Symptomatic Lumbar Spinal Stenosis Research Articles

Erratum to: Changes in dural sac caliber with standing MRI improve correlation with symptoms of lumbar spinal stenosis.

Weight bearing does alter the dimension of lumbar spinal canal, but no study has analyzed its clinical correlation. This study aims to evaluate whether the changes in dural sac cross-sectional area (DSCA) and sagittal anteroposterior (AP) diameter on standing magnetic resonance imaging (MRI) correlate better with clinical symptoms of lumbar spinal stenosis. Seventy consecutive patients with neurogenic claudication were prospectively recruited to undergo a 0.25-T MRI examination performed in supine and standing positions. Clinical symptoms including the walking distance, Visual Analogue Score of leg pain, Chinese Oswestry Disability Index, and short form-12 were assessed. DSCA and sagittal AP diameter at the most constricted spinal level on supine and standing positions were measured and correlated with each clinical symptom by Pearson correlation coefficients (r). DSCA and AP diameter on standing MRI and their % changes from supine to standing showed significant (r = 0.55, 0.53, −0.44, −0.43; p 500 m. A >30% reduction of DSCA and AP diameter was observed in patients with worse claudication distance (p < 0.05). DSCA and sagittal AP diameter on standing MRI correlate significantly and better than findings on supine MRI with claudication symptoms. Standing MRI demonstrates dynamic changes of dural sac and provides an additional value to supine MRI in correlating clinical symptoms of lumbar spinal stenosis.

Long-term Clinical Outcomes and Quality of Life in Elderly Patients Treated with Interspinous Devices for Lumbar Spinal Stenosis.

Lumbar spinal stenosis (LSS) is a common degenerative condition that occurs in the spine with increasing age. Clinically, LSS causes a progressive reduction in walking autonomy, resulting in a poor quality of life and impaired functional capacity. The aim of this study was to evaluate the clinical outcome and quality of life of elderly patients presenting with LSS and associated comorbidities after a 5-year follow-up who were treated with an interspinous process device (IPD). Sixty patients > 75 years of age presenting with symptomatic degenerative LSS were included. All were treated with an IPD under local anesthesia. American Society of Anesthesiology score, Zurich Claudication Questionnaire, and Short Form 36 were evaluated pre- and postoperatively and at the follow-up visit each year for 5 years. The mean surgery time while under local anesthesia was 20 minutes. Forty-eight patients were followed for 5 years. Significant clinical improvements in all outcome scores (p < 0.05) both postoperatively or at follow-up were found. IPD seems to be an effective and safe treatment for LSS in elderly patients with general comorbidities. In our study, all followed up patients had a meaningful improvement of their quality of life even at 5 years after surgery.

Identifying predictors for postoperative clinical outcome in lumbar spinal stenosis patients using smart-shoe technology

BackgroundApproximately 33% of the patients with lumbar spinal stenosis (LSS) who undergo surgery are not satisfied with their postoperative clinical outcomes. Therefore, identifying predictors for postoperative outcome and groups of patients who will benefit from the surgical intervention is of significant clinical benefit. However, many of the studied predictors to date suffer from subjective recall bias, lack fine digital measures, and yield poor correlation to outcomes.MethodsThis study utilized smart-shoes to capture gait parameters extracted preoperatively during a 10 m self-paced walking test, which was hypothesized to provide objective, digital measurements regarding the level of gait impairment caused by LSS symptoms, with the goal of predicting postoperative outcomes in a cohort of LSS patients who received lumbar decompression and/or fusion surgery. The Oswestry Disability Index (ODI) and predominant pain level measured via the Visual Analogue Scale (VAS) were used as the postoperative clinical outcome variables.ResultsThe gait parameters extracted from the smart-shoes made statistically significant predictions of the postoperative improvement in ODI (RMSE =0.13, r=0.93, and p<3.92×10−7) and predominant pain level (RMSE =0.19, r=0.83, and p<1.28×10−4). Additionally, the gait parameters produced greater prediction accuracy compared to the clinical variables that had been previously investigated.ConclusionsThe reported results herein support the hypothesis that the measurement of gait characteristics by our smart-shoe system can provide accurate predictions of the surgical outcomes, assisting clinicians in identifying which LSS patient population can benefit from the surgical intervention and optimize treatment strategies.

Changes in dural sac caliber with standing MRI improve correlation with symptoms of lumbar spinal stenosis.

