Aims. We compared decompression alone to decompression with fusion surgery for lumbar spinal stenosis, with or without degenerative spondylolisthesis (DS). The aim was to evaluate if five-year outcomes differed between the groups. The two-year results from the same trial revealed no differences. Methods. The Swedish Spinal Stenosis Study was a multicentre randomized controlled trial with recruitment from September 2006 to February 2012. A total of 247 patients with one- or two-level central lumbar spinal stenosis, stratified by the presence of DS, were randomized to decompression alone or decompression with fusion. The five-year Oswestry Disability Index (ODI) was the primary outcome. Secondary outcomes were the EuroQol five-dimension questionnaire (EQ-5D), visual analogue scales for back and leg pain, and patient-reported satisfaction, decreased pain, and increased walking distance. The reoperation rate was recorded. Results. Five-year follow-up was completed by 213 (95%) of the eligible patients (mean age 67 years; 155 female (67%)). After five years, ODI was similar irrespective of treatment, with a mean of 25 (SD 18) for decompression alone and 28 (SD 22) for decompression with fusion (p = 0.226). Mean EQ-5D was higher for decompression alone than for fusion (0.69 (SD 0.28) vs 0.59 (SD 0.34); p = 0.027). In the no-DS subset, fewer patients reported decreased leg pain after fusion (58%) than with decompression alone (80%) (relative risk (RR) 0.71 (95% confidence interval (CI) 0.53 to 0.97). The frequency of subsequent spinal surgery was 24% for decompression with fusion and 22% for decompression alone (RR 1.1 (95% CI 0.69 to 1.8)). Conclusion. Adding fusion to decompression in spinal stenosis surgery, with or without spondylolisthesis, does not improve the five-year ODI, which is consistent with our two-year report. Three secondary outcomes that did not differ at two years favoured decompression alone at five years. Our results support decompression alone as the preferred method for operating on spinal stenosis. Cite this article: Bone Joint J 2024;106-B(7):705–712

Aims. Lumbar spinal stenosis (LSS) is a common skeletal system disease that has been partly attributed to genetic variation. However, the correlation between genetic variation and pathological changes in LSS is insufficient, and it is difficult to provide a reference for the early diagnosis and treatment of the disease. Methods. We conducted a transcriptome-wide association study (TWAS) of spinal canal stenosis by integrating genome-wide association study summary statistics (including 661 cases and 178,065 controls) derived from Biobank Japan, and pre-computed gene expression weights of skeletal muscle and whole blood implemented in FUSION software. To verify the TWAS results, the candidate genes were furthered compared with messenger RNA (mRNA) expression profiles of LSS to screen for common genes. Finally, Metascape software was used to perform enrichment analysis of the candidate genes and common genes. Results. TWAS identified 295 genes with permutation p-values < 0.05 for skeletal muscle and 79 genes associated for the whole blood, such as RCHY1 (PTWAS = 0.001). Those genes were enriched in 112 gene ontology (GO) terms and five Kyoto Encyclopedia of Genes and Genomes pathways, such as ‘chemical carcinogenesis - reactive oxygen species’ (LogP value = −2.139). Further comparing the TWAS significant genes with the differentially expressed genes identified by mRNA expression profiles of LSS found 18 overlapped genes, such as interleukin 15 receptor subunit alpha (IL15RA) (PTWAS = 0.040, PmRNA = 0.010). Moreover, 71 common GO terms were detected for the enrichment results of TWAS and mRNA expression profiles, such as negative regulation of cell differentiation (LogP value = −2.811). Conclusion. This study revealed the genetic mechanism behind the pathological changes in LSS, and may provide novel insights for the early diagnosis and intervention of LSS. Cite this article: Bone Joint Res 2023;12(6):387–396

