measures for the treatment of spinal canal stenosis and degenerative spondylolisthesis. In this scenario conservative treatment represents an important supporting measure for surgical treatment in order to improve the mobility of patients and the outcome of surgical treatment.

CONCLUSION

The treatment of specific lower back pain due to degenerative lumbar pathologies represents an interdisciplinary challenge, requiring both conservative and surgical treatment strategies in a synergistic treatment concept in order to achieve the best results for patients.

Navigated minimally invasive unilateral laminotomy with crossover for intraoperative prediction of outcome in degenerative lumbar stenosis

BACKGROUND

Different surgical techniques have been described for treatment of degenerative lumbar stenosis (DLS). Only postoperative measures have been identified as predictors of efficacy of decompression. The objective of this study is to assess the role of navigated unilateral laminotomy with crossover to achieve and predict a satisfying decompression and outcome in DLS.

MATERIALS AND METHODS

We enrolled patients with DLS who underwent navigation-assisted unilateral laminotomy with crossover. The extent of decompression was evaluated during surgery using neuronavigation. The outcome was assessed through the Oswestry disability index (ODI) and visual analog scale (VAS) for leg pain. Outcome correlation with the extent of the intraoperative bone decompression was analyzed. Finally, the outcome, surgical time, and in-hospital length-of-stay were compared with a control group treated through standard unilateral laminotomy.

RESULTS

Twenty-five patients were treated using the navigated technique (Group A), 25 using the standard unilateral laminotomy (Group B). In Group A, a cut-off value ≥0.9 cm for bone decompression revealed to be an intraoperative predictor of good outcome, both regarding the ODI and VAS scores (P = 0.0005; P = 0.002). As compared with Group B, patients operated using the navigated technique showed similar operative times, in-hospital length-of-stay, ODI scores, but improved VAS scores for leg pain (P = 0.04).

CONCLUSIONS

The intraoperative navigated evaluation of the bone decompression could predict the outcome allowing satisfactory results in unilateral laminotomy for DLS. The navigated technique also could lead to an improved decompression of lateral recesses resulting in better control of leg pain as compared to standard unilateral laminotomy.

Shape of the Spinal Canal Is Not Associated with Success Rates of Microsurgical Unilateral Laminotomy and Bilateral Decompression for Lumbar Spinal Canal Stenosis

BACKGROUND

Anatomic shape of the spinal canal (oval, round, trefoil) has been reported to predict outcome of bilateral decompression performed in an undercutting technique via unilateral laminotomy in monosegmental lumbar spinal stenosis, with poorest results observed in a trefoil spinal canal, leading to the proposal of using bilateral instead of unilateral laminotomy. The aim of this study was to assess whether this anatomic classification into oval, round, and trefoil shapes is relevant to surgical treatment of lumbar spinal stenosis.

METHODS

Retrospective chart review of patients undergoing lumbar decompression surgery was performed. Spinal canal configuration was assessed on preoperative computed tomography based on maximal transverse and anteroposterior diameter, and shapes were classified into oval, round, and trefoil. Associations between spinal canal shape and outcome improvement (aggregate of walking distance and leg pain) were tested.

RESULTS

Decompression of 236 lumbar levels was performed in 159 patients (mean age, 73 ± 8 years; mean body mass index, 29 ± 6). Average number of operated segments was 1.3 ± 0.6. Oval configurations were detected in 155 (65%) levels, round configurations were detected in 11 (5%) levels, and trefoil configurations were detected in 70 (30%) levels. Postoperative improvement was recorded in 91.7% of patients. Spinal canal shape had no influence on surgical outcome (oval, area under the curve 0.529, P = 0.672; trefoil, area under the curve 0.500, P = 0.997; round, area under the curve 0.471, P = 0.670).

CONCLUSIONS

Spinal canal configuration varies in frequency with lumbar segment. Our results do not support the idea that this anatomic classification, particularly the nomenclature of oval, round, and trefoil, should influence surgical decision making.

Clinical and radiographic outcomes of bilateral decompression via a unilateral approach with transforaminal lumbar interbody fusion for degenerative lumbar spondylolisthesis with stenosis

BACKGROUND CONTEXT

Laminectomy with posterior lumbar interbody fusion (PLIF) has been shown to achieve satisfactory clinical outcomes, but it leads to potential adverse consequences associated with extensive disruption of posterior bony and soft tissue structures.