Weight bearing does alter the dimension of lumbar spinal canal, but no study has analyzed its clinical correlation. This study aims to evaluate whether the changes in dural sac cross-sectional area (DSCA) and sagittal anteroposterior (AP) diameter on standing magnetic resonance imaging (MRI) correlate better with clinical symptoms of lumbar spinal stenosis. Seventy consecutive patients with neurogenic claudication were prospectively recruited to undergo a 0.25-T MRI examination performed in supine and standing positions. Clinical symptoms including the walking distance, Visual Analogue Score of leg pain, Chinese Oswestry Disability Index, and short form-12 were assessed. DSCA and sagittal AP diameter at the most constricted spinal level on supine and standing positions were measured and correlated with each clinical symptom by Pearson correlation coefficients (r). DSCA and AP diameter on standing MRI and their % changes from supine to standing showed significant (r=0.55, 0.53, -0.44, -0.43; p<0.001) and better correlations than those on supine MRI (r=0.39, 0.42; p<0.001) with walking distance. Significant correlations were also found between dural sac calibers on standing MRI and leg pain scores (r=-0.20, r=-0.25; p<0.05). Patients walking ≤500m had a significantly smaller DSCA, narrower AP diameter and greater % change in dural sac calibers (p<0.01) than those walking >500m. A >30% reduction of DSCA and AP diameter was observed in patients with worse claudication distance (p<0.05). DSCA and sagittal AP diameter on standing MRI correlate significantly and better than findings on supine MRI with claudication symptoms. Standing MRI demonstrates dynamic changes of dural sac and provides an additional value to supine MRI in correlating clinical symptoms of lumbar spinal stenosis.

Health Characteristics, Neuromuscular Attributes, and Mobility Among Primary Care Patients With Symptomatic Lumbar Spinal Stenosis: A Secondary Analysis.

Mobility problems are common among older adults. Symptomatic lumbar spinal stenosis (SLSS) is a major contributor to mobility limitations among older primary care patients. In comparison with older primary care patients with mobility problems but without SLSS, it is unclear how mobility problems differ in older primary care patients with SLSS. The purpose of this study was to compare health characteristics, neuromuscular attributes, and mobility status in a sample of older primary care patients with and without SLSS who were at risk for mobility decline. We hypothesized that patients with SLSS will manifest poorer health and greater severity of neuromuscular impairments and mobility limitations. This is a secondary analysis of the Boston Rehabilitative Study of the Elderly (Boston RISE). Fifty community-dwelling primary care patients aged 65 years or older at risk for mobility decline met inclusion criteria. SLSS was determined on the basis of computerized tomography (CT) scan and self-reported symptoms characteristic of neurogenic claudication. Outcome measures included health characteristics, neuromuscular attributes (trunk endurance, limb strength, limb speed, limb strength asymmetry, ankle range of motion [ROM], knee ROM, kyphosis, sensory loss), and mobility (Late-Life Function and Disability Instrument: basic and advanced lower extremity function subscales, 400-meter walk test, habitual gait speed, and Short Physical Performance Battery score). Health characteristics were collected at a baseline assessment. Neuromuscular attributes and mobility status were measured at the annual visit closest to conducting the CT scan. Five participants met criteria for having SLSS. Differences are reported in medians and interquartile ranges. Participants with SLSS reported more global pain, a greater number of comorbid conditions [SLSS: 7.0 (2.0) vs no-SLSS: 4.0 (2.0), P < .001], and experienced greater limitation in knee ROM [SLSS: 115.0° (8.0°) vs no-SLSS: 126.0° (10.0°), P = .04] and advanced lower extremity function than those without SLSS.A limitation of this study was its small sample size and therefore inability to detect potential differences across additional measures of neuromuscular attributes and mobility. Despite the limitation, the differences in mobility for participants with SLSS may support physical therapists in designing interventions for older adults with SLSS. Participants with SLSS manifested greater mobility limitations that exceeded meaningful thresholds across all performance-based and self-reported measures. In addition, our study identified that differences in mobility extended beyond not just walking capacity but also across a variety of tasks that make up mobility for those with and without SLSS. Among older primary care patients who are at risk for mobility decline, patients with SLSS had greater pain, higher levels of comorbidity, greater limitation in knee ROM, and greater limitations in mobility that surpassed meaningful thresholds. These findings can be useful when prioritizing interventions that target mobility for patients with SLSS.

