[Minimally invasive decompression techniques for spinal cord stenosis]. / Minimal-invasive Dekompressionsverfahren der Spinalkanalstenose.

BACKGROUND: Lumbar spinal canal stenosis is frequently found among elderly patients and significantly limits their quality of life. Non-surgical therapy is an initial treatment option; however, it does not eliminate the underlying pathology. Surgical decompression of the spinal canal has now become the treatment of choice. OBJECTIVE: Minimalization of surgical approach strategies with maintaining sufficient decompression of the spinal canal and avoiding disadvantages of macrosurgical techniques, monolateral paravertebral approach with bilateral intraspinal decompression, specific surgical techniques. MATERIALS AND METHODS: Minimally invasive decompression techniques using a microscope or an endoscope are presented and different surgical strategies depending on both the extent (mono-, bi-, and multisegmental) and the location of the stenosis (intraspinal central, lateral recess, foraminal) are described. RESULTS: Minimally invasive microscopic or endoscopic decompression procedures enable sufficient widening of the spinal canal. Disadvantages of macrosurgical procedures (e. g., postoperative instability) can be avoided. The complication spectrum overlaps partially with that of macrosurgical interventions, albeit with significantly less marked severity. Subjective patient outcome is clearly improved. CONCLUSIONS: Referring to modern minimally invasive decompression procedures, surgery of lumbar spinal canal stenosis represents a rational and logical treatment alternative, since causal treatment of the pathology is only possible with surgery.

Twelve-month results of a clinical pilot study utilizing pedicle-lengthening osteotomy for the treatment of lumbar spinal stenosis.

OBJECT: Lumbar spinal stenosis (LSS) is a common condition that leads to significant disability, particularly in the elderly. Current therapeutic modalities for LSS have certain drawbacks when applied to this patient population. The object of this study was to define the 12-month postoperative outcomes and complications of pedicle-lengthening osteotomies for symptomatic LSS. METHODS: A prospective, single-treatment clinical pilot study was conducted. A cohort of 19 patients (mean age 60.9 years) with symptomatic LSS was treated by pedicle-lengthening osteotomy procedures at 1 or 2 levels. All patients had symptoms of neurogenic claudication or radiculopathy secondary to LSS and had not improved after a minimum 6-month course of nonoperative treatment. Eleven patients had a Meyerding Grade I degenerative spondylolisthesis in addition to LSS. Clinical outcomes were measured using the Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), 12-Item Short-Form Health Survey (SF-12), and a visual analog scale (VAS). Procedural variables, neurological outcomes, adverse events, and radiological imaging (plain radiographs and CT scans) were collected at the 1.5-, 3-, 6-, 9-, and 12-month time points. RESULTS: The pedicle-lengthening osteotomies were performed through percutaneous approaches with minimal blood loss in all cases. There were no operative complications. Four adverse events occurred during the follow-up period. Clinically, significant improvement was observed in the mean values of each of the outcome scales (comparing preoperative and 12-month values): ODI scores improved from 52.3 to 28.1 (p < 0.0001); the ZCQ physical function domain improved from 2.7 to 1.8 (p = 0.0021); the SF-12 physical component scale improved from 27.0 to 37.9 (p = 0.0024); and the VAS score for leg pain while standing improved from 7.2 to 2.7 (p < 0.0001). Imaging studies, reviewed by an independent radiologist, showed no evidence of device subsidence, migration, breakage, or heterotopic ossification. Thin-slice CT documented healing of the osteotomy site in all patients at the 6-month time point and an increase in the mean cross-sectional area of the spinal canal of 115%. CONCLUSIONS: Treatment of patients with symptomatic LSS with a pedicle-lengthening osteotomy procedure provided substantial enlargement of the area of the spinal canal and favorable clinical results for both disease-specific and non-disease-specific outcome measures at the 12-month time point. Future studies are needed to compare this technique to alternative therapies for lumbar stenosis.

Large C4/5 spondylotic disc bulge resulting in spinal stenosis and myelomalacia in a Klippel-Feil patient.

