Personal experience in lumbar spinal stenosis (LSS)
| Autor: | G. Iacob, M. Craciun |
|---|---|
| Jazyk: | angličtina |
| Rok vydání: | 2011 |
| Předmět: | |
| Zdroj: | Romanian Neurosurgery, Vol 18, Iss 4 (2011) |
| Druh dokumentu: | article |
| ISSN: | 1220-8841 2344-4959 |
| Popis: | Objective: To investigate the effectiveness of our strategy in lumbar spinal stenosis. This is based on the following: precise clinical radicular description of the level of claudication by electrodiagnosis, fine neuroradiologic studies, microsurgical decompression, assessment of the factors which might influence the outcome. Methods: The study was performed on 145 patients who underwent decompression in the last 8 years: 95 males, 50 females, mean age 65 yrs (50-81). Comorbidities were carefully considered when choosing the surgical procedure, especialy in elderly patients; an initial conservative approach of 3 weeks was used for most patients. Concerning etiology: 105 were degenerative, 16 post trauma, 24 others. Our cases included: 48 cases of single, focal stenosis, 97 diffuse (52 cases in 2 levels and 45 cases in 3 or more levels); 50% were graded as severe and evolved within 6 weeks, 30% were graded severe to moderate and 20% were moderate after a 2 month evolution; 15 were central, 17 lateral, 13 foraminal and 100 mixed. Precise clinical radicular description of the level of claudication by electrodiagnosis was used in all patients, MRI studies – 115 patients, CT studies - 30 patients, plain static x-rays of lumbar spine, dynamic flexion and extension x-rays of lumbar spine – all patients; disability degree evaluation: Oswestry Disability Index, pain (visual analog scale and analgesic consumption), functional improvement (Neurogenic Claudication Outcome Score), walking performance and instability degree (Pre-op and intraoperative) to all patients. We used a 4-5 cm incision for focal stenosis, 5-10 cm incision for 2-3 levels, C-arm for localization, high speed drill, cutting and diamond burrs, microscope, microinstruments, fenestration and medial facet undercutting to ensure an adequate root decompression. We excised the ligamentum flavum in the lateral recess which is often thickened. The lower lateral 6-12 mm of the lamina above and/or the superior lateral 3-9 mm of the lamina below were also resected to expose the root, the disc was excised and the posterior osteophytes were chiseled away with a fine micro chisel or diamond drill. In cases of focal stenosis we performed: foraminotomy, laminotomy, osteophytectomy, ligamentum flavectomy; diffuse/multilevel stenosis was approached as follows: laminotomies, foraminotomies, osteophytectomy, ligamentum flavectomy, medial facetectomy, fusion. In 24 cases we attempted a pedicle screw fixation and in two cases Diam devices. No re-do surgery was required. Results: One week after surgery, pain decreased in 87.9% of patients; nonsteroidal anti- inflammatory drug consumption and analgetics decreased in 81%. Two years after surgery, pain remained decreased in 79.8% of patients, Neurogenic Claudication Outcome Score decreased in 78.7% of patients and walking performance improved in 97.2% of patients. Patients who underwent both multilevel decompression or single - level decompression benefitted. Conclusions: LSS surgery is functional, never preventive; the initial management should be non-surgical except for severe cases. Electrophysiological testing correlated with thorough neurological examination is more accurate than a radiological evaluation alone when choosing the roots to be decompressed. Microsurgical selective decompression accomplishes a good balance between bony and soft tissue decompression, while also maintaining spinal stability. |
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