Objective: An anatomical study to describe the radiographic pattern of canal, foraminal and lateral recess stenosis in degenerative lumbar stenosis associated with open and closed subluxations of the lumbar spine.

Introduction: Degenerative lumbar scoliosis is a three-dimensional deformity frequently associated with facet joint subluxation. It is suggested that the causative mechanism of open subluxation is vertebral rotation, whereas closed subluxation is driven by erosion of the convex facet joint. Patients with degenerative lumbar scoliosis are predominantly symptomatic on standing. However, standing MRI scans are not currently feasible to investigate this dynamic problem, therefore an accurate interpretation of the standing and lateral radiographs is essential to effectively treat this condition. We have undertaken a study to compare standing radiographs with supine MRI to determine the pattern of nerve root entrapment with open and closed facet joint dislocations in DLS.

Methods: Plain radiographs and MRI scans of 35 consecutive patients with de novo degenerative lumbar scoliosis (average age 72 years) were evaluated. Radiographic measurements included the angle of the dislocation, degree of translation, position of osteophytes, vertebral rotation and the degree and location of any stenosis present on the axial MRI images.

Results: Open dislocations were associated with a pre-dominant contralateral lateral recess and/or foraminal stenosis in 74% of cases. Closed dislocations were associated with ipsilateral lateral recess and/or foraminal stenosis in 82% of cases. Both open and closed dislocations had a similar degree of vertebral rotation.

67% of open subluxations occurred at L3/4. In closed subluxations the most frequent level involved was LI/2 (53% of cases). Open dislocations are located closest to the apex of the curve, with closed dislocations being more peripheral. The curve was noted to rotate towards the apex.

Conclusion: Open and closed subluxations of the lumbar spine result in different, but predictable, patterns of stenosis. The findings are important in the diagnosis and planning of treatment in patients with lumbar spinal stenosis, when associated with degenerative scoliosis and lateral spondylolisthesis.

Introduction. Limited physical activity (PA) is one indication for orthopaedic intervention and restoration of PA a treatment goal. However, the objective assessment of PA is not routinely performed and in particular the effect of spinal pathology on PA is hardly known. It is the purpose of this study using wearable accelerometers to measure if, by how much and in what manner spinal stenosis affects PA compared to age-matched healthy controls. Patients & Methods. Nine patients (m/f= 5/4, avg. age: 67.4 ±7.7 years, avg. BMI: 29.2 ±3.5) diagnosed with spinal stenosis but without decompressive surgery or other musculoskeletal complaints were measured. These patients were compared to 28 age-matched healthy controls (m/f= 17/11, avg. age: 67.4 ±7.6 years, avg. BMI: 25.3±2.9). PA was measured using a wearable accelerometer (GCDC X8M-3) worn during waking hours on the lateral side of the right leg for 4 consecutive days. Data was analyzed using previously validated activity classification algorithms in MATLAB to identify the type, duration and event counts of postures or PA like standing, sitting, walking or cycling. In addition, VAS pain and OSWESTRY scores were taken. Groups were compared using the t-test or Mann-Whitney U-test where applicable. Correlations between PA and clinical scores were tested using Pearson”s r. Results. Spinal stenosis patients showed much lower PA than healthy controls regarding all parameters like e.g. daily step count (2946 vs 8039, −63%, p<0.01) or the relative daily time-on-feet (%) (8.6% vs 28.3%, −70%, p<0.01) which is matched with increased sitting durations (80.3% vs 58.8%, p<0.01). Also qualitative parameters such as walking cadence was reduced in stenosis patients (83.7 vs 97.8 steps/min). With stenosis no patient ever walked >1000 steps without interruption. Also the number of walking bouts between 250–1000 steps was 4.5 times lower than in healthy controls (p<0.01). When the relative distribution of walking bout length was calculated, it became visible that stenosis patients showed more short walking bouts of 10–50 steps (p<0.05). There were no strong and significant correlations between the clinical scores and PA parameters. Discussion & Conclusions. Spinal stenosis greatly reduced physical activity to levels below WHO guidelines (e.g. <5000 steps= sedentary lifestyle) where the risk for general health (overall mortality), cardiovascular or endocrinological health is significantly increased. Activity levels are lower than reported for end-stage hip or knee osteoarthritis. Therefore, spinal stenosis patients should not only receive pain medication, but be made aware of their limited PA and its detrimental health effects, participate in activation programs, or be considered for surgical intervention. The absence of long walking bouts and the relatively more frequent short walking bouts seem indicative of intermittent claudication as typical in spinal stenosis

