Treatment Of Degenerative Lumbar Stenosis Research Articles

Indirect Decompression for the Treatment of Degenerative Lumbar Stenosis.

Surgical treatment of symptomatic lumbar stenosis has traditionally included laminectomy for direct decompression. With increasing options for lumbar interbody fusion, there has been growing interest in indirect decompression to treat degenerative stenosis. The primary purpose of this study was to determine whether indirect decompression via anterior lumbar interbody fusion (ALIF) can provide symptomatic relief in patients with lumbar spinal stenosis. Secondary purposes were to (1) identify risk factors for failure of indirect decompression and (2) to identify risk factors for failure to obtain relief and to compare outcomes between patients undergoing stand-alone ALIF versusand those in whom ALIF was supplemented with posterior instrumentation. Chart review was performed on a consecutive series of 568 patients undergoing single-level ALIF without posterior decompression to treat degenerative stenosis during a 5-year period. Failure of indirect decompression was defined as return to the operating room for direct decompression. Subgroup analysis was performed to compare patients who underwent stand-alone ALIF (n = 247) vs those in whom supplemental posterior instrumentation was used (ALIF + PI; n = 321). Reoperation due to failure of indirect decompression occurred in 4.0% (23/568) of patients. The only factor related to failure was age. Patients older than 60 years were more likely to fail indirect decompression than were younger patients (7.0% vs 3.1%, P < 0.05). ALIF and ALIF + PI subgroups both improved significantly when comparing preoperative to postoperative mean scores on Oswestry Disability Index (ODI), back pain, and leg pain (all P < 0.01). There were no significant differences between these groups, including reoperation rate for direct decompression. Indirect decompression via ALIF was effective in treating appropriately selected patients with degenerative lumbar spinal stenosis. Older patients are at higher risk for failure of indirect decompression-potentially because of greater osseous stenosis as well as subsidence due to age-related diminished bone density with subsequent loss of distraction. 4. This study supports that indirect decompression via ALIF is a viable alternative to direct decompression in appropriately selected patients with degenerative stenosis.

65. Indirect decompression for the treatment of degenerative lumbar stenosis: clinical outcome in a consecutive series of 568 patients

BACKGROUND CONTEXT Surgical treatment of symptomatic lumbar stenosis has traditionally included laminectomy for direct decompression. With expanding options for lumbar interbody fusion, interest has been increasing in indirect decompression to treat degenerative stenosis. Segmental distraction afforded by these interbody techniques is thought to increase foraminal height and reduce ligamentous infolding, thereby indirectly decompressing neural elements. PURPOSE The primary purpose of this study was to determine whether indirect decompression via anterior lumbar interbody fusion (ALIF) can provide symptomatic relief in patients with lumbar spinal stenosis. Secondary purposes were to: (1) determine if risk factors for failure of indirect decompression could be identified, and (2) compare outcomes between patients undergoing stand-alone ALIF vs those with supplemental posterior fixation (ALIF+PF). STUDY DESIGN/SETTING This was a retrospective chart review study. PATIENT SAMPLE The study was based on a consecutive series of 568 patients undergoing single-level ALIF without posterior decompression to treat degenerative stenosis during a 5-year period. OUTCOME MEASURES Data recorded included general demographics, symptom type, Oswestry Disability Index (ODI) scores, visual analog scale (VAS) data separately assessing back and leg pain, and re-operations. METHODS Failure of indirect decompression was defined as return to the operating room for direct decompression. Patients who failed indirect decompression were compared to those who did not to determine whether differences between groups could be identified. An additional subgroup analysis was performed to compare outcomes of patients who underwent stand-alone ALIF (n=247) vs those in whom supplemental posterior fixation was used (ALIF+PF; n=321). RESULTS Re-operation due to failure of indirect decompression occurred in 4.0% (23/568) of patients. The only factor found to be related to failure was age. Patients greater than 60 years of age were more likely to fail indirect decompression than were younger patients (7.0% vs 3.1%, p 0.50). For example, prior to surgery, ODI scores were 44.0 and 43.8 in the ALIF and ALIF+PS groups, respectively. These improved significantly to 27.3 and 27.5 after surgery. The percentage of patients in the 2 groups undergoing re-operation for direct decompression was not significantly different (ALIF 4.9% vs. ALIF+PS 3.4%; p>0.05). CONCLUSIONS Indirect decompression via ALIF was effective in treating appropriately-selected patients with degenerative lumbar spinal stenosis. Significant improvements on ODI and pain scores were observed. Only 4% of patients underwent subsequent direct decompression. Increased age was the only identified risk factor for failure of indirect decompression. This may be related to increased osseous stenosis in older individuals, which may be less amenable to indirect decompression. There were no significant differences in clinical outcomes or re-operation rates when comparing ALIF vs ALIF+PF, suggesting that posterior instrumentation may be omitted without sacrificing the effectiveness of indirect decompression unless there is a well-defined indication for it. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Rigid transpedicular fusion surgery in the treatment of degenerative lumbar stenosis

