OBJECT: Recently, limited decompression procedures have been proposed in the treatment of lumbar stenosis. The authors undertook a prospective study to compare the safety and outcome of unilateral and bilateral laminotomy with laminectomy.
METHODS: One hundred twenty consecutive patients with 207 levels of lumbar stenosis without herniated discs or instability were randomized to three treatment groups (bilateral laminotomy [Group 1], unilateral laminotomy [Group 2], and laminectomy [Group 3]). Perioperative parameters and complications were documented. Symptoms and scores, such as visual analog scale (VAS), Roland-Morris Scale, Short Form-36 (SF-36), and patient satisfaction were assessed preoperatively and at 3, 6, and 12 months after surgery. Adequate decompression was achieved in all patients. The overall complication rate was lowest in patients who had undergone bilateral laminotomy (Group 1). The minimum follow up of 12 months was obtained in 94% of patients. Residual pain was lowest in Group 1 (VAS score 2.3 +/- 2.4 and 4 +/- 1 in Group 3; p < 0.05 and 3.6 +/- 2.7 in Group 2; p < 0.05). The Roland-Morris Scale score improved from 17 +/- 4.3 before surgery to 8.1 +/- 7, 8.5 +/- 7.3, and 10.9 +/- 7.5 (Groups 1-3, respectively; p < 0.001 compared with preoperative) corresponding to a dramatic increase in walking distance. Examination of SF-36 scores demonstrated marked improvement, most pronounced in Group 1. The number of repeated operations did not differ among groups. Patient satisfaction was significantly superior in Group 1, with 3, 27, and 26% of patients unsatisfied (in Groups 1, 2, and 3, respectively; p < 0.01).
CONCLUSIONS: Bilateral and unilateral laminotomy allowed adequate and safe decompression of lumbar stenosis, resulted in a highly significant reduction of symptoms and disability, and improved health-related quality of life. Outcome after unilateral laminotomy was comparable with that after laminectomy. In most outcome parameters, bilateral laminotomy was associated with a significant benefit and thus constitutes a promising treatment alternative.
Anterior column support in lumbar fusion has an important role in degenerative conditions of the lumbar spine. Its role in the form of a posterior lumbar interbody fusion (PLIF) has been supported for the treatment of degenerative spondylolisthesis by some authors. The results of simple decompression and posterolateral fusion for this disorder have been excellent. This study evaluates in a prospective randomized fashion the outcomes of these two procedures in a patient population over 60 years of age. Sixty-two patients with Grade 1/2 degenerative spondylolisthesis and accompanying spinal canal stenosis were randomized into one of two surgical groups after the failure of conservative treatment. Thirty-two patients received decompression and posterolateral fusion with pedicle screws and autologous graft (PL group). Thirty patients received decompression, posterolateral fusion with pedicle screws and autologous graft plus posterior interbody fusion with machined allograft (PLIF group). The only surgical variable was the addition of the posterior interbody fusion in the PLIF group. Patient demographics including age, sex, duration of symptoms and radiographic finding are reviewed and not statistically significantly different between groups. Follow-up was 24 months or greater in all patients averaging 32.6 months. Results are presented broken down into surgical variables (surgery time, blood loss, length of stay and complications) and outcomes (fusion, Oswestry disability index, Short Form [SF}-36 and visual pain analog scores). Surgery time (121 minute average [PL] versus 161 minute average [PLIF], p=.05), blood loss (470 cc average [PL] versus 820 cc average [PLIF], p=.01) and intraoperative complications (n=3 [PF] versus n=6 [PLIF], p=.05) were all statistically significantly greater in the PLIF group than the PL group. Length of stay was not different between groups. Fusion was assessed using flexion-extension radiographs and reconstructed computed tomography scans. Fusion was diagnosed in 28 of 32 patients (87.5%) in the PL group and 26 of 30 patients (86.7%) in the PLIF group. These were not statistically significantly different. Oswestry disability index improvement of 15% or more occurred in 26 of 32 patients (81.2%) in the PL group and 24 of 30 patients (80%) in the PLIF group. SF-36 scores and visual pain analog scores improved in both groups with no statistically significant differences between groups. The results show no difference in outcomes with the addition of a PLIF in degenerative spondylolisthesis (Grade 1/2) for patients over 60 years of age but significantly longer surgery time, higher blood loss and higher complication rates in this group. Based on this, the authors do not believe PLIF with allograft is indicated in patients over 60 years of age with Grade 1 or Grade 2 degenerative spondylolisthesis.
STUDY DESIGN: Prospective randomized comparison of anterior lumbar interbody fusion (ALIF) plus transpedicular instrumentation plus posterolateral fusion (PLF) (360 degrees fusion) to ALIF plus transpedicular instrumentation without PLF (270 degrees fusion).
OBJECTIVES: To compare the clinical outcomes, costs, and utilization of health resources of 360 degrees versus 270 degrees fusions.
