Objective To compare microendoscopic discectomy (MED) with open discectomy (OD) for degenerative lumbar spinal stenosis in terms of cl inical outcomes, and provide experience and therapeutic evidence for cl inical appl ication.Methods From May 2002 to October 2007, 215 patients with lumbar spinal stenosis were randomized into two groups, and underwent either MED or OD. In group A, 105 patients underwent MED, including 56 males and 49 females aged 34 to 83 years old (average 45 years old); the duration of the disease ranged from 9 months to 26 years (average 50 months); the spinal stenosis involved one segment in 76 cases, two segments in 27 cases, and three segments in 2 cases. In group B, 110 patients received OD, including 57 males and 53 females aged 35 to 85 years old (average 47 years old); the duration of the disease ranged from 8 months to 25 years (average 48 months); the spinal stenosis involved one segment in 78 cases, two segments in 29 cases, and three segments in 3 cases. No significant difference was evident between two groups in terms of the general information(P gt; 0.05). Results Operation was successfully performed in all cases. Volume of intraoperative blood loss was (82.14 ± 6.18) mL in group A and (149.24 ± 11.17) mL in group B. Length of hospital stay was (7.0 ± 2.1) days in group A and (12.0 ± 2.6) days in group B. Significant difference was noted between two groups in terms of the above parameters (P lt; 0.01). All the wounds healed by first intention. The patients were followed up for 13-54 months (average 27 months) in group A and 12-55 months (average29 months) in group B. Four patients in each group suffered from spinal dural rupture during operation and recovered after corresponding treatment. Three patients in group B had lumbar instabil ity 3 years after operation and recovered using lumbar interbody fusion combined with general spine system internal fixation. No such compl ications as wrong orientation, nerve root injury, cauda equina injury and infection occurred in each group, and radiology exam showed no relapse. Therapeutic effect was evaluated by Nakai standard, 52 cases in group A were graded as excellent, 45 as good, 7 as fair, 1 as poor, and the excellent and good rate was 92.4%; 53 cases in group B were graded as excellent, 48 as good, 8 as fair, 1 as poor, and the excellent and good rate was 91.8%; there was no significant difference between two groups (P gt; 0.05). Conclusion Two methods have the similar therapeutic effect, but MED el iminates the shortcomings of traditional OD, so it is one of ideal minimally invasive operative approaches for degenerative lumbar spinal stenosis.
To cure patients suffering from atlanto-axial instability following old fracture of odontoid process concomitant with stenosis of lower end of cervical spinal canal, a new operative method was designed. It included atlanto-axial fusion by Gallie technique and resection of right half of the laminae of C3-C7 spine at one stage. A female of 63 years old was treated. She was admitted with neck pain and numbness of the upper and lower limbs. A history of neck injury was noted in enquiry. In physical examination showed the sensation of pain of the upper limbs was decreased and the muscle power of the upper and lower limbs ranged from III degree to IV degree. The X-ray film and MRI suggested that there was instability of the atlanto-axial joint with stenosis of 4th-6th cervical spinal canal. The operation was satisfactory. After operation, the patient was followed up for 11 months. The physical examination indicated that sensation of the upper limbs had recovered to normal and the muscle power of the upper limbs reached IV degree and that the lower limbs reached V degree and X-ray showed bony fusion of the atlanto-axial joint. The conclusions were: 1. The stability of atlanto-axial joint was reconstructed with expanding of the spinal canal at the same time. 2. The duration, risk and cost of the therapy were reduced, and maintenance of the stability of the cervical spine throughout whole period of treatment was recommended.
Objective To investigate the surgery tactics for ossification of ligamentum flavum (OLF) associated with dural ossification (DO) in the thoracic spine and the cl inical outcome. Methods Between June 2006 and December 2009, 98 patients with thoracic spinal stenosis secondary to OLF were treated, and DO was found in 18 cases during operation. There were 11 males and 7 females with a mean age of 58 years (range, 46-73 years). The disease duration ranged from 5 to 48 months (mean,20 months). All patients underwent surgical decompression because of recent neurological aggravation. Both DO and OLF were resected with octagonal decompression by dissecting pedicle flavum tunnel. The Japanese Orthopaedic Association (JOA) score, modified Oswestry Disabil ity Index (ODI), and the Cobb angle were used to evaluate the effectiveness. Results The initial symptoms were significantly alleviated postoperatively. All patients had transient cerebrospinal fluid (CSF) leakage postoperatively, the CSF leakage disappeared after 8-10 days of conservative treatment. All the incisions healed by first intention. There was no complication of neurologic function deterioration, meningitis, wound infection, or spinocutaneous fistula. Eighteen patients were followed up 20-60 months (mean, 49 months). No recurrence of spinal cord compression symptoms,or neurologic function deterioration was observed at last follow-up. The JOA scores and effectiveness and modified ODI scores were significantly improved after 1 month and 12 months of operation when compared with preoperative scores (P lt; 0.05). The Cobb angles of kyphosis of the involved vertebrae were (6.7 ± 1.6)° before operation and (8.0 ± 1.2)° after 12 months of operation, showing significant difference (t=4.000，P=0.001). Postoperative T2-weighted axial MRI, sagittal MRI scan, and short T1 inversion recovery MRI showed that compressed deformity of the spinal cord returned to normal. Conclusion The surgery tactics for thoracic spinal stenosis secondary to the OLF with DO is safe, and no patching dura mater tears is effective.
