Degenerative Lumbar Spinal Stenosis Research Articles

Criteria for failure and worsening after surgery for lumbar spinal stenosis: a prospective national spine registry observational study

Background contextCriteria for success after surgical treatment of lumbar spinal stenosis (LSS) have been defined previously; however, there are no clear criteria for failure and worsening after surgery as assessed by patient-reported outcome measures (PROMs). PurposeWe aimed to quantify changes in standard PROMs that most accurately identified failure and worsening after surgery for LSS. Study design /settingRetrospective analysis of prospective national spine registry data with 12-months follow-up. Patient sampleWe analyzed 10,822 patients aged 50 years and older operated in Norway during a decade, and 8,258 (76%) responded 12 months after surgery. Outcome measures (PROMs)We calculated final scores, absolute changes, and percentage changes for Oswestry Disability Index (ODI), Numeric Rating Scale (NRS) for back and leg pain (0-10), and EuroQol-5D (EQ-5D). These 12 PROM derivates were compared to the Global Perceived Effect (GPE), a 7-point Likert scale. MethodsWe used ODI, NRS back and leg pain, and EQ-5D 12 months after surgery to identify patients with failure (no effect) and worsening (clinical deterioration). The corresponding GPE at 12-months was graded as failure (GPE=4-7) and worsening (GPE=6-7) and used as an external criterion. To quantify the most accurate cut-off values corresponding to failure and worsening, we calculated areas under the curves (AUCs) of receiver operating characteristics (ROC) curves for the respective PROM derivates. ResultsMean (95% CI) age was 68.3 (68.1 – 68.5) years, and 52% were females. There were 1,683 (20%) failures, and 476 (6%) patients were worse after surgery. The mean (95% CI) pre- and postoperative ODIs were 39.8 (39.5 – 40.2) and 23.7 (23.3 – 24.1), respectively. At 12 months, the mean difference (95% CI) in ODI was 16.1 (15.7 – 16.4), and the mean (95% CI) percentage improvement 38.8% (37.8 – 38.8).The PROM derivates identified failure and worsening accurately (AUC>0.80), except for the absolute change in EQ-5D. The ODI derivates were most accurate to identify both failure and worsening. We found that less than 20% improvement in ODI most accurately identified failure (AUC=0.89 [95% CI: 0.88 to 0.90]), and an ODI final score of 39 points or more most accurately identified worsening (AUC =0.91 [95% CI: 0.90 – 0.92]). ConclusionsIn this national register study, ODI derivates were most accurate to identify both failure and worsening after surgery for degenerative lumbar spinal stenosis. We recommend use of ODI percentage change and ODI final score for further studies of failure and worsening in elective spine surgery.

Efficacy and safety of Escherichia coli-derived recombinant human bone morphogenetic protein-2 in additional lumbar posterolateral fusion: minimum 1-year follow-up

Recombinant human bone morphogenetic protein-2 (BMP-2) is the growth factor with the most striking osteoinductive performance in orthopedic operations; it is also able to induce heterotopic bone formation. However, there has been little clinical research on Escherichia coli-derived BMP-2 (E.BMP-2). To confirm the efficacy and safety of E.BMP-2 with a hydroxyapatite carrier when applied to one-sided posterolateral fusion (PLF) in addition to lumbar interbody fusion (LIF), and to measure the lower dose of E.BMP-2 ever reported achieving solid fusion. Retrospective case-control study PATIENT SAMPLE: A total of 121 patients who received surgery for 1 or 2 levels of fusion for lumbar degenerative spinal stenosis or spondylolisthesis from January 2009 to December 2019 were included. Clinical and functional outcomes were evaluated using preoperative and final follow-up visual analogue scales for back pain (VAS-BP) and leg pain (VAS-LP), and Korean Oswestry disability index (K-ODI) scores. Fusion rates were evaluated by computed tomography at six months and one year after surgery. In addition, a subgroup analysis of group E according to number of fusion levels was conducted, and the fusion rates in the one-level and two-level fusion groups were compared. LIF and additional one-sided PLF was performed in all patients. They received autogenous iliac bone grafts (Group C, n=69) or 1mg of E.BMP-2 (Group E, n=52). There were no significant differences between preoperative and final VAS-BP, VAS-LP and K-ODI. The PLF rate was 79.7% for Group C and 82.7% for Group E at postoperative six months, and 94.2% for Group C and 100% for Group E at postoperative one year (P = 0.679, 0.134, respectively). The LIF rate was 71.0% in Group C and 71.2% in Group E at six months after surgery, and 97.1% in Group C and 100% in Group E at one year (P = 0.987, 0.506, respectively). In terms of numbers of fusion levels in Group E, PLF rates at six months (P = 0.486) and one year after surgery were similar in the two groups, as were LIF rates at six months (P = 0.822) and one year after surgery. There were no cases of malignancy or radiculopathy in Group E during one-year of follow-up. One milligram of E.BMP-2 is a safe and effective osteoinductive material in short-level lumbar PLF surgery.