BACKGROUND: The 360 degrees fusion is effective, but its costs and utilization of health resources are high. The PLF often resorbs and may not be necessary.
METHODS: Before and after surgery pain was measured by the Numerical Rating Scale (NRS), and function was measured by the Oswestry Low Back Disability Index (OSI). Costs were calculated by billing records. Operating times, blood loss, and hospital stays were measured at the time of hospital discharge.
RESULTS: There were 48 patients: 21 women and 27 men. Mean age was 42 years. Follow-up averaged 35 months (range 24-45 months). In both 360 degrees and 270 degrees fusions, there were significant improvements in NRS and OSI, and the percentage of solid ALIF was high. Only 14% of PLF appeared solid bilaterally and 18% appeared solid on one side only. There were no significant differences in changes in NRS, changes in OSI, or percentage solid ALIF between the 360 degrees and 270 degrees fusions. However, the 270 degrees fusion group had significantly less blood loss, shorter operative times, shorter hospital stays, and lower professional fees, and although hospital charges were lower, this difference was not significant.
CONCLUSION: Both the 360 degrees and 270 degrees fusions significantly reduce pain and improve function, and there are no significant clinical differences between them. However, there were shorter operating times, less blood loss, lower costs, and less utilization of health care resources associated with the 270 degrees fusions.
STUDY DESIGN: This prospective study analyzed the influence of transpedicular instrumented on the operative treatment of patients with degenerative spondylolisthesis and spinal stenosis.
OBJECTIVES: To determine whether the addition of transpedicular instrumented improves the clinical outcome and fusion rate of patients undergoing posterolateral fusion after decompression for spinal stenosis with concomitant degenerative spondylolisthesis.
SUMMARY OF BACKGROUND DATA: Decompression is often necessary in the treatment of symptomatic patients who have degenerative spondylolisthesis and spinal stenosis. Results of recent studies demonstrated that outcomes are significantly improved if posterolateral arthrodesis is performed at the listhesed level. A meta-analysis of the literature concluded that adjunctive spinal instrumentation for this procedure can enhance the fusion rate, although the effect on clinical outcome remains uncertain.
METHODS: Seventy-six patients who had symptomatic spinal stenosis associated with degenerative lumbar spondylolisthesis were prospectively studied. All patients underwent posterior decompression with concomitant posterolateral intertransverse process arthrodesis. The patients were randomized to a segmental transpedicular instrumented or noninstrumented group.
RESULTS: Sixty-seven patients were available for a 2-year follow-up. Clinical outcome was excellent or good in 76% of the patients in whom instrumentation was placed and in 85% of those in whom no instrumentation was placed (P = 0.45). Successful arthrodesis occurred in 82% of the instrumented cases versus 45% of the noninstrumented cases (P = 0.0015). Overall, successful fusion did not influence patient outcome (P = 0.435).
CONCLUSIONS: In patients undergoing single-level posterolateral fusion for degenerative spondylolisthesis with spinal stenosis, the use of pedicle screws may lead to a higher fusion rate, but clinical outcome shows no improvement in pain in the back and lower limbs.
We prospectively evaluated the results of decompression of the spine, with and without arthrodesis, for the treatment of lumbar spinal stenosis without instability in forty-five patients (twenty-one men and twenty-four women) who had been managed between November 1989 and November 1990. The average age at the time of the operation was sixty-seven years (range, forty-eight to eighty-seven years). The patients were randomly assigned to one of three treatment groups (fifteen patients in each group) according to when they were admitted to the hospital. Group I was treated with decompression with laminotomy and medial facetectomy; Group II, with decompression and arthrodesis of the most stenotic segment; and Group III, with decompression and arthrodesis of all of the decompressed vertebral segments. All of the operations were performed by the same surgeon. The average duration of follow-up was twenty-eight months (range, twenty-four to thirty-two months). All three groups had a significant improvement in the distance that the patients were able to walk at the time of the latest follow-up examination compared with before the operation (p < 0.001 for Group I, p < 0.002 for Group II, and p < 0.005 for Group III). With the numbers available, there were no significant differences in the results among the three groups with regard to the relief of pain (p = 0.25 for Group I compared with Group II, p = 0.36 for Group II compared with Group III, and p = 0.92 for Group I compared with Group III).(ABSTRACT TRUNCATED AT 250 WORDS)