Obese (Body Mass Index >30) Patients Have Greater Functional Improvement and Reach Equivalent Outcomes at 12 Months Following Decompression Surgery for Symptomatic Lumbar Stenosis.

To evaluate effect of obesity on 12-month functional outcomes after surgery for lumbar stenosis in adult patients. Data were collected on patients treated with lumbar laminectomy for symptomatic lumbar spinal stenosis as part of an observational registry and analyzed using a retrospective cohort study design. Patients with body mass index (BMI) >30 were compared with patients with BMI <30 with respect to baseline, 3-month, and 12-month functional status, adjusted for potential confounders. There were 101 patients. At baseline, patients with BMI >30 had significantly more back pain (P < 0.001), more leg pain (P < 0.001), lower EuroQol 5 dimensions questionnaire (EQ-5D) scores (P < 0.001), and higher Oswestry Disability Index (ODI) scores (P < 0.001). Both low- and high-BMI groups had significant improvement in back pain, leg pain, EQ-5D scores, and ODI scores after decompression (all P < 0.001). At 3 months postoperatively, high-BMI patients continued to report greater leg pain (P= 0.063) and higher ODI score (P= 0.064) relative to low-BMI patients. By 12 months, there was no difference between low- and high-BMI patients in back pain (P= 0.929), leg pain (P= 0.638), EQ-5D score (P= 0.733), or ODI score (P= 0.214). The difference between low- and high-BMI patients trended toward significance for leg pain and ODI score at 3 months, but this difference disappeared by 12 months. This suggests that obese patients with symptomatic lumbar spinal stenosis may require longer to recover after decompression but can expect to reach equivalent outcomes of similarly treated patients with BMI<30.

Association of Lumbar Spondylolisthesis With Low Back Pain and Symptomatic Lumbar Spinal Stenosis in a Population-based Cohort: The Wakayama Spine Study.

Cross-sectional study. To determine the association between lumbar spondylolisthesis and low back pain and symptomatic lumbar spinal stenosis (LSS) in a population-based cohort. The basic epidemiology of lumbar spondylolisthesis is not well known. There is little information regarding the association between lumbar spondylolisthesis and clinical symptoms such as low back pain and LSS symptoms. This cross-sectional study included data from 938 participants (308 males, 630 females; mean age, 67.3 years; range, 40-93 years). Lumbar spondylolisthesis was defined as a slip of ≥5%. Diagnostic criteria for symptomatic LSS required the presence of both leg symptoms and radiographic LSS findings on magnetic resonance imaging. The prevalence of low back pain and symptomatic LSS was compared between those with or without spondylolisthesis. Furthermore, we determined the association between the amount of slippage and presence of symptomatic LSS. The prevalence of spondylolisthesis at any level was 15.8% in the total sample, 13.0% in males, and 17.1% in females; the prevalence was not significantly different between males and females (P = 0.09). In both, males and females, symptomatic LSS was related to spondylolisthesis [odds ratio (OR): 2.07; 95% CI: 1.20-3.44]; however, no such association was found for spondylolisthesis and presence of low back pain. The amount of slippage was not related to the presence of symptomatic LSS (P = 0.93). This population-based cohort study revealed that lumbar spondylolisthesis had a closer association with leg symptoms than with low back pain. There was a significant difference in the presence of symptomatic LSS between participants with and without spondylolisthesis. However, the amount of slippage was not related to the presence of symptomatic LSS. 3.

A Meta-Analysis on the Clinical Significance of Redundant Nerve Roots in Symptomatic Lumbar Spinal Stenosis.

Symptomatic lumbar spinal stenosis (LSS), which leads to severe socioeconomic consequences and places a heavy burden on global healthcare system, is a relatively frequent spine disorder. Redundant nerve roots (RNRs) are a relatively common finding in which slender, serpiginous, or tortuous nerve roots are found in the subarachnoid space of the lumbar spine. Previous studies that evaluated the prognostic assessment of RNRs in patients with symptomatic LSS are composed of doubtful results. Therefore, the clinical significance of RNRs in symptomatic LSS is still uncertain. The aim of this meta-analysis is a systematic assessment of the clinical significance of RNR syndrome in symptomatic LSS. This study used a highly sensitive search strategy to identify all published studies in multiple databases up to January 1, 2017. All identified trials were systematically evaluated using specific inclusion and exclusion criteria. Cochrane methodology was also applied to the results of this study. This study identified 4 relevant studies involving 297 patients. Compared with a non-RNR group, the RNR group results included worse clinical outcomes that were assessed using the Japanese Orthopedic Association scores after surgery (weighted mean difference [WMD],-0.78; 95% confidence interval [CI],-1.26 to-0.29; P= 0.002; I2= 0%), for recovery rate (WMD,-9.87; 95% CI,-15.07 to-4.67; P= 0.0002; I2= 0%), and for older age (WMD, 2.51; 95% CI, 0.45-4.57; P= 0.02; I2= 43%). RNR is an entity in association with symptomatic LSS, which may be viewed as a potentially powerful prognostic indicator of worse postoperative functional recovery for symptomatic LSS.

