Tag: Lumbar stenosis

Posted on

A Comparison of Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Grade 1 Degenerative Lumbar Spondylolisthesis

Neurosurgery DOI:10.1093/neuros/nyaa097

It remains unclear if minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is comparable to traditional, open TLIF because of the limitations of the prior small-sample-size, single-center studies reporting comparative effectiveness.

OBJECTIVE: To compare MI-TLIF to traditional, open TLIF for grade 1 degenerative lumbar spondylolisthesis in the largest study to date by sample size.

METHODS: We utilized the prospective Quality Outcomes Database registry and queried patients with grade 1 degenerative lumbar spondylolisthesis who underwent singlesegment surgery with MI- or open TLIF methods. Outcomes were compared 24 mo postoperatively.

RESULTS: A total of 297 patients were included: 72 (24.2%) MI-TLIF and 225 (75.8%) open TLIF. MI-TLIF surgeries had lower mean body mass indexes (29.5±5.1 vs 31.3±7.0, P=.0497) and more worker’s compensation cases (11.1% vs 1.3%, P< .001) but were otherwise similar. MI-TLIF had less blood loss (108.8 ± 85.6 vs 299.6 ± 242.2 mL, P < .001), longer operations (228.2 ± 111.5 vs 189.6 ± 66.5 min, P < .001), and a higher return-to-work (RTW) rate (100% vs 80%, P = .02). Both cohorts improved significantly from baseline for 24-mo Oswestry Disability Index (ODI), Numeric Rating Scale back pain (NRS-BP), NRS leg pain (NRS-LP), and Euro-Qol-5 dimension (EQ-5D) (P > .001). In multivariable adjusted analyses, MI-TLIF was associated with lower ODI (β =−4.7; 95% CI=−9.3 to −0.04; P= .048), higher EQ-5D (β =0.06; 95% CI=0.01-0.11; P=.02), and higher satisfaction (odds ratio for North American Spine Society [NASS] 1/2 = 3.9; 95% CI = 1.4-14.3; P = .02). Though trends favoring MI-TLIF were evident for NRS-BP (P = .06), NRS-LP (P = .07), and reoperation rate (P = .13), these results did not reach statistical significance.

CONCLUSION: For single-level grade 1 degenerative lumbar spondylolisthesis, MI-TLIF was associated with less disability, higher quality of life, and higher patient satisfaction compared with traditional, open TLIF. MI-TLIF was associated with higher rates of RTW, less blood loss, but longer operative times. Though we utilized multivariable adjusted analyses, these findings may be susceptible to selection bias.

Posted on

Pelvic retroversion: a compensatory mechanism for lumbar stenosis

J Neurosurg Spine 27:137–144, 2017

The flexed posture of the proximal (L1–3) or distal (L4–S1) lumbar spine increases the diameter of the spinal canal and neuroforamina and can relieve symptoms of neurogenic claudication. Distal lumbar flexion can result in pelvic retroversion; therefore, in cases of flexible sagittal imbalance, pelvic retroversion may be compensatory for lumbar stenosis and not solely compensatory for the sagittal imbalance as previously thought. The authors investigate underlying causes for pelvic retroversion in patients with flexible sagittal imbalance.

METHODS One hundred thirty-eight patients with sagittal imbalance who underwent a total of 148 fusion procedures of the thoracolumbar spine were identified from a prospective clinical database. Radiographic parameters were obtained from images preoperatively, intraoperatively, and at 6-month and 2-year follow-up. A cohort of 24 patients with flexible sagittal imbalance was identified and individually matched with a control cohort of 23 patients with fixed deformities. Flexible deformities were defined as a 10° change in lumbar lordosis between weight-bearing and non–weight-bearing images. Pelvic retroversion was quantified as the ratio of pelvic tilt (PT) to pelvic incidence (PI).

RESULTS The average difference between lumbar lordosis on supine MR images and standing radiographs was 15° in the flexible cohort. Sixty-eight percent of the patients in the flexible cohort were diagnosed preoperatively with lumbar stenosis compared with only 22% in the fixed sagittal imbalance cohort (p = 0.0032). There was no difference between the flexible and fixed cohorts with regard to C-2 sagittal vertical axis (SVA) (p = 0.95) or C-7 SVA (p = 0.43). When assessing for postural compensation by pelvic retroversion in the stenotic patients and nonstenotic patients, the PT/PI ratio was found to be significantly greater in the patients with stenosis (p = 0.019).

