Diagnosis and management of lumbar spinal stenosis in primary care in France: a survey of general practitioners

Advancements in Spinal Endoscopic Surgery: Comprehensive Techniques and Pathologies Addressed by Full Endoscopy Beyond Lumbar Disc Herniation

Endoscopic spine surgery (ESS) has traditionally been employed for lumbar disc herniation (LDH). Recent innovations in surgical methods and technologies have expanded its range to address other spinal pathologies, providing minimally invasive solutions with potential clinical benefits. Our review aims to summarize the applications, clinical outcomes, and limitations of ESS beyond LDH, focusing on its role in complex spinal conditions such as stenosis, thoracic disc herniation, spinal tumors, synovial cysts, and failed back surgery syndrome. A thorough review of the literature was conducted to assess and summarize the current evidence regarding ESS applications for spinal conditions beyond LDH surgery. Areas of focus included innovations in technology and technique, as well as comparisons with conventional open surgical methods. ESS shows notable potential across different spinal conditions by providing minimally invasive alternatives to traditional open surgery. Its use could be associated with reduced surgical morbidity, shorter recovery times, and improved patient outcomes. In particular, ESS is versatile in addressing both degenerative and neoplastic conditions of the spine. Despite this, challenges such as technical complexity, steep learning curves, and limited indications for certain pathologies remain as barriers to wider adoption. ESS is evolving in spine surgery, extending its utility beyond LDH surgery. While the current evidence largely supports its clinical efficacy, further studies are needed to address the present limitations and optimize its application. Future developments in surgical training and technology will likely enhance its adoption and broaden its clinical indications.

Lumbar Spinal Stenosis: Pathophysiology, Biomechanics, and Innovations in Diagnosis and Management

Lumbar spinal stenosis (LSS) is a common condition caused by the narrowing of the spinal canal, resulting in compression of neural and vascular structures. This compression leads to symptoms such as claudication, paresthesia, and lower extremity weakness. LSS is the leading cause of low back pain and functional limitations, affecting over 103 million people worldwide. Degenerative changes, including ligamentum flavum hypertrophy, facet joint osteoarthritis, and intervertebral disc degeneration, are the primary contributors to LSS. Additional factors, such as genetic predisposition, congenital abnormalities, and autoimmune conditions, are also emerging as contributors. A major challenge in managing LSS lies in differentiating it from other causes of neurogenic symptoms and low back pain while devising an appropriate treatment plan from the wide array of conservative and surgical options available. Minimally invasive surgical techniques, such as lumbar spinous process-splitting laminoplasty and partial facetectomy, are often compared to the gold standard laminectomy with or without fusion. Surgical interventions offer significant improvements in pain relief, disability, and quality of life within 3-6 months; however, these benefits often diminish after 2-4 years. Contrasting evidence demonstrates that long-term outcomes of non-surgical treatments, such as physical therapy, pharmacological management, and lifestyle modifications, are often comparable to surgical modalities. Emerging therapies, including interspinous devices and stem cell therapy, show promise but require further research. Managing LSS requires a multidisciplinary approach tailored to patient-specific factors, including age, comorbidities, and functional goals. Future research should aim to improve diagnostic accuracy, refine surgical techniques, and explore innovative therapies to enhance outcomes for patients with LSS.

A Rare Case of Bilateral Foot Drop Following Cervical Decompression in Tandem Spinal Stenosis

This case report describes a 70-year-old male presenting with limb weakness, urinary retention and tandem cervical and lumbar spinal stenosis with complicating white cord syndrome, a rare reperfusion injury post decompression surgery. Initially admitted following an unwitnessed fall, the patient's neurological examination indicated that progressive weakness of the limbs and sensory loss etiology is cervical and lumbar spondylosis with severe spinal canal stenosis, confirmed by imaging. Due to rapid deterioration, he underwent C5 corpectomy, cervical decompression and fusion. Informed consent for surgery was obtained from the patient. Post-surgery, he experienced transient improvements but soon developed delirium, worsening right-sided weakness, and bilateral foot drop. Diagnosis of white cord syndrome was made because of repeat cervical MRI findings having signal changes in cervical spine. Subsequent treatment included intravenous steroids, antibiotics, and eventual lumbar interbody fusion. The multifactorial nature of his postoperative complications including hyperactive delirium and urinary tract infection, underscores the complexities associated with tandem stenosis and white cord syndrome management. The case highlights the need for early intervention in tandem spinal stenosis cases, cautious intraoperative monitoring, and risk factors management for reperfusion injury, stressing the role of comprehensive postoperative care to improve functional outcomes.

