Spinal Stenosis Syndrome Research Articles

Posterior instrumented fusion on lumbar stenosis syndrome can bring benefit to proximal degenerative kyphosis: A CONSORT-compliant article.

The effect on degenerative thoracolumbar kyphosis (DTLK) after short-segment instrument for lumbar spinal stenosis syndrome (LSS) remains controversial. Based on the biomechanics and compensatory of the global spino-pelvic alignment, it was assumed that the interference on the lumbar spine, instead of the thoracolumbar segment, could still make a difference on the proximal spine.To explore whether DTLK could improve with only surgery for LSS and identify influencing factors on postoperative TLK.The study was performed from January 2016 to December 2018. Sixty-nine participants (25 male) diagnosed LSS with DTLK were enrolled and surgery was only for LSS. Radiological parameters included TLK, lumbar lordosis, pelvic incidence, pelvic tilt, sacral slope, and osteoporosis. Clinical outcomes were visual analogue scale and Oswestry disability index. According to lower instrumented vertebrae (LIV) on L5 or S1, inter-group comparisons were performed between LIV on L5 (L5 group) and S1 (S1 group).Demographics were well-matched between L5 and S1 group with a mean follow-up of 24.3 ± 12.1 (m). TLK improved with a mean of 16.2 ± 7.6 (°) (P < .001). There was no significance on radiological and clinical parameters between L5 and S1 groups except for a larger pelvic tilt in S1 group (P = .046). Visual analogue scale (P = .787) and Oswestry disability index (P = .530) were both indifferent between normal TLK and DTLK at last (P > .05). Postoperative TLK was affected by osteoporosis and sacral slope, the latter was dominated by pelvic incidence and pelvic rotation. Osteoporosis was the risk factor for TLK correction (P = .001, odd risk = 9.58).DTLK decreased if instrument only performed for LSS, where TLK and clinical outcomes are comparably affected whether L5 or S1 is selected as LIV. This study supplements the compensatory mechanism of spino-pelvic alignment, especially for cases with severe osteoporosis.

Percutaneous Endoscopic Transforaminal Lumbar Discectomy via Eccentric Trepan foraminoplasty Technology for Unilateral Stenosed Serve Root Canals.

ObjectiveTo evaluate the clinical outcomes of percutaneous lumbar foraminoplasty for unilateral stenosed nerve root canals.MethodsThe article is a retrospective analysis. From May 2016 to April 2017, 32 patients with lumbar spinal stenosis syndrome (unilateral stenosed nerve root canals) were treated with percutaneous endoscopic transforaminal lumbar discectomy (PETLD). The study included 15 men and 17 women, with an average age of 53.8 ± 15.4 years, ranging from 24 to 78 years. The indexes used for preoperative and postoperative 1 day, 3 months, and final follow up were the visual analogue scale (VAS) for lumbar and leg, the Oswestry disability index (ODI), and the modified Macnab criteria. All patients were followed up for an average 6 months after the operation.ResultsThe average operative time was 75.82 ± 10.58 min, the average blood loss was 15.83 ± 3.75 mL, and the average hospital stay after surgery was 6.2 ± 4.6 days. The VAS score (leg) decreased from 6.94 ± 0.50 preoperatively to 1.16 ± 0.45 at the final follow up (P < 0.05) and ODI were obviously improved, from preoperative evaluation of 80.19 ± 5.55 to 9.44 ± 1.16 at the final follow up (P < 0.05). However, the postoperative VAS score (lumbar) did not show an improvement, reducing from 1.78 ± 0.49 preoperatively to 1.62 ± 0.55 at the final follow‐up (P > 0.05). According to the modified Macnab criteria, the outcome showed that the excellent and good rate was 90.6%. There were three patients with hip soreness, and nerve root symptoms were relieved.ConclusionPercutaneous endoscopic transforaminal lumbar discectomy has a satisfactory clinical effect in the treatment of lumbar spinal stenosis syndrome, especially for unilateral stenosed nerve root canals, and in decompressing the lateral recess and relieving the nerve root symptoms.

Optimal cut-off points of lumbar pedicle thickness as a morphological parameter to predict lumbar spinal stenosis syndrome: a retrospective study.