Aims. The aims of this study were first, to determine if adding fusion to a decompression of the lumbar spine for spinal stenosis decreases the rate of radiological restenosis and/or proximal adjacent level stenosis two years after surgery, and second, to evaluate the change in vertebral slip two years after surgery with and without fusion. Methods. The Swedish Spinal Stenosis Study (SSSS) was conducted between 2006 and 2012 at five public and two private hospitals. Six centres participated in this two-year MRI follow-up. We randomized 222 patients with central lumbar spinal stenosis at one or two adjacent levels into two groups, decompression alone and decompression with fusion. The presence or absence of a preoperative spondylolisthesis was noted. A new stenosis on two-year MRI was used as the primary outcome, defined as a dural sac cross-sectional area ≤ 75 mm. 2. at the operated level (restenosis) and/or at the level above (proximal adjacent level stenosis). Results. A total of 211 patients underwent surgery at a mean age of 66 years (69% female): 103 were treated by decompression with fusion and 108 by decompression alone. A two-year MRI was available for 176 (90%) of the eligible patients. A new stenosis at the operated and/or adjacent level occurred more frequently after decompression and fusion than after decompression alone (47% vs 29%; p = 0.020). The difference remained in the subgroup with a preoperative spondylolisthesis, (48% vs 24%; p = 0.020), but did not reach significance for those without (45% vs 35%; p = 0.488). Proximal adjacent level stenosis was more common after fusion than after decompression alone (44% vs 17%; p < 0.001). Restenosis at the operated level was less frequent after fusion than decompression alone (4% vs 14%; p = 0.036). Vertebral slip increased by 1.1 mm after decompression alone, regardless of whether a preoperative spondylolisthesis was present or not. Conclusion. Adding fusion to a decompression increased the rate of new stenosis on two-year MRI, even when a spondylolisthesis was present preoperatively. This supports decompression alone as the preferred method of surgery for spinal stenosis, whether or not a degenerative spondylolisthesis is present preoperatively. Cite this article: Bone Joint J 2022;104-B(12):1343–1351

Aims. Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort. Methods. This is a population-based study from the Norwegian Registry for Spine surgery (NORspine). We included 26,723 consecutive cases operated for lumbar spinal stenosis or lumbar disc herniation from January 2007 to December 2018. The primary outcome was the Oswestry Disability Index (ODI), presented as the proportions reaching a patient-acceptable symptom state (PASS; defined as an ODI raw score ≤ 22) and ODI raw and change scores at 12-month follow-up. Secondary outcomes were the Global Perceived Effect scale, the numerical rating scale for pain, the EuroQoL five-dimensions health questionnaire, occurrence of perioperative complications and wound infections, and working capability. Binary logistic regression analysis was conducted to examine how the number of previous operations influenced the odds of not reaching a PASS. Results. The proportion reaching a PASS decreased from 66.0% (95% confidence interval (CI) 65.4 to 66.7) in cases with no previous operation to 22.0% (95% CI 15.2 to 30.3) in cases with four or more previous operations (p < 0.001). The odds of not reaching a PASS were 2.1 (95% CI 1.9 to 2.2) in cases with one previous operation, 2.6 (95% CI 2.3 to 3.0) in cases with two, 4.4 (95% CI 3.4 to 5.5) in cases with three, and 6.9 (95% CI 4.5 to 10.5) in cases with four or more previous operations. The ODI raw and change scores and the secondary outcomes showed similar trends. Conclusion. We found a dose-response relationship between increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine. This information should be considered in the shared decision-making process prior to elective spine surgery. Cite this article: Bone Joint J 2023;105-B(4):422–430

Objectives. Pedicle-lengthening osteotomy is a novel surgery for lumbar spinal stenosis (LSS), which achieves substantial enlargement of the spinal canal by expansion of the bilateral pedicle osteotomy sites. Few studies have evaluated the impact of this new surgery on spinal canal volume (SCV) and neural foramen dimension (NFD) in three different types of LSS patients. Methods. CT scans were performed on 36 LSS patients (12 central canal stenosis (CCS), 12 lateral recess stenosis (LRS), and 12 foraminal stenosis (FS)) at L4-L5, and on 12 normal (control) subjects. Mimics 14.01 workstation was used to reconstruct 3D models of the L4-L5 vertebrae and discs. SCV and NFD were measured after 1 mm, 2 mm, 3 mm, 4 mm, or 5 mm pedicle-lengthening osteotomies at L4 and/or L5. One-way analysis of variance was used to examine between-group differences. Results. In the intact state, SVC and NFD were significantly larger in the control group compared with the LSS groups (P<0.05). After lengthening at L4, the percentage increase in SCV (per millimetre) was LRS>CCS>FS>Control. After lengthening at L5 and L4-L5, the percentage increase in SCV (per millimetre) was LRS>FS>CCS>Control. After lengthening at L4 and L4-L5, the percentage increase in NFD (per millimetre) was FS>CCS>LRS>Control. After lengthening at L5, the percentage increase in NFD (per millimetre) was CCS>LRS>control>FS. Conclusions. LRS patients are the most suitable candidates for treatment with pedicle-lengthening osteotomy. Lengthening L4 pedicles produced larger percentage increases in NFD than lengthening L5 pedicles (p < 0.05). Lengthening L4 pedicles may be the most effective option for relieving foraminal compression in LSS patients. Cite this article: P. Li, L. Qian, W. D. Wu, C. F. Wu, J. Ouyang. Impact of pedicle-lengthening osteotomy on spinal canal volume and neural foramen size in three types of lumbar spinal stenosis. Bone Joint Res 2016;5:239–246. DOI: 10.1302/2046-3758.56.2000469

