Lumbar spinal stenosis case series

152 patients of lumbar spinal stenosis treated with percutaneous pedicle screw placement were enrolled in a study. facet joint violation (FJV) was evaluated on 3-dimensional lumbar CT reconstruction. Three types of grading systems were used to evaluate FJV: Babu's system (grading by the severity of violation), Shah's system (grading by side of violation), and modified Park's system (grading by different components to cause violation). The violation rate and observer consistency of the 3 grading systems were analyzed. Clinical outcomes were evaluated by visual analog score (VAS), Oswestry disability index (ODI) score.

Kappa coefficients of interobserver consistency on Babu, Shah, and Park grading systems were 0.726,0.849,0.692, respectively. The violation rate of Babu, Shah, and Park grading systems were comparable, which were 34.54%, 32.57%, 33.55%, respectively. In all 3 grading systems, the postoperative VAS low-back pain and ODI scores in non-FJV groups were lower than those in FJV groups (P < .05), and there were no significant differences between 2 groups in VAS leg pain(P >.05).

Babu, Shah and modified Park grading system are reliable grading systems, and it reported comparable violation rate. The self-reported clinical outcomes of patients with FJV were worse at 2-year follow-up. For clinical application, it is recommended to use 2 or even 3 different grading systems together to evaluate the FJV 1)

Kim et al. conducted a retrospective study of 60 patients who underwent bilateral decompression for lumbar central canal stenosis. The patients were divided into 2 groups according to the surgical method (endoscopic ULBD vs. microscopic ULBD). We compared the outcomes between the 2 groups in terms of postoperative segmental spinal instability, dura expansion, operation time, estimated blood loss, serum creatine kinase (CK), serum C-reactive protein (CRP), visual analog scale (VAS) score, Oswestry Disability Index (ODI), modified MacNab score, and the incidence of complications.

The mean VAS, ODI, and modified MacNab score improved significantly from the preoperative period to the last follow-up in both groups and were better in the endoscopic ULBD group until the first day after treatment. The degree of horizontal displacement was lower in the endoscopic ULBD group than in the microscopic ULBD group at postoperative 12 months. Dura expansion, operation time, and estimated blood loss did not differ significantly between the 2 groups. Serum CK and CRP on the first day after treatment were lower in the endoscopic ULBD group than in the microscopic ULBD group.

This study showed that both endoscopic ULBD and microscopic ULBD can provide favorable outcomes for lumbar central canal stenosis. However, compared to microscopic ULBD, endoscopic ULBD has advantages in terms of postoperative segmental spinal instability, pain control, and serum CK and CRP 2).

Kim et al. performed a retrospective analysis of radiologic efficacy and patient satisfaction in a series of surgical patients treated at our institution. We classified patients into two groups based on the primary pathology (i.e., central or lateral recess stenosis). Medical records were analyzed retrospectively for radiologic outcomes and clinical parameters including pain and changes in quality of life. Data related to outcomes were collected at 2 weeks, 3 months, and 12 months after surgery in the outpatient clinic.

Among the 122 patients enrolled in this study, 51 had central spinal stenosis; 71 had lateral recess stenosis. Radiologically, we observed significant improvements in the anteroposterior diameter and cross-sectional area of the dural sac (central stenosis) and the lateral width of the central canal and depth of the lateral recess (lateral recess stenosis). Two weeks and 12 months after the surgical procedure, we observed significant improvements in the extent of symptoms, patient satisfaction, and quality of life (including physical function).

These findings suggest that bilateral decompression via a unilateral approach shows improved radiologic outcomes, varying based on the type of stenosis. Furthermore, patient satisfaction significantly improved regardless of the type of disease 3).

Kitab et al., performed a re-analysis of data from their previously reported prospective MRI-based study, stratifying data from the 709 cases into 3 age categories of equal size (instead of the original < 60 vs ≥ 60 years). Relative lumbar spinal canal dimensions, as well as radiological degenerative variables from L1 to S1, were analyzed across age groups in a multivariate mode. The total degenerative scale score (TDSS) for each lumbar segment from L1 to S1 was calculated for each patient. The relationships between age and qualitative stenosis grades, TDSS, disc degeneration, and facet degeneration were analyzed using Pearson's product-moment correlation and multiple regression.