Helicobacter canis bacteraemia in a rheumatoid arthritis patient treated with tofacitinib: case report and literature review

BackgroundNon-Helicobacter pylori species (NHPS) are newly emerging bacteria that naturally inhabit birds and mammals apart from humans and rarely cause diseases in humans. In recent years, a rise in the number of cases associated with NHPS infections in humans has been observed. Among them, infections with Helicobacter (H.) canis are sporadic and challenging to recognise clinically. To date, ten cases of H. canis infections in mainly immunocompromised humans have been reported in the literature. Transmission pathway is most likely zoonotic via the faecal-oral route during close contacts with dogs and cats or may result from a contaminated sheep milk intake. No clear guidelines for successful antibiotic regimen are known. Important additional risk factor for infection might be biologic agents and Janus kinase inhibitors (JAKi) used in the treatment of rheumatoid arthritis (RA) and other conditions. Herein we present the first case of H. canis bacteraemia in a RA patient treated with novel JAKi tofacitinib.Case presentationA 65-year-old female patient with RA and rituximab-induced hypogammaglobulinemia treated with tofacitinib, methotrexate, and methylprednisolone came to a planned visit in our outpatient rheumatology clinic. She presented with a history of back pain that significantly worsened 2 days before visit. She had numbness and tingling sensation in both legs and muscle weakness. Neurological examination was within a normal range. The patient was afebrile, had no chills, and was haemodynamically stable. She was in close contact with her pet dogs. Laboratory examination showed increased markers of inflammation. She was found to have H. canis bacteraemia with underlying multilevel degenerative lumbar spinal stenosis. Identification of H. canis was performed by MALDI-TOF MS and 16 S rRNA gene sequence analysis of isolate from subcultured positive aerobic blood culture bottles. Antimicrobial susceptibility testing showed low minimum inhibitory concentrations to amoxicillin-clavulanate, cefotaxime, ceftriaxone, meropenem, and gentamicin. She was treated with combined antibiotic regimen (ceftriaxone, doxycycline) for 14 days, which resulted in total remission of the infection.ConclusionsClinicians should recognise H. canis infection risk in patients with recent pet exposure and predisposing factors such as immunodeficiency disorders or diseases that demand immunosuppressive drug therapy. A minimum of two weeks of antibiotic therapy is suggested.

Predictors for clinical outcomes of tubular surgery for endoscopic decompression in selected patients with lumbar spinal stenosis.

The success rate of decompression surgery for lumbar spinal stenosis (LSS) has been reported to vary from 60 to 80%. The purpose of this study was to analyze the predictors for clinical outcomes after tubular surgery for endoscopic decompression (microendoscopic decompression) for LSS. A total of 100 patients with degenerative LSS (M/F: 61/39, Age: mean 69.7years), who underwent microendoscopic decompression and had a minimum 2-year follow-up (FU) after surgery, were reviewed. All patients suffered from leg-related symptoms predominantly without severe mechanical back pain, preoperatively. The presence of chronic arterial occlusion of the lower limbs was ruled out. The primary outcome measure was clinical evaluation at 2-year FU using the Oswestry Disability Index (ODI). Furthermore, numeric rating scales, Japanese Orthopedic Association (JOA) lumbar score and JOA Back Pain Evaluation Questionnaire were used for secondary outcome measures. Based on findings of univariable analyses, multivariable logistic regression analysis was applied to identify preoperative predictors for the clinical outcomes. Sixty-eight patients (68%) were assessed as good outcomes, on the basis of minimum clinically important difference of the ODI (13 points ≤) and final ODI score (< 30 points). The secondary outcomes were further support for the primary outcome. In multivariable logistic regression analysis, co-existence of intradiscal vacuum phenomenon with LSS (odds ratio [OR] 8.26; 95% confidence interval [95% CI] 2.32-29.34; p = 0.001) and ischemic cardiovascular comorbidities (OR, 13.3; 95% CI, 1.9-92.57; p = 0.009) were significantly associated with poor clinical outcomes. We found co-existence of intradiscal vacuum phenomenon with LSS and ischemic cardiovascular comorbidity to be preoperative predictors of less favorable clinical outcomes after microendoscopic decompression in selected patients of LSS. Although the conclusion obtained from restricted state, the information would be able to help in patient selection of the tubular surgery for endoscopic decompression for LSS.

