Causal relationships between anthropometric traits, bone mineral density, osteoarthritis and spinal stenosis: A Mendelian randomisation investigation.

OBJECTIVE: Spinal stenosis is a common condition among older individuals, with significant morbidity attached. Little is known about its risk factors but degenerative conditions, such as osteoarthritis (OA) have been identified for their mechanistic role. This study aims to explore causal relationships between anthropometric risk factors, OA, and spinal stenosis using Mendelian randomisation (MR) techniques. DESIGN: We applied two-sample MR to investigate the causal relationships between genetic liability for select risk factors and spinal stenosis. Next, we examined the genetic relationship between OA and spinal stenosis with linkage disequilibrium score regression and Causal Analysis Using Summary Effect estimates MR method. Finally, we used multivariable MR (MVMR) to explore whether OA and body mass index (BMI) mediate the causal pathways identified. RESULTS: Our analysis revealed strong evidence for the effect of higher BMI (odds ratio [OR] = 1.54, 95%CI: 1.41-1.69, p-value = 2.7 × 10-21), waist (OR = 1.43, 95%CI: 1.15-1.79, p-value = 1.5 × 10-3) and hip (OR = 1.50, 95%CI: 1.27-1.78, p-value = 3.3 × 10-6) circumference on spinal stenosis. Strong evidence of causality was also observed for higher bone mineral density (BMD): total body (OR = 1.21, 95%CI: 1.12-1.29, p-value = 1.6 × 10-7), femoral neck (OR = 1.35, 95%CI: 1.09-1.37, p-value = 7.5×10-7), and lumbar spine (OR = 1.38, 95%CI: 1.25-1.52, p-value = 4.4 × 10-11). We detected high genetic correlations between spinal stenosis and OA (rg range: 0.47-0.66), with Causal Analysis Using Summary Effect estimates results supporting a causal effect of OA on spinal stenosis (ORallOA = 1.6, 95%CI: 1.41-1.79). Direct effects of BMI, BMD on spinal stenosis remained after adjusting for OA in the MVMR. CONCLUSIONS: Genetic susceptibility to anthropometric risk factors, particularly higher BMI and BMD can increase the risk of spinal stenosis, independent of OA status. These results may inform preventative strategies and treatments.

Automatic segmentation of dura for quantitative analysis of lumbar stenosis: A deep learning study with 518 CT myelograms.

BACKGROUND: The diagnosis of lumbar spinal stenosis (LSS) can be challenging because radicular pain is not often present in the culprit-level localization. Accurate segmentation and quantitative analysis of the lumbar dura on radiographic images are key to the accurate differential diagnosis of LSS. The aim of this study is to develop an automatic dura-contouring tool for radiographic quantification on computed tomography myelogram (CTM) for patients with LSS. METHODS: A total of 518 CTM cases with or without lumbar stenosis were included in this study. A deep learning (DL) segmentation algorithm 3-dimensional (3D) U-Net was deployed. A total of 210 labeled cases were used to develop the dura-contouring tool, with the ratio of the training, independent testing, and external validation datasets being 150:30:30. The Dice score (DCS) was the primary measure to evaluate the segmentation performance of the 3D U-Net, which was subsequently developed as the dura-contouring tool to segment another unlabeled 308 CTM cases with LSS. Automatic masks of 446 slices on the stenotic levels were then meticulously reviewed and revised by human experts, and the cross-sectional area (CSA) of the dura was compared. RESULTS: The mean DCS of the 3D U-Net were 0.905 ± 0.080, 0.933 ± 0.018, and 0.928 ± 0.034 in the five-fold cross-validation, the independent testing, and the external validation datasets, respectively. The segmentation performance of the dura-contouring tool was also comparable to that of the second observer (the human expert). With the dura-contouring tool, only 59.0% (263/446) of the automatic masks of the stenotic slices needed to be revised. In the revised cases, there were no significant differences in the dura CSA between automatic masks and corresponding revised masks (p = 0.652). Additionally, a strong correlation of dura CSA was found between the automatic masks and corresponding revised masks (r = 0.805). CONCLUSIONS: A dura-contouring tool was developed that could automatically segment the dural sac on CTM, and it demonstrated high accuracy and generalization ability. Additionally, the dura-contouring tool has the potential to be applied in patients with LSS because it facilitates the quantification of the dural CSA on stenotic slices.

A New Interlaminar/Interspinous and Facet-Joint Stabilization System in Lumbar Degenerative Disk Disease: 2 Years of Results.

INTRODUCTION: In lumbar degenerative disk diseases (DDDs), we include a wide range of lumbar pathologies. Lumbar spinal stenosis with or without spondylolisthesis is a common cause of lower-limb pain in elderly patients. The surgical treatment of lumbar DDD consists of the decompression of the neural structures or the decompression and fusion of the involved motion segment. Unfortunately, rigid spinal implants followed by fusion cause increased stresses on the neighboring spinal segments, often leading to adjacent segment degeneration. The aim of this paper is to present a new system for interlaminar/interspinous and facet-joint stabilization and fusion. MATERIAL AND METHODS: From March 2018 to June 2021, 175 patients with severe lumbar back and/or leg pain were operated on with this device after the failure of conservative treatment for a minimum of 6 months. For this study, we considered 75 available patients with a minimum follow-up time of 24 months. Patients rated their back pain and leg pain on a visual analog scale (VAS) after surgery and at the last follow-up; also, the postoperative consumption of analgesic drugs was investigated. Finally, patients were asked whether they would undergo this kind of surgery again or recommend it. The device is designed to promote a better and more efficient intervertebral fusion: Bone Ingrowth technology allows the system to achieve the best response from the bone tissue. RESULTS: All procedures were performed without any complications. A reoperation was required in five cases (6.7%) because of implant failure. In one case, a spinous process and unilateral articular process fracture occurred. In four cases, a subcutaneous ISCHIA (one case) or FILICUDI (three cases) pullout was observed. Significant improvements following lumbar surgery were observed when evaluating the postoperative VAS values, analgesic drug consumption levels, and patients' satisfaction ratings. Evident fusion was seen in 58 of 75 patients (77.3%). CONCLUSIONS: Our interspinous/interlaminar and facet-joint implant solution, associated with bone grafting, provided vertebral fusion in most stenotic patients with Grade I DS undergoing bilateral microdecompression (BMD) or bilateral decompression via the unilateral approach (BDUA). A higher number of patients and a longer follow-up will certainly be required to completely validate these new devices, but this minimally invasive surgery (MIS) is currently very encouraging and satisfactory.

