Decompression, fusion, and instrumentation surgery for complex lumbar spinal stenosis

The Lumbosacral Fractional Curve in Adult Degenerative Scoliosis

Spine surgeons are often faced with a profoundly difficult challenge in surgically treating adult degenerative scoliosis. Deformity correction surgery is complicated by the difficulty in offering extensive surgical corrections to the elderly, complication-prone population it commonly affects. As spine surgeons attempt to offer minimally invasive solutions to this disease process, the need for fusion of the fractional curve at L4, L5, and S1 may be discounted. A treatment strategy to identify, address, and treat the fractional curve with either open or minimally invasive techniques can lead to improved patient outcomes and decrease revision rates in this complicated pathologic process.

Outcomes of Incidental Durotomy Repair in Thoracolumbar Spine Surgery: An Institutional Experience With Orthopedic Residents

Background The occurrence of incidental durotomies (IDs) following spinal operations is a widely recognized issue. Complications such as poor outcomes, extended hospitalization, prolonged immobilization, infections, and revision surgeries are all potential consequences of inadequate durotomy management during the initial surgery. This study aims to describe the outcomes of ID repair in thoracolumbar spine surgery in terms of the Oswestry Disability Index (ODI) score and visual analog scale (VAS) when performed with the active involvement of orthopedic residents in the surgical procedure. Methodology Between April 2021 and April 2023, a hospital-based observational study was conducted among 110 patients hospitalized in the orthopedic ward at R.L. Jalappa Hospital and Research Center in Kolar, Karnataka, who required IDs due to an accidental dural tear or a postoperative CSF fluid leak following thoracolumbar spine procedures. Patients with a previous history of thoracolumbar spine surgery, vertebral tumors, spinal metastasis, infections, e.g., spondylodiscitis, or Pott's spine were excluded. The ODI score and VAS score were calculated on the postoperative day, one month, and three months following surgery. Results The mean age of the study participants was 62.81 + 10.49 years, with a male preponderance of 67.2% among the study participants. The mean BMI of study participants was 23.77 kg/m2. Approximately 24.5% of participants had a prior history of spinal surgery. Among 110 patients, 32 had postoperative complications. Six patients reported experiencing urinary retention, followed by five with CSF leakage and one with a postural headache (five cases). Based on the ODI score, mild disability was seen in 32.7% of the study samples at three months of follow-up. Based on the VAS score, moderate pain was seen among all the study samples at three months of follow-up. The ANOVA test revealed statistically significant differences in ODI and VAS score reductions between the immediate postoperative period and the one-month and three-month follow-up periods (p = 0.001 and p = 0.0247, respectively). Conclusion Less than one-third of the samples had postoperative complications. At three months, ODI scores showed mild disability in one-third of the study samples. At three months, all study samples had moderate VAS pain. The improvement in ODI and VAS scores from the day after surgery through the one-month and three-month follow-up periods was statistically significant.

Decompression versus decompression plus fusion for treating degenerative lumbar spinal stenosis: A systematic review and meta-analysis

BACKGROUND

Degenerative lumbar spinal stenosis (DLSS) is a complex clinical syndrome that leads to spinal compression. Decompression with fusion has been the most commonly used surgical procedure for treating DLSS symptoms for many years. However, the exact role of fusion and its effectiveness in DLSS therapy has recently been debated.

OBJECTIVE

The main purpose of this study was to compare the efficacy and safety of decompression alone and decompression plus fusion in the treatment of DLSS with or without spondylolisthesis.

STUDY DESIGN

A systematic review and meta-analysis of the therapeutic effects of decompression for DLSS with or without the combination of fusion.

METHODS

A literature search in five relevant databases, including Web of Science, PubMed, Embase, Medline, and Cochrane Library was performed from the inception of the database to March 2022. Only randomized controlled trials (RCTs) assessing the comparison between decompression and decompression plus fusion for DLSS were included.

RESULTS

A total of seven studies, 894 patients were analyzed in this meta-analysis. Among these, 443 patients were included in the decompression plus fusion group while 451 patients were included in the decompression alone group. Pooled analysis showed that the combination of decompression with fusion had no superior benefits to decompression alone in terms of Oswestry Disability Index (ODI) score in the first 2 years and long-term follow-up after surgery, also no significant difference in the improvement of back and leg pain was found between two groups. Adding fusion to decompression was associated with a longer operation time, higher complication rate, more blood loss, and extended hospital stay. Furthermore, there was no difference in reoperation rates and patients' satisfaction between the two groups at the last follow-up.

CONCLUSION

Decompression plus fusion may not be associated with a better clinical outcome in ODI scores and back or leg pain improvement but with a longer duration of operation time, extended hospital stay, and more blood loss.

Incidence of Revision Surgery After Decompression With vs Without Fusion Among Patients With Degenerative Lumbar Spinal Stenosis

IMPORTANCE

Only limited data derived from large prospective cohort studies exist on the incidence of revision surgery among patients who undergo operations for degenerative lumbar spinal stenosis (DLSS).

OBJECTIVE

To assess the cumulative incidence of revision surgery after 2 types of index operations-decompression alone or decompression with fusion-among patients with DLSS.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed data from a multicenter, prospective cohort study, the Lumbar Stenosis Outcome Study, which included patients aged 50 years or older with DLSS at 8 spine surgery and rheumatology units in Switzerland between December 2010 and December 2015. The follow-up period was 3 years. Data for this study were analyzed between October and November 2021.

EXPOSURES

All patients underwent either decompression surgery alone or decompression with fusion surgery for DLSS.

MAIN OUTCOMES AND MEASURES

The primary outcome was the cumulative incidence of revision operations. Secondary outcomes included changes in the following patient-reported outcome measures: Spinal Stenosis Measure (SSM) symptom severity (higher scores indicate more pain) and physical function (higher scores indicate more disability) subscale scores and the EuroQol Health-Related Quality of Life 5-Dimension 3-Level questionnaire (EQ-5D-3L) summary index score (lower scores indicate worse quality of life).

RESULTS

A total of 328 patients (165 [50.3%] men; median age, 73.0 years [IQR, 66.0-78.0 years]) were included in the analysis. Of these, 256 (78.0%) underwent decompression alone and 72 (22.0%) underwent decompression with fusion. The cumulative incidence of revisions after 3 years of follow-up was 11.3% (95% CI, 7.4%-15.1%) for the decompression alone group and 13.9% (95% CI, 5.5%-21.5%) for the fusion group (log-rank P = .60). There was no significant difference in the need for revision between the 2 groups over time (unadjusted absolute risk difference, 2.6% [95% CI, -6.3% to 11.4%]; adjusted absolute risk difference, 3.9% [95% CI, -5.2% to 17.0%]; adjusted hazard ratio, 1.40 [95% CI, 0.63-3.13]). The number of revisions was significantly associated with higher SSM symptom severity scores (β, 0.171; 95% CI, 0.047-0.295; P = .007) and lower EQ-5D-3L summary index scores (β, -0.061; 95% CI, -0.105 to -0.017; P = .007) but not with higher SSM physical function scores (β, 0.068; 95% CI, -0.036 to 0.172; P = .20). The type of index operation was not significantly associated with the corresponding outcomes.

CONCLUSIONS AND RELEVANCE

This cohort study showed no significant association between the type of index operation for DLSS-decompression alone or fusion-and the need for revision surgery or the outcomes of pain, disability, and quality of life among patients after 3 years. Number of revision operations was associated with more pain and worse quality of life.

Comparison Between Fusion and Non-Fusion Surgery for Lumbar Spinal Stenosis: A Meta-analysis

INTRODUCTION

A large number of studies have shown that, for severe lumbar spinal stenosis, decompression surgery can often obtain better results than non-surgical treatment. However, whether the lumbar spine is fixed after decompression is still controversial. The results of biomechanical studies indicate that there is a correlation between the range of decompression and postoperative spinal instability.

METHODS

The multiple databases like Pubmed, Embase, Cochrane databases and China National Knowledge database were used to search for the relevant studies, and full-text articles involved in the evaluation of fusion and nonfusion surgery for lumbar spinal stenosis. Review Manager 5.2 was adopted to estimate the effects of the results among selected articles. Forest plots, sensitivity analysis and bias analysis for the articles included were also conducted.

RESULTS

A total of nine relevant studies were eventually satisfied the included criteria. There were significant differences in length of stay [mean difference (MD) = 3.04, 95% CI (2.00, 4.08), P < 0.000]1), but there were no differences in Oswestry Disability Index (ODI score) [MD = - 1.14, 95% CI (- 2.92, 0.63), P = 0.21; I² = 87%] and complications [RR = 1 with 95% CI (0.69, 1.46), P value of overall effect was 0.98]. The study was robust and limited publication bias was observed in this study.

CONCLUSION

Our research supported that fusion and nonfusion surgeries had no differences in clinical effects and complications for lumbar spinal stenosis, while fusion surgery involved a longer length of stay than nonfusion surgery.

Evaluating the Minimal Clinically Important Difference of EQ-5D-3L in Patients With Degenerative Lumbar Spinal Stenosis: A Swiss Prospective Multicenter Cohort Study

STUDY DESIGN

Analysis of a prospective, multicenter cohort study.

OBJECTIVE

The aim of our study was to compare thresholds of published minimal clinically important differences (MCID) for the three-level EuroQol-5D health survey (EQ-5D-3L) summary index (range -0.53 to 1.00) with our anchor-based estimate and evaluate how useful these thresholds are in determining treatment success in patients undergoing surgery for degenerative lumbar spinal stenosis (DLSS).

SUMMARY OF BACKGROUND DATA

MCID values for EQ-5D-3L are specific to the underlying disease and only three studies have been published for DLSS patients reporting different values.