Association between fatty infiltration of paraspinal muscle, sagittal spinopelvic alignment and stenosis grade in patients with degenerative lumbar spinal stenosis

IntroductionSagittal balance and fatty infiltration of paraspinal muscle are important factors in patients with lumbar spinal stenosis (LSS) that may affect patients’ quality of life. Sagittal spinopelvic parameters and fatty infiltration may be associated with the severity of LSS. The purpose of this study was to test the hypothesis that severity of fatty infiltration correlates with severity of LSS and with sagittal pelvic alignment independent of age. MethodsAge and body mass index (BMI) were extracted. Fatty infiltration was rated according to Goutallier classification and the severity of LSS was graded according to Schizas at five intervertebral disc levels. Overall fatty infiltration was computed as average fatty infiltration (aFI) and severity of LSS was defined as the highest severity of LSS of all segments. The sagittal spinopelvic parameters pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL) and PI-LL were measured. Associations among parameters were assessed using Spearman correlation coefficients adjusted for age (α = 0.05). Results165 LSS patients with a median age of 69 years were included. All parameters correlated with age (R>0.162, P<0.05) except BMI and LL (R<0.007, P>0.05). aFI correlated with PI, PT and PI-LL before (R>0.371, P<0.05) and after (R>0.180, P<0.05) adjusting for age. Severity of LSS correlated with PI, PT and PI-LL before (R>0.187, P<0.05) but not after (R<0.130, P>0.05) adjusting for age. aFI correlated with severity of LSS before (R=0.349, P<0.05) but not (R=0.114, P>0.05) after adjusting for age. ConclusionsThe correlation of aFI with sagittal spinopelvic parameters indicates that there might be a relationship between muscle characteristics and the sagittal alignment. Sagittal spinopelvic parameters and fatty infiltration of paraspinal muscles are not associated with radiological severity of LSS. Whether they are associated with clinical manifestation of LSS remains to be investigated.

Postoperative spinal epidural hematoma in a biportal endoscopic spine surgery.

Biportal endoscopic spine surgery (BESS) is extending its application to most kind of spine surgeries. Postoperative spinal epidural hematoma (POSEH) is one of the major concerns of this emerging technique. Through this study we aim to investigate the incidence of POSEH in BESS comparing to a conventional spine surgery (CSS).The patients who underwent a non-fusion decompressive spine surgery due to degenerative lumbar spinal stenosis (LSS) or herniated lumbar disc (HLD) or both between January 2015 and March 2019 were reviewed retrospectively. The incidence of clinical POSEH that demanded a revision surgery for hematoma evacuation was compared between CSS and BESS. As a second endpoint, the morphometric degree of POSEH was compared between the two groups. The maximal compression of cauda equina by POSEH was measured by 4 grade scale at the T2 axial image and the neurological state was evaluated by 5 grade scale. The indication of hematoma evacuation was more than hG3 with more than nG1. As a subgroup analysis, risk factors of POSEH in BESS were investigated.The 2 groups were homogenous in age, sex, number and level of operated segments. There was significant difference in the incidence of symptomatic POSEH as 2/142 (1.4%) in CSS and 8/95 (8.4%) in BESS (P = .016). The radiological thecal sac compression by hematoma was hG1 65 (61.3%), hG2 35 (33.0%), hG3 5 (4.7%), hG4 1 (0.9%) cases in CSS and hG1 33 (39.8%), hG2 25 (30.1%), hG3 22 (26.5%), hG4 3 cases (3.6%) in BESS. The difference was significant (P < .001). In BESS subgroup analysis, the risk factor of high grade POSEH was bilateral laminectomy (OR = 8.893, P = .023).The incidence of clinical and morphometric POSEH was higher in BESS. In BESS, POSEH developed more frequently in bilateral laminectomy than unilateral laminectomy.

How Preoperative Motor Weakness Affects the Extent of Recovery After Elective Spine Surgery in Patients with Degenerative Lumbar Spinal Stenosis.

