Stenosis in the Lumbar Spine

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CASE 3

An active 90-year-old man was referred to the spine surgery clinic with a long history of worsening bilateral buttock pain and decreased walking tolerance. He was otherwise in excellent health, but noted a burning pain in his buttocks with radiation down the posterior and lateral thighs after ambulating more than about 50 yards. The pain quickly improved with rest, and would not occur if he had a shopping cart to lean on while ambulating. Descending stairs or inclines would aggravate symptoms but ascending stairs would not. He had been evaluated by the vascular surgery service and was not found to have vascular insufficiency. Despite an intensive program of physical therapy focusing on core strengthening, flexibility, and cardiovascular fitness his symptoms persisted. Interventions by the pain management service, including epidural steroid injections, had been unsuccessful.

Physical examination was relatively unremarkable, with normal strength throughout all muscle groups and intact sensation in all dermatomes. Gait was steady and neurological testing was unremarkable.

Radiographs, seen in Figures 50-7A and B, demonstrate advanced degenerative changes, with significant disc height loss, large disc osteophyte complexes, and facet hypertrophy from L2 to L5. Sagittal and coronal MR images seen in Figure 50-8A and B show severe central, lateral recess, and foraminal stenosis, with increased fluid in the zygapophyseal joints and buckling of the ligamentum flavum.

The patient was taken to the operating room for a L2 to L5 decompression and posterolateral instrumented fusion. Postoperative images are shown in Figure 50-9A and B. At last follow-up, the patient had returned to his premorbid level of functioning, with complete resolution of his claudication symptoms and no postoperative pain.

■ FIGURE 50-7 A, AP x-ray of lumbar spine showing multilevel spondylosis with a degenerative scoliosis and mild lateral listhesis at multiple levels. B, Lateral view showing severe disc collapse and lis-thesis at multiple levels.

■ FIGURE 50-7 A, AP x-ray of lumbar spine showing multilevel spondylosis with a degenerative scoliosis and mild lateral listhesis at multiple levels. B, Lateral view showing severe disc collapse and lis-thesis at multiple levels.

Vertebrae Abnormalities Xray

■ FIGURE 50-8 A, Sagittal MR image depicting moderate to severe central stenosis from L2 to S1. B, Coronal MRI cut showing lateral recess and foraminal stenosis accompanied by facet hypertrophy and broad-based disc bulging.

Spinal Stenosis Mri

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■ FIGURE 50-9 A, Postoperative AP radiograph showing instrumented fusion from L2 to L5 with wide laminectomy from L2 to the sacrum. B, Postoperative lateral radiograph showing stabilization of the lumbar spine with screw fixation and restoration of normal lumbar lordosis.

As with stenosis found elsewhere, successful surgical management of lumbar stenosis depends on adequate decompression of the neural elements. Fusion should be considered in cases in which:

• An inherently unstable degenerative pattern is present in which a stenotic canal is found to have rotational and translational deformity resulting in either degenerative spondylolisthesis or scoliosis.

• Greater than 50% of the facet joint is removed in the process of the decompression.

• Instability is seen on preoperative static radiographs or dynamic flexion-extension radiographs.

• The restoration of normal disc height will result in increased foraminal area as well as return the ligamentum flavum back to its normal length and tension .

• Stenosis exists after prior lumbar decompression surgery.

The addition of a lumbar interbody fusion to the spinal decompression can restore the disc space back to its normal height. This helps treat the stenosis by reducing any buckling of the ligamentum flavum as well as restoring the native cross-sectional area of the neural foramina. This interbody lumbar fusion can be done from a variety of approaches: anterior (anterior lumbar interbody fusion or ALIF), retroperitoneal (extreme or direct lateral lumbar interbody fusion or XLIF/DLIF), or posterior (transforaminal lumbar interbody fusion or TLIF). ALIF and XLIF/DLIF can be used as a standalone procedure for a spinal fusion, while TLIF must be augmented with posterior pedicle screw instrumentation. Each of these approaches has its pros and cons. An ALIF allows for excellent visualization of the intervertebral disc, but it often requires an access surgeon to mobilize the great vessels off the spinal column. Additionally, since this is done in a supine patient, the patient must be turned prone if posterior decompression and/ or instrumentation is needed. An XLIF/DLIF also requires repositioning for a posterior approach. The TLIF allows for 360-degree fusion from a posterior-alone approach. No access surgeon is needed, and no repositioning is required. This approach may require some manipulation of the neural elements, thereby putting those structures at risk.

CONCLUSIONS

Spinal stenosis is primarily a condition occurring in elderly patients. It most commonly affects the lumbar spine of patients in their sixth or seventh decade of life. With the increasing average age of the general population as well as the increasing levels of activity of these elderly patients, the incidence of symptomatic spinal stenosis is increasing. Nonoperative management can be successful, but some cases are recalcitrant to nonoperative treatment. Successful surgical treatment of spinal stenosis depends on properly locating the area of compression, completely decompressing that area, and fusing the spinal segment if there is instability seen preoperatively or after decompression.

References

1. J. Hauerberg, et al., Anterior cervical discectomy with or without fusion with ray titanium cage: a prospective randomized clinical study, Spine 33 (5) (2008) 58-64.

2. P.J. Rao, et al., Clinical and functional outcomes of anterior cervical discectomy without fusion, J. Clin. Neurosci. 15 (12) (2008) 1354-1359.

3. H. Bertalanffy, H.R. Eggert, Complications of anterior cervical discectomy without fusion in 450 consecutive patients, Acta Neurochir. (Wien) 99 (1-2) (1989) 41-50.

4. R.D. Nandoe Tewarie, R.H. Bartels, WC. Peul, Long-term outcome after anterior cervical discectomy without fusion, Eur. Spine J. 16 (9) (2007) 1411-1416.

5. R.B. Raynor, J. Pugh, I. Shapiro, Cervical facetectomy and its effect on spine strength, J. Neurosurg. 63 (2) (1985) 278-282.

6. M.A. Palumbo, et al., Surgical treatment of thoracic spinal stenosis: a 2- to 9-year follow-up, Spine 26 (5) (2001) 558-566.

7. K. Yone, et al., Indication of fusion for lumbar spinal stenosis in elderly patients and its significance, Spine 21 (2) (1996) 242-248.

8. M. Cornefjord, et al., A long-term (4- to 12-year) follow-up study of surgical treatment of lumbar spinal stenosis, Eur. Spine J. 9 (6) (2000) 563-570.

9. D. Grob, T. Humke, J. Dvorak, Degenerative lumbar spinal stenosis: decompression with and without arthrodesis, J. Bone Joint Surg. Am. 77 (7) (1995) 1036-1041.

10. K. Adachi, et al., Spinal canal enlargement procedure by restorative laminoplasty for the treatment of lumbar canal stenosis, Spine J. 3 (6) (2003) 471-478.

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