PurposeLumbar spinal stenosis syndrome (LSSS) is induced by factors such as ligamentum flavum hypertrophy, facet joint hypertrophy and disc degeneration. However, the role of lumbar pedicle (LP) in LSSS has yet to be evaluated. We devised a new morphological parameter called the lumbar pedicle thickness (LPT) to evaluate the connection between LSSS and the LP. We hypothesized that the LPT is a major morphological parameter in the diagnosis of LSSS.Patients and methodsThe LPT data were collected from 136 patients diagnosed with LSSS. A total of 99 control subjects underwent lumbar spine magnetic resonance imaging (MRI) as part of a detailed medical assessment. Axial T2-weighted magnetic resonance (MR) images were acquired from all the participants. Using our picture archiving and communication system, we analyzed the thickness of the LP at the level of L5 vertebra on MRI.ResultsThe average LPT was 9.46±1.81 mm in the control group and 13.26±1.98 mm in the LSSS group. LSSS patients showed a significantly greater LPT (P<0.001) than the control group. The receiver operating characteristic (ROC) curve analysis showed an optimal cutoff point of 11.33 mm for the LPT, with 83.8% sensitivity, 83.8% specificity and area under the curve of 0.92 (95% confidence interval [CI], 0.89–0.96).ConclusionA higher LPT was associated with a higher possibility of LSSS, suggesting its importance in the evaluation of patients with LSSS.

The Utility of Paraspinal Mapping Technique in the Diagnosis of Lumbar Spinal Canal Stenosis.

Background: Lumbar spinal canal stenosis (LSCS) is a disorder that causes neurologic deficit, pain and disability. It is common in the elderly, and increasingly encountered as the population ages. Because other causes of back pain are common and difficult to prove, it is possible that mechanical backache, in conjunction with coincident neuropathy or other unrelated leg complaint, might lead to inappropriate treatment including surgery. Thus, accurate diagnosis of the clinical syndrome of spinal stenosis using paraspinal mapping technique may be of critical importance.Objectives: Asses the utility of paraspinal mapping technique in detecting the level of lumbar radiculopathies in patients with lumbar spinal canal stenosis.Subjects and methods: Ninety seven (97) patients with LSCS with a mean age of (46.3±11.2) years and thirty four (34) healthy control subjects with a mean age of (42.8±8.8) years involved in the study. Needle EMG of lumbar paraspinal muscles in addition to eight lower limbs muscles were performed.Results: Paraspinal muscles scores greater than 4 significantly differentiate the patients with LSCS from the control groups. The percentages of each level of lumbar radiculopathy by using paraspinal mapping technique differ from those by using lower limbs electromyography (EMG) for example right and left L5 radiculopathy 19.6%, 18.6% using EMG of PSM when compared with 78.2%, 79.4% using EMG of lower limbs muscles, and the percentages will increase by combination of both tests in such a way that RT and LT L5 radiculopathy increase to 84.5%, 82.5%.Conclusion: Paraspinal mapping technique is a sensitive, useful, quantifiable and quite effective method in the diagnosis of lumbar spinal canal stenosis when compared with lower limbs EMG.

Disc degeneration-related clinical phenotypes

The phenotype, or observable trait of interest, is at the core of studies identifying associated genetic variants and their functional pathways, as well as diagnostics. Yet, despite remarkable technological developments in genotyping and progress in genetic research, relatively little attention has been paid to the equally important issue of phenotype. This is especially true for disc degeneration-related disorders, and the concept of degenerative disc disease, in particular, where there is little consensus or uniformity of definition. Greater attention and rigour are clearly needed in the development of disc degeneration-related clinical phenotypes if we are to see more rapid advancements in knowledge of this area. When selecting phenotypes, a basic decision is whether to focus directly on the complex clinical phenotype (e.g. the clinical syndrome of spinal stenosis), which is ultimately of interest, or an intermediate phenotype (e.g. dural sac cross-sectional area). While both have advantages, it cannot be assumed that associated gene variants will be similarly relevant to both. Among other considerations are factors influencing phenotype identification, comorbidities that are often present, and measurement issues. Genodisc, the European research consortium project on disc-related clinical pathologies has adopted a strategy that will allow for the careful characterisation and examination of both the complex clinical phenotypes of interest and their components.