Scoping review to develop common data elements for lumbar spinal stenosis

Background ContextCommon data elements (CDE) represent an important tool for understanding and classifying health outcomes across settings. Although CDEs have been developed for a number of disorders, to date CDEs for lumbar spinal stenosis (LSS) have not been fully developed. To facilitate the identification of CDEs and measures to assess them, this technical study leverages the International Classification of Functioning, Disability and Health (ICF), peer-reviewed research, and a panel of experts to identify CDEs specific to LSS. PurposeThe study aimed to define CDEs for disease characteristics and outcomes of LSS using the World Health Organization's ICF taxonomy, and to facilitate the selection of assessment instruments for research and clinical care. DesignThis is a scoping review using a modified Delphi approach with a technical expert panel composed of clinicians and scientists representing the academia, policy and advocacy stakeholders, and professional associations with expertise in LSS. MethodsThis is a scoping review to identify measures that assess LSS symptoms. Thirty-one subject matter experts (SMEs) prioritized ICF codes and evaluated instruments measuring specific domains. We used a modified Delphi technique to evaluate item-level content and achieve consensus. ResultsSMEs prioritized 53 ICF codes; 3 received 100% endorsement, 27 received ≥90% endorsement, whereas the remaining 23 received ≥80% endorsement. Prioritized ICF codes represent diverse domains, including pain, activities and participation, and emotional well-being. The review yielded 58 instruments; we retained 24 for content analysis. ConclusionsThe retained instruments adequately represent the ICFs activities and participation, and body function domains. Body structure and environmental factors were assessed infrequently. Adoption of these CDEs may guide clinical decision making and facilitate comparative effectiveness trials for interventions focused on LSS.

An Iranian Version of the Fukushima Lumbar Spinal Stenosis Scale (FLS-25): A Validation Study.

Study DesignCross-sectional study.PurposeTo translate and validate the Fukushima lumbar spinal stenosis (LSS) scale 25 (FLS-25) for use in Iran.Overview of LiteratureTools measuring patient-reported outcomes should satisfy certain psychometric properties.MethodsFLS-25 is a self-administered scale for evaluating symptoms of LSS. A forward-backward procedure was applied to translate the questionnaire from English into Persian. A sample of patients with LSS completed the questionnaire at two points in time: once before surgery and once 6 months after the surgery. The Neurogenic Claudication Outcome Score (NCOS) was also used for assessment. The psychometric properties of FLS-25 were evaluated for internal consistency, test-retest and interobserver reliabilities, responsiveness to change, known-group comparison, and convergent validity.ResultsIn all, 131 patients were included in the study. The mean age of the patients was 61.4 (standard deviation, 11.1) years. The Cronbach's alpha coefficient for FLS-25 was 0.89. Test-retest reliability as carried out by the intraclass correlation coefficient was 0.94 (95% confidence interval, 0.95). Interobserver agreement as measured by the kappa statistics also was found to be acceptable (kappa value, 0.88), and validity was found to be satisfactory. The instrument was able to discriminate between the subgroups of patients who differed in symptom severity. The correlation between FLS-25 and NCOS scores was excellent, indicating good convergent validity (r=0.82, p<0.001). The results also indicated that the instrument was responsive to change (p<0.001).ConclusionsThe Iranian version of FLS-25 performed well, and the findings suggest that it is a valid measure of symptom severity in LSS patients.

Relationships among Disability, Quality of Life, and Physical Fitness in Lumbar Spinal Stenosis: An Investigation of Elderly Korean Women.