PURPOSE

This study aimed to compare the clinical and radiographic outcomes of bilateral decompression via a unilateral approach (BDUA) with transforaminal lumbar interbody fusion (TLIF) and laminectomy with PLIF in the treatment of degenerative lumbar spondylolisthesis (DLS) with stenosis.

STUDY DESIGN

This is a prospective cohort study.

PATIENT SAMPLE

This study compared 43 patients undergoing BDUA+TLIF and 40 patients undergoing laminectomy+PLIF.

OUTCOME MEASURES

Visual analog scale (VAS) for low back pain and leg pain, Oswestry Disability Index (ODI), and Zurich Claudication Questionnaire (ZCQ) score.

METHODS

The clinical outcomes were assessed, and intraoperative data and complications were collected. Radiographic outcomes included slippage of the vertebra, disc space height, segmental lordosis, and final fusion rate. This study was supported by a grant from The National Natural Science Foundation of China (81572168).

RESULTS

There were significant improvements in clinical and radiographic outcomes from before surgery to 3 months and 2 years after surgery within each group. Analysis of leg pain VAS and ZCQ scores showed no significant differences in improvement between groups at either follow-up. The mean improvements in low back pain VAS and ODI scores were significantly greater in the BDUA+TLIF group than in the laminectomy+PLIF group. No significant difference was found in the final fusion rate at 2-year follow-up. The BDUA+TLIF group had significantly less blood loss, shorter length of postoperative hospital stay, and lower complication rate compared with the laminectomy+PLIF group.

CONCLUSIONS

When compared with the conventional laminectomy+PLIF procedure, the BDUA+TLIF procedure achieves similar and satisfactory effects of decompression and fusion for DLS with stenosis. The BDUA+TLIF procedure appears to be associated with less postoperative low back discomfort and quicker recovery.

Clinical and Radiological Comparison between Ipsilateral and Contralateral Side Canal Decompression Using an Unilateral Laminotomy Approach

Objective

To compare the clinical and radiological outcome of both sides using the unilateral approach.

Methods

Unilateral laminotomy was performed to achieve bilateral decompression. Thirty-nine patients who underwent this procedure were analyzed prospectively using the Oswestry Disability Index (ODI), the visual analog scale (VAS) pain score to evaluate symptoms in both legs, and the radiological morphometric index to calculate the anteriorposterior diameter and midcanal width. The incidence of complications from this approach was then evaluated.

Results

The mean follow-up time was 12.2 months. The mean ODI was 48.4 preoperatively and 14.2 postoperatively. The mean dural sac widening of the ipsilateral side (187.0%) was significantly larger (p<0.01) than that of the the contralateral side (145.6%). The VAS improvement ratio ([preoperative VAS score-postoperative VAS score]/[preoperative VAS score]×100) for the pain in each leg was 75.4%(ipsilateral side) and 73.7%(contralateral side). While the VAS improvement ratio for pain in each side was significantly reduced, the difference in the VAS ratio between sides was statistically insignificant (p=0.64). There were 2 cases (5.1%) of dural tearing during the procedure, 1 case (2.6%) of transient paresthesia of nerve roots, and 2 cases (5.1%) of transient paresthesia of the contralateral nerve root. The transient paresthesias of nerve roots never lasted more than 2 weeks.

Conclusion

This technique allows for significant decompression of the contralateral canal and excellent clinical outcomes without troublesome complications. Although ipsilateral the dural sac widening was significantly larger than contralateral side, the difference in the clinical outcome between sides was statistically insignificant.

Unilateral tubular approach for bilateral laminotomy: effect on ipsilateral and contralateral buttock and leg pain

PURPOSE

Tubular laminotomy is an effective procedure for treatment of lumbar spinal stenosis (LSS) and lateral recesses stenosis. Most surgeons familiar with the procedure agree that the tubular approach appears to afford a more complete decompression of the contralateral thecal sac and nerve root, as compared to the ipsilateral approach. With this study we sought to answer the question whether this is reflected in clinically significant differences between the ipsilateral and contralateral side pain improvements.

METHODS

In a retrospective case study, patients with LSS and lateral recesses stenosis who started out with VAS scores that were similar on the right and left side were included. All patients underwent a tubular (MIS) "over the top" laminotomy from a unilateral approach and through one incision. Surgeries were performed by a single surgeon in a single center. At the last follow-up, the extent of VAS score improvement on the approach (ipsilateral) side was compared to that of the contralateral side.

