Decompressive Surgery for Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations

Comparative Analysis of Pedicle Screw Fixation and Interspinous Devices in Lumbar Spinal Fusion: Clinical and Surgical Outcomes in Degenerative Spine Conditions

Background/Objectives: Degenerative lumbar spine conditions are a major cause of disability, particularly in elderly patients or those with comorbidities. Surgical treatment often combines decompression and stabilization to address pain and instability. Pedicle screws are the gold standard for stabilization but pose challenges in patients with compromised bone quality. Interspinous devices have emerged as a less invasive alternative, but comparative studies are limited. This study aimed to compare clinical and surgical outcomes of lumbar decompression with stabilization using pedicle screws versus interspinous devices. Methods: A retrospective cohort study was conducted on patients who underwent lumbar decompression with either pedicle screw fixation or interspinous device stabilization at Mater Olbia Hospital between February 2020 and February 2023. Outcomes were evaluated using VAS for back and leg pain, SF-36 for quality of life, EQ-5D, and SCL-90 for psychological factors. Statistical analysis included paired t-tests, chi-square tests, and multivariate regression. Results: A total of 728 patients were included. The interspinous device group consisted of older patients with higher comorbidity burdens (mean age: 68.4 vs. 59.2 years, p < 0.001). Surgical time and incision size were significantly shorter in the interspinous group (p < 0.001), and no postoperative complications were reported, compared to 3.5% in the pedicle screws group (p < 0.05). Both groups demonstrated significant improvements in pain (VAS), quality of life (SF-36, EQ-5D), and psychological outcomes (SCL-90). Somatization and paranoid ideation were significant predictors of worse postoperative pain, particularly in the pedicle screws group. No significant differences in quality-of-life improvements were observed between the groups. Conclusions: Both stabilization techniques are effective for lumbar spine surgery, with interspinous devices offering a safer and less invasive option for high-risk patients. Psychological factors significantly influence pain outcomes, underscoring the need for a comprehensive approach addressing both physical and psychological aspects to optimize patient recovery.

The morphology of the lumbar vertebrae: a systematic review with meta-analysis of 1481 individuals with implications for spine surgery

INTRODUCTION

The aim of the present meta-analysis was to provide the most up-to-date and evidence-based results regarding the morphometric properties of the lumbar vertebrae.

METHODS

Medical databases such as PubMed, Scopus, Embase, Web of Science, Google Scholar, and Cochrane Library were searched through.

RESULTS

The results of this meta-analysis were established based on a total of 1481 patients. New results were established in 27 categories for each lumbar vertebra separately. The findings from this study reveal that the width of the spinal canal progressively increases towards the lower end of the lumbar spine (L1 = 22.04 mm, L5 = 26.46 mm). Additionally, the transverse processes exhibit a similar trend, widening as they approach the lower lumbar vertebrae (L1 = 68.08 mm, L5 = 85.91 mm). The pedicle height decreased from L1 to L4, with an increase observed at L5 (14.73 mm). No significant differences were observed between the measurements of the left and right pedicles.

CONCLUSION

The presented results provide physicians with normative morphometric data on the lumbar vertebrae. Having adequate knowledge of the anatomy of the lumbar vertebrae may be of immense use for surgeons performing various spinal surgeries, such as pedicle screw fixation, percutaneous endoscopic transforaminal discectomy, or lumbar disc replacement.

The 3-Steps Approach for Lumbar Stenosis with Anatomical Insights, Tailored for Young Spine Surgeons

Background/Objectives: Lumbar decompression surgery for degenerative lumbar stenosis is an intervention which addresses a degenerative condition affecting many patients. This article presents a meticulous three-phase surgical approach, derived from our clinical experiences and intertwining anatomical insights, offering a nuanced perspective tailored for the educational needs of young spinal surgeons. Methods: Six hundred and eighty-seven patients who underwent lumbar decompression surgery at a single institution were included in the present study. A retrospective analysis of patient demographics and surgical techniques was performed. All surgeries were performed by a consistent surgical team, emphasizing uniformity in approach. The surgical technique involves a meticulous three-phase process comprising exposure and skeletal visualization; microscopic identification and decompression; and undermining of the spinous process base and contralateral decompression. Results: Presenting results from 530 patients, the study examines demographic characteristics, health profiles, operative details, complications, and clinical assessments. The three-phase approach demonstrates low complication rates, absence of recurrences, and improved clinical outcomes, emphasizing its efficacy. Conclusions: The three-phase surgical approach emerges as a valuable educational tool for both novice and seasoned spinal surgeons. Rooted in anatomical insights, the structured methodology not only caters to the educational needs of young surgeons, but also ensures a standardized and safe procedure. The emphasis on tissue preservation and anatomical points aligns with current trends toward minimally invasive techniques, promising enhanced patient outcomes and satisfaction.