Objective To analyze the early effectiveness of unilateral biportal endoscopy (UBE) laminectomy in the treatment of two-level lumbar spinal stenosis (LSS). Methods The clinical data of 98 patients with two-level LSS treated with UBE between September 2020 and December 2021 were retrospectively analyzed. There were 53 males and 45 females with an average age of 59.9 years (range, 32-79 years). Among them, there were 56 cases of mixed spinal stenosis, 23 cases of central spinal canal stenosis, and 19 cases of nerve root canal stenosis. The duration of symptoms was 1.5- 10 years, with an average of 5.4 years. The operative segments were L2, 3 and L3, 4 in 2 cases, L3, 4 and L4, 5 in 29 cases, L4, 5 and L5, S1 in 67 cases. All patients had different degrees of low back pain, among of which 76 cases were with unilateral lower extremity symptoms and 22 cases were with bilateral lower extremity symptoms. There were 29 cases of bilateral decompression in both segments, 63 cases of unilateral decompression in both segments, and 6 cases of unilateral decompression and bilateral decompression of each segment. The operation time, intraoperative blood loss, total incision length, hospitalization stay, ambulation time, and related complications were recorded. Visual analogue scale (VAS) score was used to assess the low back and leg pain before operation and at 3 days, 3 months after operation, and at last follow-up. The Oswestry disability index (ODI) was used to evaluate the functional recovery of lumbar spine before operation and at 3 months and last follow-up after operation. Modified MacNab criteria was used to evaluate clinical outcomes at last follow-up. Imaging examinations were performed before and after operation to measure the preservation rate of articular process, modified Pfirrmann scale, disc height (DH), lumbar lordosis angle (LLA), and cross-sectional area of the canal (CAC), and the CAC improvement rate was calculated. Results All patients underwent surgery successfully. The operation time was (106.7±25.1) minutes, the intraoperative blood loss was (67.7±14.2) mL, and the total incision length was (3.2±0.4) cm. The hospitalization stay was 8 (7, 9) days, and the ambulation time was 3 (3, 4) days. All the wounds healed by first intention. Dural tear occurred in 1 case during operation, and mild headache occurred in 1 case after operation. All patients were followed up 13-28 months with an average of 19.3 months, and there was no recurrence or reoperation during the follow-up. At last follow-up, the preservation rate of articular process was 84.7%±7.3%. The modified Pfirrmann scale and DH were significantly different from those before operation (P<0.05), while the LLA was not significantly different from that before operation (P=0.050). The CAC significantly improved (P<0.05), and the CAC improvement rate was 108.1%±17.8%. The VAS scores of low back pain and leg pain and ODI at each time point after operation significantly improved when compared with those before operation, and the differences between each time points were significant (P<0.05). According to the modified MacNab criteria, 63 cases were excellent, 25 cases were good, and 10 cases were fair, with an excellent and good rate of 89.8%. ConclusionUBE laminectomy is a safe and effective technique with little trauma and fast recovery for two-level LSS and the early effectiveness is satisfactory.
People’s understanding of lumbar spinal stenosis has become more and more comprehensive and reasonable, however, there are still many controversies about the concepts of " central lumbar canal” and " lateral lumbar spinal canal”, and there is no unified standard at present. In this paper, we redefine and differentiate the two concepts. We believe that some kinds of central canal stenosis caused by bilateral recess stenosis can be completely solved by bilateral percutaneous endoscopic transforaminal discectomy. At the same time, the concept of " lumbar lateral recess” is ambiguous. We redefine it as " lateral lumbar spinal canal” and propose " West China Hospital classification” to guide surgical decision-making, which has been widely recognized and applied.