Multivariate analysis of TDSS and spinal canal dimensions revealed highly significant differences across the 3 age groups at L2-3 and L3-4 and a weaker, but still significant, association with changes at L5-S1. Age helped to explain only 9.6% and 12.2% of the variance in TDSS at L1-2 and L2-3, respectively, with a moderate positive correlation, and 7.8%, 1.2%, and 1.9% of the variance in TDSS at L3-4, L4-5, and L5-S1, respectively, with weak positive correlation. Age explained 24%, 26%, and 18.4% of the variance in lumbar intervertebral disc (LID) degeneration at L1-2, L2-3, and L3-4, respectively, while it explained only 6.2% and 7.2% of the variance of LID degeneration at L4-5 and L5-S1, respectively. Age explained only 2.5%, 4.0%, 1.2%, 0.8%, and 0.8% of the variance in facet degeneration at L1-2, L2-3, L3-4, L4-5, and L5-S1, respectively.

Age at presentation correlated weakly with degeneration variables and spinal canal morphometries in LSS segments. Age correlated with upper lumbar segment (L1-4) degeneration more than with lower segment (L4-S1) degeneration. The actual chronological age of the patients did not significantly correlate with the extent of degenerative pathology of the lumbar spinal stenosis segments. These study results lend support for a developmental contribution to LSS 4).

Nine hundred and eighteen patients of the Acıbadem Fulya Hospital and Acıbadem Taksim Hospital were treated for single or multilevel lumbar spinal stenosis (LSS) by bilateral decompression via unilateral approach (BDUA) between January 2002 and January 2016. 180 patients of the 918 underwent microdiscectomy with decompression. They were then followed up postoperatively, at 6 and 12 months with radiological investigations, Oswestry Disability Index (ODI) and 36-item short-form health survey (SF-36) tests.

Four hundred and ninety-two patients were females (53,6%), four hundred and twenty six were males (46,4) whose mean age was 63,83±10,16 (range: 43-79 years). Duration of symptoms ranged from 4 to 49 months. Average follow-up time was 98 months (range 25-168 months) and the reoperation rate (RR) was 2,5%. The ODI scores decreased significantly (30.65± 7.82, to 11.32 ± 2.50 at six months and 11.30 ± 2.49 at first year) and the SF-36 parameter scores demonstrated a significant improvement in the early and late follow-up results.

BDUA for LSS allowed a sufficient and safe decompression of the neural structures, resulted in a highly significant reduction of the symptoms and disability, acceptable RR, and improved health-related quality of life 5).

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 6).

A total of 25 patients between May 2015 and June 2016 affected by radiologically demonstrated one-level lumbar spinal stenosis (LSS) with facet joint degeneration and grade I spondylolisthesis were included in this prospective study. All the patients underwent laminectomy, foraminotomy, and one-level facet fixation (Facet-Link, Inc., Rockaway, New Jersey, United States). Pre- and postoperative clinical (Oswestry Disability Index [ODI], Short Form 36 [SF-36]) and radiologic (radiographs, magnetic resonance imaging, computed tomography) data were collected and analyzed.

Mean follow-up was 12 months. The L4-L5 level was involved in 18 patients (72%) and L5-S1 in 7 patients (28%); the average operative time was 80 minutes (range: 65-148 minutes), and the mean blood loss was 160 mL (range: 90-200 mL). ODI and SF-36 showed a statistically significant (p < 0.05) improvement at last follow-up.

Transfacet fixation is a safe and effective treatment option in patients with single-level LSS, facet joint degeneration, and mild instability 7).


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. Results The comparison of both surgical procedures 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. Conclusion 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 8).


726 patients with lumbar stenosis (without spondylolisthesis or scoliosis) and a baseline back pain score ≥ 5 of 10 who underwent surgical decompression only. No patient was reported to have significant spondylolisthesis, scoliosis, or sagittal malalignment. Standard demographic and surgical variables were collected, as well as patient outcomes including back and leg pain scores, Oswestry Disability Index (ODI), and EuroQoL 5D (EQ-5D) at baseline and 3 and 12 months postoperatively. RESULTS The mean age of the cohort was 65.6 years, and 407 (56%) patients were male. The mean body mass index was 30.2 kg/m2, and 40% of patients had 2-level decompression, 29% had 3-level decompression, 24% had 1-level decompression, and 6% had 4-level decompression. The mean estimated blood loss was 130 ml. The mean operative time was 100.85 minutes. The vast majority of discharges (88%) were routine home discharges. At 3 and 12 months postoperatively, there were significant improvements from baseline for back pain (7.62 to 3.19 to 3.66), leg pain (7.23 to 2.85 to 3.07), EQ-5D (0.55 to 0.76 to 0.75), and ODI (49.11 to 27.20 to 26.38). CONCLUSIONS Through the 1st postoperative year, patients with lumbar stenosis-without spondylolisthesis, scoliosis, or sagittal malalignment-and clinically significant back pain improved after decompression-only surgery 9).


