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lumbar_decompression_surgery_for_spinal_canal_stenosis

Lumbar Decompression Surgery for Spinal Canal Stenosis

Lumbar Decompression for lumbar spinal canal stenosis, is the most common indication for operative treatment in elderly.

It is a frequently performed procedure and was the fastest growing type of surgery in the US from 1980 to 2000.

Indications

For those patients with lumbar spinal canal stenosis, who do not improve with conservative care, surgery is considered an appropriate treatment alternative. The primary objective of surgery is to reconstitute the lumbar spinal canal. The role of lumbar fusion, in the absence of a degenerative deformity, is uncertain. The previous guideline recommended against the inclusion of lumbar fusion in the absence of spinal instability or a likelihood of iatrogenic instability. Since the publication of the original guidelines, numerous studies have demonstrated the role of surgical decompression in this patient population; however, few have investigated the utility of fusion in patients without underlying instability. The majority of studies contain a heterogeneous cohort of subjects, often combining patients with and without spondylolisthesis who received various surgical interventions, limiting fusions to those patients with instability. It is difficult if not impossible, therefore, to formulate valid conclusions regarding the utility of fusion for patients with uncomplicated stenosis. Lower-level evidence exists, however, that does not demonstrate an added benefit of fusion for these patients; therefore, in the absence of deformity or instability, the inclusion of a fusion is not recommended 1).

Types

Lumbar Laminectomy

Lumbar hemilaminectomy

Techniques

see Minimally Invasive Lumbar Laminectomy.

The gold standard treatment for symptomatic lumbar stenosis refractory to conservative management is a facet-preserving laminectomy. New techniques of posterior decompression have been developed to preserve spinal integrity and to minimise tissue damage by limiting bony decompression and avoiding removal of the midline structures (i.e. spinous process, vertebral arch and interspinous and supraspinous ligaments).

The traditional decompression surgery removes part of the lamina, the yellow ligaments, and facet joints.

The purpose of surgical treatment for lumbar spinal stenosis is to relieve nerve compression, ease back pain and increase spinal stability.

Lumbar laminectomy has been the “gold standard,” but minimally invasive decompression (MID) is now widely used. Another minimally invasive surgery option is X-Stop interspinous device.

see Central decompressive lumbar laminoplasty.

Outcome

Case series

A successive series of 102 patients with lumbar spinal stenosis from Aachen (with and without previous lumbar surgery) were treated with decompression alone during a 3-year period. Data on pre- and postoperative back pain and leg pain (numerical rating scale [NRS] scale) were retrospectively collected from questionnaires with a return rate of 65% (n = 66). The complete cohort as well as patients with first-time surgery and re-decompression were analyzed separately. Patients were dichotomized to short-term follow-up (< 100 weeks) and long-term follow-up (> 100 weeks) postsurgery.

Overall, both back pain (NRS 4.59 postoperative versus 7.89 preoperative; p < 0.0001) and leg pain (NRS 4.09 versus 6.75; p < 0.0001) improved postoperatively. The short-term follow-up subgroup (50%, n = 33) showed a significant reduction in back pain (NRS 4.0 versus 6.88; p < 0.0001) and leg pain (NRS 2.49 versus 6.91: p < 0.0001). Similar results could be observed for the long-term follow-up subgroup (50%, n = 33) with significantly less back pain (NRS 3.94 versus 7.0; p < 0.0001) and leg pain (visual analog scale 3.14 versus 5.39; p < 0.002) postoperatively. Patients with previous decompression surgery benefit significantly regarding back pain (NRS 4.82 versus 7.65; p < 0.0024), especially in the long-term follow-up subgroup (NRS 4.75 versus 7.67; p < 0.0148). There was also a clear trend in favor of leg pain in patients with previous surgery; however, it was not significant.

Decompression of lumbar spinal stenosis without fusion led to a significant and similar reduction of back pain and leg pain in a short-term and a long-term follow-up group. Patients without previous surgery benefited significantly better, whereas patients with previous decompression benefited regarding back pain, especially for long-term follow-up with a clear trend in favor of leg pain 2).

2017

A retrospective matched-pair cohort study included a total of 144 patients who underwent surgery for bisegmental spinal stenosis at the levels L3-4 and L4-5 between 2008 and 2012. There were 72 matching pairs that corresponded in sex, year of birth, and width of the stenosed segments. The patients' impairments were reported before, immediately after, and 6 and 12 months after surgery using the Oswestry Disability Questionnaire (ODQ-D) and the EuroQol-5D (EQ-5D). The data were evaluated statistically.