Objective To explore short-term effectiveness of floating island laminectomy surgery in treating thoracic spinal stenosis and myelopathy caused by ossification of the ligamentum flavum. Methods A total of 31 patients with thoracic spinal stenosis and myelopathy caused by ossification of the ligamentum flavum between January 2019 and April 2022 were managed with floating island laminectomy surgery. The patients comprised 17 males and 14 females, aged between 36 and 78 years, with an average of 55.9 years. The duration of symptoms of spinal cord compression ranged from 3 to 62 months (mean, 27.2 months). The lesions affected T1-6 in 4 cases and T7-12 in 27 cases. The preoperative neurological function score from the modified Japanese Orthopaedic Association (mJOA) was 4.7±0.6. Surgical duration, intraoperative blood loss, and complications were recorded. The thoracic MRI was conducted to reassess the degree of spinal cord compression and decompression after operation. The mJOA score was employed to evaluate the neurological function and calculate the recovery rate at 12 months after operation. Results The surgical duration ranged from 122 to 325 minutes, with an average of 204.5 minutes. The intraoperative blood loss ranged from 150 to 800 mL (mean, 404.8 mL). All incisions healed by first intention after operation. All patients were followed up 12-14 months, with an average of 12.5 months. The patients’ symptoms, including lower limb weakness, gait disorders, and pain, significantly improved. The mJOA scores after operation significantly increased when compared with preoperative scores (P<0.05), gradually improving with time, with significant differences observed among 1, 3, and 6 months (P<0.05). The recovery rate at 12 months was 69.76%±11.38%, with 10 cases exhibiting excellent neurological function and 21 cases showing good. During the procedure, there were 3 cases of dural tear and 1 case of dural defect. Postoperatively, there were 2 cases of cerebrospinal fluid leakage. No aggravated nerve damage, recurrence of ligamentum flavum ossification, or postoperative thoracic deformity occurred. ConclusionThe floating island laminectomy surgery is safe for treating thoracic spinal stenosis and myelopathy caused by ossification of the ligamentum flavum, effectively preventing the exacerbation of neurological symptoms. Early improvement and recovery of neurological function are achieved.
ObjectiveTo review the research status in respect of interspinous distraction devices (IDD) in the treatment of degenerative lumbar spinal stenosis (DLSS). MethodsRecent original articles related to IDD in the treatment of DLSS were retrieved extensively, and the effectiveness was analyzed and summarized. ResultsIts short-term effectiveness was superior to that of conservative treatment, no significant difference was found when compared with decompression or fusion alone. Its complication rate was higher than that of decompression or fusion alone, although complication dose not significantly affect treatment results, it still will increase the medical care cost of patients. ConclusionIDD is appropriate for patients who have failed to nonoperative treatment measures and can not tolerate open surgery, but the long-term effectiveness and durability of IDD need further research.
Objective To discuss the main points of technique and the range of fusion in posterior operation of spinal stenosis associated with lumbar degenerative kyphosis (LDK). Methods The cl inical data were retrospectively analysedfrom 20 cases of spinal stenosis associated with LDK which were performed posterior operation from February 2001 to February 2008. There were 1 male and 19 females, aged 52-81 years old with an average of 64 years old. The course of disease was 6-10 years. All patients had severe low back pain. According to Frankel’s neurologic function classification, there were 18 cases of grade E and 2 cases of grade D before operation. The apex of LDK included L1 in 3 cases, L2 in 10 and L3 in 7. The operational method was decided according to different characteristics of LDK. All patients were divided into three groups. Group 1 included 6 cases of sciatica and intermittent claudication with worse physical status, the segmental decompression of spinal canal, posterior intervertebral fusion and short transpedical instrument fixation were performed. Group 2 included 8 cases whose Cobb angle of LDK was less than 20°, the segmental decompression of spinal canal, posterior intervertebral fusion and one-level or multilevel lamina osteotomy were performed, instrumentation-assisted correction was used. Group 3 included 6 cases whose Cobb angle of LDK was more than 20°, the canal decompression and one-level transvertebral wedge osteotomy were performed, instrumentation-assisted correction, intervertebral fusion and posterior-lateral fusion were used. Results Incision healedby first intention in all patients. One patient suffered from superior mesenteric artery syndrome at 6 hours after operationand healed after symptomatic management. The neurologic function was improved to grade E at 2 weeks after opeartion. All patients were followed-up 24-54 months (average 26 months). At last follow-up，the Oswestry Disabil ity Index of all patients was 30.5% ± 9.6%; showing significant difference when compared with preoperation (55.9% ± 11.8%, P lt; 0.05). The back pain scoring and leg pain scoring were 2.8 ± 1.6 and 2.4 ± 1.6, respectively according to the Numeric Rating Scale score; showing significant differences when compared with preoperation (7.5 ± 0.5 and 7.3 ± 0.7, P lt; 0.05). The Numeric Rating Scale score and Oswestry Disabil ity Index in all patients were improved obviously when compared with before operation (P lt; 0.05). During the follow-up period, there was no instrumentation failure or correction loss and the fusion rate was up to 100%. Conclusion For spinal stenosis associated with LDK patients, the most important therapic purpose is to improve cl inical symptom through reconstruction lumbar stabil ization and spinal biomechanics l ine in sagittal plane. Overall estimate of the cl inical appearance and imageology character is necessary when making decision of which segments needed to be fixation and fusion. Individual ized treatment strategy may be the best choice.