Aims. To report the development of the technique for minimally invasive lumbar decompression using robotic-assisted navigation. Methods. Robotic planning software was used to map out bone removal for a laminar decompression after registration of CT scan images of one cadaveric specimen. A specialized acorn-shaped bone removal robotic drill was used to complete a robotic lumbar laminectomy. Post-procedure advanced imaging was obtained to compare actual bony decompression to the surgical plan. After confirming accuracy of the technique, a minimally invasive robotic-assisted laminectomy was performed on one 72-year-old female patient with lumbar spinal stenosis. Postoperative advanced imaging was obtained to confirm the decompression. Results. A workflow for robotic-assisted lumbar laminectomy was successfully developed in a human cadaveric specimen, as excellent decompression was confirmed by postoperative CT imaging. Subsequently, the workflow was applied clinically in a patient with severe spinal stenosis. Excellent decompression was achieved intraoperatively and preservation of the dorsal midline structures was confirmed on postoperative MRI. The patient experienced improvement in symptoms postoperatively and was discharged within 24 hours. Conclusion. Minimally invasive robotic-assisted lumbar decompression utilizing a specialized robotic bone removal instrument was shown to be accurate and effective both in vitro and in vivo. The robotic bone removal technique has the potential for less invasive removal of laminar bone for spinal decompression, all the while preserving the spinous process and the posterior ligamentous complex. Spinal robotic surgery has previously been limited to the insertion of screws and, more recently, cages; however, recent innovations have expanded robotic capabilities to decompression of neurological structures. Cite this article: Bone Jt Open 2024;5(9):809–817

Background. Foraminal stenosis is often encountered in patients undergoing decompression for spinal stenosis. Given the increased resection of facets and the presence of the more sensitive dorsal root ganglion, it is hypothesized that patients with foraminal stenosis have poorer postoperative outcomes. Methods. Thirty-one patients undergoing decompression without fusion for lumbar spinal stenosis were evaluated. The degree of foraminal stenosis was determined by 2 independent reviewers for absence of fat around the nerve roots. ImageJ digital imaging software was also used to evaluate the foraminal area. Patients with foraminal stenosis were compared with those without using the Oswestry Disability Index (ODI) and a numerical pain scale for back and leg pain at a minimum of 1 year follow-up. Results. Twenty patients in the foraminal stenosis group were compared with 11 without foraminal stenosis. There were no significant differences between the 2 groups regarding age, sex, comorbidities, number of levels operated on, preoperative ODI, back pain or leg pain scores. The foraminal area was significantly smaller in the foraminal stenosis group. Patients without foraminal stenosis reported significant improvements in ODI (mean 26.0), back pain (mean 3.1) and leg pain scores (mean 5.5). Patients with foraminal stenosis reported significant improvements in ODI (mean 18.8) and leg pain (mean 2.5) but not in back pain (mean 0.3). Comparing the 2 groups, the patients with foraminal stenosis had significantly less improvement in back pain (p = 0.02) and leg pain (p = 0.02). Conclusion. The results of this study suggest that presence of foraminal stenosis is a negative predictor for successful outcome following decompression surgery. This may be related to the increased instability that occurs when a foraminotomy is required. Spinal fusion may reduce this effect, and further study is required. NO DISCLOSURES