Retrospective review. This study sought to determine how baseline motor weakness (MW) affects elective spine surgery in patients with degenerative lumbar spinal stenosis (LSS). Favorable clinical outcomes have been described for elective spine surgery in patients with LSS. However, the way preoperative MW affects the patient's health-related quality of life (HRQoL) after surgery is not well understood. A retrospective review of prospectively collected data from 305 surgically treated patients with LSS who had 2-year follow-up was performed (age 71 ± 9 yrs, male 62%). Demographic, radiographic, and clinical outcomes were analyzed at baseline and at 1-year, 2-year, and 3-year postoperation. The Japanese Orthopedic Association Back Pain Evaluation Questionnaire was used to assess the HRQoLs. The HRQoLs were compared between those with or without preop MW. Adjusted multivariate logistic regression analyses were performed to determine whether MW affected HRQoLs. One hundred sixteen patients (38%) were categorized as MW+. The patient background including age, sex, presence of degenerative spondylolisthesis, type of surgery, and presence of neurological claudication were similar between the two groups. However, the 1-, 2-, and 3-year postoperative visual analogue scale of back pain, leg pain, leg numbness, the Japanese Orthopedic Association Back Pain Evaluation Questionnaire lumbar function, social life, mental health, and walking ability were all inferior in the MW+ group, whereas a similar percentage of patients achieved a minimum clinically important difference in all subdomains at 3 years. The adjusted multivariate logistic regression analyses showed that having ≥2 muscles with MW, and severity of MW (manual motor test grade) were independent risk factors for both difficulty climbing stairs and walking >15 minutes. (muscles with MW≥2; stair climbing: OR 6.4[2.3-17.4], walking: OR 3.2[1.4-7.3], severity of MW; stair climbing: OR 2.5[1.4-4.4], walking: OR 2.2[1.3-3.7]). The patients with baseline MW had inferior HRQoL for up to 3 years compared with that of those without MW; however, the amount of improvement in HRQoL was comparable. Timely follow-up is important to find out the deterioration of motor function.Level of Evidence: 4.

Clinical Outcomes of "U" Route Transforaminal Percutaneous Endoscopic Lumbar Discectomy in Chronic Pain Patients with Lumbar Spinal Stenosis Combined with Disc Herniation.

Introduction “U” route transforaminal percutaneous endoscopic lumbar discectomy (PELD) was introduced for lumbar spinal stenosis (LSS) combined with disc herniation (DH) treatment. This study aims to explore the efficacy and safety of “U” route PELD on chronic pain patients with LSS combined with DH. Methods Degenerative LSS combined with DH patients who underwent “U” route PELD were reexamined, and 80 patients were recruited and followed up for 2 years. The other 80 healthy individuals who were age- and sex-matched to the patients without chronic pain were enrolled as healthy controls. Minimum dura sac cross-sectional area (mDCSA) by MRI, Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and modified MacNab outcomes were assessed. Emotional evaluation of pain catastrophizing and depression was documented with Pain Catastrophizing Scale (PCS) and Beck Depression Inventory (BDI), respectively, for patients before and after surgery and healthy individuals. Results All patients were of the age range from 47 to 85 years, with an average of 59.5 ± 9.76 years. Symptoms duration was 114.6 ± 22.77 months, operation time was 87.7 ± 25.20 minutes, and the average hospital stay was 5.8 ± 2.81 days. Four patients quit, and hence, a total of 76 patients completed the follow-up. The results indicated that mDCSA was improved significantly after operation (p < 0.001), either low back and leg VAS or ODI decreased over time (p < 0.001), and the excellent-to-good rate was improved from 88.75% to 93.42% during postoperative 2 years (p < 0.05). Complications of dural tear, nerve root, or dysesthesia were reported in 5 patients, and all recovered after conservative therapy. The scores of pain catastrophizing were reduced after operation (p < 0.001), but no significance of BDI was found between patients and healthy controls (p > 0.05). Conclusions The “U” route PELD seems an alternative to LSS combined with DH treatment, which might reach a better decompression and effectively improve chronic pain conditions. Still, the complications were potential and required further consideration.

Degenerative lumbar spine stenosis: minimally invasive microsurgical methods of treatment

Degenerative lumbar spine stenosis is one of the main causes of chronic pain and radiculopathy in advanced age people. Along with increase in average life expectancy, degenerative lumbar spine stenosis becomes the most common indication for spinal surgery. There is still no consensus regarding the most optimal surgical approach due to the variety of modern surgical methods. In recent years, minimally invasive spinal surgery has become a more advisable alternative to open surgery due to its advanced technical features combined with less soft tissue damage, lower risk of complications and shorter postoperative recovery.