Pseudomeningocele Following Lumbar Surgery as a Cause of Low Back Pain: Report of a Case

This paper reports a case of postoperative pseudomeningocele, which was not diagnosed initially with clinical data alone; the condition was caused by an inadvertent meningeal tear that occurred during spinal surgery. Pseudomeningocele formation is a rare postoperative complication of spinal surgery characterized by the extradural accumulation of cerebrospinal fluid following extravasation through an inadvertent dural tear. A 69-year-old woman had undergone laminectomy and posterolateral fusion at the L3-L5 level 7 years previously, for spondylolisthesis with spinal stenosis syndrome; the postoperative course was uneventful. Six years after the surgery, the patient experienced increasingly severe low back pain radiating to both gluteal regions. After prolonged but unresponsive conservative treatment, a large pseudomeningocele at the L2-L3 level was identified by myelography. The findings of MRI supported the diagnosis of pseudomeningocele. Surgery via the posterior approach exposed the pseudomeningocele after a complete laminectomy of L2-L4. The pseudomeningocele was excised 7 years after the initial operation. Complete recovery and excellent remission of symptoms was noted at 6 months after the surgery. Pseudomeningocele must always be considered as a cause of chronic back pain in patients who have undergone previous lumbar surgery, no matter how many years after the surgical procedure the symptoms may occur.

Biomechanical comparison of lumbar spine instability between laminectomy and bilateral laminotomy for spinal stenosis syndrome – an experimental study in porcine model

BackgroundThe association of lumbar spine instability between laminectomy and laminotomy has been clinically studied, but the corresponding in vitro biomechanical studies have not been reported. We investigated the hypothesis that the integrity of the posterior complex (spinous process-interspinous ligament-spinous process) plays an important role on the postoperative spinal stability in decompressive surgery.MethodsEight porcine lumbar spine specimens were studied. Each specimen was tested intact and after two decompression procedures. All posterior components were preserved in Group A (Intact). In Group B (Bilateral laminotomy), the inferior margin of L4 lamina and superior margin of L5 lamina were removed, but the L4–L5 supraspinous ligament was preserved. Fenestrations were made on both sides. In Group C (Laminectomy) the lamina and spinous processes of lower L4 and upper L5 were removed. Ligamentum flavum and supraspinous ligament of L4–L5 were removed. A hydraulic testing machine was used to generate an increasing moment up to 8400 N-mm in flexion and extension. Intervertebral displacement at decompressive level L4–L5 was measured by extensometerResultsThe results indicated that, under extension motion, intervertebral displacement between the specimen in intact form and at two different decompression levels did not significantly differ (P > 0.05). However, under flexion motion, intervertebral displacement of the laminectomy specimens at decompression level L4–L5 was statistically greater than in intact or bilateral laminotomy specimens (P = 0.0000963 and P = 0.000418, respectively). No difference was found between intact and bilateral laminotomy groups. (P > 0.05).ConclusionWe concluded that a lumbar spine with posterior complex integrity is less likely to develop segment instability than a lumbar spine with a destroyed anchoring point for supraspinous ligament.

Predictors of Pain and Function in Persons With Spinal Stenosis, Low Back Pain, and No Back Pain

Longitudinal masked, double-controlled cohort study. To determine prognosis and predictors of function and pain in persons with spinal stenosis. The clinical syndrome of spinal stenosis is common and disabling, but not clearly related to anatomic measures. Prognosis not well studied. Persons 55 to 80 years of age with and without stenosis on preliminary review of magnetic resonance imaging (MRI), and asymptomatic volunteers underwent screening, questionnaires, physical examination, ambulation testing, masked electromyogram (EMG), and masked MRI scans; these were repeated at >18 months. Twenty-three asymptomatic, 28 back pain, and 32 clinically diagnosed stenosis subjects underwent follow-up. Although initial and follow-up diagnosis tended to agree (kappa = 0.394, P < 001), there were substantial shifts between the three groups. Among persons with clinically diagnosed stenosis, every measure trended for improvement, including significant changes in pain, ambulation, and EMG. Ambulation velocity and Pain Disability Index at follow-up were predicted by initial disability measures. Pain was predicted by initial sleep difficulty but not initial pain. EMG and MRI did not predict function or pain. Clinically recognized spinal stenosis is fluctuating and largely improving, and in continuum with back pain and no symptoms. Since anatomic and neurologic deficits do not predict future function, they should not be weighed heavily in surgical risk-benefit discussions.