Abstract. Objective. Flexible stabilisation has been utilised to maintain spinal mobility in patients with early-stage lumbar spinal stenosis (LSS). Previous literature has not yet established any non-fusion solution as a viable treatment option for patients with severe posterior degeneration of the lumbar spine. This feasibility study evaluates the mean five-year outcomes of patients treated with the TOPS (Total Posterior Spine System) facet replacement system in the surgical management of lumbar spinal stenosis and degenerative spondylolisthesis. Methods. Ten patients (2 males, 8 females, mean age 59.6) were enrolled into a non-randomised prospective clinical study. Patients were evaluated with standing AP, lateral, flexion and extension radiographs and MRI scans, back and leg pain visual analog scale (VAS) scores, Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ) and the SF-36 questionnaires, preoperatively, 6 months, one year, two years and latest follow-up at a mean of five years postoperatively (range 55–74 months). Flexion and extension standing lumbar spine radiographs were obtained at 2 years to assess range of motion (ROM) at the stabilised segment. Results. The clinical outcome scores for the cohort improved significantly across all scoring systems. Radiographs at 2 years did not reveal any loss of position or loosening of metal work. There were two incidental durotomies and no failures at 5 years with no patient requiring revision surgery. Conclusions. The TOPS implant maintains clinical improvement and motion in the surgical management of LSS and spondylolisthesis, indicating it can be considered an option for these indications

Endoscopic spine surgery is a promising and minimally invasive technique for the treatment of disc herniation and spinal stenosis. However, the literature on the outcome of interlaminar endoscopic decompression (IED) versus conventional microsurgical technique (CMT) in patients with lumbar spinal stenosis is scarce. We analyzed 88 patients (IED: 36/88, 40.9%; CMT: 52/88, 59.1%) presenting with lumbar central spinal stenosis between 2018–2020. Surgery-related (operation time, complications, time to hospital release (THR), ASA score, C-reactive protein (CRP), white blood cell count (WBC), side (unilateral/bilateral), patient-reported (ODI, NRS (leg-, back pain), eQ5D, COMI), and radiological (preoperative dural sack cross-sectional area (DSCA), Shizas score (SC), left (LRH) and right (RRH) lateral recess heights, left (LFA) and right (RFA) facet angle) parameters were extracted. Complication (most often re-stenosis due to hematoma and/or residual sensorimotor deficits) rates were higher in the endoscopic (38.9%) than microsurgical (13.5%) treatment group (p<0.01). Age, THR, SC, CRP, and DSCA revealed significant correlations with 3 weeks and 1 year postoperatively evaluated ODI, COMI, eQ5D, NRS leg, or NRS back values in our cohort. We did not observe significant differences in the endoscopic versus microsurgical group for the patient-reported outcomes. Age, THR, SC, CRP, and DSCA revealed significant correlations with patient-centered outcomes and should be considered in future studies. Endoscopic treatment of lumbar spinal stenosis was similarly successful as the conventional microsurgical approach, although it was associated with higher complication rates in our single-center study experience. This was probably because of the surgeons' lack of experience with this method and the resulting different learning curve compared with the conventional technique

Aims. To compare the efficacy of decompression alone (DA) with i) decompression and fusion (DF) and ii) interspinous process device (IPD) in the treatment of lumbar stenosis with degenerative spondylolisthesis. Outcomes of interest were both patient-reported measures of postoperative pain and function, as well as the perioperative measures of blood loss, operation duration, hospital stay, and reoperation. Methods. Data were obtained from electronic searches of five online databases. Included studies were limited to randomised-controlled trials (RCTs) which compared DA with DF or IPD using patient-reported outcomes such as the Oswestry Disability Index (ODI) and Zurich Claudication Questionnaire (ZCQ), or perioperative data. Patient-reported data were reported as part of the systematic review, while meta-analyses were conducted for perioperative outcomes in MATLAB using the DerSimonian and Laird random-effects model. Forest plots were generated for visual interpretation, while heterogeneity was assessed using the I. 2. -statistic. Results. A total of 13 articles met the eligibility criteria. Of these, eight compared DA with DF and six studies compared DA with IPD. Patient-rated outcomes reported included the ODI and ZCQ, with mixed results for both types of comparisons. Overall, there were few statistically significant and no clinically significant differences in patient-rated outcomes. Study quality varied greatly across the included articles. Meta-analysis of perioperative outcomes revealed DF to result in greater blood loss than DA (MD = 406.74 ml); longer operation duration (MD = 108.91 min); and longer postoperative stay in hospital (MD = 2.84 days). Use of IPD in comparison to DA led to slightly reduced operation times (MD = –25.18 min), but a greater risk of reoperation compared to DA (RR = 2.70). Conclusion. Currently there is no evidence for the use of DF or IPD over DA in both patient-rated and perioperative outcomes. Indeed, both procedures can potentially lead to greater cost and risk of complications, and therefore, a stronger evidence base for their use should be established before they are promoted as routine options in patients with degenerative spondylolisthesis