To compare an effectiveness of different methods of rigid transpedicular fixation and decompression in patients with degenerative lumbar stenosis. A prospective study included 160 patients with degenerative lumbar spine stenosis. In the first group (n=37), patients underwent laminectomy and transpedicular fixation, in the second group (n=60) - laminectomy, transpedicular fixation and implantation of interbody fusion cage. In the third group (n=30), interlaminar decompression and transpedicular fixation were carried oud, in the fourth group (n=33) - interlaminar decompression, transpedicular fixation and implantation of interbody fusion cage. Surgeries were performed in three clinics in Moscow. Outcomes were assessed using a visual analogue scale (VAS) and Oswestry questionnaire in 1 and 2 years after surgery. Between-group comparison of the outcomes was performed. In patients with unfavorable outcome, we analyzed the cause of unsatisfactory result and risk factors. Satisfactory result was noted in 103 patients (64%) in 2 years after surgery. Outcomes were comparable in all groups. More significant regression of back pain was noted in group II (laminectomy, transpedicular fixation, interbody cage) compared to other groups. Preoperative risk factors of adverse outcome were resting leg pain VAS score > 4 and age over 71 years. Incidence of pseudoarthrosis and back pain was higher among patients without interbody cage. Incidence of adjacent level lesion was higher among patients with interbody cages. Decompression type and implantation of interbody cage do not significantly change postoperative outcomes in most patients with degenerative lumbar stenosis undergoing transpedicular fixation. However, interbody cage implantation during transpedicular fixation is advisable in patients with severe back pain (VAS score > 5-6).

Indirect decompression of lumbar stenosis

Degenerative lumbar stenosis can lead to symptoms of neurogenic claudication and lumbar radiculopathy. Lumbar stenosis can be caused by static compression of the neural elements in the central canal, along the lateral recess, and in the neuroforamen, as well as by dynamic changes to the total area of the central canal and neuroforamen. Previously, surgical options for the treatment of degenerative lumbar stenosis were primarily based on direct posterior open decompressions and fusions. However, novel techniques of indirect decompression have now been developed that restore disc height to increase the area of the central canal and neuroforamen and address the dynamic aspect of stenosis, while avoiding the extensive soft tissue injury involved in posterior open decompressions and fusions. Interbody fusions and interspinous devices are two methods of indirect decompression that are being commonly used.In this study, we provide a broad overview of the advantages, disadvantages, indications, evidence, and complications of ALIF, LLIF, and OLIF, as well as interspinous devices including Coflex. Though there is limited comparative evidence demonstrating that one approach is superior to another in terms of clinical and radiographic outcomes, evidence does show that interbody techniques are effective at treating lumbar stenosis by increasing the total area of the central canal and neuroforamen while having high fusion rates. Though the newer generation of interspinous devices have lower failure rates than their predecessors, they still are not comparable to the interbody devices in terms of long term outcomes. The optimal approach for the indirect treatment of lumbar stenosis therefore depends on multiple variables, including but not limited to the spinal level of disease, the anatomy of the individual patient, the pathology being treated, and the familiarity of the surgeon.

Navigated minimally invasive unilateral laminotomy with crossover for intraoperative prediction of outcome in degenerative lumbar stenosis.