METHODS

Patients of the multicenter Lumbar Stenosis Outcome Study with confirmed DLSS undergoing first-time decompression or fusion surgery with 12-month follow-up were enrolled in this study. To calculate MCID we used the Spinal Stenosis Measure satisfaction subscale as anchor.

RESULTS

For this study, 364 patients met the inclusion criteria; of these, 196 were very satisfied, 72 moderately satisfied, 43 somewhat satisfied, and 53 unsatisfied 12 months after surgery. The MCID calculation estimated for EQ-5D-3L a value of 0.19. Compared with published MCID values (ranging from 0.30 to 0.52), our estimation is less restrictive.

CONCLUSIONS

In patients with LSS undergoing surgery, we estimated an MCID value for EQ-5D-3L summary index of 0.19 with the help of the average change anchor-based method, which we find to be the most suitable method for assessing patient change scores.

LEVEL OF EVIDENCE

3.

Long-term Results After Surgical or Nonsurgical Treatment in Patients With Degenerative Lumbar Spinal Stenosis: A Prospective Multicenter Study

STUDY DESIGN

Prospective, multicenter cohort study.

OBJECTIVE

The aim of our study was to assess the course of patients over a period of 3 years undergoing surgical or nonsurgical treatments for degenerative lumbar spinal stenoses (DLSS) based on data from the Lumbar Stenosis Outcome Study (LSOS), prospectively performed in eight hospitals.

SUMMARY OF BACKGROUND DATA

The optimal treatment strategy for patients with DLSS is still debated.

METHODS

The outcomes of patients with verified DLSS were quantified by Spinal Stenosis Measure (SSM) symptoms- and SSM function-scores, and EQ-5D-3L (quality of life) summary index (SI) over time (up to 36-month follow-up), and minimal clinically important difference (MCID) in SSM symptoms, SSM function, and EQ-5D-3L SI from baseline to 36-month follow-up.

RESULTS

For this study, 601 patients met the inclusion criteria; 430 underwent surgery, 18 of them only after more than a year after enrolment, 171 received nonsurgical treatment only. At baseline, patients in the surgical and nonsurgical groups had similar values for the SSM symptoms and SSM function scores, but patients in the surgical group suffered significantly more from buttocks pain and reported more worsening symptoms over the last 3 months before enrollment in the study. Surgically treated patients (except changers) performed significantly better in all clinical outcome measures (P < 0.001) with a plateau at 12-month follow-up staying constant until the follow-up ended. Further, two-thirds of patients in the surgical group had a relevant improvement in function, symptoms, and quality of life, compared with only about half of those in terms of symptoms and even less in terms of function and quality of life with nonsurgical treatment.

CONCLUSIONS

Surgical treatment of DLSS results in more favorable clinical outcomes with a sustained effect over time, compared to nonsurgical treatment.

LEVEL OF EVIDENCE

3.

Degenerative Lumbar Spinal Stenosis

Degenerative lumbar spinal stenosis is the most frequent cause of low back pain and/or sciatica in the elderly patient. Epidemiology, pathophysiology, clinical manifestations and testing are reviewed in a wide current bibliographic investigation. The importance of the relationship between clinical presentation and imaging study, especially magnetic resonance imaging (MRI), is emphasized. Prior to treatment indication, it is necessary to identify the precise location of pain, as well as the differential diagnosis between neurological and vascular lameness. Conservative treatment combining medications with various physical therapy techniques solves the problem in most cases, while therapeutic testing with injections, whether epidural, foraminal or facetary, is performed when pain does not subside with conservative treatment and before surgery is indicated. Injections usually perform better results in relieving sciatica symptoms and less in neurological lameness. Equine tail and/or root decompression associated or not with fusion is the gold standard when surgical intervention is required. Fusion after decompression is necessary in cases with segmental instability, such as degenerative spondylolisthesis. When canal stenosis occurs at multiple levels and is accompanied by axis deviation, whether coronal and/or sagittal, correction of axis deviations should be performed in addition to decompression and fusion, especially of the sagittal axis, in which a lumbar lordosis correction is required with techniques that correct the rectified lordosis to values close to the pelvic incidence.

Feasibility and Outcomes of Tubular Decompression in Extreme Stenosis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To report the feasibility, nuances, technical tips as well as outcomes of managing single-level grade D (extreme stenosis) and to compare the outcomes with nonextreme stenosis using the tubular retractor system.

SUMMARY OF BACKGROUND DATA

Minimally invasive decompression in extreme stenosis is a challenge due to technical difficulty, feasibility of adequate decompression, and a steep learning curve.

METHODS

Consecutive patients from January 2007 to January 2017 presenting with neurogenic claudication secondary to single-level spinal stenosis operated using tubular retractors were included in the study. The patients were divided into two groups; extreme-stenosis and nonextreme stenosis. The outcomes of surgery were evaluated and compared using visual analogue score (VAS) for leg and back pain, Oswestry disability index (ODI), and MacNab's criteria.

RESULTS

A total of 325 patients (out of 446 patients after excluding the multilevel cases) fulfilled the inclusion criteria. One hundred forty patients were cases of extreme stenosis and 185 were nonextreme stenosis. The mean VAS for back and leg pain for extreme stenosis improved from 3.23 ± 1.30 to 2.15 ± 0.91 and 7.33 ± 0.78 to 1.66 ± 1.03 respectively as compared with nonextreme stenosis where the mean VAS for back and leg pain improved from 3.01 ± 1.15 to 1.86 ± 1.10 and 6.57 ± 1.00 to 1.54 ± 1.12 respectively. The mean ODI changed from 66.47 ± 7.53 to 19.95 ± 2.90 in extreme stenosis as compared with nonextreme stenosis where mean ODI changed from 59.05 ± 5.08 to 19.88 ± 2.67. As per MacNab's criteria 102 (of 120 patients) and 139 (of 157 patients) reported excellent and good outcomes in extreme and nonextreme stenosis respectively.

CONCLUSION

Tubular decompression is feasible in patients with extreme-stenosis with no difference in the outcomes as well as complication rates when compared with a cohort of nonextreme stenosis.

LEVEL OF EVIDENCE

3.

Efficacy Analysis of Percutaneous Endoscopic Lumbar Discectomy Combined with PEEK Rods for Giant Lumbar Disc Herniation: A Randomized Controlled Study

Objective

This study describes a randomized controlled trial that assesses percutaneous endoscopic lumbar discectomy (PELD) combined with a polyetheretherketone (PEEK) rod in patients with GLDH (herniation affecting 50% of the sagittal diameter of the spinal canal) and reports the 2-year follow-up outcome.

Methods

In all, 243 patients were randomly assigned to undergo PELD or PELD combined with a PEEK rod by generating random numbers with a random number generator. Clinical outcome data, including the numerical rating scale (NRS), were used to assess the patients' back and leg pain, while the Oswestry Disability Index (ODI) was used to quantify pain and disability. Imaging data included intervertebral disc height (IDH), range of motion (ROM), and modified Pfirrmann grades.

Results

At the final follow-up, the NRS for back and leg pain and the ODI scores were significantly decreased in both groups. The NRS for back pain and the ODI scores in the PELD + PEEK group (1.32 ± 0.70, 14.10 ± 4.74) were better than those in the PELD group (1.91 ± 0.69, 16.93 ± 4.33) (P < 0.05). The IDH of the PELD + PEEK group (10.54 ± 1.62) was significantly higher than that in the PELD group (9.98 ± 1.90) (P < 0.05). The IDH of the PELD + PEEK group (10.54 ± 1.62) was significantly higher than that in the PELD group (9.98 ± 1.90) (P < 0.05). The IDH of the PELD + PEEK group (10.54 ± 1.62) was significantly higher than that in the PELD group (9.98 ± 1.90) (

Conclusion

For symptomatic patients with GLDH, both PELD and PELD combined with a PEEK rod showed good efficacy. However, the long-term effect of PELD combined with a PEEK rod is better than that of PELD alone. Moreover, PELD combined with a PEEK rod can effectively reduce the recurrence rate. Maximum benefit can be gained if we adhere to strict selection criteria for PELD combined with a PEEK rod.

Are There Differences Between Patients with Extreme Stenosis and Non-extreme Stenosis in Terms of Pain, Function or Complications After Spinal Decompression Using a Tubular Retractor System?

BACKGROUND

Micro-tubular decompression in extreme lumbar spinal stenosis is challenging because it is technically difficult to achieve adequate decompression. Whether the results of micro-tubular decompression related to pain, function, and complications in lumbar spinal stenosis of the extreme and non-extreme varieties are different has not yet been conclusively established.

QUESTIONS/PURPOSES

Are there differences between patients with extreme stenosis and non-extreme stenosis in terms of (1) VAS back or leg pain, (2) Oswestry Disability Index (ODI), or (3) complications when they were treated with spinal decompression using a tubular retractor system?