Barriers and factors associated with adherence to a home exercise program of adults with musculoskeletal pain

BACKGROUND

Home exercise programs (HEPs) are cost-effective and efficacious treatments for musculoskeletal pain conditions. Although HEPs are an important part of the continuum of care, non-adherence limits their effectiveness.

OBJECTIVE

The objective of this study was to examine adherence and specific barriers to clinician-prescribed HEPs in adults with musculoskeletal pain.

METHODS

A cross-sectional study was conducted with a total of 300 patients presenting to an outpatient pain clinic in an academic medical center. Participants' self-reported information, including HEP completion frequency and barriers, was collected through a survey.

RESULTS

The participants' mean age was 54.1 ± 15.8 years (females = 133 (65.5%)). Of 203 participants, 99 (48.8%) adhered to HEP, 56 (27.6%) partially adhered, and 48 (23.6%) did not adhere. One hundred eighty-seven (92.1%) participants reported receiving adequate instructions, and 175 (86.2%) reported receiving instructional materials. Age and "sufficient instructions" were found to be significant determinants of adherence (p< 0.05), while gender and handouts were not (p> 0.05). Pain in more than one body part was significantly (p< 0.05) associated with motivational barriers for non-adherence.

CONCLUSION

Age and participants' perception of sufficient instructions were significant factors for non-adherence. These results emphasize the importance of therapist-provided instructions to overcome barriers to adherence.

Acute disc herniation following surgical decompression of lumbar spinal stenosis: a retrospective comparison of mini-open and minimally invasive techniques

BACKGROUND

Disc herniation following decompression of lumbar spinal stenosis is a less familiar surgical complication. Previous studies suggested that open lumbar decompression techniques, associated with relative segmental instability especially in the presence of degenerated disc in older patients, are more likely to result in disc herniation compared to minimally invasive techniques. The current study compares the incidence of acute disc herniation following mini-open and minimally invasive decompression of lumbar spinal stenosis.

METHODS

This was a retrospective study reviewing 563 patients who underwent spinal decompression for symptomatic lumbar stenosis by mini-open bilateral partial laminectomy technique or minimally invasive laminotomy utilizing a tubular system. Demographic and clinical data were collected and compared between the groups.

RESULTS

Postoperative disc herniation rate was significantly lower in the minimally invasive group with 2 of 237 cases (0.8%) versus 19 of 326 cases (5.8%) in the mini-open group (p = 0.002). This finding was more noticeable following multi-level procedures with no case of postdecompression disc herniation in the minimally invasive group compared to 8 of 39 cases (20.5%) in the mini-open group (p = 0.003).

CONCLUSION

The incidence of postoperative disc herniation following spinal decompression for symptomatic lumbar stenosis was 5.8% following mini-open bilateral partial laminectomy compared to only 0.8% after minimally invasive laminotomy (p = 0.002). These findings highlight the more extensive nature of mini-open surgery associated with relative segmental instability that poses a greater risk for postoperative disc herniation.

Postoperative Evaluation of Pain and Disability in Patients Undergoing Spinal Discectomy

BACKGROUND

A spinal discectomy surgery (SDS) is a common surgical procedure performed to treat lumbosacral radiculopathy.

AIM

To evaluate postoperative patterns of pain and disability in patients undergoing spinal discectomy.

METHODS AND MATERIALS

This investigation was a retrospective longitudinal review of prospective information gathered from 543 enrolled patients for lumbar radiculoplasty. The study participants were divided into two categories: Category 1 (SDS) comprising patients of lumbar radiculoplasty managed with SDS (n=270) and Category 2 (non-SDS) comprising patients of lumbar radiculoplasty managed with therapy other than SDS (n=273). It included study participants taking medication for pain control including opioids and non-opioids and physiotherapy for strengthening lower back muscles. At baseline, three months, 12 months, and 24 months after surgery, patient-reported information was gathered. Leg pain magnitude, back pain magnitude, and pain-related impairment were the key outcome metrics of interest.

