Comparison of posterior decompression techniques and conventional laminectomy for lumbar spinal stenosis

Adjacent Level Canal Area Changes up to Two Years After Lumbar Spinal Stenosis Decompressive Surgery

STUDY DESIGN

A secondary analysis of data from the NORDSTEN-spinal stenosis trial (SST).

OBJECTIVE

The aim of the present study was to investigate whether the dural sac cross-sectional area (DSCA) on magnetic resonance imaging (MRI) of adjacent segments decreases after decompressive surgery due to lumbar spinal stenosis (LSS) up to 2 years postoperatively and to investigate possible associations with baseline variables, including preoperative patient and radiological characteristics, and surgical method used.

SUMMARY OF BACKGROUND DATA

Decompressive surgery for LSS is currently the most common spinal surgery procedure; however, there is limited knowledge of changes in the DSCA over time adjacent to a decompressed segment.

MATERIALS AND METHODS

In the NORDSTEN-SST, 437 patients were randomized to decompression with one of three minimally invasive surgical methods for LSS. The patients underwent an MRI of the lumbar spine (L2-L5) before surgery and at 3 and 24 months postoperatively. Descriptive statistics of adjacent DSCA and changes in adjacent DSCA are presented. Possible prognostic factors (preoperative factors, radiologic measures, and surgical method) for changes in the adjacent DSCA were examined using multivariate regression analyses.

RESULTS

Three hundred twenty-two patients (74%) in the original NORDSTEN-SST had undergone MRI at both 3 and 24 months postoperatively and were included (360 adjacent levels, 263 cranial, and 97 caudal to a decompressed level). Up to two years postoperatively, no decrease in adjacent DSCA was observed. No associations were found between the investigated baseline variables and DSCA change from zero to two years, except for a weak association with baseline adjacent DSCA.

CONCLUSIONS

Up to two years postoperatively, the DSCA did not decrease at adjacent levels after decompressive surgery. None of the investigated baseline variables showed any clinically meaningful prognostic value regarding adjacent DSCA changes two years postoperatively. The findings support previous reports that decompression of adjacent levels is not required to prevent subsequent stenosis.

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

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

Total joint replacement of the lumbar spine: report of the first two cases with 16 years of follow-up

Background

Total joint replacement (TJR) of the lumbar spine is a revolutionary procedure that couples the clinical benefits of neural decompression with preservation of natural motion and sagittal balance at the operative level. The TJR procedure involves reconstruction of the entire motion segment using a posterior bilateral transforaminal approach to access the disc space. The TJR implant (MOTUS, 3Spine, Chattanooga, TN, USA) replaces the function of the intervertebral disc and facet joints, performing biomechanically as a new articulation for the resected, degenerated disc and facets. The implant has been optimized to simulate the kinematic characteristics of the three-joint complex.

Case Description

Two male patients, ages 32 and 38 years, underwent the first TJR procedures in 2007 in South Africa. Both patients had imaging evidence of advanced spinal degeneration with unremitting back and leg pain refractory to conservative management. Symptom amelioration was achieved postoperatively with markedly reduced pains scores and improved function at clinical follow-up. Both cases were recently re-examined after 16 years and the patients reported that the procedure significantly changed their lives. Neither believes they have a lingering back condition and they have been able to fully participate in all functions related to work, family and recreation. There was little to no imaging evidence of adjacent segment disease or arthritic changes at this long-term follow-up interval.

Conclusions

After 16 years of clinical follow-up, the implant continues to function normally, without evidence of adjacent segment degeneration and both patients continue to enjoy activities of daily living without back or leg pain or other functional impairments.

Comparative effects of different posterior decompression techniques for lumbar spinal stenosis: a systematic review and Bayesian network meta-analysis

STUDY DESIGN

A systematic review and Bayesian network meta-analysis (NMA).

OBJECTIVE

To compare the effectiveness and safety of different posterior decompression techniques for LSS. Lumbar spinal stenosis (LSS) is one of the most common degenerative spinal diseases that result in claudication, back and leg pain, and disability. Currently, posterior decompression techniques are widely used as an effective treatment for LSS.

METHODS

An electronic literature search was performed using the EMBASE, Web of Science, PubMed, and Cochrane Library databases. Two authors independently performed data extraction and quality assessment. A Bayesian random effects model was constructed to incorporate the estimates of direct and indirect treatment comparisons and rank the interventions in order.

RESULTS

In all, 14 eligible studies comprising 1,260 patients with LSS were included. Five interventions were identified, namely, spinal processes osteotomy (SPO), conventional laminotomy/laminectomy (CL), unilateral laminotomy/laminectomy (UL), bilateral laminotomy/ laminectomy (BL), and spinous process-splitting laminotomy/laminectomy (SPSL). Among these, SPO was the most promising surgical option for decreasing back and leg pain and for lowering the Oswestry Disability Index (ODI). SSPL had the shortest operation time, while SPSL was associated with maximum blood loss. SPO and UL were superior to other posterior decompression techniques concerning lesser blood loss and shorter length of hospital stay, respectively. Patients who underwent BL had the lowest postoperative complication rates.

CONCLUSION

Overall, SPO was found to be a good surgical choice for patients with LSS.

Are We Finally Ready for Total Joint Replacement of the Spine? An Extension of Charnley's Vision

Professor Sir John Charnley has been rightfully hailed as a visionary innovator for conceiving, designing, and validating the Operation of the Century-the total hip arthroplasty. His groundbreaking achievement forever changed the orthopedic management of chronically painful and dysfunctional arthritic joints. However, the well-accepted surgical approach of completely removing the diseased joint and replacing it with a durable and anatomically based implant never translated to the treatment of the degenerated spine. Instead, decompression coupled with fusion evolved into the workhorse intervention. In this commentary, the authors explore the reasons why arthrodesis has remained the mainstay over arthroplasty in the field of spine surgery as well as discuss the potential shift in the paradigm when it comes to treating degenerative lumbar disease.

Spine Surgical Robotics: Current Status and Recent Clinical Applications

With the development of artificial intelligence and the further deepening of medical-engineering integration, spine surgical robot-assisted (RA) technique has made significant progress and its applicability in clinical practice is constantly expanding in recent years. In this review, we have systematically summarized the majority of literature related to spine surgical robots in the past decade, and not only classified robots accordingly, but also summarized the latest research progress in RA technique for screw placement such as cervical, thoracic, and lumbar pedicle screws, cortical bone trajectory screws, cervical lateral mass screws, and S2 sacroiliac screws; guiding targeted puncture and placement of endoscope via the intervertebral foramen; complete resection of spinal tumor tissue; and decompressive laminectomy. In addition, this report also provides a detailed evaluation of RA technique's advantages and disadvantages, and clarifies the accuracy, safety, and practicality of RA technique. We consider that this review can help clinical physicians further understand and familiarize the current clinical application status of spine surgical robots, thereby promoting the continuous improvement and popularization of RA technique, and ultimately benefiting numerous patients.