Bilateral decompression of multilevel lumbar spinal stenosis through a unilateral approach

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.

Decompression of lumbar canal stenosis with a bilateral interlaminar versus classic laminectomy technique: a prospective randomized study

OBJECTIVEThe aim of this study was to compare the radiological and clinical results of bilateral interlaminar canal decompression and classic laminectomy in lumbar canal stenosis (LCS).METHODSTwo hundred eighteen patients with LCS were randomized to surgical treatment with classic laminectomy (group 1) or bilateral interlaminar canal decompression (group 2). Low-back and leg pain were evaluated according to the visual analog scale (VAS) both preoperatively and postoperatively. Disability was evaluated according to the Oswestry Disability Index (ODI) preoperatively and at 1 month, 1 year, and 3 years postoperatively. Neurogenic claudication was evaluated using the Zurich Claudication Questionnaire (ZCQ) preoperatively and 1 year postoperatively. The two treatment groups were compared in terms of neurogenic claudication, estimated blood loss (EBL), and intra- and postoperative complications.RESULTSPostoperative low-back and leg pain declined as compared to the preoperative pain. Both groups had significant improvement in VAS, ODI, and ZCQ scores, and the improvements in ODI and back pain VAS scores were significantly better in group 2. The average EBL was 140 ml in group 2 compared to 260 ml in group 1. Nine patients in the laminectomy group developed postoperative instability requiring fusion compared to only 4 cases in the interlaminar group (p = 0.15). Complications frequency did not show any statistical significance between the two groups.CONCLUSIONSBilateral interlaminar decompression is an effective method that provides sufficient canal decompression with decreased instability in cases of LCS and increases patient comfort in the postoperative period.

Outcome after Surgery of Lumbar Spinal Stenosis: A Randomized Comparison of Bilateral Laminotomy, Trumpet Laminectomy, and Conventional Laminectomy

Background

Laminectomy is the traditional operating method for the decompression of spinal canal stenosis. New partial decompression processes have been suggested in the treatment of lumbar stenosis. The benefit of a micro surgical approach is the chance of an extensive bilateral decompression of the spinal canal or foramen at one or numerous levels, through a minimal para-spinal muscular separation.

Purpose

To match the safety and the clinical consequences after a bilateral laminotomy, laminectomy and trumpet laminectomy in patients with lumbar spinal stenosis who were randomized to one of three treatment groups.

Study design

Prospective study.

Methods

One hundred twenty consecutive patients with 227 levels of lumbar stenosis without significant herniated discs or instability were randomized to three treatment groups [bilateral laminotomy (Group 1), laminectomy (Group 2), and trumpet laminectomy (Group 3)]. Perioperative parameters and complications were documented. Symptoms and scores, such as a visual analog scale (VAS), Oswestry Disability Index, and patient satisfaction, were assessed preoperatively at 3, 6, and 12 months after surgery. Adequate decompression was achieved in all patients on the basis of surgeon satisfaction.

Results

The global complication rate was lowest in patients who had undertaken bilateral laminotomy (Group 1). The minimum follow-up of 12 months was achieved in 100% of patients. Matched with that experience in Group 1, but, with more remaining back and leg pain was found in Group 2, 3.85 ± 0.28 and 1.60 ± 0.44, respectively and 3.24 ± 0.22 and 2.44 ± 0.26 in Group 3, respectively compared with 1.84 ± 0.28 and 1.25 ± 0.12 (Group 1) at the 1-year follow-up assessment (p < 0.05). It was the same for the ODI scores, which reached 14 ± 8% (Group 1), 28 ± 12% (Group 2), and 26 ± 16 after 12 months of surgery (Group 3) (significant, p < 0.01 compared with preoperative scores). Patient satisfaction was higher in Group 1, with 7.5, 20, and 25% of patients displeased (in Groups 1, 2, and 3, respectively; p < 0.01).

Conclusion

Bilateral Laminotomy is certified acceptable and harmless in decompression of lumbar stenosis, causing a highly significant decrease of symptoms and disability.

Kirschner wire is more effective than the nerve root retractor in treating patients with disc herniation

OBJECTIVE

To investigate the value of using Kirschner wire in the intraspinal procedures.

METHODS

From May 2011 to October 2013, a total of 46 patients with a single-level lumbar disc herniation with concomitant lumbar instability were randomly assigned to two groups at the time of admission. Group 1 had 23 patients who underwent posterior lumbar fusion using a nerve root retractor to drag nerve root, and Group 2 also had 23 patients who underwent the same operation by fixing Kirschner wires in the vertebral body to drag nerve root. All of these patients were assessed with visual analog scales (VAS) and Japanese Orthopaedic Association (JOA) scores before surgery, and were followed up at the time points of one week (VAS score only), three, six, and twelve months respectively after surgery. The actual retraction time of the nerve root of each patient was also recorded during the operation.

RESULTS

The differences in VAS and JOA scores were not significant between Group 1 and 2 before surgery. However, these scores showed significant improvement in Group 2 at one week and three months after surgery compared with those in Group 1. At six and twelve month follow-up time points, no significant difference was observed between these two groups. However, the retraction time of the nerve root of the patients in Group 2 was significantly shorter than in Group 1.

CONCLUSIONS

Using Kirschner wires instead of the nerve root retractor to pull nerve root in the patients with a single-level lumbar disc herniation accompanied by the lumbar instability is more effective in reducing the dragging damage of the nerve root at early phases after surgery and in shortening retraction time.