Failure of conservative treatment for lumbar spinal stenosis in elderly patients

Spinal stenosis syndrome affects mainly patients at their 5th–6th decades of life. There is a strong debate in the literature whether patients with spinal stenosis should be operated or treated conservatively. Our aim was to evaluate patients with lumbar spinal stenosis who were treated conservatively. All patients over 65 years of age who were handled conservatively in the private clinic of the senior author due to spinal stenosis syndrome were evaluated. There were 21 males and 15 females aged between 65 and 88 years. Intermittent claudication was the dominant clinical presentation. The radiological examination showed a frequent narrowing at the level L4-L5. All patients had a severe stenosis of less than 10 mm diameter of the spinal canal. All patients underwent a conservative therapy which included physical therapy with ultrasound waves, short waves, and flexion exercises. All patients were offered to undergo an epidural or nerve root injection. Twenty-four patients agreed also to have one of these procedures to relieve their symptoms. All patients were followed between 6 and 10 months after the initial diagnosis. We used the Oswestry index category for evaluation. In all parameters the conservative treatment failed to improve the symptoms in the vast majority of patients. None of the patients was very satisfied with the results of conservative treatment while 33 patients (92%) were not so satisfied or unsatisfied with the results. We conclude that conservative treatment for lumbar spinal stenosis is not a success for elderly patients. These patients should be convinced to undergo operative treatment.

Surgical treatment of lumbar spinal stenosis in patients aged 65 years and older

Spinal stenosis syndrome affects mainly patients at their 5th–6th decades of life. The main goals of surgical treatment in the elderly are to allow the individual to walk longer distances, maintain the activities of daily living (ADL) and social life. Our aim was to evaluate the results of surgical treatment for lumbar spinal stenosis in elderly patients. All patients over 65 years of age who underwent surgery due to spinal stenosis syndrome between 1990 and 1998 were evaluated. There were 29 males and 17 females aged between 65 and 90 years. The clinical presentation included low back pain (89%), intermittent claudication (100%) and neurological involvement (87%). The radiological examination showed a frequent narrowing at the level L4–L5 in 93.5% of the patients. The results of the surgery in a mean follow-up of 22 months were good to excellent in 80% of the patients, fair in 11%, and poor in 9%. An improvement in the intensity of pain and in walking distances was noted in 89 and 85% of the patients, respectively. Improvement was achieved in the level of daily activity and in social lives in 57 and 61%, respectively. Major and minor complication rates were 6.5 and 19.5%, respectively. No mortality was noted in this series. Eighty-seven percent of the patients were satisfied with the results of the surgery. We conclude that Surgery for spinal stenosis is a successful and relatively safe procedure, also for patients aged over 65, and should be considered as a treatment option for these patients.

Surgical therapy for lumbar spinal stenosis: evaluation of 300 cases

Although lumbar spinal stenosis syndrome is extremely common, considerable controversy continues to surround its classification, diagnosis, and treatment. In this article, we retrospectively analyzed the clinical, radiological, and surgical characteristics of 300 patients operated on in our clinics with the diagnosis of lumbar spinal stenosis. Surgical therapy and outcome are discussed with respect to the known facts. After clinical and radiological evaluation, 300 patients were diagnosed with lumbar spinal stenosis. All patients underwent laminectomy and bilateral foraminotomy at the stenotic level. Surgical outcomes were evaluated as very good, good, same, and poor according to the clinical findings. Ninety percent of the surgically treated patients demonstrated very good and good outcomes. Our conclusion in lumbar spinal stenosis diagnosed by objective clinical and radiological findings is that decompressive laminectomy and extensive foraminotomy without instrumentation allow a good outcome.