Transforaminal Endoscopic Lumbar Lateral Recess Decompression for Octogenarian Patients.

The incidence of radiculopathy due to lumbar spinal stenosis has been on the increase in the aging population. However, patients aged ≥ 80 years hesitate to undergo conventional open surgery under general anesthesia because of the risk of postoperative morbidity and adverse events. Therefore, less invasive surgical alternatives are required for the elderly or medically handicapped patients. Transforaminal endoscopic lumbar lateral recess decompression (TELLRD) may be helpful for those patients. This study aimed to demonstrate the efficacy of TELLRD for treating radiculopathy in octogenarian patients. A total of 21 consecutive octogenarian patients with lumbar foraminal stenosis underwent TELLRD between January 2017 and January 2021. The inclusion criterion was unilateral radiculopathy, which stemmed from lumbar lateral recess stenosis. The pain source was verified using imaging studies and selective nerve blocks. Full-scale lateral canal decompression was performed using a percutaneous transforaminal endoscopic approach under local anesthesia. We found the pain scores and functional status improved significantly during the 24-month follow-up period. The clinical improvement rate was 95.24% (20 of 21 patients) with no systemic complication. In conclusion, endoscopic lateral recess decompression via the transforaminal approach is practical for octogenarian patients.

Management of lumbar spondylolisthesis: A retrospective analysis of posterior lumbar interbody fusion versus transforaminal lumbar interbody fusion.

Background: One of the most frequent etiologies for spinal surgery is unstable lumbar spondylolisthesis (ULS). To decompress affected structures while maintaining or restoring stability through fusion, surgeons utilize a variety of procedures. When paired with interbody fusion, posterior fusion is most applied, resulting in greater fusion rates. The two most popular techniques for implementing spinal fusion are posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF). As a result, these two procedures have been assessed formally. Methodology: A retrospective analysis of patients who underwent interbody fusion for lumbar stenosis through PLIF and minimally invasive (MI)-TLIF was performed. The patients were followed up for 24 months and fusion rates, Visual Analog Score (VAS), and Oswestry Disability Index (ODI) alongside the MacNab clinical outcome score, were assessed. The Bridwell interbody fusion grading system was used to evaluate fusion rates in computed tomography (CT). Results: Operations were performed in 60 cases where patients suffered from ULS. PLIF was performed on 33 patients (55%) (14 males and 19 females) and 27 patients (45%) (11 males and 16 females) who underwent MI-TLIF. In 87% of our respective cohort, either the L4-5 or the L5-S1 level was operated on. Overall fusion rates were comparable between the two groups; however, the TLIF group improved more in terms of VAS, ODI, and MacNab scores. On average, MI-TLIF surgery was longer and resulted in reduced blood loss. MI-TLIF patients were more mobile than PLIF patients postoperatively. Conclusion: With well-established adequate results in the literature, TLIF offers benefits over other methods used for interbody lumbar fusion in ULS or other diseases of the spine. However, MI-TLIF may procure more advantageous for patients if MI methods are implemented. In this instance, TLIF outperformed PLIF due to shorter operating times, less blood loss, faster ODI recovery, better MacNab scores, and a greater decline in VAS pain ratings.

Establishment and Validation of Nomograms and Web Calculators for Different Cement Leakage Risk Types in Pedicle Screw Augmentation for Degenerative Lumbar Stenosis in Osteoporotic Vertebrae.

BACKGROUND: The use of cement in pedicle screw augmentation (PSA) enhances the pullout force of pedicle screws in vertebrae affected by osteoporosis. Risks involved in the use of cement for PSA include nerve injury and vascular damage caused by cement leakage. METHODS: This study included all patients who received PSA for degenerative lumbar stenosis in osteoporotic vertebrae from January 2014 to May 2022. Postoperative computed tomography was used to assess cement leakage. Correlation analysis and logistic regression analyses were used to establish the associated clinical or radiological factors, which were then used to construct nomograms and web calculators. RESULTS: The study comprised 181 patients including 886 screws inserted into 443 vertebrae. Perivertebral cement leakage was significantly associated with female sex, decreased bone mineral density, solid screws, and scattered cement distribution. Cement leakage through segmental veins (type S, 72.1%), leakage through basivertebral veins (type B, 23.9%), and instrument-related leakage (type I, 13.9%) accounted for most cement leakage. Patients with lower bone mineral density and scattered cement distribution were more likely to experience type S or type B leakage. Our analysis data showed that cement augmentation with cannulated and fenestrated screws tended toward concentrated cement distribution. Creation and verification of each nomogram additionally showcased the prognostic capability and medical significance of the corresponding model. CONCLUSIONS: Nomograms and web-based calculators can accurately forecast the probability of cement leakage. PSA should be routinely performed using cannulated and fenestrated screws, along with a moderate amount of high-viscosity cement, with continuous monitoring using fluoroscopy.