METHODS

Between January 2007 and January 2017, one surgeon performed 325 single-level lumbar micro-tubular decompressions without fusion. Of those, 43% (140 of 325) had extreme stenosis (defined as the absence of cerebrospinal fluid signal and a grey homogeneous dural sac with unrecognizable rootlets and posterior epidural fat in T2 weighted axial MRI image) and the rest had non-extreme stenosis. During this time, we used tubular retractors for these procedures in patients with simple lumbar spinal stenosis who had persistent symptoms despite conservative treatment for neurogenic claudication. No alternate form of decompression was performed in the study period. Patients with complex lumbar spinal stenosis associated with a deformity or instability who were treated with instrumented fusion were excluded. A total of 14% (20 of 140) patients in the extreme stenosis group and 15% (28 of 185) patients in the non-extreme stenosis group were lost to follow-up before 2 years; the remaining 120 patients with extreme stenosis and 157 patients with non-extreme stenosis were analyzed at a mean follow-up of 33 ± 5 months in this retrospective, comparative study. The groups were not different at baseline in terms of preoperative VAS score for back pain, age, gender, BMI or the percentage who had diabetes or who smoked. However, patients with extreme stenosis had higher preoperative ODI scores and higher preoperative VAS score for leg pain compared with the non-extreme group. There was a higher proportion of men in the non-extreme stenosis group (56% [104 of 185] versus 50% [71 of 140]; p = 0.324). Study endpoints were VAS score for leg and back pain, ODI, and complications, all of which were ascertained by chart review. With the numbers available, we could detect with 80% power at p < 0.05 a difference of 0.93 cm of 10 cm on a 10-cm VAS scale for VAS leg pain; a difference of 1.00 cm of 10 cm on a 10-cm VAS scale for VAS back pain and a difference of 2.12 cm of 100 cm on a 100-cm ODI scale.

RESULTS

In terms of pain, both groups improved after surgery, but there was no between-group difference in terms of the VAS scores at the most recent follow-up. VAS back pain improved from a mean of 3 ± 1 to 2 ± 1 in the extreme stenosis group and from 3 ± 1 to 1 ± 1 in the non-extreme stenosis group (p = 0.904); VAS leg pain improved from 7 ± 1 to 1 ± 1 versus 6 ± 1 to 1 ± 1, respectively (p = 0.537). ODI scores likewise improved in both groups, with no between-group difference in the ODI scores at latest follow-up (66 ± 7 to 19 ± 2 in the extreme stenosis group versus 59 ± 5 to 19 ± 2 in the non-extreme stenosis group (p = 0.237). Complications in the group with extreme stenosis occurred in six patients (incidental dural tears in two patients, urinary retention in three patients, and Syndrome of Inappropriate Anti Diuretic Hormone secretion (SIADH) in one patient); complications in the non-extreme stenosis occurred in two patients (incidental dural tears in two patients).

CONCLUSIONS

The results in terms of improvement in VAS for leg and back pain and ODI scores were not different between patients with extreme and non-extreme stenosis. Micro-tubular decompression can be thus considered an alternative for patients with extreme stenosis. Future studies, ideally multicentre, comparative trials, are needed to confirm our preliminary results.

LEVEL OF EVIDENCE LEVEL

III, therapeutic study.

Revision after spinal stenosis surgery

PURPOSE

To make a literature review on spinal stenosis recurrence after a first surgery and edit rules to avoid this complication.

METHODS

We conducted two separate PUBMED searches to evaluate the revision post-stenosis and degenerative scoliosis surgery using the terms: lumbar vertebrae/surgery, spinal stenosis, spine, scoliosis and reoperation. The resulting papers were categorized into three groups: (1) those that evaluated reoperation post-simple decompression; (2) those that evaluated spinal decompression and fusion for short (3 levels or less) or long (more than 3 levels) segment spinal fusion; and (3) those diagnosing the stenosis during the surgery.

RESULTS

(1) We found 11 relevant papers that only looked at revision spine surgery post-laminectomy for spinal stenosis. (2) We found 20 papers looked at reoperation post-laminectomy and fusion amongst which there were two papers specifically comparing long-segment (> 3 level) and short-segment (3 or less levels) fusions. (3) In the unspecified group, we found only one article. Fifteen articles were excluded as they were not specifically looking at our objective criteria for revision surgery. In regard to revision post-adult deformity surgery, we found 18 relevant articles.

CONCLUSIONS

After this literature review and analysis of post-operative stenosis, it seems important to provide some advice to avoid revision surgeries more or less induced by the surgery. It looks interesting when performing simple decompression without fusion in the lumbar spine to analyse the risk of instability induced by the decompression and facet resection but also by a global balance analysis. Regarding pre-operative stenosis in a previously operated area, different causes may be evocated, like screw or cage malpositionning but also insufficient decompression which is a common cause. Intraoperatively, the use of neuromonitoring and intraoperative CT scan with navigation are useful tool in complex cases to avoid persisting stenosis. Pre-op analysis and planning are key parameters to decrease post-op problems. These slides can be retrieved under Electronic Supplementary Material.

Decompression with fusion is not in superiority to decompression alone in lumbar stenosis based on randomized controlled trials: A PRISMA-compliant meta-analysis

BACKGROUND

Although some studies had been published, it was more controversial on the superiority of decompression alone (D) and decompression with fusion (F) for the treatment of lumbar spinal stenosis (LSS) recently, especially newest articles with different opinions. A meta-analysis was performed to compare efficacy on D and F for LSS regardless of degenerative spondylolisthesis (DS) with randomized controlled trials (RCTs).

METHODS

The databases include PUBMED/MEDLINE, EMBASE, Cochrane Library, and Web of Science from January 1970 to December 2018. The information of screened studies included demographics, clinical outcomes, and secondary measures, then data synthesis and meta-analysis were progressed. Subgroup analysis was stratified by DS and follow-up time (36 months). Continuous variables and dichotomous variables were respectively reported as weighted mean difference and odds ratios (ORs). The strength of evidence was evaluated by the grades of recommendation, assessment, development, and evaluation (GRADE) system.

RESULTS

Nine RCTs met inclusion criteria with a total of 857 patients (367 were in D group and 490 were in F group). There were no statistical difference in visual analog scale changes on back and leg pain between D and F group (mean difference [MD] = -0.03, 95% confidence interval [CI] [-0.38, 0.76], z = 0.08, P = .94; MD = 0.11, 95% CI [-1.08, 1.30], z = 0.18, P = .86, respectively); patients' satisfaction was of no difference between the 2 groups, together with the change of the Oswestry disability index and European quality of life-5 dimensions (P > .05). There were no difference in the rate of complication (P = .50) and reoperation (P = .11) while a statistical significance of longer operation duration (P < .0001), more blood loss (P = .004) but amazing lower rate of adjacent segment degenerative/disease (ASD) (OR = 2.35, P = .02) in F group. The subgroup analysis on DS showed that basically all measures were in consistency with meta-analysis. There was a higher reoperation rate in middle-to-long term (>36 months) in D group and ASD was the most seasons of reoperation no matter the follow-up time. According to the GRADE system, the grade of this meta-analysis was of "High" quality.

CONCLUSION

F group has no better clinical results than D alone in LSS, regardless of DS and follow-up. The conclusion is of "High" quality and the grade strength of recommendation was "Strong."

Outcome of unilateral versus standard open midline approach for bilateral decompression in lumbar spinal stenosis: is "over the top" really better? A Swiss prospective multicenter cohort study

OBJECTIVE

In this retrospective analysis of a prospective multicenter cohort study, the authors assessed which surgical approach, 1) the unilateral laminotomy with bilateral spinal canal decompression (ULBD; also called "over the top") or 2) the standard open bilateral decompression (SOBD), achieves better clinical outcomes in the long-term follow-up. The optimal surgical approach (ULBD vs SOBD) to treat lumbar spinal stenosis remains controversial.

METHODS

The main outcomes of this study were changes in a spinal stenosis measure (SSM) symptoms score, SSM function score, and quality of life (sum score of the 3-level version of the EQ-5D tool [EQ-5D-3L]) over time. These outcome parameters were measured at baseline and at 12-, 24-, and 36-month follow-ups. To obtain an unbiased result on the effect of ULBD compared to SOBD the authors used matching techniques relying on propensity scores. The latter were calculated based on a logistic regression model including relevant confounders. Additional outcomes of interest were raw changes in main outcomes and in the Roland and Morris Disability Questionnaire from baseline to 12, 24, and 36 months.

RESULTS

For this study, 277 patients met the inclusion criteria. One hundred forty-nine patients were treated by ULBD, and 128 were treated by SOBD. After propensity score matching, 128 patients were left in each group. In the matched cohort, the mean (95% CI) estimated differences between ULBD and SOBD for change in SSM symptoms score from baseline to 12 months were -0.04 (-0.25 to 0.17), to 24 months -0.07 (-0.29 to 0.15), and to 36 months -0.04 (-0.28 to 0.21). For change in SSM function score, the estimated differences from baseline to 12 months were 0.06 (-0.08 to 0.21), to 24 months 0.08 (-0.07 to 0.22), and to 36 months 0.01 (-0.16 to 0.17). Differences in changes between groups in EQ-5D-3L sum scores were estimated to be -0.32 (-4.04 to 3.40), -0.89 (-4.76 to 2.98), and -2.71 (-7.16 to 1.74) from baseline to 12, 24, and 36 months, respectively. None of the group differences between ULBD and SOBD were statistically significant.

CONCLUSIONS

Both surgical techniques, ULBD and SOBD, may provide effective treatment options for DLSS patients. The authors further determined that the patient outcome results for the technically more challenging ULBD seem not to be superior to those for the SOBD even after 3 years of follow-up.

What is the treatment effect of surgery compared with nonoperative treatment in patients with lumbar spinal stenosis at 1-year follow-up?

OBJECTIVE

The aim of this study was to obtain an unbiased causal treatment estimate of the between-group difference of surgery versus nonoperative treatment with respect to outcomes on quality of life, pain, and disability in patients with degenerative lumbar spinal stenosis (DLSS) 12 months after baseline.

METHODS

The authors included DLSS patients from a large prospective multicenter observational cohort study. Propensity score matching was used, including 15 demographic, clinical, and MRI variables. Linear and logistic mixed-effects regression models were applied to quantify the between-group treatment effect. Unmeasured confounding was addressed in a sensitivity analysis, assessing the robustness of the results.