The role of trabecular bone score, inaddition to FRAX, for the measurementof fracture risk in patients withdegenerative lumbar spine stenosis

Objectives: To investigate the relevance of Concomitant Trabecular Bone Score (TBS) and Areal Bone Mineral Density (aBMD) assessments to estimate fracture risk in patients with Degenerative Lumbar Spine Stenosis (DLSS). Methods: A cross-sectional prospective study was performed. Dual energy X-ray absorptiometry scans of the lumbar spine and hip were acquired in 50 patients with DLSS. TBS and aBMD were calculated from the anteroposterior views of L1-L4 vertebrae. The World Health Organisation Fracture Risk Assessment Tool (FRAX) was utilised to estimate hip or Major Osteoporotic Fracture (MOF) risk. Results: L1-L4 TBS scores revealed degraded microarchitecture, (TBS ≤ 1.20), partially degraded microarchitecture (TBS >1.20 and <1.35) or normal appearances (TBS ≥ 1.35) in 9 (18%), 14 (28%) and 27 (54%) patients, respectively. L1-L4 aBMD assessment demonstrated osteoporosis (T-score ≤- 2.5), osteopenia (T-score between -1.1 and -2.4) or normal bone density in 15 (30%), 11 (22%) and 24 (48%) patients, respectively. There was no relationship seen between L1-L4 aBMD and TBS measurements (r = 0.046; p = 0.75). A negative relationship was observed between TBS and body mass index (r = -0.438; p = 0.001) andbetween L1-L4 aBMD and FRAX (r = -0.617; p < 0.001); the latter included MOF and risk of hip fracture (r = -0.497; p < 0.001).No relationship was observed between TBS and FRAX included MOF and risk of hip fracture (r = -0.118; p = 0.416 and r = -0.014; p = 0.926, respectively) Conclusion: In patients with DLSS, TBS is a reliable, strong and standalone indicator of fracture risk

Evaluation of posterior decompressive lumbar surgery for multilevel lumbar spinal canal stenosis with and without fusion

BackgroundThere is no consensus regarding the best treatment of patients with multilevel lumbar stenosis. Surgical and invasive procedures are widely used in adults with degenerative lumbar spinal stenosis when conservative treatments fail. However, little is known about the comparative efficacy and safety of these interventions.Aim and objectiveThe aim was to study and evaluate the outcome of surgery for degenerative lumbar canal stenosis (LCS) on a clinical, radiological, and functional basis and to identify whether spinal decompression with fusion has a better effect than decompression alone for patients with degenerative lumbar spinal stenosis or not.Patients and methodsA prospective study of 50 patients was carried out at the Department of Neurosurgery, Matarya Teaching Hospital, in whom the lumbar canal stenosis was confirmed. The functional assessment preoperatively and postoperatively was calculated according to the Japanese Orthopedic Association (JOA) score.ResultsSuccessful outcomes were significantly associated with posterior decompression and fusion. Clinical outcome assessed according to the JOA score was excellent or good in 68% of the patients who underwent posterior decompression alone and in 84% of patients who underwent posterior decompression with posterolateral fusion.ConclusionSurgical treatment of degenerative lumbar canal stenosis with posterior decompression and spinal fusion yields excellent results as observed on the basis of JOA scoring system.

Clinical Efficacy of Percutaneous Endoscopic Bilateral Decompression via Unilateral Interlaminar Approach in the Treatment of Degenerative Lumbar Spinal Stenosis

To investigate the therapeutic effect of percutaneous endoscopic bilateral decompression via unilateral interlaminar approach in the treatment of degenerative lumbar spinal stenosis is the main objective. One hundred and thirty-eight patients with degenerative lumbar spinal stenosis admitted to our hospital from March 2018 to July 2020 were selected and divided into a control group and a trial group according to a randomized double-blind method, with 69 cases in each group. The control group was treated with laminectomy and decompression, while the trial group was treated with percutaneous endoscopic bilateral decompression via unilateral interlaminar approach. The Visual analogue scale score and Oswestry Disability Index were assessed before, on the first day after surgery and at the last postoperative follow-up (3 mo after surgery), and the patients were analyzed for postoperative complications, surgical indicators and overall efficacy using the modified MacNab criteria. In addition, the intervertebral space height index and the cross-sectional area of the spinal canal were measured pre and postoperatively in the operated segment and in the adjacent segment superior to the operated segment. The results showed that the operation time, bleeding volume, incision length and hospital stay of the study group were lower than those of the control group, and the differences were statistically significant (p<0.05, respectively. And the excellent rate of the study group was higher than that of the control group, and the difference was significant (p<0.05). In addition, there was no significant difference in Visual Analogue Scale score and Oswestry Disability Index between the two groups before operation. After operation, the Visual Analogue Scale score and Oswestry Disability Index of the two groups were both significantly improved, and the Visual Analogue scale score and Oswestry Disability Index of the study group were lower than those of the control group, and the differences were significant (p<0.05, respectively). What’s more, the incidence of complications in the study group was lower than that in the control group (p<0.05). The results also indicated that at the last follow-up, there were no significant differences in intervertebral height index before and after operation in the both operated segment and the superior adjacent segment (p>0.05). In addition, at the last follow-up, the cross-sectional area of the spinal canal of the operated segment was significantly increased, and the improvement was more obvious in the study group than the control group, and the difference was statistically significant (p<0.05). However, there was no significant increase in the superior adjacent segment compared with that before operation (p>0.05). Percutaneous endoscopic bilateral decompression via unilateral interlaminar approach has the advantages of minimal trauma, precise decompression and rapid recovery in improving degenerative lumbar spinal stenosis, with good recent results.