ObjectiveTo explore the predictive value of the nerve root sedimentation sign in the diagnosis of lumbar spinal stenosis (LSS). Methods Between January 2019 and July 2021, 201 patients with non-specific low back pain (NS-LBP) who met the selection criteria were retrospectively analyzed. There were 67 males and 134 females, with an age of 50-80 years (mean, 60.7 years). Four intervertebral spaces (L1, 2, L2, 3, L3, 4, L4, 5) of each case were studied, with a total of 804. The nerve root sedimentation sign was positive in 126 intervertebral spaces, and central canal stenosis was found in 203 intervertebral spaces. Progression to symptomatic LSS was determined by follow-up for lower extremity symptoms similar to LSS, combined with central spinal stenosis. Univariate analysis was performed for gender, age, visual analogue scale (VAS) score for low back pain at initial diagnosis, treatment, dural sac cross-sectional area at each intervertebral space, number of spinal stenosis segments, lumbar spinal stenosis grade, positive nerve root sedimentation sign, and number of positive segments between patients in the progression group and non-progression group, and logistic regression analysis was further performed to screen the risk factors for progression to symptomatic LSS in patients with NS-LBP. ResultsAll patients were followed up 17-48 months, with an average of 32 months. Of 201 patients with NS-LBP, 35 progressed to symptomatic LSS. Among them, 33 cases also had central spinal stenosis, which was defined as NS-LBP progressing to symptomatic LSS (33 cases in progression group, 168 cases in non-progression group). Univariate analysis showed that CSA at each intervertebral space, the number of spinal stenosis segments, lumbar spinal stenosis grade, whether the nerve root sedimentation sign was positive, and the number of nerve root sedimentation sign positive segments were the influencing factors for the progression to symptomatic LSS (P<0.05); and further logistic regression analysis showed that positive nerve root sedimentation sign increased the risk of progression of NS-LBP to symptomatic LSS (OR=8.774, P<0.001). ConclusionThe nerve root sedimentation sign may be associated with the progression of NS-LBP to symptomatic LSS, and it has certain predictive value for the diagnosis of LSS.
Objective To investigate the technique and effectiveness of modified laminoplasty for lumbar spinal stenosis (LSS) and to explore the application value of modified laminoplasty in maintaining the stability of the spine by comparing with the conventional laminectomy. Methods Fifty-six patients with LSS were included between June 2012 and July 2013, and they were divided into 2 groups: 27 patients underwent modified laminoplasty in group A, and 29 patients received conventional laminectomy in group B. There was no significant difference in sex, age, disease duration, narrow segment, visual analogue scale (VAS) score of low back pain and leg pain, Japanese Orthopaedic Association (JOA) score, and walking tolerance between 2 groups (P > 0.05). The postoperative VAS score of low back pain and leg pain, JOA score, walking tolerance, X-ray film, and CT were used to evaluate the clinical results. Results Dural tear occurred in 2 cases of group A and 1 case of group B and were repaired during operation. All incisions primarily healed without infection. The patients were followed up 24-31 months (mean, 24.7 months) in group A, and 24-37 months (mean, 26.2 months) in group B. The bone healing time was 6-12 months (mean, 9 months) in group A. CT showed healing at the junction of spinous process and vertebral plate in group A at 12 months after operation; new scar in varying degre es was observed in group B. At last follow-up, lumbar spondylolisthesis and instability occurred in 4 and 2 cases of group B respectively, and received re-operation. The change value of slip distance was (0.27±0.23) mm in group A and was (0.83±1.22) mm in group B, showing significant difference (t=-2.405, P=0.023). The postoperative JOA score, VAS score, and walking tolerance were significantly improved when compared with preoperative ones in 2 groups (P < 0.05). At last follow-up, group A was better than group B in VAS score of low back pain (P < 0.05), but no significant difference was found in the other indexes between 2 groups (P > 0.05). Conclusion The modified laminoplasty is better than the conventional laminectomy in relieving low back pain and maintaining the stability of the lumbar spine.