The comparison of both surgical procedures (Bisegmental Fenestration versus Hemilaminectomy)regarding walking ability (walking a distance with and without a walking aid) revealed a significant difference. Patients who underwent hemilaminectomy had better postoperative results. The individual criteria of the ODQ-D and EQ-5D revealed no significant differences between 2-level fenestration and hemilaminectomy; however, there is always significant postoperative improvement in comparison with preoperative status. Age, sex, body mass index, comorbidities, smoking, and alcohol consumption had no influence on the surgical results. The reoperation rate was between 13% and 15% for both surgical techniques, not being significantly different.

Fenestration and hemilaminectomy are equivalent therapies for bisegmental lumbar spinal canal stenosis. Regarding walking, the study revealed better results for hemilaminectomy than for fenestration in this cohort of patients. Pain intensity, personal care, lifting and carrying of objects, sitting, social life, and travel all improved significantly postoperatively as compared with preoperatively. In both groups, health status as the decisive predictor improved considerably after surgery. We could show that both surgical methods result in significant postoperative improvement of all the individual criteria of the ODQ-D and the EQ-5D 3).

2015

Patients who underwent lumbar decompression between 2008 and 2014. Inclusion necessitated a minimum follow-up of six months.

Postoperative change in the EuroQol 5-Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire 9 (PHQ-9) at last follow-up. The secondary outcome variable was postoperative change in QOL measures exceeding the MCID.

QOL data were collected using the institutional prospectively-collected database of patient-reported health status measures. Simple and multivariable logistic regressions were used to assess the impact of diabetes upon normalized change in QOL and improvement exceeding the MCID.

There were 212 patients who met inclusion criteria. While non-diabetics experienced significant improvements in EQ-5D, PDQ, and PHQ-9 (p<0.01), diabetics experienced no significant changes in any measures. More non-diabetics achieved the EQ-5D MCID compared with diabetics (55% v. 23%, p<0.01). Following multivariable regression, chronic kidney disease (CKD, β=-0.15, p=0.04) and diabetes (β=-0.05, p=0.04) were identified as significant independent predictors of diminished improvement in EQ-5D postoperatively. Furthermore, diabetes was also identified as a significant independent predictor of failure to achieve an EQ-5D MCID (OR 0.20, p<0.01), while CKD trended toward predicting diminished improvement (OR <0.01, p=0.09).

The burden of comorbidities may impact the QOL benefit of decompression spine surgery. In the present study, diabetes was found to independently predict diminished improvement in QOL after lumbar decompression 4).

1)
Resnick DK, Watters WC 3rd, Mummaneni PV, Dailey AT, Choudhri TF, Eck JC, Sharan A, Groff MW, Wang JC, Ghogawala Z, Dhall SS, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 10: lumbar fusion for stenosis without spondylolisthesis. J Neurosurg Spine. 2014 Jul;21(1):62-6. doi: 10.3171/2014.4.SPINE14275. Review. PubMed PMID: 24980587.
2)
Geiger MF, Bongartz N, Blume C, Clusmann H, Müller CA. Improvement of Back and Leg Pain after Lumbar Spinal Decompression without Fusion. J Neurol Surg A Cent Eur Neurosurg. 2018 Dec 5. doi: 10.1055/s-0038-1669473. [Epub ahead of print] PubMed PMID: 30517963.
3)
Schüppel J, Weber F. Retrospective Matched-Pair Cohort Study on Effect of Bisegmental Fenestration versus Hemilaminectomy for Bisegmental Spinal Canal Stenosis at L3-L4 and L4-L5. J Neurol Surg A Cent Eur Neurosurg. 2017 Jan 9. doi: 10.1055/s-0036-1597617. [Epub ahead of print] PubMed PMID: 28068753.
4)
Silverstein MP, Miller JA, Xiao R, Lubelski D, Benzel EC, Mroz TE. The impact of diabetes upon quality of life outcomes after lumbar decompression. Spine J. 2015 Dec 15. pii: S1529-9430(15)01626-5. doi: 10.1016/j.spinee.2015.10.041. [Epub ahead of print] PubMed PMID: 26704860.
lumbar_decompression_surgery_for_spinal_canal_stenosis.txt · Last modified: 2018/12/07 12:06 by administrador