Clinical assessment and management of lumbar spinal stenosis: clinical dilemmas and considerations for surgical referral

Lumbar spinal stenosis is the leading indication for spine surgery in older adults. Surgery is recommended in clinical guidelines if non-surgical treatments have been provided with insufficient benefit. The difficulty for clinicians is that the current number of randomised controlled trials is low, which creates uncertainty about which treatments to provide. For non-surgical clinicians this paucity of data leads to a clinical dilemma of whether to continue managing the patient or refer to a spine surgeon. This Viewpoint aims to provide an update on the assessment of lumbar spinal stenosis, treatment recommendations, indications for referral to a spine surgeon, and current clinical dilemmas facing non-surgical clinicians and spinal surgeons.

Older Adults' Experiences Living With and Having Spine Surgery for Degenerative Spine Disease

BACKGROUND AND OBJECTIVES

Globally, older adults are undergoing spine surgery for degenerative spine disease at exponential rates. However, little is known about their experiences of living with and having surgery for this debilitating condition. This study investigated older adults' understanding and experiences of living with and having surgery for degenerative spine disease.

RESEARCH DESIGN AND METHODS

Qualitative methods, grounded theory, guided the study. Fourteen older adults (≥65 years) were recruited for in-depth interviews at 2 time-points: T1 during hospitalization and T2, 1-3-months postdischarge. A total of 28 interviews were conducted. Consistent with grounded theory, purposive, and theoretical sampling were used. Data analysis included open, axial, and selective coding.

RESULTS

A conceptual model was developed illustrating the process older adults with degenerative spine disease experience, trying to get their life back. Three key categories were identified (1) Losing Me, (2) Fixing Me, and (3) Recovering Me. Losing Me was described as a prolonged process of losing functional independence and the ability to socialize. Fixing Me consisted of preparing for surgery and recovery. Recovering Me involved monitoring progression and reclaiming their personhood. Conditions, including setbacks and delays, slowed their trajectory. Throughout, participants continually adjusted expectations.

DISCUSSION AND IMPLICATIONS

The conceptual model, based on real patient experiences, details how older adults living with and having surgery for degenerative spine disease engage in recovering who they were prior to the onset of symptoms. Our findings provide a framework for understanding a complex, protracted trajectory that involves transitions from health to illness working toward health again.

Comparison of Postoperative Outcomes Between Percutaneous Endoscopic Lumbar Interbody Fusion and Minimally Invasive Transforaminal Lumbar Interbody Fusion for Lumbar Spinal Stenosis

Objective

This study aimed to compare postoperative outcomes in surgical and patient-reported outcomes (PROs) between percutaneous endoscopic lumbar interbody fusion (PE-LIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for the treatment of lumbar spinal stenosis (LSS).

Methods

We reviewed a total of 89 patients undergoing single-level surgery for lumbar spinal stenosis from January 2018 to July 2021. The cases were categorized as PE-LIF (Group PE-LIF, 41 cases) or MIS-TLIF (Group MIS-TLIF, 48 cases) approach. Parameters obtained at baseline through at least six months of follow-up were collected. The surgical outcomes involving the operative time, estimated blood loss, postoperative bed staying time, and length of hospital stays were analyzed. PROs included the Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), modified MacNab standard evaluation, intervertebral fusion rate, and postoperative complications.

Results

A total of 89 patients were included in this analysis involving 41 patients who underwent PE-LIF and 48 patients who underwent MIS-TLIF. The 2 groups were similar in gender, age, body mass index, follow-up time and surgery levels (P > 0.05), and were not significantly different in the length of hospital stays (P > 0.05). PE-LIF had a significantly longer operative time, greater fluoroscopy time, lower estimated blood loss and shorter bed rest time than MIS-TLIF. Both groups improved significantly from baseline for the VAS and ODI scores. PE-LIF was associated with a lower VAS score for back pain at three-day after surgery. There were no significant differences between PE-LIF and MIS-TLIF in the excellent or good rates and intervertebral fusion rates at the last follow-up (P > 0.05). As for related complications, there were no significant complications occurred, and no significant differences were seen in the complications between both groups (P > 0.05).

Conclusions

To summarize, PE-LIF and MIS-TLIF are both safe and effective for LSS. PE-LIF has a definite short-term curative effect with less trauma.