One hundred, twenty-four patients undergoing lumbar or lumbosacral fusion for degenerative conditions were entered into a prospective study. The patients were randomly assigned to one of three treatment groups. Group I underwent posterolateral fusion using autogenous bone graft. Group II had autogenous posterolateral fusions supplemented by a semi-rigid pedicle screw/plate fixation system (Luque II; Danek Medical, Memphis, Tennessee). Group III patients underwent posterolateral autogenous fusion with a rigid pedicle screw/rod fixation system (Texas Scottish Rite Hospital [TSRH]-Danek Medical, Memphis, Tennessee). All the patients were operated on by the same surgeon, identical bone grafting technique was used in all, and all were treated in an identical fashion postoperatively. Fusion status was determined from the anteroposterior, oblique, and flexion-extension radiographs obtained at 1 year. Clinical results were rated as excellent if the patients were pain-free and had returned to work; good if the patients had mild backache requiring non-narcotic analgesics and had returned to work; fair if continuing back pain prevented a return to work; or poor if the pain was worse than that which the patient experienced preoperatively or the patient required revision surgery. Nine patients who were originally assigned to Group II or Group III were placed in Group I intraoperatively. This change was due to the identification of severe osteopenia and the determination that pedicle screw purchase was poor. One patient was lost to follow-up. Thus, 51 patients were in Group I, 35 in Group II, and 37 in Group III. Follow-up ranged from 9 to 28 months, averaging 16 months.(ABSTRACT TRUNCATED AT 250 WORDS)
We assigned 67 patients with central lumbar stenosis alternately to either multiple laminotomy or total laminectomy. The protocol, however, allowed multiple laminotomy to be changed to total laminectomy if it was thought that the former procedure might not give adequate neural decompression. There were therefore three treatment groups: group I consisting of 26 patients submitted to multiple laminotomy; group II, 9 patients scheduled for laminotomy but submitted to laminectomy; and group III, 32 patients scheduled for, and submitted to, laminectomy. The mean follow-up was 3.7 years. Bilateral laminotomy at two or three levels required a longer mean operating time than total laminectomy at an equal number of levels. The mean blood loss at surgery and the clinical results did not differ in the three groups. The mean subjective improvement score for low back pain was higher in group I but there was also a higher incidence of neural complications in this group. No patient in group I had postoperative vertebral instability, whereas this occurred in three patients in groups II and III, who had lumbar scoliosis or degenerative spondylolisthesis preoperatively. Multiple laminotomy is recommended for all patients with developmental stenosis and for those with mild to moderate degenerative stenosis or degenerative spondylolisthesis. Total laminectomy is to be preferred for patients with severe degenerative stenosis or marked degenerative spondylolisthesis.
Fifty patients who had spinal stenosis associated with degenerative lumbar spondylolisthesis were prospectively studied clinically and radiographically to determine if concomitant intertransverse-process arthrodesis provided better results than decompressive laminectomy alone. There were thirty-six women and fourteen men. The mean age of the twenty-five patients who had had an arthrodesis was 63.5 years and that of the twenty-five patients who had not had an arthrodesis, sixty-five years. The level of the operation was between the fourth and fifth lumbar vertebrae in forty-one patients and between the third and fourth lumbar vertebrae in nine patients. The patients were followed for a mean of three years (range, 2.4 to four years). In the patients who had had a concomitant arthrodesis, the results were significantly better with respect to relief of pain in the back and lower limbs.
Recently, limited decompression procedures have been proposed in the treatment of lumbar stenosis. The authors undertook a prospective study to compare the safety and outcome of unilateral and bilateral laminotomy with laminectomy.
METHODS:
One hundred twenty consecutive patients with 207 levels of lumbar stenosis without herniated discs or instability were randomized to three treatment groups (bilateral laminotomy [Group 1], unilateral laminotomy [Group 2], and laminectomy [Group 3]). Perioperative parameters and complications were documented. Symptoms and scores, such as visual analog scale (VAS), Roland-Morris Scale, Short Form-36 (SF-36), and patient satisfaction were assessed preoperatively and at 3, 6, and 12 months after surgery. Adequate decompression was achieved in all patients. The overall complication rate was lowest in patients who had undergone bilateral laminotomy (Group 1). The minimum follow up of 12 months was obtained in 94% of patients. Residual pain was lowest in Group 1 (VAS score 2.3 +/- 2.4 and 4 +/- 1 in Group 3; p < 0.05 and 3.6 +/- 2.7 in Group 2; p < 0.05). The Roland-Morris Scale score improved from 17 +/- 4.3 before surgery to 8.1 +/- 7, 8.5 +/- 7.3, and 10.9 +/- 7.5 (Groups 1-3, respectively; p < 0.001 compared with preoperative) corresponding to a dramatic increase in walking distance. Examination of SF-36 scores demonstrated marked improvement, most pronounced in Group 1. The number of repeated operations did not differ among groups. Patient satisfaction was significantly superior in Group 1, with 3, 27, and 26% of patients unsatisfied (in Groups 1, 2, and 3, respectively; p < 0.01).
CONCLUSIONS:
Bilateral and unilateral laminotomy allowed adequate and safe decompression of lumbar stenosis, resulted in a highly significant reduction of symptoms and disability, and improved health-related quality of life. Outcome after unilateral laminotomy was comparable with that after laminectomy. In most outcome parameters, bilateral laminotomy was associated with a significant benefit and thus constitutes a promising treatment alternative.