RESULTS

A total of 408 patients were included in this study, 222 patients after matching, with 111 in each treatment group. Patients with nonoperative treatment had lower quality of life at the 12-month follow-up (-6.21 points, 95% CI -9.93 to -2.49) as well as lower chances of reaching a minimal clinically important difference in Spinal Stenosis Measure (SSM) symptoms (OR 0.26, 95% CI 0.13 to 0.53) and SSM function (OR 0.26, 95% CI 0.14 to 0.49), than patients undergoing surgery. These results were very robust in case of unmeasured confounding. The surgical complication rate was low; 5 (4.5%) patients experienced a durotomy during intervention, and 5 (4.5%) patients underwent re-decompression.

CONCLUSIONS

The authors used propensity score matching to assess the difference in treatment efficacy of surgery compared with nonoperative treatment in elderly patients with DLSS. This study delivers strong evidence that surgical treatment is superior to nonoperative treatment. It helps in clinical decision-making, especially when patients suffer for a long time, sometimes over many years, hoping for a spontaneous improvement of their symptoms. In light of these new results, the number of years with disability can hopefully be reduced by providing adequate treatment at the right time for this ever-growing elderly and frail population.

Prognostic function to estimate the probability of meaningful clinical improvement after surgery - Results of a prospective multicenter observational cohort study on patients with lumbar spinal stenosis

BACKGROUND

Approximately two thirds of patients with lumbar spinal stenosis (LSS) who undergo surgical treatment benefit from the surgery. The objective of this study was to derive a prognostic probability function (PPF) to identify patients with a high probability of post-surgical improvement because there is currently no method available.

METHODS

In this multicenter, prospective, observational study, we collected data from eight medical centers in Switzerland in which patients underwent surgery for LSS. The endpoints were meaningful clinically important differences (MCID) in pain and disability one year after baseline. We developed a PPF named PROCESS (PostopeRative OutComE Spinal Stenosis), based on a large set of prognostic indicators extracted from the literature. The PPF was derived using data from a random subset of two thirds of the patients and validated in the remaining third. We addressed overfitting by shrinking the regression coefficients. The area under the ROC curve (AUC) and calibration determined the accuracy of the PPF.

RESULTS

In this study, 452 LSS patients received surgery. 73% of the 300 patients in the derivation subset reached an MCID in pain and 68% reached an MCID in disability. The corresponding values were 70% and 63% in the validation subset, respectively. In the derivation subsample, the AUC was 0.64 (95% CI 0.57 to 0.71) for of the PPF predicting MCID in pain and 0.71 (0.64 to 0.77) for MCID in disability, after shrinkage. The corresponding numbers were 0.62 (0.52 to 0.72) and 0.70 (0.60 to 0.79) in the validation subsample, and the PPF showed good calibration.

CONCLUSIONS

Surgical treatment for patients with lumbar spinal stenosis is being performed with increasing frequency. PROCESS is conditional on the individual pattern of preoperatively available prognostic indicators, and may be helpful for clinicians in counselling patients and in guiding the discussion on individual treatment decision in the era of personalized medicine.

Do Preoperative Corticosteroid Injections Increase the Risk for Infections or Wound Healing Problems After Spine Surgery?: A Swiss Prospective Multicenter Cohort Study

STUDY DESIGN

A prospective multicenter cohort study.

OBJECTIVES

This study evaluates the risk for surgical site infections (SSIs) or wound healing problems (WHPs) in patients who underwent corticosteroid injection before lumbar decompression surgery.

SUMMARY OF BACKGROUND DATA

Corticosteroid injections are often used for the treatment of the degenerated spine. However, their well-known immunosuppressive effects could increase the risk for local infections, particularly if a surgical intervention follows the injection rapidly.

METHODS

The Swiss Lumbar Stenosis Outcome Study (LSOS), which is a prospective multicenter cohort study of patients with symptomatic lumbar spinal stenosis, was used as database. Of 743 patients, 422 patients underwent surgery and were eligible for the study. Ten patients (2.4%) were revised for either SSIs (n = 6) or WHPs (n = 4). A control group (n = 19) was constructed matched according to age, sex, diabetes, and body mass index (BMI). Odds ratios (ORs) were calculated by using a conditional logistic regression model to quantify the risk of SSI or WHP after preoperative corticosteroid injection. Subgroup analysis was performed for patients with injection within 0 to 3 months before surgery, 0 to 6 months before surgery, or any injection at all before surgery.

RESULTS

Within this cohort, no significant association could be found between preoperative corticosteroid injection and postoperative SSI or WHP in patients with corticosteroid injections within 0 to 3 months before surgery [OR = 0.36, 95% confidence interval (95% CI) 0.04-3.22], 0 to 6 months before surgery (OR = 0.69 95% CI 0.14-3.49), or any time before surgery (OR = 0.43, 95% CI 0.04-3.22).

CONCLUSION

Within the here investigated cohort, the risk of SSIs or WHPs following lumbar spinal decompression surgery seems not highly associated with preoperative corticosteroid injections. However, the safe time interval between corticosteroid infiltrations and surgery remains unknown, should not be decreased incautiously, and is the subject of further research.

LEVEL OF EVIDENCE

2.

Bilateral decompression and intervertebral fusion via unilateral fenestration for complex lumbar spinal stenosis with a mobile microendoscopic technique

For complex lumbar spinal stenosis, using of endoscopy technique may provide clear vision with less invasive dissection of paravertebral muscle. The objective of this study was to evaluate the feasibility and clinical efficacy of bilateral decompression and intervertebral fusion via unilateral fenestration for complex lumbar spinal stenosis using mobile microendoscopic discectomy (MMED) technique.A total of 61 patients with complex lumbar spinal stenosis (lumbar canal stenosis combined with degenerative spondylolisthesis, instability, and scoliosis) were treated with this procedure. Patients with isolated lumbar spinal stenosis or spondylolisthesis greater than grade II were excluded. The index levels included L4/5 in 52 patients, L5/S1 in 6 patients, L3-L5 in 2 patients and L4-S1 in 1 patient. The preoperative Oswestry Disability Index (ODI) score was 42.6 ± 10.2, lumbar visual analog scale (VAS) score was 6.1 ± 4.2, and leg VAS score was 7.1 ± 5.1. During the operation, ipsilateral enlarged fenestration was made using the MMED technique. The disc and cartilage endplate were thoroughly removed, and the contralateral ligamentum flavum and the inner layer of lamina were undercut to release the contralateral nerve root. The intervertebral space was released and prepared, followed by bone grafting and cage insertion. Percutaneous pedicle system was used for reduction and fixation. The operative time and blood loss were recorded, and patients were followed-up for at least 3 years (36-48 months, average 41 months) to evaluate the clinical efficacy.The procedure was successful in all patients, with no nerve injury or conversion to open operation. The mean operative time was 120 minutes (range, 100-180 minutes), with a mean blood loss of 100 mL (range, 50-200 mL). Postoperative x-ray and CT showed sufficient decompression and improvement of spinal alignment. At 3 years after surgery, the ODI scores, lumbar and leg VAS scores decreased from preoperative 42.6 ± 10.2, 6.1 ± 4.2, and 7.1 ± 5.1 to 8.6 ± 7.0, 1.8 ± 1.3, and 0.9 ± 0.6, respectively (P = .00 for each comparison). The clinical results were excellent in 36 cases, good in 23, and fair in 2, according to the MacNab scale.The procedure of bilateral decompression and intervertebral fusion via unilateral fenestration using the MMED technique can provide satisfactory clinical results for complex lumbar spinal stenosis.

Influence of Paravertebral Muscle Quality on Treatment Efficacy of Epidural Steroid Infiltration or Surgical Decompression in Lumbar Spinal Stenosis-Analysis of the Lumbar Spinal Outcome Study (LSOS) Data: A Swiss Prospective Multicenter Cohort Study

STUDY DESIGN

Prospective multicenter cohort study.

OBJECTIVE

To study the question whether paravertebral muscle quality may affect the clinical outcome of epidural steroid infiltration (ESI) or surgical decompression in patients with symptomatic lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

To the present, the impact of paravertebral muscle quality on clinical outcome of ESI or surgical decompression in patients with LSS has not been clarified.

METHODS

The Lumbar Stenosis Outcome Study was used as database. Patients with symptomatic LSS who received an ESI (group I) or lumbar decompression surgery (group II), had a follow-up of at least 12 months and a pretreatment lumbar magnetic resonance imaging were included (n = 205). Paravertebral muscle quality was quantified by the degree of fatty degeneration (according to Goutallier) on the level L3. Clinical outcome was assessed using the Spinal Stenosis Measure, Numeric Rating Scale, Roland and Morris Disability Questionnaire, and EQ-5D-3L sum score. Reinfiltration, surgery following infiltration, or revision was defined as treatment failure.

RESULTS

ESI (group I) and surgical treatment (group II) were associated with a failure rate of 60% and 12.7%, respectively. In group I, there was a tendency for the rate of reintervention to be less in patients with bad muscle quality (P = 0.22). In group II, improvements in the clinical outcomes up to 12 months did not differ between Goutallier stage ≤1 and ≥2. Patients with Goutallier stage ≤1 had more improvement in Spinal Stenosis Measure symptoms (P = 0.04).

CONCLUSION

Relevant fatty degeneration of the paravertebral musculature, as a sign of low muscle quality, has low impact on clinical outcome and the high failure rates with conservative treatment by ESI compared to surgical decompression. Therefore fatty degeneration has no relevant prognostic value for LSS treatment.

LEVEL OF EVIDENCE

2.

The Influence of Single-level Versus Multilevel Decompression on the Outcome in Multisegmental Lumbar Spinal Stenosis: Analysis of the Lumbar Spinal Outcome Study (LSOS) Data

STUDY DESIGN

This is prospective multicenter cohort study.