Navigated Exoscopic Transtubular Approach for Lumbar Decompression: Surgical Video.

Tubular retractors in minimally invasive lumbar stenosis permit surgeons to achieve satisfactory neural decompression while minimizing the morbidity of the surgical access.1-3 Transtubular lumbar decompression requires intraoperative image guidance and microscopic magnification to achieve precise and reproductible surgical results. Use of 2-dimensional image guidance in transtubular lumbar decompression has a major limitation due to the lack of multiplanar orientation. Consequently, there is a risk of incomplete decompression and excessive bone removal resulting in iatrogenic instability. Furthermore, available microscopes have limited optics (short focal lengths) and unsatisfactory surgeon ergonomics. To overcome these limitations, the authors present a step-by-step video of the navigated exoscopic transtubular approach (NETA) for spinal canal decompression (Video 1). The patient suffers from bilateral L5 radiculopathy due to L4-L5 bilateral synovial cysts responsible for severe L4-L5 canal stenosis. During the entire surgical procedure, NETA implements the use of navigation based on intraoperative 3-dimensional (3D) fluoroscopic images for retractor placement, bone mapping, and neural decompression.4 NETA represents a modification of the "standard" MIS transtubular technique for bilateral lumbar decompression. NETA is based on the use of neuronavigation during each surgical step to guide the placement of tubular retractor. This tailors the bone resection to achieve adequate neural decompression while minimizing the risks of potential spine instability. After precise placement of the tubular retractor, bone removal and neural decompression are accomplished under robotic exoscope magnification with 4k 3D images. Using a 3D robotic exoscope (Modus V, Synaptive, Toronto, Canada) allows better tissue magnification and improves surgeon ergonomics during lumbar decompression through tubular retractors.5,6.

Decompression Alone Versus Interspinous/Interlaminar Device Placement for Degenerative Lumbar Pathologies: Systematic Review and Meta-Analysis.

INTRODUCTION: Interspinous devices (ISDs) and interlaminar devices (ILDs) are marketed as alternatives to conventional surgery for degenerative lumbar conditions; comparisons with decompression alone are limited. The present study reviews the extant literature comparing the cost and effectiveness of ISDs/ILDs with decompression alone. METHODS: Articles comparing decompression alone with ISD/ILD were identified; outcomes of interest included general and disease-specific patient-reported outcomes, perioperative complications, and total treatment costs. Outcomes were analyzed at <6 weeks, 3 months, 6 months, 1 year, 2 years, and last follow-up. Analyses were performed using random effects modeling. RESULTS: Twenty-nine studies were included in the final analysis. ILD/ISD showed greater leg pain improvement at 3 months (mean difference, -1.43; 95% confidence interval, [-1.78, -1.07]; P < 0.001), 6 months (-0.89; [-1.55, -0.24]; P = 0.008), and 12 months (-0.97; [-1.25, -0.68]; P < 0.001), but not 2 years (P = 0.22) or last follow-up (P = 0.09). Back pain improvement was better after ISD/ILD only at 1 year (-0.87; [-1.62, -0.13]; P = 0.02). Short-Form 36 physical component scores or Zurich Claudication Questionnaire (ZCQ) symptom severity scores did not differ between the groups. ZCQ physical function scores improved more after decompression alone at 6 months (0.35; [0.07, 0.63]; P = 0.01) and 12 months (0.23; [0.00, 0.46]; P = 0.05). Oswestry Disability Index and EuroQoL 5 dimensions scores favored ILD/ISD at all time points except 6 months (P = 0.07). Reoperations (odds ratio, 1.75; [1.23, 2.48]; P = 0.002) and total care costs (standardized mean difference, 1.19; [0.62, 1.77]; P < 0.001) were higher in the ILD/ISD group; complications did not differ significantly between the groups (P = 0.41). CONCLUSIONS: Patient-reported outcomes are similar after decompression alone and ILD/ISD; the observed differences do not reach accepted minimum clinically important difference thresholds. ISD/ILDs have higher associated costs and reoperation rates, suggesting current evidence does not support ILD/ISDs as a cost-effective alternative to decompression alone.

[ Symptomatic Triple-Region Spinal Stenosis (TRSS): case report and narrative Literature Review] / Estenosis Espinal de Triple Región Sintomática (EETRS): reporte de un caso y revisión narrativa de la literatura.

Introduction: Simultaneous spinal stenosis in three regions of the spine is an unusual condition that demands proper clinical evaluation and imaging. Currently, there are no established guidelines for its diagnostic and therapeutic approach. Objective: The objective of this study is to describe, based on a case report, the clinical presentation, treatment, and patient progression concerning triple stenosis, contrasting it with available evidence through a narrative review of the literature. Case Presentation: A 69-year-old woman presented with a progressive paraparesis accompanied by right sciatica and positive signs of upper motor neuron involvement. Imaging confirmed triple stenosis: cervical, dorsal, and lumbar. Dorsal decompression and tumor resection were performed in association with conservative treatment for cervical and lumbar stenosis, resulting in a favorable evolution one year post-surgery. Conclusion: Symptomatic triple-region spinal stenosis is an unusual condition. Proper clinical and radiological assessments will enable accurate diagnosis and timely management.