Pain relief after selective nerve root block as a predictor of postoperative functional outcome in patients with degenerative lumbar spinal stenosis patients undergoing decompressive surgery : SNRB and surgical outcome in DLSS

Pain relief after selective nerve root block as a predictor of postoperative functional outcome in patients with degenerative lumbar spinal stenosis patients undergoing decompressive surgery : SNRB and surgical outcome in DLSS

Three-Dimensional Volumetric Changes and Clinical Outcomes after Decompression with DIAM™ Implantation in Patients with Degenerative Lumbar Spine Diseases.

Background and objectives: The prevalence of degenerative lumbar spine diseases has increased. In addition to standard lumbar decompression and/or fusion techniques, implantation of interspinous process devices (IPDs) can provide clinical benefits in highly selected patients. However, changes in spinal structures after IPD implantation using magnetic resonance imaging (MRI) have rarely been discussed. This volumetric study aimed to evaluate the effect of IPD implantation on the intervertebral disc and foramen using three-dimensional assessment. Materials and Methods: We retrospectively reviewed patients with lumbar degenerative disc diseases treated with IPD implantation and foraminotomy and/or discectomy between January 2016 and December 2019. The mean follow-up period was 13.6 months. The perioperative lumbar MRI data were processed for 3D-volumetric analysis. Clinical outcomes, including the Prolo scale and visual analog scale (VAS) scores, and radiographic outcomes, such as the disc height, foraminal area, and translation, were analyzed. Results: Fifty patients were included in our study. At the one-year follow-up, the VAS and Prolo scale scores significantly improved (both p < 0.001). The disc height and foraminal area on radiographs also increased significantly, but with limited effects up to three months postoperatively. MRI revealed an increased postoperative disc height with a mean difference of 0.5 ± 0.1 mm (p < 0.001). Although the mean disc volume difference did not significantly increase, the mean foraminal volume difference was 0.4 ± 0.16 mm3 (p < 0.05). Conclusions: In select patients with degenerative disc diseases or lumbar spinal stenosis, the intervertebral foramen was enlarged, and disc loading was reduced after IPD implantation with decompression surgery. The 3D findings were compatible with the clinical benefits.

Degenerative Lumbar Stenosis Surgery: Predictive Factors of Clinical Outcome—Experience with 1001 Patients

Degenerative lumbar spinal stenosis (DLSS) carries a high risk of morbidity and represents a financial burden to society. A late diagnosis can lead to severe disability. Although lumbar decompressive surgery has been widely used worldwide, the proper preoperative factors to define the ideal candidates for decompression are missing. A total of 1001 patients who had undergone decompressive surgery from 2012 to 2019 for DLSS were screened for the presence of 9 clinical and radiological parameters. For all cases, the differences between the baseline and postoperative Oswestry disability index were calculated and the results categorized as 5 different classes (ranging from very poor outcomes to excellent outcomes) according to the specific scores. Generalized ordinal logistic regression was then used to analyze the significance of the 9 parameters (coded as dummy variables) in predicting the outcome as measured by Oswestry disability index improvement after surgery. Of the 9 parameters, 8 were found to be significant predictors. The radiological grade of compression was the strongest, followed by polyneuropathy, obesity, symptom duration, gait autonomy, radicular deficits, American Society of Anesthesiologists score, and level of surgery. In contrast, previous back surgery was not predictive of the outcome. Our findings have indicated that the ideal candidate for surgery will have the following preoperative characteristics: Schizas grade D, no signs of peripheral polyneuropathy, body mass index <30 kg/m2, symptom duration of <2 years, gait autonomy <100 m, no radicular deficits, 1 level of stenosis, and an American Society of Anesthesiologists score of 1, 2, or3.