CONCLUSIONS For flexible sagittal imbalance, preoperative attention should be given to the root cause of the sagittal misalignment, which could be compensation for lumbar stenosis. Pelvic retroversion can be compensatory for both the lumbar stenosis as well as for sagittal imbalance.

 

Posted on

Three-Year Follow-up of the Prospective, Randomized, Controlled Trial of Coflex Interlaminar Stabilization vs Instrumented Fusion in Patients With Lumbar Stenosis

Three-Year Follow-up of the Prospective, Randomized, Controlled Trial of Coflex Interlaminar Stabilization vs Instrumented Fusion in Patients With Lumbar Stenosis

Neurosurgery 79:169–181, 2016

Traditional surgical options for the treatment of symptomatic lumbar spinal stenosis include decompression alone vs decompression and fusion; both options have potential limitations.

OBJECTIVE: To report the 36-month follow-up analysis of the coflex Interlaminar Stabilization (Paradigm Spine, LLC, New York, New York) after decompression, examined under a Food and Drug Administration investigational device exemption clinical trial, which is intended to provide stabilization after decompression while preserving normal segmental motion at the treated level.

METHODS: The coflex trial was a prospective, randomized investigational device exemption study conducted at 21 clinical sites in the United States. Baseline and followup visits collected demographics, clinical, and radiographic status. The primary endpoint was a measure of composite clinical success 24 months postoperatively. For this current 36-month analysis, composite clinical success was calculated using analogous methods.

RESULTS: Composite clinical success at 36 months was achieved by 62.2% among 196 coflex Interlaminar Stabilization patients and 48.9% among 94 fusion patients (difference = 13.3%, 95% confidence interval, 1.1%-25.5%, P = .03). Bayesian posterior probabilities for noninferiority (margin = 210%) and superiority of cofle Interlaminar Stabilization vs fusion were .0.999 and 0.984, respectively. Substantial and comparable improvements were observed in both groups for patient-reported outcomes, although the percentage with a clinically significant improvement ($15) in the Oswestry Disability Index seemed larger for the coflex Interlaminar Stabilization group relative to the fusion group (P = .008). Radiographic measurements maintained index level and adjacent level range of motion in coflex Interlaminar Stabilization patients, although range of motion at the level superior to fusion was significantly increased (P = .005).

CONCLUSION: Coflex Interlaminar Stabilization for stenosis is proven to be effective and durable at improving overall composite clinical success without altering normal spinal kinematic motion at the index level of decompression or adjacent levels.

Posted on

Minimally invasive lateral fusion for adjacent disease

Minimally invasive lateral interbody fusion for the treatment of rostral adjacent-segment lumbar degenerative stenosis without supplemental pedicle screw fixation

J Neurosurg Spine 21:861–866, 2014

Adjacent-segment degeneration and stenosis are common in patients who have undergone previous lumbar fusion. Treatment typically involves a revision posterior approach, which requires management of postoperative scar tissue and previously implanted instrumentation. A minimally invasive lateral approach allows the surgeon to potentially reduce the risk of these hazards. The technique relies on indirect decompression to treat central and foraminal stenosis and placement of a graft with a large surface area to promote robust fusion and stability in concert with the surrounding tensioned ligaments. The goal in this study was to determine if lateral interbody fusion without supplemental pedicle screws is effective in treating adjacent-segment disease.

Methods. For a 30-month study period at two institutions, the authors obtained all cases of lumbar fusion with new back and leg pain due to adjacent-segment stenosis and spondylosis failing conservative measures. All patients had undergone minimally invasive lateral interbody fusion from the side of greater leg pain without supplemental pedicle screw fixation. Patients were excluded from the study if they had undergone surgery for a nondegenerative etiology such as infection or trauma. They were also excluded if the intervention involved supplemental posterior instrumented fusion with transpedicular screws. Postoperative metrics included numeric pain scale (NPS) scores for leg and back pain. All patients underwent dynamic radiographs and CT scanning to assess stability and fusion after surgery.