Introducción: La estenosis espinal de las tres regiones de la columna en simultáneo es una entidad infrecuente, que requiere una adecuada valoración clínica e imagenológica. Actualmente no existen guías establecidas para su abordaje diagnóstico y terapéutico. Objetivo: El objetivo de este trabajo es describir, partiendo del reporte de un caso, la presentación clínica, el tratamiento y la evolución en un paciente con triple estenosis y contrastarlo con la evidencia disponible a través de una revisión narrativa de la literatura. Presentación del caso: Mujer de 69 años de edad que consultó con un cuadro de paraparesia progresiva asociado a ciatalgia derecha y signos de motoneurona superior positivos. Imagenologicamente se constató una triple estenosis: cervical, dorsal y lumbar, realizándose una descompresión y resección tumoral dorsal asociado al tratamiento conservador de las estenosis cervical y lumbar, con una evolución favorable al año postquirúrgico. Conclusión: La estenosis espinal de triple región sintomática es una condición rara, las valoraciones clínicas y radiológicas adecuadas permitirán un diagnóstico correcto con un abordaje adecuado y oportuno.

Clinical and radiological outcome of stand-alone percutaneous pedicle screw fixation (SAPF) versus minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). A propensity-matched cohort study.

In adult patients affected by degenerative disc disease with lumbar instability and chronic low back pain, spine surgery with lumbar fixation aims to reduce segmental instability and pain. Different techniques have been developed, but the optimal surgical technique remains controversial. No studies have compared the clinical and radiological outcomes between stand-alone pedicle screw fixation (SAPF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). This was a retrospective study. All patients who underwent surgery for single-level L4-L5 or L5-S1 lumbar stenosis, associated with minor lumbar instability and treated with SAPF or MI-TLIF techniques were included in the study. Data were collected preoperatively and at 24 monts follow-up. Clinical primary outcomes were Oswestry Disability Index (ODI) and Numerical Rating Scale (NRS). Secondary outcomes were patient satisfaction, walking ability and self reported back and leg pain. In addition, perioperative data and complications were recorded. Segmental lordosis (L4-L5 and L5-S1) and overall lumbar lordosis (L1-S1) were measured on lumbar X-Rays preoperatively and at least 24 months postoperatively. 277 patients were firstly identified. Baseline data and a minimum of two-year follow-up were available for 62 patients. After the propensity score matching, 44 patients (22 patients in the SAPF group and 22 patients in the MI-TLIF group) were matched. At 24 months follow-up, no difference between the two groups of patients in NRS (p = 0.11) and ODI scores (p = 0.21) were observed. Patients' satisfaction at follow-up was also not significantly different between the two groups. In both groups, a significant improvement in the walked distance was observed after surgery (p = 0.05) while no difference was observed regarding the type of surgery performed (p = 1.00). No differences were found in the pre- and post-operative median lumbar lordosis (p = 0.91 and p = 0.67) and the same findings were observed for lumbar segmental lordosis (p = 0.65 and p = 0.41 respectively). Significant improvements in ODI and NRS-scores were recorded after 24 months follow-up with both SAPF and MI-TLIF. No significant differences in postoperative PROMs and patients' satisfaction were observed between the groups. The results of our study indicate no superiority of either surgical technique concerning pain and functional outcomes after 24 months.

Clinical Outcomes of Prone Transpsoas Lumbar Interbody Fusion: A 1-Year Follow-Up.

BACKGROUND: Lateral lumbar interbody fusion (LLIF) is commonly used to address various lumbar pathologies. LLIF using the prone transpsoas (PTP) approach has several potential advantages, allowing simultaneous access to the anterior and posterior columns of the spine. The aim of this study was to report the 1-year outcomes of LLIF via PTP. METHODS: This is a retrospective review of 97 consecutive patients who underwent LLIF via PTP. Radiographic parameters, including lumbar-lordosis, segmental-lordosis, anterior disc height, and posterior disc height, were measured on preoperative, initial-postoperative, and 1-year postoperative imaging. Patient-reported outcomes measures, including Oswestry Disability Index, visual analog scale (VAS), pain EQ5D, and postoperative complications, were reviewed. RESULTS: Ninety-seven consecutive patients underwent 161 levels of LLIF. Fifty-seven percent underwent 1-level LLIF, 30% 2-level LLIF, 6% 3-level LLIF, and 7% 4-level LLIF. The most common level was L4 to L5 (35%), followed by L3 to L4 (33%), L2 to L3 (21%), and L1 to L2 (11%). Significant improvements were noted at initial and 1-year postoperative periods in lumbar-lordosis (2° ± 10°, P = 0.049; 3° ± 9°, P = 0.005), segmental-lordosis (6° ± 5°, P < 0.001; 5° ± 5°, P < 0.001), anterior disc height (8 mm ± 4 mm, P < 0.001; 7 mm ± 4 mm, P < 0.001), and posterior disc height (3 mm ± 2 mm, P < 0.001; 3 mm ± 2 mm, P < 0.001). Significant improvements were seen in Oswestry Disability Index at 6 weeks (P = 0.002), 6 months (P < 0.001), and 1 year (P < 0.001) postoperatively; pain EQ5D at 6 weeks (P < 0.001), 6 months (P < 0.001), and 1 year (P < 0.001) postoperatively; and leg and back visual analog scale at 2 weeks (P < 0.001), 6 months (P < 0.001), and 1 year (P < 0.001) postoperatively. The average length of stay was 2.5 days, and the most common complications were ipsilateral hip flexor pain (46%), weakness (59%), and contralateral hip flexor pain (29%). CONCLUSION: PTP is a novel way of performing LLIF. These 1-year data support that PTP is an effective, safe, and viable approach with similar patient-reported outcome measures and complications profiles as LLIF performed in the lateral decubitus position.