Symptomatic lumbar spinal stenosis is a common entity and increasing in prevalence. Limited evidence is available regarding patient reported outcomes comparing primary vs revision surgery for those undergoing lumbar decompression, with or without fusion. Evidence available suggest a lower rate of improvement in the revision group. The aim of this study was to assess patient reported outcomes in patients undergoing revision decompression, with or without fusion, when compared to primary surgery. Patient data was collected from the Canadian Spine Outcomes Research Network (CSORN) database. Patients undergoing lumbar decompression without or without fusion were included. Patients under 18, undergoing discectomy, greater than two level decompressions, concomitant cervical or thoracic spine surgery were excluded. Demographic data, smoking status, narcotic use, number of comorbidities as well as individual comorbidities were included in our propensity scores. Patients undergoing primary vs revision decompression were matched in a four:one ratio according to their scores, whilst a separate matched cohort was created for those undergoing primary vs revision decompression and fusion. Continuous data was compared using a two-tailed t-test, whilst categorical variables were assessed using chi-square test. A total of 555 patients were included, with 444 primary patients matched to 111 revision surgery patients, of which 373 (67%) did not have fusion. Patients undergoing primary decompression with fusion compared to revision patients were more likely to answer yes to “feel better after surgery” (87.8% vs 73.8%, p=0.023), “undergo surgery again” (90.1% vs 76.2%, P=0.021) and “improvement in mental health” (47.7% vs 28.6%, p=0.03) at six months. There was no difference in either of these outcomes at 12 or 24 months. There was no difference between the groups ODI, EQ-5D, SF 12 scores at any time point. Patients undergoing primary vs revision decompression alone showed no difference in PROMs at any time point. In a matched cohort, there appears to be no difference in improvement in PROMS between patients undergoing primary vs revision decompression, with or without fusion, at two year follow-up. This would suggest similar outcomes can be obtained in revision cases

Summary Statement. Tandem stenosis is a prevalent condition in an Asian population with the narrowest cervical canal diameters and risk factors include advanced age and increased levels of lumbar canal stenosis. Introduction. Tandem spinal stenosis (TSS) is defined as patient with concomitant spinal canal stenosis found in both cervical (C) and lumbar (L) spinal region. Few studies have reported the incidence of TSS is ranged from 5–25%, but these are all noncomparative, small cohort studies. To the best of author knowledge this is the 1st study aims to compare the prevalence of TSS and its risk factors of development in a large multiracial Asian population. Methods. A retrospective review of all mid-sagittal T2MRI whole spine image was carried out at a University hospital in year 2007. Patients with spinal tumour, fracture and congenital stenosis were excluded. Spinal stenosis was defined as canal diameter of ≤10mm, measured from the posterior cervical vertebral/disc wall to anterior surface of the corresponding lamina. Patients were divided into 4 groups, no stenosis(NS), lumbar stenosis only(LS), cervical stenosis only(CS) and TSS. Patients’ demographics, race, co-morbidities and lumbar radiological report data were examined. Potential risk factors for the development of TSS were analyzed using SPSS software. Results. 926 (479 male, 447 female) patients with average age 50 (20–96) yrs were studied. Cervical canal diameters (mm) in TSS patients were the narrowest among the 4groups with C2/3 disc: 11.6, C3/4: 9.7, C4/5: 9.4, C5/6: 8.9, C6/7: 10.0 and C7T1: 11.4mm. The incidence of TSS was 26.2%. The prevalence of TSS in Chinese was 30.7%, Indian 12.5%, Malay 22.5%. The TSS prevalence in patients with 1 level lumbar canal stenosis was 12.5%, 2 levels lumbar stenosis was 6.4% and 3 levels was 4.1%. Multivariate analysis showed patients aged between 40–59 yrs (p=0.000, Exp(B):5.8, 95%CI 2.8–12.0), aged > 60yrs (p=0.000, Exp(B): 10.5, 95%CI 4.8–22.9), Chinese race (p=0.008, Exp(B): 2.5, 95%CI 1.3–4.9), patients with 1 level lumbar stenosis (p=0.000, Exp(B): 63.3, 95%CI 29.2–137.3), 2 levels lumbar stenosis (p=0.000, Exp(B): 67.7, 95%CI 29.4–155.7) and 3 levels lumbar stenosis (p=0.000, Exp(B): 106.6, 95%CI 43.6–260.5) are statistical significant risk factors for TSS development. Conclusion. The incidence of TSS was 26.2%. TSS patients have the narrowest cervical canal measurements among the studied groups. The prevalence of TSS in Chinese is the highest (30.7%). Patients advancing in age or have increased levels of lumbar canal stenosis are at risk of developing TSS