Study DesignA cross-sectional, case-control study.PurposeTo investigate associations between physical fitness measures and disabilities related to back pain and quality of life (QOL) by the presence of symptomatic lumbar spinal stenosis (LSS) in elderly Korean women.Overview of LiteratureLSS leads to decreased functioning and reduced QOL. However, correlations among physical fitness, disability, and QOL have not been investigated in elderly women with LSS.MethodsParticipants included women aged 65 years and older (n=192), divided into a study group (n=38) and a control group (n=154) based on the presence/absence of LSS. All participants underwent physical function and fitness tests. Oswestry disability index (ODI) scores and EuroQol five-dimensional questionnaire (EQ-5D-5L) scores were used to assess disability and health-related QOL.ResultsThe results for the handgrip strength, sit-and-reach, functional reach, and timed up and go (TUG) tests were significantly higher in the control group than the LSS group. ODI scores were significantly higher and EQ-5D-5L scores significantly lower in the LSS group. TUG and functional reach test scores were significantly correlated with ODI scores, and handgrip strength was strongly interrelated with ODI and EQ-5D-5L scores in the LSS group. No other physical fitness measures showed statistically significant relationships with ODI or EQ-5D-5L scores.ConclusionsIn elderly Korean women with LSS, back pain-related disability and QOL are significantly associated with some physical fitness parameters such as handgrip strength. Handgrip strength reflects general muscle strength, which is significantly interrelated with the level of disability and QOL. Our results suggest that enhancing generalized muscle strength helps to reduce disability due to back pain and improve QOL in patients with LSS.

Long-Term Effects of Repeated Injections of Local Anesthetic With or Without Corticosteroid for Lumbar Spinal Stenosis: A Randomized Trial

ObjectiveTo determine the overall long-term effectiveness of treatment with epidural corticosteroid injections for lumbar central spinal stenosis and the effect of repeat injections, including crossover injections, on outcomes through 12 months. DesignMulticenter, double-blind, randomized controlled trial comparing epidural injections of corticosteroid plus lidocaine versus lidocaine alone. SettingSixteen clinical sites. ParticipantsParticipants with imaging-confirmed lumbar central spinal stenosis (N=400). InterventionsParticipants were randomized to receive either epidural injections with corticosteroid plus lidocaine or lidocaine alone with the option of blinded crossover after 6 weeks to receive the alternate treatment. Participants could receive 1 to 2 injections from 0 to 6 weeks and up to 2 injections from 6 to 12 weeks. After 12 weeks, participants received usual care. Main Outcome MeasuresPrimary outcomes were the Roland-Morris Disability Questionnaire (RDQ) (range, 0–24, where higher scores indicate greater disability) and leg pain intensity (range, 0 [no pain] to 10 [pain as bad as you can imagine]). Secondary outcomes included opioid use, spine surgery, and crossover rates. ResultsAt 12 months, both treatment groups maintained initial observed improvements, with no significant differences between groups on the RDQ (adjusted mean difference, −0.4; 95% confidence interval [CI], −1.6 to 0.9; P=.55), leg pain (adjusted mean difference, 0.1; 95% CI, −0.5 to 0.7; P=.75), opioid use (corticosteroid plus lidocaine: 41.4% vs lidocaine alone: 36.3%; P=.41), or spine surgery (corticosteroid plus lidocaine: 16.8% vs lidocaine alone: 11.8%; P=.22). Fewer participants randomized to corticosteroid plus lidocaine (30%, n=60) versus lidocaine alone (45%, n=90) crossed over after 6 weeks (P=.003). Among participants who crossed over at 6 weeks, the 6- to 12-week RDQ change did not differ between the 2 randomized treatment groups (adjusted mean difference, −1.0; 95% CI, −2.6 to 0.7; P=.24). In both groups, participants crossing over at 6 weeks had worse 12-month trajectories compared with participants who did not choose to crossover. ConclusionsFor lumbar spinal stenosis symptoms, epidural injections of corticosteroid plus lidocaine offered no benefits from 6 weeks to 12 months beyond that of injections of lidocaine alone in terms of self-reported pain and function or reduction in use of opioids and spine surgery. In patients with improved pain and function 6 weeks after initial injection, these outcomes were maintained at 12 months. However, the trajectories of pain and function outcomes after 3 weeks did not differ by injectate type. Repeated injections of either type offered no additional long-term benefit if injections in the first 6 weeks did not improve pain.

The prevalence of tandem spinal stenosis and its characteristics in a population-based MRI study: The Wakayama Spine Study.