88 patients with LSS (47 men and 41 women) who ranged in age from 39 to 86 years (mean age 68.7 years). All patients had undergone microendoscopic laminotomy at Osaka City University Graduate School of Medicine from May 2008 through October 2012. The minimum duration of clinical and radiological follow-up was 6 months. All patients were evaluated by Japanese Orthopaedic Association (JOA) and visual analog scale (VAS) scores for low back pain, leg pain, and leg numbness before and after surgery.

The distance between the C7 plumb line and the posterior corner of the sacrum (sagittal vertical axis [SVA]) was measured on lateral standing radiographs of the entire spine obtained before surgery.

Radiological factors and clinical outcomes were compared between patients with a preoperative SVA ≥ 50 mm (forward-bending trunk [F] group) and patients with a preoperative SVA < 50 mm (control [C] group).

A total of 35 patients were allocated to the F group (19 male and 16 female) and 53 to the C group (28 male and 25 female).

The mean SVA was 81.0 mm for patients in the F group and 22.0 mm for those in the C group. At final follow-up evaluation, no significant differences between the groups were found for the JOA score improvement ratio (73.3% vs 77.1%) or the VAS score for leg numbness (23.6 vs 24.0 mm); the VAS score for low-back pain was significantly higher for those in the F group (21.1 mm) than for those in the C group (11.0 mm); and the VAS score for leg pain tended to be higher for those in the F group (18.9 ± 29.1 mm) than for those in the C group (9.4 ± 16.0 mm).

Preoperative alignment of the spine in the sagittal plane did not affect JOA scores after microendoscopic laminotomy in patients with LSS. However, low-back pain was worse for patients with preoperative anterior translation of the C-7 plumb line than for those without 10).

Zhao Y, Yuan S, Liu W, Tian Y, Liu X. Clinical Validity of 3 Different Grading Systems for Facet Joint Violation: A Retrospective Study and In-Depth Review. Global Spine J. 2021 Apr 20:21925682211006028. doi: 10.1177/21925682211006028. Epub ahead of print. PMID: 33878942.
Kim HS, Choi SH, Shim DM, Lee IS, Oh YK, Woo YH. Advantages of New Endoscopic Unilateral Laminectomy for Bilateral Decompression (ULBD) over Conventional Microscopic ULBD. Clin Orthop Surg. 2020;12(3):330-336. doi:10.4055/cios19136
Kim SK, Ryu S, Kim ES, Lee SH, Lee SC. Radiologic Efficacy and Patient Satisfaction after Minimally Invasive Unilateral Laminotomy and Bilateral Decompression in Patients with Lumbar Spinal Stenosis: A Retrospective Analysis. J Neurol Surg A Cent Eur Neurosurg. 2020 May 15. doi: 10.1055/s-0040-1701621. [Epub ahead of print] PubMed PMID: 32413931.
Kitab S, Habboub G, Abdulkareem SB, Alimidhatti MB, Benzel E. Redefining lumbar spinal stenosis as a developmental syndrome: does age matter? J Neurosurg Spine. 2019 May 17:1-9. doi: 10.3171/2019.2.SPINE181383. [Epub ahead of print] PubMed PMID: 31100722.
Yüce İ, Kahyaoğlu O, Çavuşoğlu HA, Çavuşoğlu H, Aydın Y. Long term clinical outcome and reoperation rate for microsurgical bilateral decompression via unilateral approach of lumbar spinal stenosis. World Neurosurg. 2019 Jan 30. pii: S1878-8750(19)30203-7. doi: 10.1016/j.wneu.2019.01.105. [Epub ahead of print] PubMed PMID: 30710724.
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.
Trungu S, Pietrantonio A, Forcato S, Tropeano MP, Martino L, Raco A. Transfacet Screw Fixation for the Treatment of Lumbar Spinal Stenosis with Mild Instability: A Preliminary Study. J Neurol Surg A Cent Eur Neurosurg. 2018 Sep;79(5):358-364. doi: 10.1055/s-0038-1655760. Epub 2018 Jul 16. PubMed PMID: 30011420.
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.
Crawford CH 3rd, Glassman SD, Mummaneni PV, Knightly JJ, Asher AL. Back pain improvement after decompression without fusion or stabilization in patients with lumbar spinal stenosis and clinically significant preoperative back pain. J Neurosurg Spine. 2016 Nov;25(5):596-601. PubMed PMID: 27285666.
Dohzono S, Toyoda H, Matsumoto T, Suzuki A, Terai H, Nakamura H. The influence of preoperative spinal sagittal balance on clinical outcomes after microendoscopic laminotomy in patients with lumbar spinal canal stenosis. J Neurosurg Spine. 2015 Jul;23(1):49-54. doi: 10.3171/2014.11.SPINE14452. Epub 2015 Apr 3. PubMed PMID: 25840041.
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