A prospective study of lumbar facet arthroplasty in the treatment of degenerative spondylolisthesis and stenosis: cost-effective assessment from the Total Posterior Spine system (TOPSTM) IDE Study: 2-year model revision and sensitivity analyses based on 305 subjects.

BACKGROUND CONTEXT: A previous cost-effectiveness analysis published in 2022 found that the Total Posterior Spine (TOPSTM) system was dominant over transforaminal lumbar interbody fusion (TLIF). This analysis required updating to reflect a more complete dataset and pricing considerations. PURPOSE: To evaluate the cost-effectiveness of TOPSTM system as compared with TLIF based on an updated and complete FDA investigational device exemption (IDE) data set. STUDY DESIGN/SETTING: Cost-utility analysis of the TOPSTM system compared to TLIF. PATIENT SAMPLE: A multicenter, FDA IDE, randomized control trial (RCT) investigated the efficacy of TOPSTM compared to TLIF with a current population of n=305 enrolled and n=168 with complete 2-year follow-up. OUTCOME MEASURES: Cost and quality adjusted life years (QALYs) were calculated to determine our primary outcome measure, the incremental cost-effectiveness ratio. Secondary outcome measures included: net monetary benefit as well at willingness-to-pay (WTP) thresholds. METHODS: The primary outcome of cost-effectiveness is determined by incremental cost-effectiveness ratio. A Markov model was used to simulate the health outcomes and costs of patients undergoing TOPSTM or TLIF over a 2-year period. alternative scenario sensitivity analysis, one-way sensitivity analysis, and probabilistic sensitivity analysis were conducted to assess the robustness of the model results. RESULTS: The updated base case result demonstrated that TOPSTM was immediately and longitudinally dominant compared with the control with an incremental cost-effectiveness ratio of -9,637.37 $/QALY. The net monetary benefit was correspondingly $2,237, both from the health system's perspective and at a WTP threshold of 50,000 $/QALY at the 2-year time point. This remained true in all scenarios tested. The Alternative Scenario Sensitivity Analysis suggested cost-effectiveness irrespective of payer type and surgical setting. To remain cost-effective, the cost difference between TOPSTM and TLIF should be no greater than $1,875 and $3,750 at WTP thresholds of $50,000 and 100,000 $/QALY, respectively. CONCLUSIONS: This updated analysis confirms that the TOPSTM device is a cost-effective and economically dominant surgical treatment option for patients with lumbar stenosis and degenerative spondylolisthesis compared to TLIF in all scenarios examined.

Influencia de la obesidad en los resultados del tratamiento quirúrgico de la estenosis lumbar degenerativa / Obesity Influence on the Surgical Treatment Results of Degenerative Lumbar Stenosis

Introducción: La estenosis lumbar degenerativa altera la calidad de vida y disminuye la capacidad funcional en adultos mayores. La obesidad representa un problema de la salud mundial actual. Objetivo: Detallar los efectos de la obesidad sobre el riesgo quirúrgico, los índices de complicaciones posoperatorias y los resultados funcionales en pacientes adultos mayores sometidos a cirugía electiva por estenosis lumbar degenerativa. Métodos: Estudio prospectivo-descriptivo, con pacientes adultos mayores intervenidos quirúrgicamente por diagnóstico de estenosis lumbar degenerativa y valorados un año después. Resultados: 55 pacientes, 23 obesos, 32 no obesos; relación de sexos 1,5:1 masculino-femenino, mayor cantidad de espacios intervenidos, tiempo quirúrgico y pérdida de sangre en obesos. Los obesos presentaron un mayor número de complicaciones postquirúrgicas y resultados funcionales menos buenos. Conclusiones: La obesidad constituye un mayor riesgo quirúrgico, que, aunque la diferencia en los resultados clínicos no sea muy importante, provoca intervenciones más prolongadas y mayor incidencia de complicaciones quirúrgicas(AU)

Introduction: Degenerative lumbar stenosis alters quality of life and decreases functional capacity in older adults. Obesity represents a current global health problem. Objective: To detail the effects of obesity on surgical risk, postoperative complication rates, and functional outcomes in older patients undergoing elective surgery for degenerative lumbar stenosis. Methods: Prospective-descriptive study with elderly patients who underwent surgery for a diagnosis of degenerative lumbar stenosis, who were evaluated one year later. Results: Fifty-five patients, 23 obese, 32 non-obese; sex ratio 1.5:1 male-female, higher number of intervened spaces, surgical time and blood loss in obese subjects. The obese patients showed higher number of post-surgical complications and less good functional results. Conclusions: Obesity constitutes a higher surgical risk, even when the difference in clinical results is not very important, it causes longer interventions and higher incidence of surgical complications(AU)

Surgical treatment for lumbar spinal stenosis: a single-blinded randomized controlled trial

Abstract Objective: To evaluate the effectiveness of surgery for the management of patients with symptomatic lumbar spinal stenosis. Methods: Sixty-three patients with lumbar canal stenosis were randomized into two groups: the intervention group (IG) and control group (CG). IG patients underwent surgery and both groups participated in the same physical therapy program twice a week for a period of 12 weeks and were followed up at 1 year. The primary endpoint was visual analogue scale for pain, and the secondary endpoints were function (6-min walk test, Roland Morris and Oswestry questionnaires), quality of life (SF-36 questionnaire) and satisfaction with treatment (Likert scale). Results: No significant difference between groups was observed for pain over time (p = 0.145). Significant differences between groups, in favor of the IG, were observed for the Oswestry score (p = 0.006) and vitality domain score of the SF-36 (p = 0.047). Function in the Roland Morris and 6-min walk test and the role of the physical domain of SF-36 also showed significant differences between the groups; however, these differences occurred due to a worsening of the IG in the short term, and the medium-term. The Likert scale demonstrated greater satisfaction with the IG treatment compared to control group. Conclusions: Lumbar stenosis surgery did not improve pain in short and medium terms. Function and vitality were better in the group that underwent surgery in the medium term, and patients were more satisfied with the surgical treatment. Trial registration: Clinicaltrials.gov (NCT02879461).