Role of Epidural Steroid Injection in Lumbar Spinal Stenosis—A Randomized Controlled Trial

Abstract Background Degenerative lumbar spinal stenosis (DLSS) is an important cause of pain and disability among the elderly and common indication for spinal surgery. However, due to age-related comorbidities, it becomes difficult for elderly patients of DLSS to immediately go for operative treatment. Caudal epidural steroid injection (CESI) can be an effective procedure for a selected group of patients who have chronic function-limiting lower back and lower extremity pain secondary to DLSS. The aim of this study was to compare the effects of CESI with physical therapy in patients afflicted with DLSS. Materials and Methods It is a single center, open-label randomized controlled trial conducted in department of Physical Medicine and Rehabilitation at a tertiary care center of northern India from January 2016 to August 2017 among DLSS patients. Trial was registered under the clinical trial registry of India. Patients were randomized in two groups–32 in intervention group A (CESI with local anesthetic and physical therapy) and 32 in control group B (physical therapy alone). Outcome measures were numerical pain rating scale (NPRS), Oswestry disability index (ODI), and mean claudication distance (MCD) at 3, 6, 12, and 24 weeks. Results NPRS and ODI showed significant improvement at 3, 6, 12, and 24 weeks (group A &gt;&gt; group B). Improvement in MCD was seen at each follow-up from baseline (group A &gt;&gt; group B). Conclusion Caudal epidural steroid administration can ameliorate pain, disability and claudication distance in DLSS patients, which provides them a window period for further definitive management.

Spinous Process Inclination in Degenerative Lumbar Spinal Stenosis Individuals.

The aim of this study is to determine the sagittal inclination of lumbar spinous processes (SPs) in individuals with degenerative lumbar spinal stenosis (DLSS). It is a retrospective computerized tomography (CT) study including 345 individuals divided into two groups: control (90 males, 90 females) and stenosis (80 males and 85 females. The SP inclination was measured in the midsagittal plane from L1 to L5 levels. Stenosis males (L3-L5) and females (L1, L4) manifested significantly greater SP inclination compared to their counterparts in the control group. Males had significantly horizontal SP orientation compared to females (L1, L2). We also found that SP inclination became steeper as we descend caudally. This study indicates that SP inclinations are significantly associated with DLSS.

Clinical Efficacy and Rehabilitation of Microscopic "Over the Top" for Bilateral Decompression in Degenerative Lumbar Stenosis: A Retrospective Study.

Background Recently, “over the top” (also called ULBD; microscopic unilateral laminotomy for bilateral decompression) is a less invasive technique for symptomatic degenerative lumbar spinal stenosis (LSS), and this minimally invasive surgical technique has demonstrated favorable therapeutic outcomes. However, the risk of postoperative complications remains controversial. Objective This study is aimed at determining the clinical efficacy and complication and rehabilitation of the microscopic “over the top” for degenerative LSS in geriatric patients. Study Design. This was a retrospective study. Setting. All data were obtained from the People's Hospital of a University. Methods A retrospective analysis of 39 consecutive elderly patients treated for LSS by microscopic “over the top” between January 2016 and January 2018 was performed. A postoperative rehabilitation program for geriatric patients with restricted weight-bearing was instituted after the microscopic “over the top” treatment. Estimated blood loss, duration of operation, length of hospitalization, and total complications were also evaluated. The CT and MRI examinations of the lumbar spine were collected to evaluate the completeness of the nerve decompression. Clinical data were assessed at 6 months and 12 months after operation utilizing the visual analog scale (VAS), Oswestry Disability Index (ODI), and 36-Item Short-Form Health Survey (SF-36). Preoperative comorbidities, complications, and revision surgery were also recorded. Results We enrolled a total of 39 degenerative LSS patients (27 male and 12 female patients, mean age of 75.8 ± 9.2 years). Twenty patients had one-level of degenerative LSS; thirteen patients had two-level of LSS; six patients had three-level of LSS. The average follow-up time in our study was 14.6 ± 7.8 months (range, 6-24 months). The overall complication rate was 10.2% (4/39), and the reoperation rates at one year were 2.5% (1/39). VAS back and leg pain score at 6 months were decreased to 1.8 ± 0.7 and 1.4 ± 0.6, respectively, and remained at 1.9 ± 0.3 and 1.2 ± 0.2 at 12 months, respectively. ODI scores improved significantly from 32.26 ± 6.82 to 11.44 ± 2.50 at 6 months and 10.56 ± 2.29 at 12 months. 36-Item Short-Form Health Survey scores revealed a significant improvement throughout follow-up. Postoperative complications included dural tear (n = 2), neurologic deficit (n = 1), and reoperation (n = 1). No infections or hematomas were reported. Limitation. Multicenter research is recommended to confirm our results and investigate the factors related to clinical and radiographic results. Conclusions Microscopic “over the top” technique is a safe, effective option in the therapy of degenerative LSS and obtained satisfactory functional outcomes when coupled with aggressive rehabilitation, with a long recurrence-free recovery.

