Interspinous distractor devices for the management of lumbar spinal stenosis: a miracle cure for a common problem?

Neurogenic claudication due to lumbar spinal stenosis is the commonest cause of back and leg pain in the elderly. It consumes large amounts of healthcare resource and is a common reason for GP consultations. Surgical management by decompressive laminectomy is the traditional method used for those patients in whom conservative management has failed. However, the advent of minimally invasive interspinous distraction devices, which are designed to alleviate symptoms of neurogenic intermittent claudication without subjecting the patient to a major operation, has potentially revolutionised the management of lumbar spinal stenosis. This review describes the principles of interspinous distraction devices, the rationale for their use in the management of lumbar spinal stenosis, indications and predictors of outcome. Published data on the safety and efficacy of the various devices available is encouraging but long term results are awaited. The superiority of interspinous distraction devices over conservative treatment has already been established, however, the precise indication for this new technology and whether the implants can replace conventional decompressive surgery in some situations has not been clearly defined.

Swelling and enhancement of the cervical spinal cord: when is a tumour not a tumour?

OBJECTIVE: To describe the management of patients with co-existing cervical spondylotic compression and enhancing intramedullary swelling of uncertain aetiology. We describe the key features, suggest a management plan and review the literature. MATERIAL AND METHODS: A short series of six cases with cervical myelopathy and radiological features of spondylotic compression, swollen cervical cord and intramedullary enhancement is described. Detailed descriptions of clinical features, radiological findings, surgical approaches and outcomes are discussed. All patients underwent cervical decompression via an anterior approach, posterior approach or both. Despite initial concerns that the aetiology might be tumour, no biopsy of cervical cord was required in any of the cases. RESULTS: Symptoms improved in four cases whilst contrast enhancement only improved in two cases following decompression. One patient who failed to improve postoperatively was found to have neurosarcoidosis. No patient became worse after the cervical decompression. CONCLUSION: Swelling of the spinal cord with enhancement and co-existing spondylotic cord compression, in the first instance, should be treated by decompression only. Biopsy to diagnose intrinsic tumour or inflammatory conditions should not be performed unless there is radiological or clinical progression despite adequate decompression.

A randomized controlled trial of the X-Stop interspinous distractor device versus laminectomy for lumbar spinal stenosis with 2-year quality-of-life and cost-effectiveness outcomes.

OBJECTIVE: Lumbar spinal stenosis (LSS) is a common and debilitating condition that is increasing in prevalence in the world population. Surgical decompression is often standard treatment when conservative measures have failed. Interspinous distractor devices (IDDs) have been proposed as a safe alternative; however, the associated cost and early reports of high failure rates have brought their use into question. The primary objective of this study was to determine the cost-effectiveness and long-term quality-of-life (QOL) outcomes after treatment of LSS with the X-Stop IDD compared with surgical decompression by laminectomy. METHODS: A multicenter, open-label randomized controlled trial of 47 patients with LSS was conducted; 21 patients underwent insertion of the X-Stop device and 26 underwent laminectomy. The primary outcomes were monetary cost and QOL measured using the EQ-5D questionnaire administered at 6-, 12-, and 24-month time points. RESULTS: The mean monetary cost for the laminectomy group was £2712 ($3316 [USD]), and the mean cost for the X-Stop group was £5148 ($6295): £1799 ($2199) procedural cost plus £3349 mean device cost (£2605 additional cost per device). Using an intention-to-treat analysis, the authors found that the mean quality-adjusted life-year (QALY) gain for the laminectomy group was 0.92 and that for the X-Stop group was 0.81. The incremental cost-effectiveness ratio was -£22,145 (-$27,078). The revision rate for the X-Stop group was 19%. Five patients crossed over to the laminectomy arm after being in the X-Stop group. CONCLUSIONS: Laminectomy was more cost-effective than the X-Stop for the treatment of LSS, primarily due to device cost. The X-Stop device led to an improvement in QOL, but it was less than that in the laminectomy group. The use of the X-Stop IDD should be reserved for cases in which a less-invasive procedure is required. There is no justification for its regular use as an alternative to decompressive surgery. Clinical trial registration no.: ISRCTN88702314 (www.isrctn.com).

Cervical laminectomy vs laminoplasty: is there a difference in outcome and postoperative pain?

BACKGROUND: Cervical laminoplasty is often used for the decompression of multilevel cervical spondylotic myelopathy without creating spinal instability and kyphosis. OBJECTIVE: To assess the axial pain, quality of life, sagittal alignment, and extent of decompression after standard cervical laminectomy or laminoplasty. We further evaluate whether the sagittal alignment changes over time after both procedures and whether axial pain depends on sagittal alignment. METHODS: We reviewed 268 patients with cervical radiculopathy or myelopathy who had undergone standard cervical laminectomy or laminoplasty between January 1999 and January 2009. The clinical outcome was analyzed by visual analog scale for neck pain. The quality of life was analyzed by EQ-5D questionnaire. The degree of deformity and extent of decompression were assessed using the Ishihara index and Pavlov's ratio, respectively. RESULTS: Laminoplasty was associated with more neck pain and worse quality of life when 4 or more levels were decompressed compared with the laminectomy group. For operations of 3 or fewer levels, there was no difference. Interestingly, the radiological effectiveness of decompression was greater in the laminoplasty group. CONCLUSION: Laminoplasty for 4 or more cervical levels was associated with more axial pain and consequently poorer quality of life than laminectomy. There was a similar loss of sagittal alignment in both the laminectomy and laminoplasty groups over time. Our results suggest there is no clear benefit of laminoplasty over laminectomy in patients who do not have spinal instability.

Spinal meningocele due to iatrogenic dural puncture during epidural analgesia for childbirth: 5-year history of headache with a spinal etiology.

Patients undergoing epidural injection for labor pains occasionally sustain iatrogenic inadvertent puncture of the dura with or without damage to the underlying neurological structures. This may be associated with CSF leakage, headache, neurological deficit, and infection. Rarely, the headache persists for years. To the authors' knowledge, chronic headache due to acquired spinal meningocele featuring as a duplicated dural sac, as a sequela of traumatic inadvertent dural puncture, has not been previously reported. The authors report a case of a 20-year-old woman with persistent headaches following an epidural injection. Five years later, the persistent headache was found to be due to a large acquired spinal meningocele. The operative removal of the meningocele led to resolution of headaches. This report highlights the importance of considering a spinal condition as a culprit for chronic headache and postulates a mechanism for the formation of the acquired spinal meningocele appearing as a duplicated dural sac. The authors recommend early MR imaging of the spine for any persisting headache that has a history of attempted spinal access. If an acquired spinal meningocele collection is found, exploration with a view to complete removal of the sac should be considered. To the authors' knowledge, this is the first case report depicting a rare, treatable cause of chronic spinal hypotension resulting in headaches.