Evaluación funcional mediante la escala de oswestry en pacientescon artrodesis postero-lateral por canal lumbar estrecho / Functional evaluation by oswestry disability index in patients with postero-lateral arthrodesis for lumbar spinal stenosis

OBJETIVOS: Establecer la evolución funcional y condición neurológica con la escala de Oswestry en la biomecánica de la columna lumbar en pacientes que fueron intervenidos mediante descompresión neurológica y artrodesis posterolateral más estabilización con tornillos transpediculares por presentar diagnóstico de canal lumbar estrecho (CLE) en el Hospital Obrero N°1 de la ciudad de La Paz, Bolivia, durante las gestiones 2012 a 2014. Identificar los factores clínicos, socio-demográficos de pacientes en los cuales se realizó artrodesis en columna vertebral por canal lumbar estrechó. MÉTODOS: Se realizó un estudio retrospectivo, descriptivo, de corte transversal de pacientes en los cuales se realizó artrodesis postero-lateral por CLE en el servicio de ortopedia traumatología entre las gestiones 2012-2014, en el Hospital Obrero Nro1. Se evaluó 16 pacientes que cumplieron los criterios de inclusión. RESULTADOS: Según valoración de la escala de Oswestry: un 56% de pacientes tienen limitación funcional mínima y un 6% discapacidad a los 6 meses post operatorio. El género más afectado fue el femenino con un 57%, la edad promedio fue de 64 años, el tiempo previo al tratamiento quirúrgico fue mayor a 12 meses en el 63%, los niveles instrumentados más frecuentes fueron de L3-L5 y L5-S1 con un 25%. CONCLUSIONES: Se realizaron técnicas quirúrgicas descompresivas: laminectomia, foraminectomia con instrumentación. El índice de discapacidad de Oswestry permite valorar que la técnica fue efectiva debido a que los pacientes presentan una evolución funcional sin limitaciones en su vida cotidiana en la mayoría de los casos.

OBJECTIVES: To stablish the functional evolution and neurological condition through Oswestrydisability index (ODI)inthe biomechanics of the lumbar spine in patients who underwent neurological decompression and posterolateral arthrodesisand transpedicular screws stabilization by presenting lumbar spinalstenosis(LSS) in Obrero Hospital N° 1, La Paz city, Bolivia. To identify clinical, social and demographic factors of patients with degenerative lumbar spinal stenosis in which postero-lateral arthrodesis was performed. METHODS: A retrospective, descriptive and cross-sectional study between 2012 and 2014 was conducted. Patients who were treated with postero-lateral arthrodesis for lumbar spinal stenosis, in the traumatology service at Obrero Hospital in La Paz city were considered. We evaluated 16 patients who met the inclusion criteria. RESULTS: According to Oswestrydesability index, 56% of the patients have minimal functional limitation and 6% of disability at 6-month postoperative. The most affected gender were females with 57%, the average age was 64 years, prior time to surgical treatment was more than 12 months in 63%, and the most frequent instrumented levels were L3-L5 and L5-S1 with 25%. CONCLUSIONS: We performed decompressive surgical techniques: laminectomy, foraminotomy with instrumentation. Oswestry disability index helped to determine the applied techniqueswere effective. In most cases, patients displayed a functional evolution without limitations in their daily lives.

Surgical treatment of the osteoporotic spine with bone cement-injectable cannulated pedicle screw fixation: technical description and preliminary application in 43 patients

OBJECTIVES: To describe a new approach for the application of polymethylmethacrylate augmentation of bone cement-injectable cannulated pedicle screws. METHODS: Between June 2010 and February 2013, 43 patients with degenerative spinal disease and osteoporosis (T-score <-2.5) underwent lumbar fusion using cement-injectable cannulated pedicle screws. Clinical outcomes were evaluated using a Visual Analog Scale and the Oswestry Disability Index. Patients were given radiographic follow-up examinations after 3, 6, and 12 months and once per year thereafter. RESULTS: All patients were followed for a mean of 15.7±5.6 months (range, 6 to 35 months). The Visual Analog Scale and Oswestry Disability Index scores showed a significant reduction in back pain (p = 0.018) and an improvement in lower extremity function (p = 0.025) in patients who underwent lumbar fusion using the novel screw. Intraoperative cement leakage occurred in four patients, but no neurological complications were observed. Radiological observation indicated no loosening or pulling out of the novel screw, and bone fusion was excellent. CONCLUSIONS: The described polymethylmethacrylate augmentation technique using bone cement-injectable cannulated pedicle screws can reduce pain and improve spinal dysfunction in osteoporotic patients undergoing osteoporotic spine surgery. .