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

Spinal stenosis is a condition resulting in the compression of the neural elements due to narrowing of the spinal canal. Anatomical factors including enlargement of the facet joints, thickening of the ligaments, and bulging or collapse of the intervertebral discs contribute to the compression. Decompression surgery alleviates spinal stenosis through a laminectomy involving the resection of bone and ligament. Spinal decompression surgery requires appropriate planning and variable strategies depending on the specific situation. Given the potential for neural complications, there exist significant barriers to residents and fellows obtaining adequate experience performing spinal decompression in the operating room. Virtual teaching tools exist for learning instrumentation which can enhance the quality of orthopaedic training, building competency and procedural understanding. However, virtual simulation tools are lacking for decompression surgery. The aim of this work was to develop an open-source 3D virtual simulator as a teaching tool to improve orthopaedic training in spinal decompression. A custom step-wise spinal decompression simulator workflow was built using 3D Slicer, an open-source software development platform for medical image visualization and processing. The procedural steps include multimodal patient-specific loading and fusion of Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) data, bone threshold-based segmentation, soft tissue segmentation, surgical planning, and a laminectomy and spinal decompression simulation. Fusion of CT and MRI elements was achieved using Fiducial-Based Registration which aligned the scans based on manually placed points allowing for the identification of the relative position of soft and hard tissues. Soft tissue segmentation of the spinal cord, the cerebrospinal fluid, the cauda equina, and the ligamentum flavum was performed using Simple Region Growing Segmentation (with manual adjustment allowed) involving the selection of structures on T1 and/or T2-weighted scans. A high-fidelity 3D model of the bony and soft tissue anatomy was generated with the resulting surgical exposure defined by labeled vertebrae simulating the central surgical incision. Bone and soft tissue resecting tools were developed by customizing manual 3D segmentation tools. Simulating a laminectomy was enabled through bone and ligamentum flavum resection at the site of compression. Elimination of the stenosis enabled decompression of the neural elements simulated by interpolation of the undeformed anatomy above and below the site of compression using Fill Between Slices to reestablish pre-compression neural tissue anatomy. The completed workflow allows patient specific simulation of decompression procedures by staff surgeons, fellows and residents. Qualitatively, good visualization was achieved of merged soft tissue and bony anatomy. Procedural accuracy, the design of resecting tools, and modeling of the impact of bone and ligament removal was found to adequately encompass important challenges in decompression surgery. This software development project has resulted in a well-characterized freely accessible tool for simulating spinal decompression surgery. Future work will integrate and evaluate the simulator within existing orthopaedic resident competency-based curriculum and fellowship training instruction. Best practices for effectively teaching decompression in tight areas of spinal stenosis using virtual simulation will also be investigated in future work

Introduction: Operations inside the spinal canal are afflicted with a certain number of iatrogenic dural lesions. Incidence figures in the literature vary from 1 to 17% and are mainly based on retrospective studies. The Swedish Spine Register, SweSpine, provides a good possibility to study the incidence in a prospective patient material. Patients and Methods: During 5 years more than 9 000 patients had surgical treatment for lumbar disc herniation or lumbar spinal stenosis and were registered according to the protocol of the Swedish Spine Register. One year follow-up data were present for 74 % of the patients. Pre- and postoperative data are entirely based on questionnaires answered by the patient whereas surgical data are completed by the surgeon. Complication and re-operation registration is included. Mean patient age for LDH was 45 (12–88) years, for spinal stenosis 68 (27–93) years and 56% of the disc herniation patients and 43% of the spinal stenosis patients were males. Most common level for LDH operation was L5/S1 followed by L4/L5 and for spinal stenosis L4/L5 followed by L3/L4. The one-year result was studied. Results: The incidence of dural lesion in lumbar disc herniation surgery was 2.7% and in spinal stenosis decompression 7.3%. The risk for dural lesion was more than doubled in patients with previous surgery which, thus, was a significant but also the only risk factor. At one year after surgery the result was similar for patients with and without dural lesion when VAS pain, ODI, SF-36 and patient graded global assessment were studied. Correlation between previous surgery and inferior outcome was seen but was not affected by the dural lesion as such. Three and 5% respectively in the groups were subjected to repeat surgery before discharge from the hospital. The lost-to follow-up group (26%) had similar pre-operative demographics and the same incidence of dural lesion as those followed-up. Conclusion: In a large prospectively studied material, the incidence of dural lesion in lumbar disc herniation surgery was 2.7% and in decompressive spinal stenosis surgery 7.3%. Previous surgery was a significant risk factor for dural lesion. The dural lesion as such did not negatively influence the one-year outcome