OBJECTIVES: The purpose of this report is to document a case of cervical spinal stenosis and myelomalacia in a patient with Klippel-Feil (KF) syndrome with a large C4/5 disc bulge presenting with cervical radiculopathy. SUBJECT: A 39-year-old man was referred to a private chiropractic practice for a consultation. He complained of limited motion in his neck with pain and numbness radiating down both arms and left leg. Diagnostic imaging revealed KF syndrome and a large spondylotic disc bulge at C4/5 compressing the cord and causing myelomalacia. A plethora of symptoms and objective findings associated with KF syndrome were also present. RESULTS: After reviewing the previous diagnostic imaging, examining this patient, and discovering that upper motor neuron pathological reflexes were present, the patient was recommended to proceed with the surgical intervention as recommended by his neurosurgeon. No chiropractic care was rendered. CONCLUSIONS: This patient presented with primary complaints consistent with cervical radiculopathy. However, due to the severity of the neurologic findings and presence of myelomalacia, the patient was not treated. The patient had not previously been diagnosed with KF syndrome, although he presented clinically with many of the congenital issues commonly associated with the condition. This case demonstrates the vital importance of differential diagnostic skills as well as the need to continue fostering improved communication and integration of care among various clinical disciplines for patients presenting with challenging symptoms.

Lumbar stenosis rates in symptomatic patients using weight-bearing and recumbent magnetic resonance imaging.

OBJECTIVE: The purpose of this study was to determine the rate of lumbar stenosis detected via magnetic resonance imaging (MRI) in patients with symptomatic foraminal stenosis, lateral recess stenosis, or central stenosis. METHODS: A retrospective review was performed on 1983 MRI scans from a 2-year period on 1486 symptomatic patients. Of these patients, 761 were scanned in the recumbent position using low-field (0.3 T, Airis II; Hitachi, Twinsburg, Ohio) MRI, and 725 were scanned in an upright sitting position using midfield (0.6 T) open Upright MRI (Fonar Corp, Melville, NY). In total, 986 serial scans (recumbent) and 997 serial scans (weight-bearing) were performed. RESULTS: Of scans performed in the recumbent position, stenoses were identified in 382 scans (38.8%), central stenosis in 119 scans (12%), lateral recess stenosis in 91 scans (9.2%), and foraminal stenosis in 327 scans (33.2%). Of scans performed in a weight-bearing position, stenoses were identified in 565 scans (56.7%), central stenosis in 136 scans (13.6%), lateral recess stenosis in 206 scans (20.7%), and foraminal stenosis in 524 scans (52.6%). CONCLUSIONS: The stenosis rates as indicated by MRI interpretation ranged between 38.5% (recumbent) and 56.7% (weight-bearing). These rates are higher than those reported in the medical literature for asymptomatic patients. Further study is needed to determine whether weight-bearing, compared with recumbent, MRI better informs the clinician in the diagnosis of spinal stenosis.

Fluoroscopically guided transforaminal epidural dry needling for lumbar spinal stenosis using a specially designed needle.

BACKGROUND: This report describes the methodological approach and clinical application of a minimally invasive intervention to treat lumbar spinal stenosis (LSS). METHODS: Thirty-four patients with LSS underwent fluoroscopically guided transforaminal epidural dry needling using a specially designed flexed Round Needle. The needle was inserted 8-12 cm lateral to the midline at the level of the stenosis and advanced to a position between the anterior side of the facet joint and pedicle up to the outer-third of the pedicle. The needle was advanced medially and backed laterally within a few millimetres along the canal side of the inferior articular process between the facet joint and pedicle. The procedure was completed when a marked reduction in resistance was felt at the tip of the needle. The procedure was performed bilaterally at the level of the stenosis. RESULTS: The average follow-up period was 12.9 +/- 1.1 months. The visual analogue scale (VAS) pain score was reduced from 7.3 +/- 2.0 to 4.6 +/- 2.5 points, the Oswestry Disability Index (ODI) score decreased from 41.4 +/- 17.2 to 25.5 +/- 12.6% and the average self-rated improvement was 52.6 +/- 33.1%. The VAS scores indicated that 14 (41.2%) patients reported a "good" to "excellent" treatment response, while 11 (32.4%) had a "good" to "excellent" treatment response on the ODI and 22 (64.7%) had a "good" to "excellent" treatment response on the self-rated improvement scale. CONCLUSIONS: These results suggest that fluoroscopically guided transforaminal epidural dry needling is effective for managing LSS.