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Spinal Stenosis*†

Spinal stenosis is a narrowing or stricture of the spinal canal. Cauda equina and nerve-root compression are noted in many asymptomatic individuals8. Therefore, narrowing alone does not explain all of the symptoms and signs seen in patients who have the clinical syndrome of spinal stenosis, or neurogenic claudication. The spinal degenerative process associated with aging leads to pathoanatomical and pathophysiological changes with occasional clinical consequences. Not only does narrowing occur, but abnormal spinal motion can further increase the degree of compression. With progressive degenerative changes and compression, spinal stenosis may become symptomatic, although the severity of the symptoms is not necessarily associated with the magnitude of the compression seen on imaging studies. Spinal stenosis can be classified as either congenital or acquired3 (Table I). Congenital stenosis is commonly seen in individuals who have achondroplasia or another short-stature syndrome. The congenital classification also includes stenosis in individuals of normal stature who have congenitally short pedicles accompanied by bulging discs at multiple levels. The latter group frequently has symptoms when they are between the ages of thirty and forty years old. View this table: TABLE I CLASSIFICATION OF STENOSIS OF THE SPINAL CANAL Acquired degenerative stenosis tends to lead to symptoms in women at a mean age of seventy-three years and in men at a somewhat younger age86. Degenerative spondylolisthesis, seen more often in women than in men, also may contribute to the symptoms of spinal stenosis67,69,70,147. Although there are many causes of spinal stenosis, this discussion will focus on the degenerative process. Degenerative changes and narrowing can occur (1) centrally; (2) in the lateral recess, leading to nerve-root impingement from an overhanging, hypertrophic facet joint; (3) within the nerve-root canal (foraminal stenosis); or (4) extraforaminally, frequently because of entrapment by osteophytes, …

Mechanisms of chronicity?

Most of us experience acute episodes of back pain. Clinical evaluation helps us segregate patients into those with simple backache, nerve root pain and possible serious spinal pathology. The vast majority are in the first group. The prognosis of simple backache is good, with most being better within a couple of weeks and 90% better within 6 weeks. However, a small proportion have persistent problems and it is these which require difficult management decisions and lead to the medical and societal costs of backache. This article focuses on the reasons why simple backache may fail to resolve and some patients develop chronic persistent problems. In this context, I will restrict myself to mechanical disorders and not deal with inflammatory conditions such as ankylosing spondylitis, metabolic bone disease or neoplasms. Some patients have persistent nociception, e.g. there may be a chronic herniated disc, a spondylolisthesis or spinal stenosis syndrome. There are specific and well identified clinical features enabling us to recognise these conditions. The vast majority have so-called non-specific back pain. They may show pain and tenderness over the facet joints or the sacroiliac joints. However, there is no clear evidence that pathology in

The Indications for Lumbar Spinal Fusion With and Without Instrumentation

Literature review. A review, analysis, and discussion of the extensive literature on lumbar spinal fusion were done to attempt to place in perspective the indications and success rate for lumbar spinal fusion with and without instrumentation. A wide variety of lumbar spinal conditions have been managed by spinal fusion. Results appear better when the diagnosis is very specific and related to definable instability or deformity in patients with a stable psychologic state. Search of literature. Success rates are higher in isthmic spondylolisthesis, unstable spinal stenosis syndromes (degenerative spondylolisthesis, degenerative scoliosis), and in patients with objective segmental instability. Variable success rates are reported for disc-related low back pain conditions and in patients with failed previous surgery. Instrumentation appears to be beneficial in situations where complex deformities or obvious instability is present. When applied for other diagnoses (e.g., internal disc disruption), results appear no better than with traditional surgical techniques. The outcome of lumbar spinal fusion depends on careful assessment of the anatomic cause of pain and of the patient's functional state and expectations.

Lumbar Spinal Stenosis Syndrome

Seventy-six operations were performed by the author for lumbar spinal stenosis syndrome over 25 years. The characteristic symptoms of pain, sensory changes, and intermittent pseudoclaudication in connection with the extent of nerve root compression confirmed by laboratory examinations and the operative findings allow the author to stress the following points. (1) In Greece, lumbar spinal stenosis syndrome is not a very common entity. (2) Spinal stenosis cases of acquired type are the most common while those of developmental character are very rare, only two in this series, (3) Surgical intervention, which is the treatment of choice, includes a generous decompressive procedure that must free all the neural elements. Sometimes it is necessary to remove part or all of the facets in one or more levels. (4) The rate of complications is low, and complications are of minor character. (5) The results on the whole are very satisfactory and lasting, provided the planning and execution of the operation are based on sound preoperative assessment using both clinical examination and laboratory investigation. (6) Development of the acquired form of stenosis of the spine seems not to be preventable. The pathogenesis of the syndrome has not been fully established.