Low back pain is the single most common cause for disability in individuals aged 45 years or younger, it carries tremendous weight in socioeconomic considerations. Degenerative aging of the structural components of the spine can be associated with genetic aspects, lifetime of tissue exposure to mechanical stress & loads and environmental factors. Mechanical consequences of the disc degenerative include loss of disc height, segment instability and increase the load on facets joints. All these can lead to degenerative changes and osteophytes that can narrow the spinal canal. Surgery is indicated in patients with spinal stenosis who have intractable pain, altered quality of life, substantially diminished functional capacity, failed non-surgical treatment and are not candidates for non-surgical treatment. The aim was to determine the reasons for refusal of surgery in patients with established degenerative lumber spine pathology eligible for surgery. All patients meeting the study criteria, patients older than 18 years, patients with both clinical and radiological established symptomatic degenerative lumbar spine pathology and patients eligible for surgery but refusing it were recruited. Questionnaire used to investigate reasons why they are refusing surgery. Results 59 were recruited, fifty-one (86.4 %) females and eight (13.6 %) males. Twenty (33.8 %) were between the age of 51 and 60 years, followed by nineteen (32.2 %) between 61 and 70 years, and fourteen (23.7 %) between 71 and 80 years. 43 (72 %) patients had lumber spondylosis complicated by lumber spine stenosis, followed by nine (15.2 %) with lumbar spine spondylolisthesis and four (6.7 %) had adjacent level disease. 28 (47.4 %) were scared of surgery, fifteen (25.4 %) claimed that they are too old for surgery and nine (15.2 %) were not ready. Findings from this study outlined that patients lack information about the spinal surgery. Patients education about spine surgery is needed

To determine the clinical efficacy of vitamin-D supplementation on pain intensity and functional disability in patients with chronic lower back pain. This prospective cohort study was conducted from 20th March 2017 to 19th March 2019. The inclusion criteria were patients of CLBP aged between 15 to 55 years. Exclusion criteria included all the patients with Disc prolapse, Spinal stenosis, Any signs of neurological involvement, Metabolic bone disease (Hypo- or Hyperparathyroidism) and Chronic kidney disease/Chronic liver disease. Patients were supplemented with 50,000 IU of oral vitamin-D3 every week for 8 weeks (induction phase) and 50,000 IU of oral vitamin-D3 once monthly for 6 months (maintenance phase). Efficacy parameters included pain intensity and functional disability measured by VAS and modified Oswestry disability questionnaire (MODQ) scores at baseline, 2, 3 and 6 months post-supplementation. Vitamin-D3 levels were measured at baseline,2,3 and 6 months. A total of 600 patients were included in the study. The mean age of patients was 44.2 ± 11.92 years. There were 337 (56.2%) male patients while 263 (43.8%) female patients. Baseline mean vitamin-D levels were 13.32 ± 6.10 ng/mL and increased to 37.18 ± 11.72 post supplementation (P < 0.0001). There was a significant decrease in the pain score after 2nd, 3rd& 6th months (61.7 ± 4.8, 45.2 ± 4.6 & 36.9 ± 7.9, respectively) than 81.2 ± 2.4 before supplementation (P < 0.001). The modified Oswestry disability score also showed significant improvement after 2nd, 3rd & 6th months (35.5, 30.2 & 25.8, respectively) as compared to baseline 46.4 (P < 0.001). About 418 (69.7%) patients attained normal levels after 6 months. Vitamin-D supplementation in chronic lower back pain patients may lead to improvement in pain intensity and functional ability