Tandem spinal stenosis (TSS) is a condition of combined spinal stenosis in the cervical and lumbar regions. The purpose of this study was to determine the prevalence of radiographic TSS and its association with developmental canal stenosis (DCS). The second purpose was to investigate the extent to which radiographic TSS is associated with cervical myelopathy and symptomatic LSS. We recruited 1011 (336 men and 675 women) participants in this population-based study. After excluding those with a pacemaker, a history of cervical or lumbar surgery, disqualification, the MRI data of whole spine was analysed in 931 (mean, 67.3years) participants. Cervical cord compression (CCC) and radiographic lumbar spinal stenosis (LSS) were evaluated by MRI. The canal-to-body ratio was also measured by plain X-ray. DCS was diagnosed as canal-to-body ratio <0.75. The diagnosis of cervical myelopathy and symptomatic LSS was made by presentation of both symptoms and radiographic compression using MRI. The prevalence of CCC was 24.7%, that of radiographic LSS was 30.2%, and that of radiographic TSS was 11.0% (men, 14.1%; women, 9.4%). The prevalence of TSS was significantly higher in the DCS group than in the non-DCS group (p<0.001). Among the participants with radiographic TSS, the prevalence of cervical myelopathy and symptomatic LSS was 9.8 and 18.6%, respectively. The coexisting cervical myelopathy and symptomatic LSS was 6.1% in the participants with LSS. The present study is the first population-based study to clarify TSS characteristic using whole-spine MRI.

Association of Neuromuscular Attributes With Performance-Based Mobility Among Community-Dwelling Older Adults With Symptomatic Lumbar Spinal Stenosis

ObjectivesTo identify differences in health factors, neuromuscular attributes, and performance-based mobility among community-dwelling older adults with symptomatic lumbar spinal stenosis; and to determine which neuromuscular attributes are associated with performance-based measures of mobility. DesignCross-sectional; secondary data analysis of a cohort study. SettingOutpatient rehabilitation center. ParticipantsCommunity-dwelling adults aged ≥65 years with self-reported mobility limitations and symptomatic lumbar spinal stenosis (N=54). InterventionsNot applicable. Main Outcome MeasuresShort Physical Performance Battery score, habitual gait speed, and chair stand test. ResultsSymptomatic lumbar spinal stenosis was classified using self-reported symptoms of neurogenic claudication and imaging. Among 430 community-dwelling older adults, 54 (13%) met criteria for symptomatic lumbar spinal stenosis. Compared with participants without symptomatic lumbar spinal stenosis, those with symptomatic lumbar spinal stenosis had more comorbidities, higher body mass index, greater pain, and less balance confidence. Participants with symptomatic lumbar spinal stenosis had greater impairment in trunk extensor muscle endurance, leg strength, leg strength asymmetry, knee flexion range of motion (ROM), knee extension ROM, and ankle ROM compared with participants without symptomatic lumbar spinal stenosis. Five neuromuscular attributes were associated with performance-based mobility among participants with symptomatic lumbar spinal stenosis: trunk extensor muscle endurance, leg strength, leg strength asymmetry, knee flexion ROM, and knee extension ROM asymmetry. ConclusionsCommunity-dwelling older adults with self-reported mobility limitations and symptomatic lumbar spinal stenosis exhibit poorer health characteristics, greater neuromuscular impairment, and worse mobility when compared with those without symptomatic lumbar spinal stenosis. Poorer trunk extensor muscle endurance, leg strength, leg strength asymmetry, knee flexion ROM, and knee extension ROM asymmetry were associated with performance-based mobility among participants with symptomatic lumbar spinal stenosis.

The Influence of Pre- and Postoperative Fear Avoidance Beliefs on Postoperative Pain and Disability in Patients With Lumbar Spinal Stenosis: Analysis of the Lumbar Spinal Outcome Study (LSOS) Data.