RESULTS

The mean postoperative visual analog scale (VAS) score for leg pain at three-month follow-up was 4.3±1.2 in study participants in SDS and 8.1±1.3 in the non-SDS category. The VAS score was lower in the SDS category showing greater reduction in postoperative pain with statistically meaningful results (p<0.001). The mean postoperative VAS score at 12-month follow-up was 2.8±1.1 in study participants in SDS and 7.9±1.5 in the non-SDS category. The VAS score was lower in the SDS category showing greater reduction in postoperative pain with statistically meaningful results (p<0.001). The mean postoperative VAS score at 24-month follow-up was 1.7±1.2 in study participants in SDS and 7.1±1.1 in the non-SDS category. The VAS score was lower in the SDS category showing greater reduction in postoperative pain with statistically meaningful results (p<0.001).

CONCLUSION

 It was observed that after discectomy, patients suffering from lumbar radiculopathy have significant pain and disability recovery. According to these results, only a small percentage of individuals exhibit negative results at the level of impairment.

Delta large-channel technique versus microscopy-assisted laminar fenestration decompression for lumbar spinal stenosis: a one-year prospective cohort study

PURPOSE

When it comes to treating lumbar spinal stenosis (LSS), a procedure known as microscope-assisted fenestration decompression has expediently become the gold standard. With the advancement of spinal endoscopy, the Delta large-channel approach has shown promising clinical outcomes in the management of lumbar spinal stenosis. However, case studies of this method being used to treat lumbar spinal stenosis are still uncommon. The purpose of this research was to examine how well microscopy-assisted laminectomy and the Delta large-channel approach work in treating LSS in the clinic.

METHODS

From May 2018 to June 2020, 149 patients diagnosed with LSS were divided into 80 patients in Delta large-channel technique groups (FE group) and 69 patients in microscope groups (Micro group). Lower back and lower limb pain were measured using the visual analogue scale (VAS-LBP and VAS-LP), while lower limb numbness was evaluated using the 11-point numerical rating scale (NRS-LN); modified Oswestry Disability Index (ODI) was used to evaluate the quality of life, and modified MacNab criteria were used to assess the clinical efficacy before surgery and at one week, three months, six months, and 12 months after surgery. All patients had single-level lumbar spinal stenosis, and clinical data such as hospital stay, operation time, intraoperative blood loss were statistically analyzed.

RESULTS

Finally, 111 patients (62 in FE group and 49 in Micro group) completed follow-up. Compared with preoperative results, postoperative VAS-LBP, VAS-LP, NRS-LN score and modified ODI score were significantly improved in 2 groups (P < 0.05), but there was no significant difference in postoperative follow-up at each time point (P > 0.05), Except 1 week after surgery, VAS-LBP in FE group was lower than that in Micro group (P < 0.05). It is noteworthy that the FE group had a shorter hospital stay, less intraoperative blood loss, and a quicker time of getting out of bed when compared with the microscope group，but the operation time was just the opposite (P < 0.05). The excellent and good rate was 83.87% in FE group and 85.71% in Micro group (P > 0.05).

CONCLUSIONS

Both microscope-assisted laminar fenestration decompression and Delta large-channel procedures provide satisfactory treatment outcomes, however the Delta large-channel approach has some potential advantages for the treatment of LSS, including quicker recovery and sooner reduced VAS-LBP. Long-term consequences, however, will necessitate additional follow-up and research.

Degenerative Lumbar Spine Stenosis Consensus Conference: the Italian job. Recommendations of the Spinal Section of the Italian Society of Neurosurgery

In the modern era evidence-based medicine, guidelines and recommendations represent a key-point of daily activity. The Spinal Section of the Italian Society of Neurosurgery introduced some recommendations regarding Degenerative Lumbar Spine Stenosis based on those of the Spine Committee of World Federation of Neurosurgical Societies, revising them on the basis of Italian common practice. In June 2019, a Committee of 21 spine surgeons met in Rome to validate the recommendations of the WFNS. Furthermore, they decided to review the ones that did not reach a consensus to create Italian Recommendations on Degenerative Lumbar Spine Stenosis. A literature review of the last ten years was performed and the statements were voted using the Delphi method. Forty-one statements were discussed, and 7 statements were voted again to reach a consensus with respect to those of the WFNS. A total of 40 statements reached a consensus, of which 36 reached a positive consensus and 4 a negative consensus, while no consensus was reached in 1 case. Conservative multimodal therapy, tailored on the patient, is a reasonable and effective first option choice for the treatment of LSS patients with tolerable moderate symptoms. Surgical treatment is reserved for symptomatic patients non-responding to conservative treatment or with neurological deficits. The best surgical technique to use depends on personal experience; modern MISS techniques are equivalent to open decompressive surgery with some advantages and higher cost-effectiveness. Fusion surgery and mobility preserving surgery only have a marginal role in the treatment of DLSS without instability.