Resultado del tratamiento quirúrgico de la estenosis lumbar degenerativa en el adulto mayor / Résultats du traitement chirurgical de la sténose lombaire dégénérative chez les personnes âgées / Results of surgical treatment of degenerative lumbar stenosis in the older adult

Introducción: la estenosis lumbar degenerativa en pacientes adultos mayores constituye un grave problema de salud actual. El tratamiento quirúrgico parece ser el de mejor resultado, pero presenta la disyuntiva de si a todos los pacientes que padezcan esta enfermedad se les debe tratar con igual técnica. Objetivos: mostrar los resultados obtenidos en el tratamiento quirúrgico de la estenosis lumbar degenerativa en pacientes mayores de 65 años. Métodos: se realizó un estudio descriptivo prospectivo en pacientes mayores de 65 años con diagnóstico de estenosis lumbar degenerativa, en el Centro de investigaciones en Longevidad, Envejecimiento y Salud, entre el 1 de enero de 2009 y el 1 de enero de 2011 (ambos incluidos). La serie quedó constituida por 28 pacientes. Las variables estudiadas fueron: edad, sexo, sintomatología, localización, principales condiciones comorbidas, clasificación radiográfica y por resonancia magnética. Se seleccionó la técnica quirúrgica empleada atendiendo al área anatómica estenosada. Se empleó el índice de Oswestry y la escala Visual Analógica de dolor como instrumentos evaluadores. Resultados: predominó el sexo masculino (67,6 por ciento), la localización en dos niveles vertebrales, y las condiciones comorbidas cardiovasculares. El síntoma predominante mostró valores semejantes entre el dolor lumbar, el irradiado y la claudicación. El índice de Oswestry y la Escala Visual Analógica del dolor mostraron significativa mejoría en el posquirúrgico. Se obtuvo un 89,2 porciento de buenos resultados. Conclusiones: el empleo de laminectomía para las estenosis centrales y recalibraje para las de receso lateral parece ser adecuada(AU)

Introduction: degenerative lumbar spinal stenosis is a serious health problem in the older adults at present. The surgical treatment seems to attain better results, but the controversy is whether all the patients suffering the disease can be treated with this procedure or not. Objectives: to show the results of the surgical treatment of degenerative lumbar spinal stenosis in over 65 years-old patients. Methods: a prospective and descriptive study was carried out in patients aged over 65 years and diagnosed with degenerative lumbar spinal stenosis in the Center of Research on Old Age, Aging and Health from January 1st 2009 to January 1st, 2011. The series was finally made up of 28 patients. The study variables were age, sex, symptoms, location, main comorbid conditions, and classification according to radiographies and to magnetic resonance. The choice of the surgical technique depended on the stenosed anatomical area. The Oswestry Disability Index and the Analogue Visual Scale of pain were the evaluation instruments. Results: males (67.6 percent), the location of disease at two vertebral levels and comorbid cardiovascular conditions prevailed. The predominant symptom showed similar values among lumbar pain, the irradiated pain and claudication. Oswestry Disability Index and the Analog Visual Scale of pain showed the significant improvement of patient in the postsurgical period. Good results reached 89.2 perent. Conclusions: laminectomy for central stenosis and regaging for the lateral recess seem to be adequate(AU)

Introduction: des nos jours, la sténose lombaire dégénérative constitue un sérieux problème de santé chez les personnes âgées. La chirurgie paraît être le traitement le plus prometteur, mais une question se pose, est-ce que tous les patients atteints de cette maladie doivent être traités par la même technique? Objectif: le but de cette étude est de montrer les résultats obtenus avec le traitement chirurgical de la sténose lombaire dégénérative chez les personnes âgées de plus de 65 ans. Méthode: une étude descriptive prospective de patients âgés de plus de 65 ans, diagnostiqués de sténose lombaire dégénérative, a été réalisée au Centre de recherches sur la longévité, le vieillissement et la santé entre le 1e janvier 2009 et le 1e janvier 2011. La série a été conformée de 28 patients. Les variables en étude comprennent âge, sexe, symptomatologie, localisation, comorbidité, classification radiographique et RM. La technique chirurgicale a été déterminée en accord avec la localisation de la sténose; l'index d'Oswestry et l'Échelle visuelle analogique (EVA) de la douleur ont été utilisés comme instruments d'évaluation. Résultats: dans l'étude, quelques variables ont prédominé (67.6 pourcent du sexe masculin, localisation à deux niveaux vertébraux, comorbidité cardiovasculaire, irradiation de la douleur lombaire, et claudication). L'index d'Oswestry et l'Échelle visuelle analogique de la douleur ont montré une amélioration significative dans le post-chirurgical. En général, on a obtenu de très bons résultats (89.2 pourcent). Conclusions: Dans le cas de la sténose centrale et de la sténose latérale, la laminectomie et le récalibrage respectivement semblent être appropriées(AU)

Tratamiento quirúrgico de la estenosis lumbar degenerativa del adulto mayor según la imagenología / Traitement chirurgical de la sténose lombaire dégénérative chez les personnes âgées, d'après les résultats d'imagerie / Surgical treatment of degenerative lumbar stenosis in elderly patients based on imaging findings