Feasibility of Unilateral Approach for Bilateral Decompressive Endoscopic Spinal Surgery for Lumbar Stenosis to Improve Back and Leg Pain: A Consecutive Single-Center Series of 60 Patients.

Introduction: Endoscopic surgery is one of the methods that achieve the goal of decompression while minimizing collateral tissue damage. Its efficacy and safety have been supported by numerous studies. There is a plethora of studies on lumbar stenosis regarding the outcomes and related issues in endoscopic spine surgery. However, few studies evaluated the outcome of the decompressive lumbar spine surgery. The present study aims to analyze the outcome of a unilateral approach to endoscopic surgery for lumbar stenosis using the visual analog scale (VAS), the Oswestry Disability Index (ODI), and MacNab's criteria.Methods: This is a retrospective study (level IV) conducted between January 2009 and December 2013 on 60 patients who underwent endoscopic interlaminar decompressive spine surgery (Destandau method) for lumbar degenerative spinal stenosis in the Hospital Universiti Sains Malaysia. The clinical outcome was measured pre-operatively and post-operatively for VAS: for back and leg pain, motor and sensory grading, the ODI, and MacNab's criteria. A paired t-test was used for statistical analysis.Results: The mean age of patients was 60.82 years comprising 23 males (38.3%) and 37 females (61.7%). The mean follow-up period was 30.1 months (range = 17.2–43 months). The mean operation time was 183.6 min (ranging from 124.8 to 242.4 min), and the mean blood loss was 150.18 mL (ranging from 30.82 to 269.54 mL). Post-operatively, mean hospital stay was 2.45 days (ranging from 1.34 to 3.56 days). The most frequently involved level was L4/L5 in 51 patients (52.6%), followed by L3/L4 in 19 patients (19.6%), L5/S1 in 24 patients (24.7%), and L2/L3 in three patients (3.1%). Improvement in the post-operative VAS for back and leg pain and the ODI for pre-operation and post-operation was statistically significant (p < 0.001). Conversely, the reduction in neurological status was statistically insignificant. Based on MacNab's criteria, 88.4% showed excellent to good outcomes.Conclusion: To summarize, unilateral percutaneous endoscopic spine surgery to achieve the bilateral decompression in lumbar stenosis provides excellent yet safe and effective outcomes. It improves back and leg pain and patients' function significantly.

Lumbar Spine Fusion Before Revision Total Hip Arthroplasty Is Associated With Increased Dislocation Rates

The aim of this study was to determine whether timing of lumbar spinal fusion (LSF) before revision total hip arthroplasty (THA) would impact dislocation and rerevision rates. This retrospective analysis includes a total of 505 patients who underwent revision THA with concomitant diagnosis of degenerative lumbar spinal stenosis with spondylolisthesis. Patients were stratified into the following two cohorts: (1) 328 patients who underwent revision THA with previous LSF and (2) 177 patients who underwent revision THA, followed by LSF. Postoperative complications including dislocation and rerevision rates were evaluated. Patients who underwent revision THA with previous LSF demonstrated significantly higher dislocation rates and rerevision rates compared with patients who underwent revision THA, followed by LSF, at the 1-year follow-up (6.7% versus 5.1%, P < 0.01; 8.5% versus 7.0%, P = 0.02). Patients who underwent revision THA, followed by LSF within 1 year demonstrated significantly higher dislocation and rerevision rates (5.6% versus 4.1%; 7.6% versus 6.4%). This study demonstrates that patients who underwent revision THA with previous LSF demonstrated notably higher dislocation rates and rerevision rates compared with patients who underwent revision THA, followed by LSF, with the greater the intervals between revision THA and LSF, the lower the postoperative dislocation rates and rerevision rates.