OBJECTIVE

To assess whether patients with confirmed multisegmental lumbar spinal stenosis benefit more from a single-level or a multilevel decompression.

SUMMARY OF BACKGROUND DATA

In multisegmental lumbar spinal stenotic cases, the decision as to how many levels of stenosis need to be operated to achieve the best possible clinical outcome is still unknown and remains a controversy between spine surgeons.

MATERIALS AND METHODS

Patients of the Swiss Lumbar Stenosis Outcome Study (LSOS) with confirmed multisegmental LSS undergoing first-time decompression without fusion were enrolled in this study. The main outcomes of this study were Spinal Stenosis Measure (SSM) symptoms and function over time, measured at baseline, 6, 12, and 24 months follow-up. Further outcomes of interest were changes in SSM, numeric rating scale, feeling thermometer, the EQ-5D-EL, and the Roland and Morris disability questionnaire from baseline to 6, 12, and 24 months.

RESULTS

After 12 months, a total of 141 patients met the inclusion criteria; of these, 33 (23%) underwent a single-level and 108 (77%) a multilevel decompression. Multilevel decompression was associated with a significantly less favorable SSM symptoms and function score, respectively, as compared with single-level decompression. In all further outcomes of interest single-level as well as multilevel patients improved over time.

CONCLUSIONS

Our study showed that in multisegmental stenotic cases a single-level decompression was associated with a significantly more favorable SSM symptoms and function score, respectively, as compared with multilevel decompression. This study provides evidence that in multisegmental stenotic cases a single-level decompression might be sufficient to improve patient's symptoms and function.

Adult Degenerative Lumbar Scoliosis

Adult degenerative lumbar scoliosis is a 3-dimensional deformity defined as a coronal deviation of greater than 10°. It causes significant pain and disability in the elderly. With the aging of the population, the incidence of adult degenerative lumbar scoliosis will continue to increase. During the past decade, advancements in surgical techniques and instrumentation have changed the management of adult spinal deformity and led to improved long-term outcomes. In this article, the authors provide a comprehensive review of the pathophysiology, diagnosis, and management of adult degenerative lumbar scoliosis. [Orthopedics. 2017; 40(6):e930-e939.].

Application of Gelatin Sponge Impregnated with a Mixture of 3 Drugs to Intraoperative Nerve Root Block Combined with Robot-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery in the Treatment of Adult Degenerative Scoliosis: A Clinical Observation Including 96 Patients

OBJECTIVE

Application of nerve root block is mainly for diagnosis with less application in intraoperative treatment. The aim of this study was to observe clinical and imaging outcomes of application of gelatin sponge impregnated with a mixture of 3 drugs to intraoperative nerve root block combined with robot-assisted minimally invasive transforaminal lumbar interbody fusion surgery in to treat adult degenerative lumbar scoliosis.

METHODS

From January 2012 to November 2014, 108 patients with adult degenerative lumbar scoliosis were treated with robot-assisted minimally invasive transforaminal lumbar interbody fusion surgery combined with intraoperative gelatin sponge impregnated with a mixture of 3 drugs. Visual analog scale and Oswestry Disability Index scores were used to evaluate postoperative improvement of back and leg pain, and clinical effects were assessed according to the 36-Item Short-Form Health Survey. Imaging was obtained preoperatively, 1 week and 3 months postoperatively, and at the last follow-up. Fusion status, complications, and other outcomes were assessed.

RESULTS

Follow-up was complete for 96 patients. Visual analog scale scores of leg and back pain on postoperative days 1-7 were decreased compared with preoperatively. At 1 week postoperatively, 3 months postoperatively, and last follow-up, visual analog scale score, Oswestry Disability Index score, coronal Cobb angle, and coronal and sagittal deviated distance decreased significantly (P = 0.000) and lumbar lordosis angle increased (P = 0.000) compared with preoperatively. Improvement rate of Oswestry Disability Index was 81.8% ± 7.4. Fusion rate between vertebral bodies was 92.7%.

CONCLUSIONS

Application of gelatin sponge impregnated with 3 drugs combined with robot-assisted minimally invasive transforaminal lumbar interbody fusion for treatment of adult degenerative lumbar scoliosis is safe and feasible with advantages of good short-term analgesia effect, minimal invasiveness, short length of stay, and good long-term clinical outcomes.

Decompression Surgery Alone Versus Decompression Plus Fusion in Symptomatic Lumbar Spinal Stenosis: A Swiss Prospective Multicenter Cohort Study With 3 Years of Follow-up

STUDY DESIGN

Retrospective analysis of a prospective, multicenter cohort study.

OBJECTIVE

To estimate the added effect of surgical fusion as compared to decompression surgery alone in symptomatic lumbar spinal stenosis patients with spondylolisthesis.

SUMMARY OF BACKGROUND DATA

The optimal surgical management of lumbar spinal stenosis patients with spondylolisthesis remains controversial.

METHODS

Patients of the Lumbar Stenosis Outcome Study with confirmed DLSS and spondylolisthesis were enrolled in this study. The outcomes of this study were Spinal Stenosis Measure (SSM) symptoms (score range 1-5, best-worst) and function (1-4) over time, measured at baseline, 6, 12, 24, and 36 months follow-up. In order to quantify the effect of fusion surgery as compared to decompression alone and number of decompressed levels, we used mixed effects models and accounted for the repeated observations in main outcomes (SSM symptoms and SSM function) over time. In addition to individual patients' random effects, we also fitted random slopes for follow-up time points and compared these two approaches with Akaike's Information Criterion and the chi-square test. Confounders were adjusted with fixed effects for age, sex, body mass index, diabetes, Cumulative Illness Rating Scale musculoskeletal disorders, and duration of symptoms.

RESULTS

One hundred thirty-one patients undergoing decompression surgery alone (n = 85) or decompression with fusion surgery (n = 46) were included in this study. In the multiple mixed effects model the adjusted effect of fusion compared with decompression alone surgery on SSM symptoms was 0.06 (95% confidence interval: -0.16-0.27) and -0.07 (95% confidence interval: -0.25-0.10) on SSM function, respectively.

CONCLUSION

Among the patients with degenerative lumbar spinal stenosis and spondylolisthesis our study confirms that in the two groups, decompression alone and decompression with fusion, patients distinctively benefited from surgical treatment. When adjusted for confounders, fusion surgery was not associated with a more favorable outcome in both SSM scores as compared to decompression alone surgery.

LEVEL OF EVIDENCE

3.

Radiographic Risk Factors of Reoperation Following Minimally Invasive Decompression for Lumbar Canal Stenosis Associated With Degenerative Scoliosis and Spondylolisthesis

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

Microsurgical bilateral decompression via a unilateral approach (MBDU), a minimally invasive surgical (MIS) decompression method, has been performed for numerous degenerative lumbar diseases, including degenerative lumbar scoliosis (DLS) or degenerative spondylolisthesis (DS), at our institution. In this study, we evaluated the appropriateness of MBDU for DLS or DS patients.

METHODS

A total of 207 patients treated by MBDU were included (88 women and 119 men; mean age, 70 [40-86] years). Thirty-seven cases were diagnosed as DLS (group A), 51 as DS (group B), and 119 as lumbar canal stenosis (group C). Patient clinical status assessed by JOA score was evaluated preoperatively and 2 years postoperatively. We evaluated the prevalence of cases that required reoperation among the groups and the radiographic risk factors related to reoperation.

RESULTS

There was no significant difference in recovery ratios of JOA scores among the groups. Reoperation after MBDU was needed in 13 cases (6.3%); the revision rate did not significantly differ among the groups. Reoperation was associated with poor clinical status, low visual analog scale score for low back pain, and low SF-36 mental component summary score. Reoperation was significantly associated with preoperative scoliotic disc wedging with Cobb's angle ≥3° in L4-5 (odds ratio = 9.88) and lateral listhesis (odds ratio = 5.22 [total], 12.9 [L4-5]).

CONCLUSIONS

When we are careful to indicate decompression for patients with these risk factors related to reoperation, MIS decompression alone can successfully improve DLS patients with a Cobb's angle of ≤20° or DS patients.

Effectiveness of decompression alone versus decompression plus fusion for lumbar spinal stenosis: a systematic review and meta-analysis

INTRODUCTION

The debate on efficacy of fusion added to decompression for lumbar spinal stenosis (LSS) is ongoing. No meta-analysis has compared the effectiveness of decompression versus decompression plus fusion in treating patients with LSS.

METHODS

A literature search was performed in the Web of Science, PubMed, Embase, and Springer databases from 1970 to 2016. Relevant references were selected and the included studies were manually reviewed. We included trials evaluating decompression surgery compared to decompression plus fusion surgery in treating patients with LSS. The primary outcomes analyzed were back pain, leg pain, Oswestry Disability Index scores (ODI), the quality-of-life EuroQol-5 Dimensions (EQ-5D), duration of operation, intraoperative blood loss, length of hospital stay, major complications, walking ability, number of reoperation, and finally clinically excellent and good rates. Data analysis was conducted using the Review Manager 5.2 software.