Prospective multicenter cohort study. To evaluate the effect of pre- and postoperatively assessed fear avoidance beliefs (FAB) on pain and disability in patients with degenerative lumbar spinal stenosis (LSS) after decompression surgery. To the present, the influence of pre- and postoperative FAB on the prognosis after surgery for LLS is still unclear. Patients of the Swiss Lumbar Stenosis Outcome Study (LSOS) with confirmed LSS undergoing first-time decompression without fusion were enrolled in this study. The main outcome of this study was minimal clinically important difference (MCID) in spinal stenosis measure symptoms (pain) and function (disability) after 12 months. To analyze the influence of pre- and postoperatively assessed FAB on pain and disability we built simple and multiple logistic regression models. In this analysis of 234 patients undergoing decompression surgery for symptomatic degenerative LSS we found baseline FAB measured by the FAB physical activity subscale (FABQ-P) not to be associated with pain (OR 0.95; 95% CI: 0.55-1.67) and disability (OR 1.11; 95% CI: 0.64-1.92) at 12 months' follow-up. In the final multiple logistic regression models patients with high FABQ-P at 6 months (OR 0.46; 95% CI: 0.24-0.91) and high persistent FABQ-P at baseline and 6 months (OR 0.34, 95% CI: 0.16-0.73) were less likely to report a MCID for spinal stenosis measure symptoms at 12 months. Our analysis found a similar trend for disability; however, the results were not statistically significant. In elderly patients undergoing decompression surgery for symptomatic degenerative LSS preoperative fear avoidance beliefs were not a prognostic indicator for the outcome. Patients with FAB at 6 months and persistent FAB were less likely to experience clinically relevant improvement in pain at 12 months. Studies should address the importance of persistent postoperative FAB. 3.

Histopathological Analysis of Ligamentum Flavum in Lumbar Spinal Stenosis and Disc Herniation.

Study DesignHistopathological analyses were performed in ligamentum flavum (LF) hypertrophy patients with lumbar spinal stenosis (LSS) and lumbar disc herniation (LDH).PurposeThe aim of the present study was to evaluate histopathological changes in LF patients with LSS and LDH.Overview of LiteratureLSS is the most common spinal disorder in elderly patients. This condition causes lower back and leg pain and paresis, and occurs as a result of degenerative changes in the lumbar spine, including bulging of the intervertebral discs, bony proliferation of the facet joints, and LF thickening; among these, LF thickening is considered a major contributor to the development of LSS.MethodsA total of 71 patients operated with the surgical indications of LSS and LDH were included. LF samples were obtained from 31 patients who underwent decompressive laminectomy for symptomatic degenerative LSS (stenotic group) and from 40 patients who underwent lumbar discectomy for LDH (discectomy group). LF materials were examined histopathologically, and other specimens were examined for collagen content, elastic fiber number and array, and presence of calcification.ResultsThe stenotic and discectomy groups did not differ with regard to mean collagen concentration or mean elastic fiber number (p=0.430 and p=0.457, respectively). Mean elastic fiber alignment was 2.36±0.99 in the stenotic group and 1.38±0.54 in the discectomy group (p<0.001). Mean calcification was 0.39±0.50 in the stenotic group, whereas calcification was not detected (0.00±0.00) in the discectomy group; a statistically significant difference was detected (p<0.001) between groups.ConclusionsLF hypertrophy in spinal stenosis may occur as a result of elastic fiber misalignment along with the development of calcification over time. Further studies determining the pathogenesis of LSS are needed.

Botulinum Toxin Treatment for Nocturnal Calf Cramps in Patients With Lumbar Spinal Stenosis: A Randomized Clinical Trial

ObjectivesTo evaluate the clinical effectiveness of botulinum toxin (BTX) injection into the gastrocnemius muscles in patients with lumbar spinal stenosis (LSS) who have frequent nocturnal calf cramps (NCCs). DesignProspective, randomized clinical trial. SettingOutpatient department for interventional pain management. ParticipantsPatients (N=50) with LSS who have NCCs at least once per week were enrolled. InterventionPatients were randomly allocated to receive either conservative treatments plus gabapentin (group GPN) or BTX injection (group BTX). Main Outcome MeasuresWe assessed back/leg pain intensity, the frequency and severity of NCCs, insomnia severity, and functional disability at baseline and after 2 weeks, 1 month, and 3 months. Additionally, Patient Global Impression of Change was assessed. ResultsForty-five patients completed all assessments (group GPN, n=21; group BTX, n=24). Compared with group GPN, leg pain intensity, cramp frequency, and cramp severity were significantly decreased in group BTX at all follow-up visits (all, P<.01). Also, insomnia significantly improved in group BTX at the 2-week (P=.018) and 1-month follow-up (P=.037). Functional disability significantly improved in group BTX at 2 weeks' follow-up (P=.041). At the 3-month follow-up, patients in group BTX reported a higher impression of improvement for NCC symptoms than did those in group GPN (P<.001). A mean dose of 642.8mg of gabapentin was given daily in group GPN, but 7 patients (33.3%) reported systemic side effects. There were no serious complications related to BTX use. ConclusionsBTX treatment appears to be effective and safe for NCCs in symptomatic LSS patients receiving conservative care.