Results. During the 30-month study period, 21 patients (43% female) were successfully treated using minimally invasive lateral interbody fusion without the need for subsequent posterior transpedicular fixation. The mean patient age was 61 years (range 37–87 years). Four patients had two adjacent levels fused, while the remainder had single-level surgery. All patients underwent surgery without conversion to a traditional open technique, and recombinant human bone morphogenetic protein–2 was used in the interbody space in all cases. The mean follow-up was 23.6 months. The mean operative time was 86 minutes, and the mean blood loss was 93 ml. There were no major intraoperative complications, but one patient underwent subsequent direct decompression in a delayed fashion. The leg pain NPS score improved from a mean of 6.3 to 1.9 (p < 0.01), and the back pain NPS score improved from a mean of 7.5 to 2.9 (p < 0.01). Intervertebral settling averaged 1.7 mm. All patients had bridging bone on CT scanning at the last follow-up, indicating solid bony fusion.

Conclusions. Adjacent-segment stenosis and spondylosis can be treated with a number of different operative techniques. Lateral interbody fusion provides an attractive alternative with reduced blood loss and complications, as there is no need to re-explore a previous laminectomy site. In this limited series a minimally invasive lateral approach provided high fusion rates when performed with osteobiological adjuvants.

Posted on

Microdecompressive Laminatomy With a 5-year Follow-up Period for Severe Lumbar Spinal Stenosis

J Spinal Disord Tech 2010;23:229–235

Study Design: The 2 groups of patients with severe lumbar spinal stenosis were prospectively compared as a case control study.

Objectives: This prospective case control study sought to evaluate bilateral microdecompressive laminatomy (MDL) for treatment of severe lumbar spinal stenosis.

Summary of Background Data: Total laminectomy is a general consensus on the therapy of severe spinal stenosis. The authors tried to investigate a new minimal invasive approach.

Methods: Patients were randomly divided into 2 groups. In first group, 34 patients underwent total laminectomy (TL) for severe lumbar spinal stenosis. In the second group, 37 patients with the same diagnosis underwent bilateral MDL. The groups were compared for disability, walking distance, degree of postoperative back and leg pain, perioperative complications, and postoperative instability. Radiographic analyses were performed at regular intervals to demonstrate satisfactory decompression.

Results: Mean follow-up was 5 years. Postoperative computerized tomography and magnetic resonance imaging demonstrated adequate decompressions in both groups. The walking distance, pain control, and disability scores were slightly higher among patients in the MDL group, although these results did not achieve statistical significance. Perioperative complications and postoperative instability were significantly higher in the TL group (P<0.05).

Conclusions: Compared with classic approaches, bilateral MDL provides adequate and safe decompression in lumbar spinal stenosis. It significantly reduces clinical symptoms and disability. However, TL shows higher perioperative complications and postoperative instability. To the best of our knowledge, this is the first study to define a bilateral MDL approach to treat the stenotic lumbar spine without a herniated disc.

Posted on

Results After Lumbar Decompression With and Without Discectomy: Comparison of the Transspinous and Conventional Approaches

Neurosurgery 66[ONS Suppl 1]:ons152-ons160, 2010 DOI: : 10.1227/01.NEU.0000365826.15986.40

OBJECTIVE: To evaluate the efficacy of the transspinous approach compared with the conventional approach in single-level lumbar laminotomies with and without discectomies.
METHODS: Forty consecutive patients underwent single-level lumbar decompression with or without a discectomy. The first 20 patients underwent surgery by the conventional approach (11 with discectomy and 9 without), and the transspinous approach was used in the remaining 20 patients (11 with discectomy and 9 without). Results between the groups were assessed by comparing the following measures: length of inpatient hospital stay, postoperative pain and analgesia use, estimated blood loss, rate of postoperative disability and complications, and incision length.
RESULTS: The groups did not differ significantly with respect to age, level of pathology, insurance status, or type of analgesia used. The primary outcome was physical disability, measured using the Roland-Morris Disability Questionnaire. The secondary outcome was pain intensity, measured using the Brief Pain Inventory. Patients who underwent the transspinous approach had better outcomes across all measures with significance appreciated in those who underwent transspinous decompression with discectomies. Other statistically significant differences were identified in incision length and postoperative analgesia use at the end of 1 week. No statistically significant differences were identified in the rates of complications, estimated blood loss, inpatient narcotic analgesia use, or length of inpatient hospital stay.
CONCLUSION: Patients who underwent single-level lumbar decompression with or without discectomy had similar outcomes as those who underwent the conventional approach. Although of modest clinical significance, the transspinous approach may afford early mobilization and reduced postoperative pain while providing a satisfactory neurological and functional outcome.

Proudly powered by WordPress