Introduction. We propose that Total Hip Replacement with correction of fixed flexion deformity of the hip and exaggerated lumbar lordosis will result in relief of symptoms from spinal stenosis, possibly avoiding a spinal surgery. A sequence of patients with this dual pathology has been assessed to examine this and suggest a possible management algorithm. Materials and methods. A retrospective study of 19 patients who presented with dual pathology was performed and the patients were assessed with regards to pre and post-operative symptoms, walking distance, and neurological status. Results. There were 17 patients with improvement in the spinal stenotic symptoms following hip replacement to an extent that none required spinal surgery. There were two patients who had spinal surgery after THR, at varying lengths following hip replacements as their spinal stenotic symptoms worsened over time, and had lateral spinal stenosis on MRI. Discussion. In advanced hip osteoarthritis, a fixed flexion deformity may develop at the hip leading to an exaggerated lumbar lordosis in erect posture. In the presence of co-existing spinal stenosis, the exaggerated lumbar lordosis may worsen the spinal stenotic symptoms while standing and walking. Cadaveric & Radiological studies have shown that canal narrowing occurs with increased lordosis/ extension in the lumbar spine. Our findings suggest that when central lumbar spinal stenosis coexists with bilateral hip arthritis and FFD at the hip, THR should be offered first. Successful hip surgery for arthritis correcting significant fixed flexion deformity would lessen the lumbar lordosis, thus correcting the excessive pathological narrowing. If a patient is fit enough, simultaneous bilateral THR via an anterior type of approach makes surgical correction of FFD easier. Although it has been suggested in the literature that patients with spinal stenosis have a increased risk of neurological impairment following THR, we did not find any clear association

The primary objective of this study was to determine if surgical treatment for spinal stenosis is comparable to total hip and knee arthroplasty in improving patients’ self-reported quality of life. An age, sex and time of surgery matched cohort of patients who had undergone elective primary one-two level spinal decompression (n=90) with (n=26 /90) or without fusion for spinal stenosis (n=40 with degenerative spondylolisthesis) and elective primary total hip (n=90) and knee (n = 90) arthroplasty for osteoarthritis were compared. The primary outcome measure was the preoperative and two year postoperative Medical Outcomes Study Short Form-36 (SF-36) questionnaire. There was no significant difference in the mean pre-operative Physical Component Summary (PCS) / Mental Component Summary between groups [Spine −32/43; Hip − 30/45; Knee 31/46 (p > 0.5)]. With the exception of the knee MCS (p=0.2), postoperative scores were significantly improved for all groups [Spine −40/53; Hip − 43/51; Knee 39/48 (p < 0.001)]. Overall the hip surgery had the great impact on PCS and the spine surgery on MCS. Studies have shown the significant impact on overall patient quality of life and cost-effectiveness of primary total joint arthroplasty. The results of this unique study show that surgical intervention for spinal stenosis has a similar positive effect at two year follow up. This study provides data that supports the need advocacy regarding waiting time initiatives and surgical resources for the treatment of patients with symptomatic spinal stenosis with a similar demographic to those with primary OA of the hip or knee