RESULTS

Fifteen studies involving 17,785 patients with LSS were included. The overall effect mean difference (MD) (95% CI) in the differences between pre- and post-operative back pain, leg pain, operative time, intraoperative blood loss, and length of stay were 0.04 (-0.36, 0.44), 0.69 (-0.38, 1.76), -2.04 (-3.12, -0.96), -3.96 (-6.64, -1.27) and -4.21 (-10.03, 1.62) (z = 0.18, 1.26, 3.71, 2.89 and 1.41, respectively; P = 0.86, 0.55, 0.0002, 0.004 and 0.16, respectively) in random effects models. The overall effect MD (95% CI) in ODI, EQ-5D, and walking ability were 0.43 (-1.15, 2.00), 0.01 (-0.01, 0.03) and 0.04 (-0.49, 0.57) (z = 0.52, 1.16 and 0.15, respectively; P = 0.59, 0.24 and 0.88, respectively) in fixed effects models. The overall effect odds ratio (OR) (95% CI) of major complications, number of reoperations, and clinically excellent and good rates between the two groups were 0.70 (0.60, 0.81), 1.04 (0.90, 1.19) and 0.31 (0.06, 1.59) (z = 4.63, 0.53 and 1.40, respectively; P < 0.00001, 0.60 and 0.16, respectively). Our study reveals no difference in the effectiveness between the two surgical techniques.

CONCLUSIONS

The additional fusion in the management of LSS yielded no clinical improvements over decompression alone within a 2-year follow-up period. But fusion resulted in a longer duration of operation, more blood loss, and a higher risk of complications. Therefore, the appropriate surgical protocol for LSS should be discussed further.

Minimally invasive decompression surgery for lumbar spinal stenosis with degenerative scoliosis: Predictive factors of radiographic and clinical outcomes

There is ongoing controversy regarding the most appropriate surgical treatment for lumbar spinal stenosis (LSS) with concurrent degenerative lumbar scoliosis (DLS): decompression alone, decompression with limited spinal fusion, or long spinal fusion for deformity correction. The coexistence of degenerative stenosis and deformity is a common scenario; Nonetheless, selecting the appropriate surgical intervention requires thorough understanding of the patients clinical symptomatology as well as radiographic parameters. Minimally invasive (MIS) decompression surgery was performed for LSS patients with DLS. The aims of this study were (1) to investigate the clinical outcomes of MIS decompression surgery in LSS patients with DLS, and (2) to identify the predictive factors for both radiographic and clinical outcomes after MIS surgery. 438 consecutive patients were enrolled in this study. Inclusion criteria was evidence of LSS and DLS with coronal curvature measuring greater than 10°. The Japanese Orthopaedic Association (JOA) score, JOA recovery rate, low back pain (LBP), and radiographic features were evaluated preoperatively and at over 2 years postoperatively. Of the 438 patients, 122 were included in final analysis, with a mean follow-up of 2.4 years. The JOA recovery rate was 47.6%. LBP was significantly improved at final follow-up. Cobb angle was maintained for 2 years postoperatively (p = 0.159). Clinical outcomes in foraminal stenosis patients were significantly related to sex, preoperative high Cobb angle and progression of scoliosis (p = 0.008). In the severe scoliosis patients, the JOA recovery was 44%, and was significantly depended on progression of scoliosis (Cobb angle: preoperation 29.6°, 2-years follow-up 36.9°) and mismatch between the pelvic incidence (PI) and the lumbar lordosis (LL) (preoperative PI-LL 35.5 ± 21.2°) (p = 0.028). This study investigated clinical outcomes of MIS decompression surgery in LSS patients with DLS. The predictive risk factors of clinical outcomes were severe scoliosis, foramina stenosis, progressive scoliosis and large mismatch of PI-LL.

The Influence of Pre- and Postoperative Fear Avoidance Beliefs on Postoperative Pain and Disability in Patients With Lumbar Spinal Stenosis: Analysis of the Lumbar Spinal Outcome Study (LSOS) Data

STUDY DESIGN

Prospective multicenter cohort study.

OBJECTIVE

To evaluate the effect of pre- and postoperatively assessed fear avoidance beliefs (FAB) on pain and disability in patients with degenerative lumbar spinal stenosis (LSS) after decompression surgery.

SUMMARY OF BACKGROUND DATA

To the present, the influence of pre- and postoperative FAB on the prognosis after surgery for LLS is still unclear.

METHODS

Patients of the Swiss Lumbar Stenosis Outcome Study (LSOS) with confirmed LSS undergoing first-time decompression without fusion were enrolled in this study. The main outcome of this study was minimal clinically important difference (MCID) in spinal stenosis measure symptoms (pain) and function (disability) after 12 months. To analyze the influence of pre- and postoperatively assessed FAB on pain and disability we built simple and multiple logistic regression models.

RESULTS

In this analysis of 234 patients undergoing decompression surgery for symptomatic degenerative LSS we found baseline FAB measured by the FAB physical activity subscale (FABQ-P) not to be associated with pain (OR 0.95; 95% CI: 0.55-1.67) and disability (OR 1.11; 95% CI: 0.64-1.92) at 12 months' follow-up. In the final multiple logistic regression models patients with high FABQ-P at 6 months (OR 0.46; 95% CI: 0.24-0.91) and high persistent FABQ-P at baseline and 6 months (OR 0.34, 95% CI: 0.16-0.73) were less likely to report a MCID for spinal stenosis measure symptoms at 12 months. Our analysis found a similar trend for disability; however, the results were not statistically significant.

CONCLUSION

In elderly patients undergoing decompression surgery for symptomatic degenerative LSS preoperative fear avoidance beliefs were not a prognostic indicator for the outcome. Patients with FAB at 6 months and persistent FAB were less likely to experience clinically relevant improvement in pain at 12 months. Studies should address the importance of persistent postoperative FAB.

LEVEL OF EVIDENCE

3.

The impact of incidental durotomy on the outcome of decompression surgery in degenerative lumbar spinal canal stenosis: analysis of the Lumbar Spinal Outcome Study (LSOS) data--a Swiss prospective multi-center cohort study

Background

Incidental durotomy is a well-known complication during surgery for degenerative lumbar spinal stenosis (DLSS). In this prospective multicenter cohort study including eight medical centers our aim was to assess whether incidental durotomy during first-time lumbar spinal stenosis decompression surgery without fusion has an impact on long-term outcome.

Methods

Patients of the multi-center Lumbar Stenosis Outcome Study (LSOS) with confirmed DLSS undergoing first-time decompression without fusion were enrolled in this study. Baseline patient characteristics and outcomes were analyzed at 6, 12, and 24 months follow-up respectively with the Spinal Stenosis Measure (SSM), the Numeric Rating Scale (NRS), Feeling Thermometer (FT), the EQ-5D-EL, and the Roland and Morris Disability Questionnaire (RMDQ).

Results

A total of 167 patients met the inclusion criteria. Fifteen (9 %) of those patients had an incidental durotomy. Baseline characteristics were similar between the durotomy and no-durotomy group. All patients improved over time. In the group of durotomy patients, the median improvement in SSM symptoms scale was 1.1 points at 6 months, 1.1 points at 12 months, and 1.6 points at 24 months after baseline. For the no-durotomy group, these improvements were 0.8, 0.9, and 0.9. For SSM function the improvements were 1.0, 0.8, and 0.9 in the durotomy group, and 0.6, 0.8, and 0.8 in the no-durotomy group. None of the between-group differences were statistically significant.

Conclusions

Incidental durotomy in patients with DLSS undergoing first-time decompression surgery without fusion did not have negative effect on long-term outcome and quality of life. However, only 15 patients were included in the durotomy group but these findings remained even after adjusting for observed differences in baseline characteristics.

Analysis of surgeries for Degenerative lumbarstenosis in elderly patients

Objective:

To analyze the effect of decompression alone and combined decompression, fusion and internal fixation procedure for degenerative lumbar stenosis in elderly patients.

Methods:

We reviewed 168 lumbar stenosis patients treated using decompression alone or with combined procedures in the department of orthopaedics of Tianjin 4^th Centre Hospital from October 2010 to January 2014. The clinical data including age, gender, procedure type, operation time, follow-up period, blood loss, preoperative and postoperative JOA and ODI scores were recorded. The patients were divided into decompression alone group and combined surgeries group according to the procedure type.

Results:

The combined surgeries group presented with larger blood loss (p<0.05) and more operation time (p<0.05), compared with the group of decompression alone. The preoperative and postoperative JOA scores were significantly higher (p<0.05), and the ODI scores significantly lower in the decompression alone group (P<0.05), but at the final follow-up, there were no significant difference between the two groups (p>0.05). The complication rate was lower in the group of decompression alone, but there was no significant difference between the two groups (p>0.05).

Conclusion:

Both the decompression alone and combined surgeries can result in a satisfactory effects in elderly patients with degenerative lumbar spinal stenosis, but the combined surgeries presented with a relatively higher complication rate.

Clinical outcome in lumbar decompression surgery for spinal canal stenosis in the aged population: a prospective Swiss multicenter cohort study

STUDY DESIGN

This is a prospective, multicenter cohort study including 8 medical centers in the metropolitan area of the Canton Zurich, Switzerland.

OBJECTIVES

To examine whether outcome and quality of life might improve after decompression surgery for degenerative lumbar spinal stenosis (DLSS) even in patients older than 80 years and to compare data with a younger patient population from our own patient collective.

SUMMARY AND BACKGROUND DATA

Lumbar decompression surgery without fusion has been shown to improve quality of life in lumbar spinal canal stenosis. In the population older than 80 years, treatment recommendations for DLSS show conflicting results.

METHODS

Eight centers in the metropolitan area of Zurich, Switzerland agreed on the classification of DLSS, surgical principles, and follow-up protocols. Patients were followed from baseline, at 6 months, and 12 months. Baseline characteristics were analyzed with 5 different questionnaires "Spinal Stenosis Measure, Feeling Thermometer, Numeric Rating Scale, 5D-3L, and Roland and Morris Disability Questionnaire." In addition, our study population was compared with a younger control group. Furthermore, we calculated the minimal clinically important differences.