RESULTS

Thirty-three patients were included in. At the latest follow-up of 25.8 ± 3.4 months, there were statistically significant improvements in ODI and back VAS scores (p = 0.002 and p < 0.0001, respectively). In addition, buttock VAS scores were significantly improved both on the ipsilateral and the contralateral side (p < 0.001, and p = 0.001, respectively). Similarly, leg VAS scores were improved significantly on both sides (p < 0.001, and p = 0.001, respectively). There were no statistically significant differences between the extent of pain improvement on the ipsilateral and the contralateral side.

CONCLUSIONS

MIS tubular laminotomy through a unilateral approach results in clinically effective bilateral decompression of LSS and lateral recesses, regardless of the approach side.

Clinical outcomes following sublaminar decompression and instrumented fusion for lumbar degenerative spinal pathology

Traditional treatment for lumbar stenosis with instability is laminectomy and posterolateral arthrodesis, with or without interbody fusion. However, laminectomies remove the posterior elements and decrease the available surface area for fusion. Therefore, a sublaminar decompression may be a preferred approach for adequate decompression while preserving bone surface area for fusion. A retrospective review of 71 patients who underwent sublaminar decompression in conjunction with instrumented fusion for degenerative spinal disorders at a single institution was performed. Data collected included demographics, preoperative symptoms, operative data, and radiographical measurements of the central canal, lateral recesses, and neural foramina, and fusion outcomes. Paired t-tests were used to test significance of the outcomes. Thirty-one males and 40 females with a median age 60years underwent sublaminar decompression and fusion. A median of two levels were fused. The mean Visual Analog Scale pain score improved from 6.7 preoperatively to 2.9 at last follow-up. The fusion rate was 88%, and the median time to fusion was 11months. Preoperative and postoperative mean thecal sac cross-sectional area, right lateral recess height, left lateral recess height, right foraminal diameter, and left foraminal diameter were 153 and 209mm(2) (p<0.001), 5.9 and 5.9mm (p=0.43), 5.8 and 6.3mm (p=0.027), 4.6 and 5.2mm (p=0.008), and 4.2 and 5.2mm (p<0.001), respectively. Sublaminar decompression provided adequate decompression, with significant increases in thecal sac cross-sectional area and bilateral foraminal diameter. It may be an effective alternative to laminectomy in treating central and foraminal stenosis in conjunction with instrumented fusion.

Lumbar Interspinous Process Fixation and Fusion with Stand-Alone Interlaminar Lumbar Instrumented Fusion Implant in Patients with Degenerative Spondylolisthesis Undergoing Decompression for Spinal Stenosis

STUDY DESIGN

Prospective cohort study.

PURPOSE

To assess the ability of a stand-alone lumbar interspinous implant (interspinous/interlaminar lumbar instrumented fusion, ILIF) associated with bone grafting to promote posterior spine fusion in degenerative spondylolisthesis (DS) with vertebral instability.

OVERVIEW OF LITERATURE

A few studies, using bilateral laminotomy (BL) or bilateral decompression by unilateral laminotomy (BDUL), found satisfactory results in stenotic patients with decompression alone, but others reported increased olisthesis, or subsequent need for fusion in DS with or without dynamic instability.

METHODS

Twenty-five patients with Grade I DS, leg pain and chronic low back pain underwent BL or BDUL and ILIF implant. Olisthesis was 13% to 21%. Follow-up evaluations were performed at 4 to 12 months up to 25 to 44 months (mean, 34.4). Outcome measures were numerical rating scale (NRS) for back and leg pain, Oswestry disability index (ODI) and short-form 36 health survey (SF-36) of body pain and function.

RESULTS

Fusion occurred in 21 patients (84%). None had increased olisthesis or instability postoperatively. Four types of fusion were identified. In Type I, the posterior part of the spinous processes were fused. In Type II, fusion extended to the base of the processes. In Type III, bone was present also around the polyetheretherketone plate of ILIF. In Type IV, even the facet joints were fused. The mean NRS score for back and leg pain decreased by 64% and 80%, respectively. The mean ODI score was decreased by 52%. SF-36 bodily pain and physical function mean scores increased by 53% and 58%, respectively. Computed tomography revealed failed fusion in four patients, all of whom still had vertebral instability postoperatively.

CONCLUSIONS

Stand-alone ILIF with interspinous bone grafting promotes vertebral fusion in most patients with lumbar stenosis and unstable Grade I DS undergoing BL or BDUL.