Caudal epidural steroid injections versus selective nerve root blocks for single-level lumbar spinal stenosis: a study protocol for a randomized controlled trial

BACKGROUND

Lumbar spinal stenosis (LSS) is a common degenerative condition associated with old age. Its incidence continues to increase with the rapidly aging population in China. Treatment for LSS usually begins with conservative treatments, as some patients refuse surgical procedures or have surgery contraindications. Caudal epidural steroid injections (CESIs) and selective nerve root blocks (SNRBs) are two commonly used conservative treatments for LSS, which have proven to be effective at relieving LSS symptoms in many studies. However, there are no randomized controlled trials comparing these two procedures. We planned the first study to assess which one of these two procedures is more effective in treating LSS. We will compare the efficacy of these two treatment methods in terms of duration of symptom relief and recurrence rate. We hope our findings will help clinicians choose an optimal treatment for LSS patients.

METHODS/DESIGN

We plan to conduct a 1-year randomized controlled trial that will include a total of 76 subjects. They will be randomly divided into two groups: group A (patients will receive CESIs) and group B (patients will receive SNRBs). Two days before the procedure, we will assess these patients using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale, Oswestry Disability Index (ODI), and numeric rating scale (NRS) for pain. One day, 2 weeks, 3 months, 6 months, and 1 year after the procedure, we will assess the condition of these patients again with the NRS and ODI.

DISCUSSION

We hope our findings will lay the foundation for the design of further comprehensive studies and help clinicians make a choice between CESIs and SNRBs for LSS patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1900028038 . Registered on 8 December 2019.

Diagnosis and Treatment of Sciatica in the Netherlands: A Survey among Neurologists and Anesthesiologists

BACKGROUND

This study aimed to assess how Dutch neurologists and anesthesiologists diagnose and treat people with sciatica in secondary care and to evaluate their adherence to the newest guidelines.

METHODS

We conducted a cross-sectional survey. Respondents were asked about their current clinical practice related to sciatica. Three authors rated the respondents' adherence to the guidelines on a three-point Likert scale.

RESULTS

Eighty neurologists and 44 anesthesiologists completed the questionnaire. Neurologists diagnose their sciatica patients primarily using a magnetic resonance imaging (89%). Selective diagnostic nerve blocks are considered useful by 81% of the neurologists. Neurologists primarily treat patients with pain medication, and 40% of them think epidural steroid injections are effective in 40-60% of injected patients. Twenty-nine percent of neurologists refer patients to a neurosurgeon after 4 months. Anesthesiologists consider a selective diagnostic nerve root block to have a higher diagnostic value than mapping. The most reported side effect of epidural injections is exacerbation of pain (82%). Pulse radiofrequency is applied in 9-11% of acute cases. The results also indicate that Dutch neurologists and anesthesiologists follow an evidence-based approach that is strictly or broadly in line with the guideline.

CONCLUSIONS

Neurologists treat sciatica patients initially with pain medication and physiotherapy, followed by epidural steroid injections and referral for surgery. Anesthesiologists treat sciatica patients with one or more steroid injections or may perform a selective nerve root block. Imaging, selective nerve root blocks, medication, physiotherapy, and pulse radiofrequency are topics of further research.

Management for lumbar spinal stenosis: A network meta-analysis and systematic review

BACKGROUND

Conventional paired meta-analyses have shown inconsistent results regarding the safety and efficacy of different interventions.

OBJECTIVE

To perform a network meta-analysis (NMA) and systematic review based on randomized controlled trials (RCTs) evaluating the efficacies of different interventions for lumbar spinal stenosis (LSS).

METHODS

We searched PubMed, Embase, Cochrane Library, Web of Science, and major scientific websites from inception to October 10, 2019, for randomized controlled trials comparing the nine most commonly used interventions for LSS. The main outcomes were disability and pain intensity. The PROSPERO number was CRD42020154247.

RESULTS

First, laminotomy was better in improving patients' short- and long-term dysfunction (probability 49% and 25%, respectively). Second, decompression, decompression plus fusion, endoscopic decompression, interspinous process spacer device implantation, laminectomy, laminotomy and minimally invasive decompression were significantly more efficacious in relieving pain than non-surgical interventions (mean difference in the short-term -21.82, -22.00, -16.68, -17.47, -17.75, -17.61 and -18.86; in the long-term -37.14, -34.04, -34.07, -39.79, -36.14, -32.75 and -39.14, respectively). Third, endoscopic decompression had a lower complication rate (probability 51%). In addition, laminotomy had a lower reoperation rate (probability 45%). Fourth, decompression plus fusion resulted in more blood loss than any other surgical intervention (probability 96%). Finally, endoscopic decompression had the shortest hospitalization time (probability 96%).

CONCLUSIONS

There were no significant differences among the different interventions in improving patient function. Surgical interventions were associated with better pain relief but a higher incidence of complications. Decompression plus fusion is not necessary for patients. In addition, endoscopic decompression as a novel and less invasive surgical approach may be a good choice for LSS patients.