With the increase in the elderly population, there is a dramatic increase in the number of spinal fusions. Spinal fusion is usually performed in cases of primary instability. However it is also performed to prevent iatrogenic instability created during surgical treatment of spinal stenosis in most cases. In literature, up to 75% of adjacent segment disease (ASD) can be seen according to the follow-up time. 1. Although ASD manifests itself with pathologies such as instability, foraminal stenosis, disc herniation or central stenosis. 1,2. There are several reports in the literature regarding lumbar percutaneous transforaminal endoscopic interventions for lumbar foraminal stenosis or disc herniations. However, to the best our knowledge, there is no report about the treatment of central stenosis in ASD. In this study, we aimed to investigate the short-term results of unilateral biportal endoscopic decompressive laminotomy (UBEDL) technique in ASD cases with symptomatic central or lateral recess stenosis. The number of patients participating in the prospective study was 8. The mean follow-up was 6.9 (ranged 6 to 11) months. The mean age of the patients was 68 (5m, 3F). The development of ASD time after fusion was 30.6 months(ranged 19 to 42). Mean fused segments were 3 (ranged 2 to 8). Preoperative instability was present in 2 of the patients which was proven by dynamic lumbar x-rays. Preoperative mean VAS-back score was 7.8, VAS Leg score was 5.6. The preoperative mean JOA (Japanese Orthopaedic Association) score was 11.25. At 6th month follow-up, the mean VAS back score of the patients was 1, and the VAS leg score was 0.5. This improvement was statistically significant (p = 0.11 and 0.016, respectively). The mean JOA score at the 6th month was 22.6 and it was also statistically significant comparing preoperative JOA score(p = 0.011). The preoperative mean dural sac area measured in MR was 0.50 cm2, and it was measured as 2.1 cm. 2. at po 6 months.(p = 0.012). There was no progress in any patient's instability during follow-up. In orthopedic surgery, when implant related problems develop in any region of body (pseudoarthrosis, infection, adjacent fracture, etc.), it is generally treated by using more implants in its final operation. This approach is also widely used in spinal surgery. 3. However, it carries more risk in terms of devoloping ASD, infection or another complications. In the literature, endoscopic procedures have almost always been used in the treatment of ventral pathologies which constitute only 10%. In ASD, disease devolops as characterized by wide facet joint arthrosis and hypertrophied ligamentum flavum in the cranial segment and it is mostly presented both lateral recess and santal stenosis symptoms (39%). In this study, we found that UBEDL provides successful results in the treatment of patients without no more muscle and ligament damage in ASD cases with spinal stenosis. One of the most important advantages of UBE is its ability to access both ventral and dorsal pathologies by minimally invasive endoscopic aproach. I think endoscopic decompression also plays an important role in the absence of additional instability at postoperatively in patients. UBE which has already been described in the literature given successful results in most of the spinal degenerative diseases besides it can also be used in the treatment of ASD. Studies with longer follow-up and higher patient numbers will provide more accurate results

Purpose: The primary objective of this study was to determine if surgical treatment for spinal stenosis is comparable to total hip arthroplasty in improving patients’ self-reported quality of life. Methods: An age, sex and time of surgery matched cohort of patients who had undergone elective primary 1–2 level spinal decompression (n=90) with (n=30/90) or without fusion for spinal stenosis (n=40 with degenerative spondylolisthesis) and elective primary total hip arthroplasty for osteoarthritis (n=90) were compared. The primary outcome measure was the preoperative and one year postoperative Medical Outcomes Study Short Form-36 (SF-36) questionnaire. Results: The mean Physical Component Summary (PCS) / Mental Component Summary (MCS) for the stenosis compared to hip patients were 32.0/43.3 vs. 30.5/46.2 preoperatively (analysis between groups: p = 0.2/0.1) and 39.1/47.3 vs.44.1/46.1 postoperatively (analysis between groups: p = 0.003/0.4). The pre- and postoperative PCS significantly improved for both groups (p < 0.0001);however, the pre- and postoperative MCS improved in the stenosis group only (p = 0.04). Conclusions: Studies have shown the significant impact on overall patient quality of life and cost-effectiveness of primary total hip arthroplasty. The results of this unique study show that surgical intervention for spinal stenosis also has a very positive overall effect on patients’ self-reported quality of life at one year follow up. This study provides data that supports the need for a long term prospective study and advocacy regarding waiting time initiatives and surgical resources for the treatment of patients with symptomatic spinal stenosis with a similar demographic to those with primary OA of the hip