Background:Different surgical techniques have been described for treatment of degenerative lumbar stenosis (DLS). Only postoperative measures have been identified as predictors of efficacy of decompression. The objective of this study is to assess the role of navigated unilateral laminotomy with crossover to achieve and predict a satisfying decompression and outcome in DLS.Materials and Methods:We enrolled patients with DLS who underwent navigation-assisted unilateral laminotomy with crossover. The extent of decompression was evaluated during surgery using neuronavigation. The outcome was assessed through the Oswestry disability index (ODI) and visual analog scale (VAS) for leg pain. Outcome correlation with the extent of the intraoperative bone decompression was analyzed. Finally, the outcome, surgical time, and in-hospital length-of-stay were compared with a control group treated through standard unilateral laminotomy.Results:Twenty-five patients were treated using the navigated technique (Group A), 25 using the standard unilateral laminotomy (Group B). In Group A, a cut-off value ≥0.9 cm for bone decompression revealed to be an intraoperative predictor of good outcome, both regarding the ODI and VAS scores (P = 0.0005; P = 0.002). As compared with Group B, patients operated using the navigated technique showed similar operative times, in-hospital length-of-stay, ODI scores, but improved VAS scores for leg pain (P = 0.04).Conclusions:The intraoperative navigated evaluation of the bone decompression could predict the outcome allowing satisfactory results in unilateral laminotomy for DLS. The navigated technique also could lead to an improved decompression of lateral recesses resulting in better control of leg pain as compared to standard unilateral laminotomy.

311 Prolonged Preoperative Opioid Therapy in Patients with Degenerative Lumbar Stenosis In a Worker's Compensation Setting

Abstract INTRODUCTION Opiates are commonly used for the initial treatment of degenerative lumbar stenosis (DLS). However, current evidence suggests that overuse of opioids may alter pain-modulatory systems and increase pain sensitivity, which may worsen the underlying condition. As such, patients undergoing operative treatment for DLS with concomitant opioid use represent a clinically challenging population. Moreover, patients with Workers' compensation (WC) are a clinically distinct population with variable outcomes. Our objective was to investigate the impact of prolonged opioid use in the preoperative treatment plan for WC patients with DLS. METHODS 1901 WC subjects from the Ohio Bureau of Workers' Compensation (BWC) with DLS were identified. 140 subjects were then identified that were on opioid therapy before index surgery. The Short-Term Opioid (STO) use group included 60 subjects who received opioids for less than 3 months and a Long-Term Opioid (LTO) use group included 80 subjects who received opioids for greater than 3 months before their surgery. Our primary outcome was if patients were able to make a stable return to work (RTW). A multivariate regression analysis was used to examine the relationship of duration of opioid therapy with RTW. RESULTS &gt;Patients in the STO cohort had a significantly higher RTW rate compared to the LTO cohort (25/60[42%] vs. 18/80[23%]; P = 0.01). A logistic regression was performed to examine the effect of preoperative opioid therapy duration on RTW status. Our regression model showed that opioid use greater than 3 months remained a significant negative predictor of RTW(OR: 0.35, 95% CI: 0.13-0.89; P = 0.02). Costs accrued over the 3 years after index surgery was significantly higher in the LTO cohort. CONCLUSION Prolonged preoperative opioid use was associated with poor clinical outcomes after lumbar decompression. These results suggest that a shorter course of opioid therapy and earlier surgical intervention may improve outcomes and lower postoperative morbidity in patients with DLS.

COMPLICATIONS OF SURGICAL TREATMENT OF DEGENERATIVE LUMBAR STENOSIS

Objective. To study the structure of complications after surgical treatment of degenerative lumbar stenosis and to analyze their influence on outcomes and indications for revision. Material and Methods . A total of 513 patients with degenerative lumbar stenosis underwent decompression and stabilization of stenotic spinal motion segments including transpedicular fixation and fusion (TLIF or PLIF). All complications both during operations and in the early and late periods of follow-up were systematized. Results . The total rate of complications was 26.51 %. The rate of early complications, including intraoperative ones was 12.67 %, and of late complications - 13.84 %. Conclusion . Unsatisfactory outcome in the early postoperative period was associated with pulmonary embolism and suppuration of postoperative wound with generalization of the infection process. Unsatisfactory long-term results of treatment were most often caused by loosening of instrumentation and late suppuration.