Observer agreement of spine stenosis on magnetic resonance imaging analysis of patients with cervical spine myelopathy.

OBJECTIVES: The purpose of this study was to measure the intraobserver and interobserver reliability of magnetic resonance detection of cervical spondylotic myelopathy with and without operational guidelines. METHODS: Seven radiologists examined images from 10 patients with cord signal abnormalities and clinical signs of myelopathy. Radiologist examined films twice, with and without operational guidelines designed to define stenotic changes, while blinded to the clinical findings of the patients. Analyses included a Fleiss kappa assessment of intraobserver and interobserver reliability. RESULTS: Results demonstrated high percentage of agreement and strong intraobserver reliability and variable Fleiss kappa values for interobserver assessment. Operational guidelines did not improve the intraobserver or interobserver agreement. CONCLUSION: Although the percentage of agreement was high in some cases, the kappa agreement was low-most likely a result of the base rate problem of a kappa analysis. Sample bias toward severe degenerative changes resulted in highly prevalent selections and kappa adjusted values. Nonetheless, the results do suggest that substantial intraobserver kappa agreement and a wide range of interobserver kappa agreement exists among trained radiologists during detection of stenotic changes associated with cervical spondylotic myelopathy.

Descriptive epidemiology and prior healthcare utilization of patients in the Spine Patient Outcomes Research Trial's (SPORT) three observational cohorts: disc herniation, spinal stenosis, and degenerative spondylolisthesis.

STUDY DESIGN: Prospective observational cohorts. OBJECTIVE: To describe sociodemographic and clinical features, and nonoperative (medical) resource utilization before enrollment, in patients who are candidates for surgical intervention for intervertebral disc herniation (IDH), spinal stenosis (SpS), and degenerative spondylolisthesis (DS) according to SPORT criteria. SUMMARY OF BACKGROUND DATA: Intervertebral disc herniation, spinal stenosis, and degenerative spondylolisthesis with stenosis are the three most common diagnoses of low back and leg symptoms for which surgery is performed. There is a paucity of descriptive literature examining large patient cohorts for the relationships among baseline characteristics and medical resource utilization with these three diagnoses. METHODS: The Spine Patient Outcomes Research Trial (SPORT) conducts three randomized and three observational cohort studies of surgical and nonsurgical treatments for patients with IDH, SpS, and DS. Baseline data include demographic information, prior treatments received, and functional status measured by SF-36 and the Oswestry Disability Index (ODI-AAOS/Modems version). The data presented represent all 1,411 patients (743 IDH, 365 SpS, 303 DS) enrolled in the SPORT observational cohorts. Multiple logistic regression was used to generate independent predictors of utilization adjusted for sociodemographic variables, diagnosis, and duration of symptoms. RESULTS: The average age was 41 years for the IDH group, 64 years for the SpS group, and 66 years for the DS group. At enrollment, IDH patients presented with the most pain as reported on the SF-36 (BP 26.3 vs. 33.2 SpS and 33.8 DS) and were the most impaired (ODI 51 vs. 42.3 SpS and 41.5 DS). IDH patients used more chiropractic treatment (42% vs. 33% SpS and 26% DS), had more Emergency Department (ED) visits (21% vs. 7% SpS and 4% DS), and used more opiate analgesics (49% vs. 29% SpS and 27% DS). After adjusting for age, gender, diagnosis, education, race, duration of symptoms, and compensation, Medicaid patients used significantly more opiate analgesics (58% Medicaid vs. 41% no insurance, 42% employer, 33% Medicare, and 32% private) and had more ED visits compared with other insurance types (31% Medicaid vs. 22% no insurance, 16% employer, 3% Medicare, and 11% private). CONCLUSION: IDH patients appear to have differences in sociodemographics, resource utilization, and functional impairment when compared with the SpS/DS patients. In addition, the differences in resource utilization for Medicaid patients may reflect differences in access to care. The data provided from these observational cohorts will serve as an important comparison to the SPORT randomized cohorts in the future.