Low Back Pain in Patients with Lumbar Spinal Stenosis-Hemodynamic and electrophysiological study of the lumbar multifidus muscles.

Introduction Several studies have demonstrated improvement in low back pain (LBP) after decompression surgery for lower extremity symptoms in lumbar spinal stenosis (LSS); however, the influence of neuropathic disorders on LBP is uncertain. Aim of this study is to identify the features of motion-induced and walking-induced LBP in patients with LSS and to assess whether neuropathic LBP develops. Methods In total, 234 patients with LSS including L4/5 lesion were asked to identify their LBP. Subjects were classified into three groups: walking-induced LBP that aggravated during walking (W group), motion-induced LBP that aggravated during sitting up (M group), and no LBP (N group). Cross-sectional areas of the dural sac, lumbar multifidus, and the erector spinae were measured. Intramuscular oxygenation was evaluated with near-infrared spectrophotometer. Surface electromyography (EMG) and mechanomyography (MMG) were performed on the lumbar multifidus. Morphological, hemodynamic, and electrophysiological differences in the onset of LBP were evaluated. Results The prevalence of W, M, and control groups was 31.2%, 32.1%, 36.8%, respectively. Concordance between the laterality of LBP and leg symptoms including pain and numbness was 86.3% in the W group and 47.0% in the M group. Dural sac area was lower in the W group than in the M and control groups. In the hemodynamic evaluation, the oxygenated hemoglobin level was significantly lower in the W group than in the M and N groups. In electrophysiological evaluation of lumbar multifidus, the mean power frequency in EMG was significantly higher in the W group than in the N group. Amplitude in MMG was significantly lower in the W group than in the N group. Conclusions Neurologic disturbance in patients with LSS may be attributed to “neuropathic LBP.” Neuropathic multifidus disorder plays a role in walking-induced LBP.

Preliminary experience with lumbar facet distraction and fixation as treatment for lumbar spinal stenosis.

Objectives:To assess the properties of facet fixation with the Facet Wedge system in patients affected by lumbar spinal stenosis (LSS).Summary of Background Data:Implant of intra-articular spacers is an emerging technique for lumbar degenerative disease.Methods:This study included forty patients (Group 1) with symptomatic LSS in whom intra-articular spacers have been implanted along with microdecompression (MD) of the neural structures. Group 1 has been compared with a homogeneous group of patients with LSS treated with MD without intra-articular spacers implant (Group 2). Clinical findings have been observed preoperatively and 3, 6, 12 months postoperatively using dedicated questionnaires (Zurich Claudication Questionnaire, visual analog scale, and Oswestry disability index).Results:One year following surgical treatment, 87% of the patients presented with good improvement of symptoms and 97% referred satisfaction for surgery. Overall, patients of Group 1 presented with significantly better clinical outcome when compared with the control group (P < 0.01).Conclusions:Intra-articular spacers showed significant and clinically meaningful improvements in pain and disability for up to 1 year. These findings need further studies and a longer follow-up.

Does smoking affect the outcomes of lumbar decompression surgery?

Introduction: Lumbar decompressions and micro-discectomies are commonly performed non-complex spinal surgeries that do not involve the insertion of metalwork into the spine and are done for symptomatic disc prolapse and lumbar spinal stenosis, whereas complex-spinal surgery does require metalwork [1]. Studies of complex-spinal surgeries show that smoking has a significant negative impact on the outcome of the surgery [2] therefore, the cessation of smoking is advised prior to surgery [3]. There are evidences in the literature supportive as well as opposing this statement about continued smoking and poor outcome of decompressive spinal surgeries. Methods: We retrospectively reviewed 143 consecutive patients who have had either a micro-discectomy or a micro-decompression. Results: We found no statistical difference between smokers and non-smokers in the outcomes of lumbar decompression surgery. Both groups improved equally and significantly in terms of back pain, leg pain and functions. Out of 143 patients, only 2% more non-smokers had improved leg pain compared to smokers, 1% less non-smokers had improved back pain and 2% more non-smokers had an improved Oswestry Disability Index (ODI) score. Discussion: We recommend that it is important to surgically treat both smokers and non-smokers in need of a lumbar spinal decompression.