Introducción: la estenosis lumbar degenerativa en pacientes adultos mayores constituye un grave problema de salud actual. Objetivo: demostrar la validez del tratamiento quirúrgico de la estenosis lumbar degenerativa del adulto mayor cuando la decisión del tipo de técnica a realizar se determina por los hallazgos imagenológicos por rayos X y resonancia magnética. Métodos: se estudiaron 102 pacientes mayores de 65 años, atendidos en el Centro de investigaciones en Longevidad, Envejecimiento y Salud, entre el 1 de enero de 2002 y el 31 de diciembre de 2008, ambos incluidos. Las variables estudiadas fueron: edad, sexo, localización, principales condiciones comorbidas, clasificación por rayos X y por resonancia magnética. La decisión de la técnica quirúrgica empleada estuvo en relación con los hallazgos imagenológicos, se empleó el índice de Oswestry y la escala visual analógica de dolor como instrumentos evaluadores. Las técnicas quirúrgicas fueron: liberación simple, recalibraje y laminectomía, instrumentación y fusión. Resultados: hubo predominio del sexo masculino, entre 65 y 70 años de edad con localización en dos niveles vertebrales y condiciones comorbidas cardiovasculares, el mayor número de casos se encontró en los grados 3 y 4 de Kellgren y IV y V de Pfirrmann. El índice de Oswestry y la escala visual analógica del dolor mostraron significativa mejoría a los dos años y se obtuvo el 88 por ciento de buenos resultados. Conclusiones: determinar la técnica quirúrgica a emplear según los hallazgos imagenológicos, permite obtener buenos resultados en altos porcentajes de pacientes intervenidos. La relación imagenología/técnica quirúrgica, es adecuada(AU)

Introduction: degenerative lumbar stenosis in elderly patients is a serious health problem. Objective: demonstrate the validity of the surgical treatment of degenerative lumbar stenosis in elderly patients when decision on what technique to apply is based on X-ray and magnetic resonance imaging findings. Methods: a study was conducted of 102 patients aged over 65 cared for at the Center for Research on Longevity, Aging and Health from 1 January 2002 to 31 December 2008. The variables considered were age, sex, location, main comorbid conditions, and classification based on X-ray and magnetic resonance imaging. Decision on the surgical technique to apply was based on imaging findings. The Oswestry index and the Pain Visual Analog Scale were used as evaluation instruments. The surgical techniques applied were simple release, recalibration and laminectomy, instrumentation and fusion. Results: there was a predominance of male patients in the 65-70 age group with location at two vertebral levels and cardiovascular comorbid conditions. The largest number of cases were classed as degrees 3 and 4 on Kellgren's scale, and IV and V on Pfirrmann's. The Oswestry index and the Pain Visual Analog Scale showed significant improvement at two years, and 88 percent of the results obtained were good. Conclusions: determination of the surgical technique to apply based on imaging findings makes it possible to obtain good results in a high percentage of the patients undergoing surgery. There is an appropriate relationship between imaging findings and surgical technique(AU)

Introduction: de nos jours, la sténose lombaire dégénérative chez des patients âgés constitue un problème grave de santé. Objectif: le but de cette étude es de démontrer la validité du traitement chirurgical de la sténose lombaire dégénérative chez les personnes âgées lorsque la technique à utiliser est décidée par imagerie (rayons-X et résonance magnétique). Méthodes: cent-deux patients âgés de 65 ans ont été étudiés et traités au Centre de recherches de la longévité, le vieillissement et la santé entre le 1e janvier 2002 et le 31 décembre 2008. Les variables étudiées ont compris l'âge, le sexe, la localisation, les principales conditions de comorbidité, et la classification par rayons-X et résonance magnétique. Le choix de la technique chirurgicale à utiliser a été en rapport avec les résultats d'imagerie, et les instruments d'évaluation ont compris l'indice d'Oswestry et l'échelle visuelle analogique de la douleur. Les techniques chirurgicales ont compris la libération simple, le recalibrage et la laminectomie, l'instrumentation et la fusion. Résultats: les patients du sexe masculin, âgés de 65 - 70 ans, avec une sténose localisée à deux niveaux vertébraux, une comorbidité cardiovasculaire, en grades 3 et 4 de Kellgren, et IV et V de Pfirmann en majorité, ont été les plus souvent touchés. L'indice d'Oswestry et l'échelle visuelle analogique de la douleur ont montré une amélioration significative en deux ans, et la plupart de cas a eu de bons résultats (88 pourcent). Conclusions: le choix de la technique chirurgicale selon les résultats d'imagerie permet d'atteindre de bons résultats dans un grand nombre de patients opérés. Le rapport entre l'imagerie et la technique chirurgicale est effectivement approprié(AU)

Degenerative lumbar stenosis: update / Estenose lombar degenerativa: atualização

We present a literature review of the diagnosis and treatment of acquired lumbar spinal stenosis (LS), with a brief description of new surgical techniques. LS is the most common cause of spinal surgery in individuals older than 65 years of age. Neurogenic claudication and radiculopathy result from compression of the cauda equina and lumbosacral nerve roots by degenerated spinal elements. Surgical decompression is a well established treatment for patients with refractory, or moderate to severe clinical symptoms. However, the variety of surgical options is vast. New techniques have been developed with the goal of increasing long term functional outcomes. In this article we review lumbar decompression and fusion as treatment options for LS but also present other recent developments. Prospective long term studies are necessary to know which procedures would result in optimal patient outcome.

Apresentamos uma revisão de literatura do diagnóstico e tratamento da estenose lombar (EL) adquirida, enfatizando as novas técnicas de manejo cirúrgico. A EL é a causa mais comum de cirurgia na coluna de pacientes com mais de 65 anos de idade. Claudicação neurogênica e radiculopatias são sintomas resultantes da compressão das raízes lombossacrais pelos elementos degenerados. A descompressão cirúrgica é um procedimento bem estabelecido para pacientes com sintomas severos ou refratários ao tratamento clínico. Contudo, as opções cirúrgicas são amplas. Novas técnicas de fusão e artrodese são úteis para melhorar os resultados funcionais. Neste artigo, varias alternativas cirúrgicas são apresentadas, incluindo as novas tecnologias na área. Evidências científicas mais contundentes com seguimento longo são necessárias para a incorporação destas práticas na atividade médica de rotina.