Long-Term Results and Efficacy of Laminectomy with Fusion Versus Young Laminoplasty for the Treatment of Degenerative Spinal Stenosis

In the treatment of degenerative lumbar stenosis, facet-sparing laminectomy with instrumented fusion (FSL) was recently almost totally replaced by less invasive, allegedly equally effective surgical techniques. We performed a long-term comparison between outcomes after Young laminoplasty (YL) as a representative of the less invasive technique and FSL. From December 4, 2000, to March 11, 2005, 56 patients with a history of neurogenic claudication and radiologically verified absolute lumbar stenosis were surgically treated. After applying inclusion and exclusion criteria, 44 patients were enrolled. Using the Oswestry Disability Index scale, significant improvement on 1-year and 8-year follow-up examinations was noticed in the FSL and YL groups. The Oswestry Disability Index was significantly better in the FSL group compared with the YL group at the 8-year follow-up (27.82 ± 1.918 vs. 40.74 ± 2.163). FSL is a more invasive and more expensive surgical technique than YL. In a short-term and long-term follow-up comparison, FSL is a more successful operative technique, and the difference increases over time in favor of FSL.

Surgical treatment of degenerative lumbar stenosis: comorbidities and complications

Objectives: To study the characteristics of patients who underwent surgical treatment of degenerative spinal stenosis in the last 10 years (2000&amp;#226;&amp;#8364;"2010) at the Hospital das Cl&amp;#237;nicas da Faculdade de Medicina de Ribeir&amp;#227;o Preto (USP-HCFMR) and correlate the postoperative complications and preoperative comorbidities found in the study population. Methods: Retrospective review of medical records and radiographs of patients with degenerative lumbar stenosis treated surgically. Descriptive analysis of data was done with SAS 9.0. Results: 92 patients were included, 47 (51.08%) males and 45 (48.91%) females, with ages ranging from 32 to 86 years (mean age of 64.27 years). The most prevalent comorbidities were hypertension (47.82%) and diabetes mellitus (25%). Twenty-three patients (25%) had two or more comorbidities. Postoperative infection was the most common complication found in 12 cases (13%). Patients with only one preoperative comorbidity showed similar complication rates compared to the population without comorbidities. However, patients with two or more comorbid conditions had a higher incidence of postoperative complications (p&amp;lt;0.001). Conclusions: Comorbidities negatively influenced the outcome of surgical treatment of degenerative lumbar stenosis with higher rates of postoperative complications.

Factors influencing the surgical decision for the treatment of degenerative lumbar stenosis in a preference-based shared decision-making process.

In a preference-based shared decision-making system, several subjective and/or objective factors such as pain severity, degree of disability, and the radiological severity of canal stenosis may influence the final surgical decision for the treatment of lumbar spinal stenosis (LSS). However, our understanding of the shared decision-making process and the significance of each factor remain primitive. In the present study, we aimed to investigate which factors influence the surgical decision for the treatment of LSS when using a preference-based, shared decision-making process. We included 555 patients, aged 45-80years, who used a preference-based shared decision-making process and were treated conservatively or surgically for chronic leg and/or back pain caused by LSS from April 2012 to December 2012. Univariate and multivariable-adjusted logistic regression analyses were used to assess the association of surgical decision making with age, sex, body mass index, symptom duration, radiologic stenotic grade, Oswestry Disability Index (ODI), visual analog scale (VAS) scores for back and leg pain, Short Form-36 (SF-36) subscales, and motor weakness. In univariate analysis, the following variables were associated with a higher odds of a surgical decision for LSS: male sex; the VAS score for leg pain; ODI; morphological stenotic grades B, C, and D; motor weakness; and the physical function, physical role, bodily pain, social function, and emotional role of the SF-36 subscales. Multivariate analysis revealed that male sex, ODI, morphological stenotic grades C and D, and motor weakness were significantly associated with a higher possibility of a surgical decision. Motor weakness, male sex, morphological stenotic grade, and the amount of disability are critical factors leading to a surgical decision for LSS when using a preference-based shared decision-making process.

Selective Decompression and Interlaminar Dynamic Stabilization for the Treatment of Degenerative Lumbar Stenosis: A Perspective of 3 to 5 Years Follow-up Evaluation