RESULTS

Thirty-seven patients with an average age of 82.5 ± 2.5 years reached the 12-month follow-up. Spinal Stenosis Measure scores, the Feeling Thermometer, the Numeric Rating Scale, and the Roland and Morris Disability Questionnaire showed significant improvements at the 6-month and 12-month follow-ups (P < 0.001). One EQ-5D-3Lsubgroup "anxiety/depression" showed no significant improvement (P = 0.109) at 12-month follow-up. The minimal clinically important difference for the "Symptom Severity scale" in the Spinal Stenosis Measure was achieved with improvement of 70% in the older patient population.

CONCLUSION

Patients 80 years or older can expect a clinically meaningful improvement after lumbar decompression for symptomatic DLSS. Our patient population showed significant positive development in quality of life in the short- and long-term follow-ups.

LEVEL OF EVIDENCE

3.

Can decompression surgery relieve low back pain in patients with lumbar spinal stenosis combined with degenerative lumbar scoliosis?

INTRODUCTION

Decompression with fusion is usually recommended in patients with lumbar spinal stenosis (LSS) combined with degenerative lumbar scoliosis (DLS). However, elderly patients with LSS and DLS often have other comorbidities, and surgical treatment must be both safe and effective. The aim of this study was to investigate whether decompression surgery alone alleviates low back pain (LBP) in patients with LSS and DLS, and to identify the predictors of postoperative residual LBP.

MATERIALS AND METHODS

A total of 75 patients (33 males and 42 females) with a mean age of 71.8 years (range 53-86 years) who underwent decompression surgery for LSS with DLS (Cobb angle ≥ 10°) and had a minimum follow-up period of 1 year, were retrospectively reviewed using the Japanese Orthopaedic Association scoring system for the assessment of lumbar spinal diseases (JOA score). Radiographic measurements included coronal and sagittal Cobb angles, apical vertebral rotation (Nash-Moe method), and anteroposterior and lateral spondylolisthesis. Logistic regression analysis was performed to investigate the predictors of residual LBP after surgery.

RESULTS

Forty-nine patients had preoperative LBP, of which 29 (59.1 %) experienced postoperative relief of LBP. Logistic regression analysis demonstrated that the degree of apical vertebral rotation on preoperative radiography was significantly associated with postoperative residual LBP (odds ratio, 8.16, 95 % confidence interval, 1.55-83.81, p = 0.011).

CONCLUSION

A higher degree of apical vertebral rotation may therefore be an indicator of mechanical LBP in patients with LSS and DLS. Decompression with fusion should be recommended in these patients.

Bacterial wound contamination during simple and complex spinal procedures. A prospective clinical study

BACKGROUND CONTEXT

Spinal procedures have a potential of intraoperative contamination. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have been used to diagnose postoperative infections after spinal surgery. However, it has not been demonstrated if there is an association between surgical site contamination and clinical manifestation of postoperative infection based on inflammatory markers and patients' clinical course.

PURPOSE

The purpose of this prospective study was to evaluate the association between surgical site contamination and the development of a postoperative infection in simple and complex surgical procedures. C-reactive protein and ESR levels were observed. The correlation between their values, surgical time, type of surgical procedures, and contaminated surgical sites was investigated.

STUDY DESIGN

Prospective clinical study.

PATIENT SAMPLE

The study consisted of 40 patients divided into two groups. Group A included 20 patients (mean age, 46.2 years; 12 women and 8 men) who underwent an open discectomy for a lumbar herniated disc. Group B consisted of 20 patients (mean age, 67.9 years; 11 women and 9 men) who underwent a decompression and instrumented fusion for lumbar spinal stenosis. They were followed up for an average of 26.7 months (range, 11-40 months).

OUTCOME MEASURES

Samples were obtained for cultures in standard time intervals during surgery. The types of bacteria cultured were evaluated, and CRP and ESR levels were measured.

METHODS

Simple lumbar discectomy (Group A, 20 patients) and instrumented lumbar decompression for degenerative lumbar stenosis (Group B, 20 patients) were performed in a prospective consecutive series of patients. All patients were operated by the same surgeon in the same operating room. Surgical site preparation in each patient was done by a standard manner. Samples were obtained for cultures in standard time intervals during surgery. C-reactive protein and ESR levels were measured preoperatively on the 3rd, 7th, and 21st postoperative days, and the clinical course of each patient was recorded.

RESULTS

From 40 patients, three patients in Group A and five patients in Group B, a total of eight patients (20%) had positive cultures for bacteria. There was no statistical significance between contamination and duration of surgery in both groups. None of the patients with positive intraoperative cultures developed any clinical signs of superficial or deep postoperative spinal infection, and no additional antibiotic treatment was administered. Three patients with negative cultures developed a postoperative infection. There were no differences in CRP and ESR values between patients with contamination and noncontamination in both groups. C-reactive protein and ESR levels were significantly elevated in complex procedures (Group B) than in simple procedures (Group A). Statistical analysis of CRP and ESR values in both groups and types of bacteria cultured intraoperatively are presented.

CONCLUSIONS

The results of this study demonstrate that intraoperative contamination can occur during simple and complex spinal procedures. In the absence of postoperative signs of infection in patients with intraoperative contamination, there is no need of continuing antibiotic treatment. Postoperative kinetics of CRP and ESR showed to be the same in patients with and without intraoperative contamination. Higher levels of inflammatory markers were noted in complex spinal procedures where instrumentation was applied.

LumbSten: the lumbar spinal stenosis outcome study

Background

Lumbar spinal stenosis is the most frequent reason for spinal surgery in elderly people. For patients with moderate or severe symptoms different conservative and surgical treatment modalities are recommended, but knowledge about the effectiveness, in particular of the conservative treatments, is scarce. There is some evidence that surgery improves outcome in about two thirds of the patients. The aims of this study are to derive and validate a prognostic prediction aid to estimate the probability of clinically relevant improvement after surgery and to gain more knowledge about the future course of patients treated by conservative treatment modalities.

Methods/Design

This is a prospective, multi-centre cohort study within four hospitals of Zurich, Switzerland. We will enroll patients with neurogenic claudication and lumbar spinal stenosis verified by Computer Tomography or Magnetic Resonance Imaging. Participating in the study will have no influence on treatment modality. Clinical data, including relevant prognostic data, will be collected at baseline and the Swiss Spinal Stenosis Questionnaire will be used to quantify severity of symptoms, physical function characteristics, and patient's satisfaction after treatment (primary outcome). Data on outcome will be collected 6 weeks, and 6, 12, 24 and 36 months after inclusion in the study. Applying multivariable statistical methods, a prediction rule to estimate the course after surgery will be derived.

Discussion

The ultimate goal of the study is to facilitate optimal, knowledge based and individualized treatment recommendations for patients with symptomatic lumbar spinal stenosis.

Validity and reproducibility of self-report measures of walking capacity in lumbar spinal stenosis

STUDY DESIGN

Measurement (validity) study.

OBJECTIVE

Examine validity and reproducibility of self-report measures of walking capacity for use in patients with lumbar spinal stenosis (LSS).

SUMMARY OF BACKGROUND DATA

Treatment outcomes in patients with LSS are often determined using data from self-report questionnaires. Despite some validity evidence available to support the use of self-report instruments in the evaluation of walking capacity in LSS, it is not certain that the construct being tapped using any of the self-report measures is, in fact, walking capacity.

METHODS

Validity of the Physical Function Scale of the Swiss Spinal Stenosis Questionnaire, the Oswestry Disability Index (ODI), self-predicted walking capacity (distance in meters) and a number of single item walking capacity questions was evaluated through comparison with a criterion measure of walking capacity, the Self-Paced Walking Test, in patients with LSS. Test-retest reproducibility was also examined for each of the self-report measures.

RESULTS

Subjects included 49 patients (65.8 ± 10.0 years of age) with LSS confirmed on imaging and by a spine specialist surgeon. The measures found to be most highly associated with the criterion Self-Paced Walking Test were the walking distance item from the ODI (r = 0.83) and self-reported walking capacity in meters (with the aid of a distance reference) (r = 0.80). Reported walking capacity in meters had the lowest test-retest reproducibility (intraclass correlation coefficient = 0.65) of the measures studied.

CONCLUSION

This study provides new information to help guide health professionals and researchers in the selection of appropriate outcome tools when examining walking in an LSS population. Study results support the use of the Physical Function Scale, self-reported walking distance, and the walking specific items from the ODI and the Physical Function Scale.

How do validated measures of functional outcome compare with commonly used outcomes in administrative database research for lumbar spinal surgery?

Clinical interpretation of health services research based on administrative databases is limited by the lack of patient-reported functional outcome measures. Reoperation, as a surrogate measure for poor outcome, may be biased by preferences of patients and surgeons and may even be planned a priori. Other available administrative data outcomes, such as postoperative cross sectional imaging (PCSI), may better reflect changes in functional outcome. The purpose was to determine if postoperative events captured from administrative databases, namely reoperation and PCSI, reflect outcomes as derived by validated functional outcome measures (short form 36 scores, Oswestry disability index) for patients who underwent discretionary surgery for specific degenerative conditions of the lumbar spine such as disc herniation, spinal stenosis, degenerative spondylolisthesis, and isthmic spondylolisthesis. After reviewing the records of all patients surgically treated for disc herniation, spinal stenosis, degenerative spondylolisthesis, and isthmic spondylolisthesis at our institution, we recorded the occurrence of PCSI (MRI or CT-myelograms) and reoperations, as well as demographic, surgical, and functional outcome data. We determined how early (within 6 months) and intermediate (within 18 months) term events (PCSI and reoperations) were associated with changes in intermediate (minimum 1 year) and late (minimum 2 years) term functional outcome, respectively. We further evaluated how early (6–12 months) and intermediate (12–24 months) term changes in functional outcome were associated with the subsequent occurrence of intermediate (12–24 months) and late (beyond 24 months) term adverse events, respectively. From 148 surgically treated patients, we found no significant relationship between the occurrence of PCSI or reoperation and subsequent changes in functional outcome at intermediate or late term. Similarly, earlier changes in functional outcome did not have any significant relationship with subsequent occurrences of adverse events at intermediate or late term. Although it may be tempting to consider administrative database outcome measures as proxies for poor functional outcome, we cannot conclude that a significant relationship exists between the occurrence of PCSI or reoperation and changes in functional outcome.