Background. Epidural steroid injections can provide temporary relief of symptoms in the treatment of lumbar spinal stenosis. Surgery is indicated when conservative measures fail. We hypothesise that patients who gain temporary relief of symptoms from the administration of epidural steroid injections are more likely to result in an improvement in symptoms following surgical intervention compared to patients who do not respond to injection therapy. Method. The records of patients who had received both an epidural injection and surgical intervention for lumbar spinal stenosis between July 2008 and July 2010 were identified and retrospectively reviewed. Relief of symptoms following epidural injection was noted at 6 weeks post procedure and the patients symptoms following surgical intervention was noted and classified according to MacNab's criteria at 3 months post-surgery. Results. 60 patients who received both an epidural injection and surgical intervention for lumbar spinal stenosis were identified. 76% of patients who gained relief of symptoms from epidural injection scored good or excellent according to MacNab's criteria following surgery (n=34). Only 30% of patients who did not respond to injection therapy scored good or excellent according to MacNab's criteria following surgical intervention (n=5). Conclusion. Patients who gained temporary relief of symptoms from epidural injection were more likely to benefit from surgical intervention in the treatment for lumbar spinal stenosis. No conflicts of interest. No funding obtained. We confirm that this abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Introduction: Lumbar spinal stenosis is a frequent indication for spinal surgery. The predictive quality of treadmill testing and MRI for diagnostic verification is not yet clearly defined. The aim of our study was to assess correlations between treadmill testing and MRI findings in the lumbar spine. Methods: Patients with lumbar spinal stenosis who had been admitted for surgical treatment by means of decompression with or without stabilisation were prospectively examined. We included patients with lumbar spinal stenosis as defined by clinical symptoms like low back and/or leg pain, which increased when walking, and by the area of the dural sac examined by MRI. We excluded patients with clinically manifest peripheral arterial disease, polyneuropathy or musculoskeletal impairments compromising the ability to walk. Treadmill tests were performed using the standardized testing protocoll by Deen at a speed of 0.5 m/sec without inclination. After the onset of symptoms (pain, weakness or dysaesthesia), each patient decided when to end the test. The area of the dural sac and neuroforamina was examined with MRI for the narrowest spinal segment. ODI and VAS were used for clinical assessment. Results: 25 patients were included with a median age of 67 years (Interquartile range IQR 60–72 yrs). In the narrowest spinal segment the median area of the dural sac was 91mm2 (IQR 67–135 mm2). The median ODI was 66 percent (IQR 64–72 percent). The median walking distance in the treadmill test was 70 m (IQR 30–130 m). The distance reached in the treadmill test correlated with the area of the dural sac (Spearman’s rho=0.53) and ODI (rho=0.51), but not with the area of the neuroforamina and VAS. Discussion: The treadmill test helps objectifying pre- and postsurgical clinical complaints and verifying a lumbar spinal stenosis by creating a situation of dynamic strain. Moreover, the treadmill test lets the patient experience his own physical limits and enables the examiner to attain a replicable postoperative assessment. The distance reached in the treadmill test predicts the grade of stenosis in MRI but has a limited diagnostic importance for the level of clinical symptoms in lumbar spinal stenosis

The October 2014 Spine Roundup. 360 . looks at: microdiscectomy is not exactly a hands-down winner; lumbar spinal stenosis unpicked; Wallis implant helpful in lumbosacral decompression; multidisciplinary rehabilitation is good for back pain; and understanding the sciatic stretch test