Introduction To evaluate the clinical efficacy and safety of posterior Coflex dynamic stabilization for the treatment of degenerative lumbar stenosis, a perspective clinical and radiographic study was conducted and 3 to 5 years outcome was reported. Materials and Methods Between September 2007 and August 2009, 48 consecutive patients with degenerative lumbar stenosis were prospectively enrolled and treated with selective decompression and Coflex interlaminar dynamic stabilization. There were 23 male and 25 female (age 60.3 years; range, 48-79). Forty-six patients underwent single-level procedure and two patients with two-level procedures. The outcome evaluations were using VAS scale, modified ODI score, and radiographic results with the ROM of surgery and adjacent level as well as complications. All data were analyzed and patient's satisfaction was evaluated at final follow-up examination. Results Follow-up examinations were conducted at 1, 3, 6, 12, 24, and 36 months postoperatively and clinical and radiographic evaluations were performed. All patients were followed up at least 36 months (36-60 months, average 45.2 months). The average VAS scale was 8.1 pre-op, 2.9 post-op, and 2.5 at latest follow-up. The ODI score was 54.3 pre-op, 21.8 post-op, and 24.5 at the latest follow-up. All data mentioned above were statistically significantly improved. During follow-up, the range of motions (ROM) of operated levels were maintained (2-6 degrees, average 3.6 degrees) and there was no significant increase of ROM in adjacent level. Seven cases of Coflex device-related complications (14.6%) were occurred, but no patient underwent revision surgery for it. Conclusion From this prospective study from single institute, mid- to long-term satisfactory clinical outcome could be achieved in patients with single level of DLS treated by selective decompression and posterior Coflex interlaminar dynamic stabilization, with few device-related complications and ASD occurred. Disclosure of Interest None declared

Unilateral, multilevel, interlaminar fenestration in the removal of a multisegment cervical intramedullary ependymoma

Background contextLaminectomy is the traditional approach to intramedullary ependymomas and may lead to spinal instability and spinal deformities. Hemilaminectomy and laminoplasty have been developed to preserve the spinal stability and have been found to be effective. Unilateral, multilevel, interlaminar fenestration is another approach that may have more advantages in preserving the spinal stability; however, it has rarely been used by now. PurposeUnilateral, multilevel, interlaminar fenestration was often used in the surgical treatment of degenerative lumbar stenosis; however, it was rarely used for tumors. The aim of this study was to discuss the characteristics and advantages of its use for a multisegment intramedullary ependymoma. Study designCase report and literature review. MethodsThe 22-year-old man suffered from muscular atrophy of the left hand and the right hand for a period of 1.5 years and 3 months, respectively, and the cervical magnetic resonance imaging revealed an intramedullary mass of C4–C7. A right, unilateral, multilevel, interlaminar fenestration of the C3–C7 was performed with the help of high-speed air drills, and a midline myelotomy was made under microscope. The tumor was removed totally using piecemeal resection. ResultsThe magnetic resonance imaging, obtained 1 year after the operation, revealed that there were no residual mass lesion and no spinal instability, and the patient acquired an excellent functional outcome. So, this technique proved to be safe and easy in this case. ConclusionsUnilateral, multilevel, interlaminar fenestration allows good access to a long intraspinal segment, protects the structures essential to spinal stability as much as possible, preserves the spinal stability, and results in no additional injury to the spinal cord. It may be applicable to many other kinds of intraspinal tumors.

Posterior dynamic stabilization in the treatment of degenerative lumbar stenosis: validity of its rationale

The authors undertook this study to investigate the validity of the rationale for posterior dynamic stabilization using the Device for Intervertebral Assisted Motion (DIAM) in the treatment of degenerative lumbar stenosis. A cohort of 31 patients who underwent single-level decompression and DIAM placement for degenerative lumbar stenosis were followed up for at least 2 years and data pertaining to their cases were analyzed prospectively. Of these patients, 7 had retrolisthesis. Preoperative and postoperative plain lumbar radiographs obtained in all patients and CT images obtained in 14 patients were analyzed. Posterior disc heights; range of motion (ROM) of proximal, distal, and implant segments; lordotic angles of implant segments; percentage of retrolisthesis; and cross-sectional area and heights of intervertebral foramina on CT sagittal images were analyzed. Clinical outcomes were evaluated using visual analog scale scores and Oswestry Disability Index scores. The mean values for posterior disc height before surgery, at 1 week after surgery, and at the final follow-up visits were 6.4 ± 2.0 mm, 9.7 ± 2.8 mm, and 6.8 ± 2.5 mm, respectively. The mean lordotic angles at the implant levels before surgery, at 1 week after surgery, and at the final follow-up visits were 7.1° ± 3.3°, 4.1° ± 2.7°, and 7.0° ± 3.7°, respectively. No statistically significant difference was found between the preoperative values and values from final follow-up visits for posterior disc height and lordotic angles at implant levels (p = 0.17 and p = 0.10, respectively). There was no statistically significant difference between the preoperative and final follow-up visit values for intervertebral foramen cross-sectional area and heights on CT images. The ROMs of proximal and distal segments also showed no significant decrease (p = 0.98 and p = 0.92, respectively). However, the ROMs of implant segments decreased significantly (p = 0.02). The average 31.4-month improvement for all clinical outcome measures was significant (p < 0.001). Based on radiological findings, the DIAM failed to show validity in terms of the rationale of indirect decompression, but it did restrict motion at the instrumented level without significant change in adjacent-segment ROM. The clinical condition of the patients, however, was improved, and improvement was maintained despite progressive loss of posterior disc height after surgery.