Purpose: A retrospective study comparing the fusion rate and, the incidence of junctional spinal stenosis between a rigid (Wiltse) and a semirigid (Varifix) posterior spinal fusion system. Material & Methods: 92 patients, mean age 52.3 year old, underwent posterior fusion with semirigid Varifix system (rod diameter 5.0 mm), and 89 patients, mean age 49.8 year old, with rigid Wiltse system (6.5 mm). The mean follow-up was 4.8 years (range 2–9) for Varifix group and 11.7 years (range 9–17) for Wiltse group. Preoperative diagnosis was spinal stenosis (n=56), disc degenerative disease (n=43), degenerative spondylolisthesis (n=37), post-laminectomy instability (n=34), and isthmic spondylolisthesis (n=11). In all patients autologous iliac crest bone graft was used. Spinal fusion was confirmed by A-P, lateral, and flexion-extension radiographic studies, or by direct surgical exploration and observation. Pain intensity was recorded using the Visual Analogue Scale (VAS). Results: Successful fusion was achieved in 92.4% in the semirigid group and in 93.2% for the rigid group. There was no statistical difference in fusion rate between these two groups (p=0.82). Eight patients with pseudoarthrosis were treated by anterior fusion and 5 by repaired posterior fusion, with a fusion rate of 100%. Postoperative infection was diagnosed in 5 patients (5.4%) in the semirigid group and in 4 patients (4.5%) in the rigid group. They were treated by debridement, irrigation, and intravenous antibiotics. Hardware removal because of pain was performed in 9 patients (9.8%) in the semirigid group, and 17 patients (19.1%) in rigid group. Removal of hardware resulted in improvement in pain in all patients. Junctional spinal stenosis was diagnosed in 2 patients (2.2%) in semirigid group and in 7 patients (7.9%) in rigid group. There was a trend for higher incidence of adjacent level stenosis in rigid group (p=0.07). Conclusion: Biomechanical studies have shown that the stiffness of spinal construct depends on rod diameter and a decrease in rod rigidity can increase the risk of implant failure. In our study we didn’t find any difference in the fusion rate and in complication rate between these two systems. The increased percentage of the junctional spinal stenosis in rigid group may be explained by the longer follow-up in this group. According to our data the semirigid system may be better tolerated than the rigid system

To estimate the outcomes after posterior dynamic stabilization in situ with Dynesys (Zimmer Spine, Minneapolis, MN) for treatment of symptomatic spinal stenosis and degenerative spondylolisthesis in long-term follow-up. 28 patients(mean age 73 years old) with symptomatic spinal stenosis and spondylolisthesis underwent inter-laminar decompression and stabilization with Dynesys. Patients were evaluated clinically and radiologically after a follow-up from 6 months to 4 years. Pain on VAS and walking distance improved significantly at less than 2 years and remained unchanged at 4 years follow-up. Radiographically, spondylolisthesis did not progress and the motion segments remained stable. 2 patients showed screw-loosening at 1 year follow-up and underwent revision. Overall, patient satisfaction remained high as 93% and would undergo the same procedure again. In elderly patients with spinal stenosis and degenerative spondylolisthesis, decompression and dynamic stabilization lead to excellent clinical and radiologic results. It maintains enough stability to prevent progression of spondylolisthesis. Because no bone grafting is necessary, donor site morbidity, which is one of the main drawbacks of fusion is eliminated

Retrospective analysis of radiology reports of conventional MRI in 100 patients with definite spinal stenosis to determine the incidence of reported “foraminal stenosis”. Prospective study of MRI including T2 coronal and T2 STIR coronal sequences in 57 patients with suspected stenosis. Three surgeons and one radiologist independently compared the diagnoses on conventional and coronal scans. Patients with suspected spinal stenosis undergoing MRI. Incidence of “foraminal stenosis” on radiologists' reports. Diagnoses obtained by different scanning methods. Retrospective analysis: “foraminal stenosis” called by radiologists in 46% using conventional axial and sagittal sequences. Prospective study - 57 patients: conventional sequences diagnosed lateral recess stenosis well but also suggested foraminal stenosis in 33%. However, coronal sequences clearly showed no foraminal nerve compression. In degenerative spondylolisthesis conventional scans suggested foraminal stenosis in 8 of 11 cases. Coronals showed no foraminal stenosis. Excellent correlation was found in normal spines and in disc herniation. In far lateral disc herniation and isthmic spondylolisthesis, true foraminal stenosis was confirmed by conventional and coronal imaging. Additional coronal MRI sequences prove that foraminal stenosis is over-diagnosed and is rare in spinal stenosis, but true foraminal nerve compression occurs in isthmic spondylolisthesis and far lateral disc herniation