Although previous studies have shown poor correlation between clinical symptoms due to lumbar stenois and radiologic stenosis, no study has corrected for congenital variation in vertebral body size among individuals. This purpose of this study is to determine the relationship between the degree of radiographic lumbar spinal stenosis, adjusted with an internal control for vertebral body size, and disability from lumbar stenosis. One hundred and twenty-three consecutive patients with clinical and radiologic confirmation of neural impingement secondary to lumbar stenosis were enrolled prospectively. Thecal sac AP diameter (TSD) and cross sectional area (CSA), and vertebral body AP dimension (VBD) were determined. These parameters were then correlated with patients’ symptoms using the modified Roland-Morris Questionnaire (RMQ) disability score. This study found no statistically significant inverse correlation between TSD and RMQ score (p=0.433) or CSA and RMQ Score (p=0.124). In addition, there was no significant inverse correlation between CSA/VBD ratio and RMQ score (p=0.036) or TSD/VBD ratio and RMQ score (p=0.109). There was a significant difference in mean RMQ scores when the patients were divided into those with CSA greater than or equal to 70 mm2 and those less than 70 mm2, with T=−2.104 and p=0.038. The degree of radiographic lumbar spinal stenosis, even with the use of an internal control of vertebral body size and standardized disability questionnaires, does not correlate with clinical symptoms. However, patients with more severe stenosis below a cross-sectional area critical threshold of 70mm2, have significantly greater functional disability

We evaluate the patients with lumbar spinal stenosis in multiple levels that were treated with posterior decompression and posterolateral fusion, using transpedicular screw fixation system. Twenty-six patients, mean age 65.7 years (range 49 to 77years), with lumbar spinal stenosis, in more than three levels, were treated surgically between 1994 and 2002. Indications for surgical treatment included low back pain and neurogenic claudication for more than 6 months. The diagnostic approach consisted of x-rays, MRI, myelography and myelo-CT. Oswestry disability score and VAS (visual analog scale), were used for the clinical evaluation of the patients. Surgical procedure consisted of wide posterior decompression, regarding laminectomy, complete or incomplete facetectomy and foraminotomy, combined with posterolateral fusion, using transpedicular screw systems and bone graft. Fusion in three levels was performed at seven patients, in four levels at ten, in five levels at seven, in six and seven levels at one patient respectively. Mean follow-up was 26.8 months (range 12 to 38 months). Oswestry score and VAS revealed improvement 40.75% and 5.4 levels respectively. The better results were concerned to pain (2.88 levels improvement) and the less good to lifting (1.58 levels improvement). Two cases with superficial infections were observed and treated with surgical debridement. Screw breakage was observed in 1 patient and treated conservatively. Loosening of two sacral screws, which were removed, was observed in one patient. We conclude that myelography and myelo-CT revealed with satisfactory accuracy intra and outer foraminal lumbar spinal stenosis. Posterior decompression and instrumented fusion, offer satisfactory clinical results in patients with lumbar spinal stenosis in multiple levels when performed by experienced surgical team

Purpose: The quality of the functional result for surgical treatment of lumbar stenosis has been the subject of much debate. The objectives of this retrospective review were to assess functional outcome ten years after surgical treatment of lumbar stenosis and determine the rate of revision in order to identify factors influencing outcome at last follow-up. Material and methods: One hundred forty-one patients underwent surgery for lumbar stenosis between January 1990 and December 1992. Mean follow-up was ten years. Functional outcome at last follow-up was assessed with a specific questionnaire with items for lumbar and radicular pain and signs of radicular ischemia and with a self-administered satisfaction questionnaire as well as two visual analogue scales (VAS) for lumbar and radicular pain. Other data noted were: epidemiological and morphological features, comorbidity, presence or not of objective signs of neurological involvement, the SF-36, and a self-assessed anxiety-depression score (GHQ28). Two types of analysis were performed. A descriptive analysis to determine the severity of functional signs observed at last follow-up, patient satisfaction and incidence and reasons for surgical revision. Multivariate analysis was designed to search for factors affecting the self-administered senosis score. Results: During the study period, fifteen patients underwent a revision procedure involving the lumbar spine. At last follow-up the overall satisfaction index was 71%. The best results were obtained for radiculalgia and intermittent neurogenic claudication. Residual lumbalgia was the main complaint at last follow-up. The patient’s psychological profile was the predominant factor affecting functional outcome. Other factors influencing functional outcome were revision surgery, persistent objective neurological disorders, and comorbidity. Conclusion: Surgical treatment of lumbar stenosis allows satisfactory long-term results in the majority of patients. At ten years, the risk of revision surgery was 10%. A review of the literature shows that these results are better than those obtained with medical treatment and that these surgical interventions enable quality-of-life similar to that observed in an age-matched population