Cost-effectiveness of multilevel hemilaminectomy for lumbar stenosis–associated radiculopathy

Laminectomy for lumbar stenosis-associated radiculopathy is associated with improvement in pain, disability, and quality of life. However, given rising health-care costs, attention has been turned to question the cost-effectiveness of lumbar decompressive procedures. The cost-effectiveness of multilevel hemilaminectomy for radiculopathy remains unclear. To assess the comprehensive medical and societal costs of multilevel hemilaminectomy at our institution and determine its cost-effectiveness in the treatment of degenerative lumbar stenosis. Prospective single cohort study. Fifty-four consecutive patients undergoing multilevel hemilaminectomy for lumbar stenosis-associated radiculopathy after at least 6 months of failed conservative therapy were included. Self-reported measures were assessed using an outcomes questionnaire that incorporated total back-related medical resource utilization, missed work, and improvement in leg pain (visual analog scale for leg pain [VAS-LP]), disability (Oswestry Disability Index [ODI]), quality of life (Short Form-12 [SF-12]), and health state values (quality-adjusted life years [QALYs], calculated from EuroQuol 5D [EQ-5D] with US valuation). Over a 2-year period, total back-related medical resource utilization, missed work, and improvement in leg pain (VAS-LP), disability (ODI), quality of life (SF-12), and health state values (QALYs, calculated from EQ-5D with US valuation) were assessed. Two-year resource use was multiplied by unit costs based on Medicare national allowable payment amounts (direct cost), and patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). Mean total 2-year cost per QALY gained after multilevel hemilaminectomy was assessed. Compared with preoperative health states reported after at least 6 months of medical management, a significant improvement in VAS-LP, ODI, and SF-12 (physical and mental components) was observed 2 years after multilevel hemilaminectomy, with a mean 2-year gain of 0.72 QALYs. Mean±standard deviation total 2-year cost of multilevel hemilaminectomy was $24,264±10,319 (surgery cost, $10,220±80.57; outpatient resource utilization cost, $3,592±3,243; and indirect cost, $10,452±9,364). Multilevel hemilaminectomy was associated with a mean 2-year cost per QALY gained of $33,700. Multilevel hemilaminectomy improved pain, disability, and quality of life in patients with lumbar stenosis-associated radiculopathy. Total cost per QALY gained for multilevel hemilaminectomy was $33,700 when evaluated 2 years after surgery with Medicare fees, suggesting that multilevel hemilaminectomy is a cost-effective treatment of lumbar radiculopathy.

Aperius PercLID Stand Alone Interspinous System for the Treatment of Degenerative Lumbar Stenosis

This study is a retrospective clinical investigation of a new interspinous device implanted via a totally percutaneous technique involving 152 consecutive patients. Evaluation of the efficacy of the percutaneous Aperius stand alone implant in patients with degenerative lumbar stenosis and neurogenic intermittent claudication that did not respond to conservative treatment. The use of interspinous implants grew markedly during the last years. Nowadays, many extension controller devices are positioned through minimally invasive procedures. From January 2007 to February 2008, 152 consecutive patients with neurogenic intermittent claudication were treated with Aperius PercLID system. Under a local anesthesia, a 1.5 cm skin incision was performed. Trocars for interspinous space distraction were positioned using fluoroscopy guidance. A suitable size Aperius was positioned and released in the interspinous space with a totally percutaneous technique. In 145 patients 1 level was treated, whereas 6 patients received 2 level treatments, and 1 patient received 3 level treatments. The levels treated were L4-L5 in 125 patients (78.2%), L3-L4 level in 26 patients (16.3%), L2-L3 level in 5 patients (3.1%), L5-S1 level in 3 patients (1.8%), and L1-L2 level in 1 patient (0.6%). The surgical time ranged from 8 to 14 minutes for 1 single level. No adverse events were noted. In 1 case (0.6%), Aperius was not implanted because of hypertrophic facet joints that have hindered the correct insertion of the device; we observed only 2 cases of therapeutic failure (1.3%). There was a significant improvement in the Visual Analog Scale and Zurich Claudication Questionnaire scores for low-back and leg pain and for neurogenic claudication. These results indicate that Aperius PercLID system offers an easy, safe, and effective treatment for patients with lumbar degenerative stenosis. Thus, this device system treatment represents a valid alternative to the traditional surgical techniques.