Characterization of cultured human ligamentum flavum cells in lumbar spine stenosis.

To investigate the pathogenesis of the degenerative changes of the ligamentum flavum occurring in lumbar spine stenosis, yellow ligament cells from patients with lumbar spine stenosis were cultured for the first time and subjected to biochemical, histochemical and immunohistochemical study. Stenotic ligamentum flavum (SLF) cells were seen to express high levels of alkaline phosphatase (ALP) activity and to produce a matrix rich in type I and III collagen, fibronectin and osteonectin. The matrix mineralized only following beta-glycerophosphate (betaGP) and ascorbic acid supplementation. Stimulation with human parathyroid hormone (PTH) increased intracellular cAMP concentration. These findings indicate that there was significant evidence of osteoblast-like activity in these cells. SLF cells also stained for S100 protein, type II and type X collagen, and co-localized type II collagen and ALP labelling, reflecting the presence of hypertrophic chondrocyte-like cells. Cultures from control patients showed neither osteoblastic nor chondrocytic features: they expressed type I and type III collagen and fibronectin, but did not stain for osteonectin, nor were bone-like calcifications observed in presence or absence of betaGP. Normal ligamentum flavum (NLF) cells did not synthesized S100 protein or type II or type X collagen, and showed a weaker response to PTH stimulation. Our data demonstrated the presence of hypertrophic chondrocytes with an osteoblast-like activity in the ligamentum flavum of patients with spinal stenosis suggesting that they could have a role in the pathophysiology of the heterotopic ossification of ligamentum flavum (OLF) in lumbar spine stenosis.

Mechanisms of neurovascular compression within the spinal and intervertebral canals.

OBJECTIVE: To describe some possible causes of encroachment on human spinal and intervertebral canal (foramen) neurovascular II structures. DATA SELECTION AND SYNTHESIS: A review of some imaging films of patients aged 38 to 52 years and some human autopsy histopathologic sections from 40- to 60-year-old cadavers to determine what structures may be responsible for neurovascular compression in individuals in this relatively young-to-middle-age group and to illustrate some examples. RESULTS: Stenosis of the spinal and intervertebral canal neurovascular structures can be caused by various bony and soft-tissue structures. Stenosis can be related to osteophytosis of the vertebral body, uncoverte-intervertebral disc protrusion, ossification of the posterior longitudinal ligament, and ligamentum flavum hypertrophy or buckling. DISCUSSION: Various forms of spinal and intervertebral canal stenosis can cause compression of neurovascular structures that may, in turn, be responsible for symptomatology. Of course, autopsy findings cannot be equated with painful syndromes in patients.

A single case report of healing through specific martial art therapy: comparison of MRI to clinical resolution in severe cervical stenosis: a case report.

OBJECTIVES: A 76-year-old patient with chronic and severe spinal cord compression secondary to cervical stenosis, a cervical osteophyte, and a herniated intervertebral cervical disk had lasting resolution of symptoms after completing a specific, martial art-based, physical therapy program. We wanted to determine if there were structural changes in the cervical spine that could account for the prompt resolution of symptoms. DESIGN: A 76-year-old female completed 8 weeks of a specific, martial art-based, physical therapy. The pretherapy and posttherapy cervical magnetic resonance images (MRIs) were compared. A follow-up evaluation was done at 1 year. RESULTS: The patient was symptom-free within 8 weeks of the start of therapy. She remained symptom-free at 1 year follow-up evaluation. There were no obvious structural differences in the pretherapy and posttherapy MRI studies. CONCLUSIONS: Resolution of symptoms was directly related to the specific martial art therapy. However, there were no changes in the pretherapy and posttherapy MRI studies, suggesting a significant adaptation to the spinal compression had occurred. These data suggest a viable option to surgery in elderly patients with chronic and severe cervical spinal stenosis.

Multilevel spinal stenosis: a case report.

Presented here is a case of lumbar spine lateral recess stenosis. A brief discussion of etiology, symptoms, diagnosis and the role of imaging is included. The accuracy of computed tomography provides the radiologist with the opportunity of frequently identifying the type of stenosis and informing the clinician of the exact anatomical location.