Low back disorders: conservative management.

Painful disorders of the low back may arise from a large variety of mechanisms and there is no simple, single solution to them. They have a great social and economic cost in industrialized countries. The major syndromes of low back pain and sciatica are reviewed, including myofascial pain syndromes, disc herniations, radiculopathies, spinal stenosis and facet syndromes. Non-operative management is reviewed, including bed rest, medications, traction, manipulation, external supports, physical modalities, therapeutic exercise, trigger point injection and chemonucleolysis. Prevention should become the main goal of physicians dealing with this multifaceted problem.

Lumbar vertebral canal morphometry for computerised tomography in spinal stenosis.

Computerised tomography is described in recent literature as a sophisticated but noninvasive technique with a particularly appropriate application in the discovery of space-occupying lesions in the lumbar vertebral canal and nerve root tunnels. Although the spinal stenosis syndrome must remain a clinical diagnosis in the first instance, computerised tomography is expected to play an increasing role in confirming the presumptive diagnosis of developmental or degenerative spinal stenosis, and in confirming the presence of a trefoil configuration or narrow lateral recess. However, the diagnosis of spinal stenosis on computerised tomography is impossible unless dimensions can be compared with established ranges of normal. The morphometry of a large sample of human skeletons of both sexes, in two race groups, and for each of the five lumbar vertebral levels, is intended to provide this information.

The trefoil configuration of the lumbar vertebral canal. A study of South African skeletal material.

The shallow lateral recesses of the trefoil shape of the lumbar spinal canal have been implicated in the production of the spinal stenosis syndrome. In the present study, 485 skeletons of South African Blacks and Whites were examined in order to establish the incidence and possible genesis of the trefoil configuration. The overall incidence was 14 per cent, with little variation between the sexes or races. The incidence was not related to increasing age, measured stenosis of the spinal canal or osteophytosis. Of 74 trefoil-shaped vertebrae, 68 (92 per cent) were found at the fifth lumbar level. It is suggested that the trefoil configuration is a common non-pathological condition, usually of the fifth lumbar vertebral canal, and is probably a developmental variation of normal anatomy.

Factors in the development of the spinal stenosis syndrome.

The spinal stenosis syndrome is a potential hazard when congenital or developmental narrowing of the bony canal, particularly in its lateral recesses where it can be demonstrated by axial tomography, places the emergent nerve root and its blood supply at risk to further small compressive elements. When lumbar disc degeneration allows rotatory and lateral instability, posterolateral bulging of the annulus fibrosus into the root canal occurs when weight is taken on the ipsilateral lower limb. Symptoms of the spinal stenosis syndrome do not arise until the development of this instability. To relieve the symptoms, the nerve root must be freely mobilised and decompressed by full lateral decompression, with partial or total facetectomy if necessary, by enucleation of the intervertebral disc and by removal of the posterolateral portions of the annuli fibrosi.

The morphometry and pathological anatomy of the lumbar spine in South African negroes and caucasoids with specific reference to spinal stenosis.

Direct measurements were made on 2,166 lumbar vertebrae of 433 adult negro and caucasoid skeletons. On statistical analysis, forty-five vertebrae in twenty-seven skeletons were found to be stenotic, the mid-sagittal diameter being the significantly reduced dimension. Whereas spinal stenosis syndromes are rare in South African negroes, the lumbar canal is marginally narrower in the negro. There is a uniformity of configuration and capacity of the lumbar spinal canal, which transcends race and sex. By a new method of determining the dorsal limit of the lumbar canal on lateral plain radiography, the overall average lower limit of normal of the mid-sagittal diameter is established at 15 millimetres, and of the transverse diameter 20 millimetres. Bony degenerative changes are more likely to cause neurological compression in the nerve root tunnel than in the spinal canal. The role of skeletal narrowing of the spinal canal as an exclusive cause of the spinal stenosis syndrome may have been exaggerated.