Morbidity and mortality in the surgical treatment of 10,329 adults with degenerative lumbar stenosis

The purpose of this study was to evaluate the prospectively collected Scoliosis Research Society (SRS) database to assess the incidences of morbidity and mortality (M&M) in the operative treatment of degenerative lumbar stenosis, one of the most common procedures performed by spine surgeons. All patients who underwent surgical treatment for degenerative lumbar stenosis between 2004 and 2007 were identified from the SRS M&M database. Inclusion criteria for analysis included an age >or= 21 years and no history of lumbar surgery. Patients were treated with either decompression alone or decompression with concomitant fusion. Statistical comparisons were performed using a 2-sided Fisher exact test. Of the 10,329 patients who met the inclusion criteria, 6609 (64%) were treated with decompression alone, and 3720 (36%) were treated with decompression and fusion. Among those who underwent fusion, instrumentation was placed in 3377 (91%). The overall mean patient age was 63 +/- 13 years (range 21-96 years). Seven hundred nineteen complications (7.0%), including 13 deaths (0.1%), were identified. New neurological deficits were reported in 0.6% of patients. Deaths were related to cardiac (4 cases), respiratory (5 cases), pulmonary embolus (2 cases), and sepsis (1 case) etiologies, and a perforated gastric ulcer (1 case). Complication rates did not differ based on patient age or whether fusion was performed. Minimally invasive procedures were associated with fewer complications and fewer new neurological deficits (p = 0.01 and 0.03, respectively). The results from this analysis of the SRS M&M database provide surgeons with useful information for preoperative counseling of patients contemplating surgical intervention for symptomatic degenerative lumbar stenosis.

Étude à long terme du risque de réintervention après traitement chirurgical d’une sténose canalaire lombaire

The short- and mid-term symptom-relief of surgical treatment for lumbar stenosis is generally acknowledged, but the probability of a long-term reoperation remains to be studied. The purpose of this work was to determine the long-term risk of reoperation after surgical treatment of degenerative lumbar stenosis and to search for factors influencing this probability. All patients who underwent from 1989 to 1992 surgical treatment for degenerative lumbar spine stenosis were included in this work. At last follow-up, we noted functional outcome using a specific self-administered questionnaire, patient satisfaction, lumbalgia and radiculalgia using a visual analog scale, SF36 quality-of-life, reoperation or not with time since first operation if performed and the reasons and modalities of the reoperation. The probability of reoperation was determined with the acturarial method. A Cox model was used to search for factors linked with the probability of reoperation; variables studied were: age, comorbid factors, extent of the release, posterolateral arthrodesis or not, extent of the potential fusion, use or not of instrumentation for arthrodesis. The study included 262 patients. At last follow-up, 61 patients had died a mean 3.7+/-3 years after the operation; only one of these patients had a second operation 22 months after the first. Forty-four patients were lost to follow-up at mean 6.6+/-3 years. Among these 44 patients, four had a second operation during their initial follow-up at mean 47 months. One hundred fifty-seven patients were retained for this analysis at mean 15+/-1 years follow-up. Among these 157 patients, 29 had a second operation a mean 75 months after the first. There were four reasons for reoperating: insufficient release, destabilization within or above the zone of release, development or renewed zone of stenosis, development or renewed discal herniation. The risk of a second operation was 7.4% [95% CI 4.8-11.6], 15.4% [95% CI 10.7-21.1] and 16.5% [95% CI 11.7-219] at five, 10 and 15 years respectively after the first operation. Among the risk factors studied, only one had a significant impact on reoperation: extent of the zone of release (p=0.003). Compared with a release limited to one level, the risk of reoperation after release of three levels or more was five times greater [95% CI 1.8-12.7].

Treatment of Degenerative Lumbar Stenosis with Minimal Decompression

Treatment of Degenerative Lumbar Stenosis with Minimal Decompression