Clinical results of microsurgical bilateral decompression via unilateral approach for lumbar canal stenosis with multiple-level involvement

OBJECT

Microsurgical decompression of the lumbar spine is a beneficial approach for selected patients of lumbar spinal stenosis (LSS). The purpose of this prospective study was to describe the clinical results of surgical treatment for microsurgical bilateral decompression via unilateral approach on patients with LSS with multiple-level involvement.

MATERIALS AND METHODS

Seventy-three consecutive patients who had microsurgical bilateral decompression via unilateral approach of more than two spinal levels were included in this study. Seventy-seven patients who had surgery at a single level over the same time periods were compared as a single-level LSS group.

RESULTS

The preoperative Japanese Orthopaedic Association scores averaged 11.7 points, and the postoperative scores averaged 21.2 points with an average recovery rate (RR) of 56% in the multiple-level LSS group. There was no significant difference in the RR between the groups. There were no major complications related to the surgery in the both groups.

CONCLUSION

Microsurgical bilateral decompression via unilateral approach was a useful and safe operative procedure for LSS patients. Sufficient clinical results that were comparable to single-level LSS patients were obtained even in the patients with multiple-level LSS, if the patient were correctly selected and the microsurgical decompression surgery were carefully performed.

Treatment of multilevel degenerative lumbar spinal stenosis with spondylolisthesis using a combination of microendoscopic discectomy and minimally invasive transforaminal lumbar interbody fusion

Degenerative lumbar spinal stenosis (DLSS) has become increasingly common and is characterized by multilevel disc herniation and lumbar spondylolisthesis, which are difficult to treat. The current study aimed to evaluate the short-term clinical outcomes and value of the combined use of microendoscopic discectomy (MED) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for the treatment of multilevel DLSS with spondylolisthesis, and to compare the combination with traditional posterior lumbar interbody fusion (PLIF). A total of 26 patients with multilevel DLSS and spondylolisthesis underwent combined MED and MI-TLIF surgery using a single cage and pedicle rod-screw system. These cases were compared with 27 patients who underwent traditional PLIF surgery during the same period. Data concerning incision length, surgery time, blood loss, time of bed rest and Oswestry Disability Index (ODI) score prior to and following surgery were analyzed statistically. Statistical significance was reached in terms of incision length, blood loss and the time of bed rest following surgery (P<0.05), but there was no significant difference between the surgery time and ODI scores of the two groups. The combined use of MED and MI-TLIF has the advantages of reduced blood loss, less damage to the paraspinal soft tissue, shorter length of incision, shorter bed rest time, improved outcomes and shorter recovery times and has similar short-term clinical outcomes to traditional PLIF.

Midterm outcome after unilateral approach for bilateral decompression of lumbar spinal stenosis: 5-year prospective study

The aim of our study is to evaluate the results and effectiveness of bilateral decompression via a unilateral approach in the treatment of degenerative lumbar spinal stenosis. We have conducted a prospective study to compare the midterm outcome of unilateral laminotomy with unilateral laminectomy. One hundred patients with 269 levels of lumbar stenosis without instability were randomized to two treatment groups: unilateral laminectomy (Group 1), and laminotomy (Group 2). Clinical outcomes were assessed with the Oswestry Disability Index (ODI) and Short Form-36 Health Survey (SF-36). Spinal canal size was measured pre- and postoperatively. The spinal canal was increased to 4-6.1-fold (mean 5.1 +/- SD 0.8-fold) the preoperative size in Group 1, and 3.3-5.9-fold (mean 4.7 +/- SD 1.1-fold) the preoperative size in Group 2. The mean follow-up time was 5.4 years (range 4-7 years). The ODI scores decreased significantly in both early and late follow-up evaluations and the SF-36 scores demonstrated significant improvement in late follow-up results in our series. Analysis of clinical outcome showed no statistical differences between two groups. For degenerative lumbar spinal stenosis unilateral approaches allowed sufficient and safe decompression of the neural structures and adequate preservation of vertebral stability, resulted in a highly significant reduction of symptoms and disability, and improved health-related quality of life.

Minimally invasive lumbar decompression

With the increasing elderly population, the number of patients presenting with symptoms secondary to lumbar stenosis can be expected to increase accordingly. Therefore, treatment of this disease process should become more prevalent, and the minimally invasive techniques offer another treatment option. As surgeons become more experienced in minimally invasive techniques, the reported advantages of the minimal access surgery, including reduction in soft tissue injury, less blood loss, shorter hospitalization, and faster recovery, should make this an attractive alternative to traditional open surgery. Continuing efforts in the minimally invasive field can be expected to yield new and potentially less invasive as well as possibly more efficacious treatment options in the future.

Lumbale Spinalkanalstenose

Lumbal spinal stenosis is gaining more and more clinical relevance because of changing population structure and increasing demand on lifequality in the elderly. Current treatment recommendations are based on clinical experience, expert opinions and single studies rather than on proven evidence. The radiologic degree of stenosis does not correlate with the patients' clinical situation. It is not the main factor indicating surgery but rather the typical history and spinal claudication. Symptomatic patients with light to moderate complaints should undergo multimodal conservative treatment. Epidural injections, delordosating physiotherapy and medication are useful. In patients with severe symptomatic stenosis surgery is indicated after a conservative treatment of 3 months. Relevant pareses or a cauda equina syndrome are absolute indications for surgery. The general aim is to decompress sufficiently while maintaining or restoring segmental stability. A laminectomy is not necessarily required. In patients with accompanying degenerative Meyerding grade I-II spondylolisthesis or instability in functional radiographs, fusion or dynamic stabilisation are recommended in addition to decompression, depending on the patient's age and activity level.