Cross-cultural adaptation of the Norwegian version of the spinal stenosis measure

In order to satisfy the need of a tool for assessing the treatment of patients with degenerative lumbar spinal stenosis, an evaluation was made of the reliability, construct validity, and responsiveness of the Norwegian version of Spinal Stenosis Measure (SSM, original by Stucki)). This study was a part of a prospective, cohort study. About 75 patients referred for surgery for spinal stenosis participated in the study. A subsample of 30 patients answered the questionnaire twice, test and retest, with at least one week in between. The SSM was translated according to the Guillemin criteria. Reliability was assessed by Bland and Altman's repeatability, intraclass correlation coefficient (ICC) and the coefficient of variance (CV). Internal consistency was assessed by Cronbach's alpha. Construct validity was analysed by correlation analyses. Responsiveness was calculated by the effect size. The reliability between test and retest scores was good for all three subscales of SSM as the ICC-values were above 0.9 and the CVs were below 15%. Cronbach's alpha was above 0.8. The correlation analyses showed high correlation between scales that assessed the same construct, and low to moderate correlation between scales that assessed different constructs. Large effect sizes were found in all the SSM subscales with effect sizes > or =1.2. The Norwegian SSM version has added a highly useful tool for assessing the disease specific status and outcome after treatment in patients who suffer from degenerative lumbar spinal stenosis.

Construct validity of the physical function scale of the Swiss Spinal Stenosis Questionnaire for the measurement of walking capacity

STUDY DESIGN

Measurement (validity) study using data from a prospective longitudinal study of lumbar spinal stenosis.

OBJECTIVE

Provide convergent and divergent validity evidence for the use of the Physical Function Scale of the Swiss Spinal Stenosis Questionnaire for the measurement of walking capacity in persons with lumbar spinal stenosis. We were also interested in the association between the Physical Function Scale and the Oswestry Disability Index (ODI).

SUMMARY OF BACKGROUND DATA

The Physical Function Scale has been used to assess walking capacity in persons with lumbar spinal stenosis; however, there have been limited studies investigating its psychometric properties. No validity studies have compared the Physical Function Scale and the ODI head to head.

METHODS

The Physical Function Scale was correlated with the ODI, Health Utilities Index, Centres for Epidemiologic Studies Depression Scale, Medical Outcomes Survey Social Support Scale, and an additional item from the Oxford Claudication Score.

RESULTS

As hypothesized, the Physical Function Scale was correlated highly with those instruments and items intended to measure walking capacity and minimally with those instruments intended to measure different constructs. The correlation between the Physical Function Scale and the ODI was r = 0.719.

CONCLUSION

Results support construct validity of the Physical Function Scale for the measurement of walking in an lumbar spinal stenosis population. However, it cannot be ascertained from the current study that the construct being measured is, indeed, walking capacity. Further research is warranted to investigate criterion validity evidence for the use of the Physical Function Scale in the measurement of walking capacity in lumbar spinal stenosis, by examining the relationships between self-report and observational measures of walking.

Degenerative lumbar scoliosis associated with spinal stenosis

BACKGROUND CONTEXT

Degenerative de novo scoliosis is commonly present in older adult patients with spinal pain. The degenerative process including disc bulging, facet arthritis, and ligamentum flavum hypertrophy contributes to the appearance of symptoms of spinal stenosis in these patients.

PURPOSE

The etiology, prevalence, biomechanics, classification, symptomatology, and treatment of degenerative lumbar scoliosis in association with spinal stenosis are reviewed.

STUDY DESIGN

Review study.

METHODS

Retrospective analysis of studies focused on all parameters concerning degenerative scoliosis associated with stenosis.

RESULTS

There is a variety of treatment methods of degenerative scoliosis based on symptomatology and radiologic measurements of scoliosis and stenosis. Satisfactory clinical results reported in relevant retrospective studies after operative treatment range from 83% to 96% but with increased percentage of complications. An algorithm for operative treatment corresponding to a newly proposed classification system of degenerative lumbar scoliosis with associated canal stenosis is presented.

CONCLUSIONS

There is an increasing prevalence of degenerative scoliosis in the aged population. Even though the exact percentage of patients with symptomatology of spinal stenosis is not known, the main goal is to provide pain relief and improved functional lifestyle with minimum intervention.

Lumbar spinal stenosis

Lumbar spinal stenosis (LSS) is a narrowing of the spinal canal with cord or nerve root impingement resulting in radiculopathy or pseudoclaudication. It is a common diagnosis that is occurring with increased frequency in sports medicine clinics. Symptoms include radicular pain, numbness, tingling, and weakness. Peripheral vascular disease presents similarly and must be considered in the differential diagnosis. Imaging for LSS usually begins with plain radiographs, but often requires additional testing with MRI or CT myelography. There are currently limited controlled data regarding both conservative and surgical treatment of LSS. Most physicians agree that mild disease should be treated conservatively with medications, physical therapy, and epidural steroid injections. Severe disease appears to be best treated surgically; laminectomy continues to be the gold standard treatment.

Methodological approaches to developing criteria for improvement in lumbar spinal stenosis surgery

STUDY DESIGN

The study design was an outcomes measure validation for overall patient success.

OBJECTIVE

The objective of this study was to validate an established lumbar spinal stenosis outcomes measure for individual patient success.

SUMMARY OF BACKGROUND DATA

The Brigham Spinal Stenosis (BSS) Questionnaire has been used to evaluate lumbar spinal stenosis patients since the early 1990s. The three-domain questionnaire has been previously validated for patient improvement in each domain, but criteria for overall patient success have not been established.

METHODS

The sample consisted of preoperative and 24-month postoperative BSS scores from 197 individuals who had undergone a lumbar decompressive procedure with or without an instrumented fusion. For each of the three BSS domains, we determined a threshold score that marked a successful outcome in that domain using receiver operator characteristic (ROC) curves. We combined these threshold scores in different ways to produce varying definitions of overall surgical success.

RESULTS

The threshold for changes in the Symptom Severity and Physical Function domain scores were calculated as 0.46 and 0.42, respectively, while for Patient Satisfaction it was 2.42 based on the ROC analysis. The definition for individual patient success that requires the patient achieve threshold scores in each domain was less sensitive but more specific than alternative definitions of overall success that required the patient achieve at least two criteria or at least one criterion.

CONCLUSIONS

The threshold values for each domain were similar to previously established values and the most balanced definition of overall success required that a patient achieve at least two criteria.

Low back pain--differential diagnosis, prognosis and treatment

From January 2002 to February 2003, 137 patients complaining of low back pain were treated at the Institute for Orthopedic Surgery "Banjica", Belgrade, Serbia. There were 89 male and 48 female patients aged 13 to 77, mean age 42.2. Their condition was diagnosed through use of radiography, CT, MRI, EMNG, standard battery of neurological tests, and laboratory analyses (urine and blood analysis). Surgical treatment was performed on 39 patients; all other patients received some form of non-surgical care (physical therapy, medication or corset). Treatment efficacy was evaluated by use of the visual analog scales (VAS) and the Oswestry index, before and after treatment. The use Wilcoxon's pair test revealed statistically significant difference between before and after treatment data on VAS and Oswestry index for all patients.

Patient-based outcomes for the operative treatment of degenerative lumbar spinal stenosis

STUDY DESIGN

A retrospective surgical case series was conducted using a condition-specific, patient-based outcomes assessment.

OBJECTIVE

The goal of this study was to describe the outcome predictors of decompressive surgery for degenerative lumbar spinal stenosis (DLSS).

SUMMARY OF BACKGROUND DATA

Surgical decompression is the recommended treatment for patients with moderate to severe DLSS. Previous studies have reported that factors such as the number of operated levels and patient health status are predictors of surgical outcomes.

METHODS

This study analyzed the success rates of 58 DLSS patients treated with decompressive surgery. Outcomes were measured with the Zurich Claudication Questionnaire (ZCQ) completed pre-operatively and at least 12 months post-operatively (range 12-54 months). The ZCQ includes three distinct domains that involve symptom severity, physical function, and patient satisfaction. Variables such as age, sex, pre-operative symptom severity, and arthrodesis were analyzed as predictors of success.

RESULTS

The study group included 21 males and 37 females, and the mean age of all patients was 66 years (range 41-80 years). Overall, 63.8% of the patients had significant clinical improvement in Symptom Severity, 55.2% had significant clinical improvement in Physical Function, and 58.6% of the patients were at least somewhat satisfied; 63.8% (37/58) of the patients were considered to be clinically successful. Patients with more severe pre-operative symptoms and more physical function restrictions had better success results than those patients with milder symptoms and less restrictive physical function. Also, patients who were followed for less than 24 months had better success than those followed for more than 24 months. There was no significant difference in the clinical success rates of (1) patients who were fused and those not fused, (2) males and females, (3) patients aged less than 65 years and those greater than 65 years, and (4) patients who were treated at one or two levels and those treated at three or four levels.

CONCLUSION

The results of this retrospective study indicate that operative decompression of the lumbar spine offers significant improvement for patients with DLSS. Although not all comparisons were statistically significant, there was a trend for DLLS patients aged less than 65 years with more severe pre-operative symptoms and physical function disturbances treated at one or two levels with a laminectomy and fusion to have the best outcomes.