Background context: Surgical treatment of lumbar spinal stenosis is one of the most frequent procedures in spinal surgery. Nevertheless, the predictive quality of instruments like treadmill test and MRI has not yet been clearly defined for the lumbar spinal stenosis. Purpose: Objective of this study was to verify correlations between treadmill test and MRI findings in the narrowest spinal segment. Methods: In a prospective study (EBM-level 3) 25 patients with inpatient treatment for lumbar spinal stenosis were investigated between 01/2005 and 06/2005. Exclusion criteria were a reduced walking capacity for other reasons (e.g. gonarthrosis). Treadmill tests were performed following the protocol by Deen. Patients estimated their maximum walking distance before performing the tests. Area of the dural sac, area of the neuroforamina and disc height at the dorsal margin were examined by MRI for the narrowest spinal segment. VAS and ODI were used as clinical assessment instruments. Outcome Measures: The median age of patients was 67 yrs (IQR 58–73 yrs) with 44 % females. The median distance reached in the treadmill test was 70 m (IQR 30–135 m), the median estimated maximum walking distance 200 m (IQR 100–300 m). In the narrowest spinal segment the median area of the dural sac was 91 mm2 (IQR 65–143 mm2), the median area of the neuroforamina 43 mm2 (IQR 36–51 mm2) and the median disc height 1,4 mm (IQR 0,9–2,5 mm). The median VAS was 7 (IQR 6,5–8) and the median ODI 33 (IQR 32–37). Results: The distance reached in the treadmill test correlated with the maximum walking distance estimated by the patients (Spearman’s rho=0,62, p=0,001), area of the dural sac (rho=0,54, p=0,006) and disc height (rho=0,45, p=0,03), but not with area of the neuroforamina and VAS. VAS correlated with the disc height (rho=−0,6, p=0,002), but with no other MRI findings. Conclusions: The distance reached in the treadmill test and MRI findings in the narrowest spinal segment predict the level of clinical symptoms. Possible reasons for the slightly limited predictive quality of MRI findings are that this study did not regard the time of development of the stenosis, that effects of multilevel stenosis were not considered, and that MRI findings in lying position without lordosis might differ from findings in standing position. However, the treadmill test is a valid and highly practicable pre-surgery diagnostic instrument in lumbar spinal stenosis

Introduction: Lumbar spinal stenosis commonly affects elderly patients with multiple co-morbidities. They are at increased risk of complications following surgical interventions. Non-operative strategies for treating them are desirable and previous studies have shown some benefit of subcutaneous salmon calcitonin for the treatment of spinal stenosis. Objectives: To assess the effectiveness of nasal salmon calcitonin for the treatment of lumbar spinal stenosis in a cohort of patients. Study design: Prospective cohort study. Methods: 34 patients with MRI proven lumbar spinal stenosis were enrolled into the trial. They received salmon calcitonin in the form of a nasal spray for 6 weeks. All the patients had multiple co-morbidities making them high risk for any surgical intervention. They were followed up at 6 weeks and at 12 weeks. The main outcome measures were oswestry disability index (ODI), low back outcome score (LBOS) and visual analogue scale (VAS). The patient’s were also subjectively asked to rate the treatment excellent, good, fair or poor. Results: The mean age was 73.5 years (range 51–92 years). The mean duration of symptoms was 32.6 months (range 3–120 months) The mean ODI pre-treatment was 50 and after 6 weeks of treatment decreased to 47 (p=0.14). The mean LBOS was 18 pre-treatment and increased to 21 (p=0.02) after 6 weeks of treatment. The mean VAS for leg pain was 76mm pre-treatment and decreased to 64mm (p=0.001) after treatment and the mean VAS for back pain only decreased from 64mm to 61mm (p=0.5). 11 patients (32%) had a minimum 20mm change in VAS scores after treatment and 7 patients (21%) improved their ODI score by a minimum of 10 points. All results remained stable at 12 weeks follow-up, suggesting a longer effect than the duration of treatment. With regards to patient’s subjective outcome 9 patients (27%) rated the treatment as fair, 3 rated it as good (9%) and 17 reported no change (50%). Conclusion: Our results suggest the benefits of nasal salmon calcitonin treatment are marginal, with a minimal improvement in symptoms of patients with lumbar spinal stenosis