Introduction. In degenerative lumbar spine, it seems possible that foraminal stenosis is over-diagnosed as axial scanning is not performed in the plane of the exiting nerve root. We carried out a two-part study to determine the true incidence of foraminal stenosis. Patients and Methods. Initially we performed a retrospective analysis of radiology reports of conventional Magnetic Resonance Imaging in 100 cases of definite spinal stenosis to determine the incidence of reported ‘foraminal stenosis’. Subsiquently we performed a prospective study of MRI including fine slice T2 and T2 STIR coronal sequences in 100 patients with suspected stenosis. Three surgeons and one radiologist independently compared the diagnoses on conventional axial and sagittal sequences with the coronal scans. Results. The retrospective analysis found that ‘foraminal stenosis’ was reported by radiologists in 46% using conventional axial and sagittal sequences. In the prospective study of 100 patients suspected of having stenosis, spinal stenosis was reported in 40; degenerative spondylolisthesis in 14; posterolateral disc herniation in 14; normal report in 13; far lateral disc herniation in 7; isthmic (lytic) spondylolisthesis in 6; and degenerative scoliosis in 6. Conventional sequences diagnosed lateral recess stenosis reliably, but also suggested foraminal stenosis in 43%. However, coronal sequences clearly showed no foraminal nerve compression at all. In degenerative spondylolisthesis conventional scans suggested foraminal stenosis in 10 of 14 cases. Coronal imaging again showed no foraminal stenosis. Excellent correlation was found in normal spines and in disc herniation. Foraminal nerve compression was confirmed by conventional and coronal imaging only in isthmic spondylolisthesis, degenerative scoliosis and far lateral disc herniation. Conclusion. The addition of coronal MRI proves that foraminal stenosis is over-diagnosed. True foraminal stenosis definitely exists in isthmic spondylolisthesis, degenerative scoliosis and far lateral disc herniation, but we question its existence in spinal stenosis and degenerative spondylolisthesis

Purpose: To compare two different techniques of inter-body fusion in treatment for single level degenerative spondylolisthesis with symptomatic spinal stenosis. Methods: Retrospective review of patients with degenerative spondylolisthesis and spinal stenosis treated with decompression and instrumented posterior interbody fusion with and without cages. Between 1996 and 2003 there were 59 patients with single level degenerative spondylolisthesis and spinal stenosis. Of these 32 were treated with complete laminectomy, interbody grafting and pedicle screw fixation. In the second group of 27 patients, the technique was modified by the incorporation of an interbody cage in an attempt to improve the restoration of lordosis. Both groups were comparable in terms of pathology, age, sex, intraoperative technique and were treated by the same surgeon. All patients were followed up at 6, 12, 26 and 52 weeks with radiographs and were assessed for fusion and maintenance of lordosis at a minimum of 1 year. Results: There was a statistically significant difference between pre and postoperative lordotic angles in both groups. There was no significant difference in clinical outcomes between the two groups, nor was there a statistical difference in postoperative lordotic angles at the end of 1 year between the two groups. We had 2 deep infections in the cage group. There was one implant failure in the no cage group. Conclusion: We did not find any advantage in using interbody cages in treating single level degenerative spondylolisthesis

Study design: Prospective cohort study. Objective: Despite wide acceptance of decompression surgery for spinal stenosis, the reported success rates remain variable. Our aim is to investigate the value of various predictors of functional outcome in patients undergoing primary lumbar decompression surgery secondary to degenerative spinal stenosis. Subjects: Eligible patients who had primary posterior lumbar decompression surgery for degenerative spinal stenosis with follow up for 2 years. Outcome measures: Oswestry Disability index (ODI), Low Back Outcome Score (LBOS), Visual Analogue Score (VAS), claudication walking distance and patient’s subjective assessment of the outcome of the surgery. Results: Ninety-nine patients who had primary lumbar decompression surgery were recruited between July 1994 and December 2001. The follow up rate was 100% at one year and 76% at two years. There is a statistical significant association between duration of symptoms and the change in ODI, change in LBOS, change in VAS and change in walking distance both at one year and two years follow up. One-way analysis of variance also showed that the groups of patients with symptoms less than 33 months have a much better functional outcome at two years follow up. We have not found modified somatic perception score, modified zung depression score and gender to influence the outcome of the surgery. Conclusion: This study indicates that patients with a prolonged duration of symptoms have a less favourable functional outcome. Patient’s satisfaction is greatest if surgery occurs within 33 months

Introduction: It is likely that the incidence of spinal stenosis will increase with ageing populations. The outcome after surgery in central spinal stenosis has been satisfying in quite many studies. The appropriateness of the indications for surgery has been found to be only around 60% however. Recently we reported that the degree of cauda equina constriction at the most constricted level in the lumbar spine directly was related to typical preoperative symptoms like walking distance, radiating pain but also quality of life. The aim of this study was to relate the degree of preoperative constriction to the results one year postoperatively. MATERIAL AND Methods: 35 men and 47 women, mean age 64 years with preoperative imaging of the lumbar spine, completed preoperative questionnaires and operated for central stenosis between June 2002 and May 2004 were followed up one year postop. The self administered pre- and postoperative questionnaires asked for pain intensity in the back or leg(s) (VAS), walking distance before neurogenic claudication, health related quality of life (EQ5D) etc.. In all the subjects the preoperative cross sectional area (CSA) of the most stenotic (constricted) vertebral level was determined from magnified CT or MR examinations and related to the one year postoperative. Results: Results: The average CSA for the most constricted lumbar level was 58.0 SD 23 mm2. For those with a CSA < 68 mm2 parameters like walking ability, pain intensity in the leg and back, health related QoL was improved in a statistically significant way. For those with a preoperative CSA > 68 mm2 no signifcant improvement was found one year postoperatively. Conclusion: Subjects operated for central spinal stenosis having a pronounced cauda equina constriction (CSA) also had the best outcome one year postoperatively

Bilateral decompression of spinal stenosis may induce instability which compromises outcome. In an attempt to overcome this problem, bilateral decompression can be carried out through a unilateral approach. The ipsilateral side is decompressed by hemi-laminectomy with undercutting partial facetectomy and the contra-lateral side is treated by careful excavation beneath the spinous processes and laminae with preservation of the laminae, posterior ligament complexes and paraspinal muscles. This is achieved with the aid of an operating microscope or loupe and headlight. Previous reports contain little information about outcome and complications. We reviewed 30 patients with bilateral spinal stenosis, but without significant spondylolisthesis who were decompressed bilaterally from a unilateral approach by a single surgeon during a calendar year. They represented a third of our annual operations for spinal stenosis. Thirty patients had 45 levels decompressed. Female to male ratio was 2:1 and average age was 66 years. The average duration of preoperative symptoms was 1.6 years. The mean follow up period was 30 weeks (12 weeks to one year). Assessment was carried out using the Oswestry Disability Index, pre- and post-operative visual analogue pain scores for leg pain and back pain, walking distance and MacNab criteria of patient outcome. Results: improvement in Oswestry Disability Index, pain scores for sciatica and back pain and improved walking distance. All but one case had good or excellent outcome. Complications: one dural tear and two cases with temporary dermatomal sensory change. Whilst the technique is safe, and effective, a longer randomised controlled study is needed to demonstrate any real advantage over traditional approaches

Objective: The purpose of this study was to determine the safety and efficacy and evaluate several radiographic parameters after implantation of coflex™ for the primary diagnosis of spinal stenosis (1 or 2 levels) in patients with neurogenic claudication and low back pain between the ages of 40 and 80 years old. Methods: Retrospective data were gathered on 589 patients from 5 sites with 429 patients having contemporaneous clinical and radiographic follow-up. Clinical analysis was performed on 209 patients with spinal stenosis using VAS and objective examination measures to determine safety and efficacy of the coflex in relieving neurogenic claudication, radiculopathy and back pain. The median follow-up was 20 months (range 6 to 121 months) For the 209 patients, radiographic data was collected for evaluation of spinal segment motion (index and adjacent levels), implant position, migration and bony remodeling at the bone-implant interface. All device complications were recorded and independently reviewed by Medical Metrics, Inc. (Houston, TX) and an independent orthopaedic spinal surgeon (KP). Results: Moderate to severe low back pain improved in 75% of patients, while leg pain improved in 88% of patients. Claudication improved in 91% of patients and improvement in walking distance occurred in 79% of the patients. These results were achieved at 1 year and did not deteriorate over the long-term. Patient satisfaction was 88%. Complete radiographs with excellent quality were available for 180 implanted coflex devices. Sagittal rotation and translation measurements were essentially the same for all diagnoses, follow-up time points and levels of implantation. No expulsions and only 1 migration (> 5 mm) was observed. Mild and moderate bone-implant interface remodeling was noted in 15.4 %. No broken or permanently deformed implants were noted. Conclusions: coflex interspinous stabilization after microsurgical decompression for spinal stenosis demonstrates excellent short term and long term results for back pain, neurogenic claudication and patient satisfaction