Effective Posterior Lumbar Decompression and Fusion Strategies

What is Lumbar Spinal Stenosis?

Lumbar spinal stenosis (LSS) is when the spinal canal in the lower back narrows over time, which can compress the spinal cord and nerves, thus causing pain, numbness, or weakness in the legs. Lumbar spinal stenosis is caused by impingement on the neural elements, due to a combination of anatomic considerations including: the intervertebral disc, hypertrophic facet capsule, ligamentum flavum, impinging osteophytes and vertebral body instability. Degenerative conditions such as Lumbar Spinal Stenosis (LSS) are one of the most common diseases of the spine with up to 75% of elderly individuals displaying moderate to severe stenosis on MRI. 

What are the symptoms of Spinal Stenosis?

The most common symptoms of spinal stenosis include neurogenic claudication (the feeling of heaviness, numbness or tingling in the lower back, buttocks and thighs) or radiculopathy (a radiating electrical or sharp sensation traveling down the leg).

Should I have surgery for Spinal Stenosis?

While nonoperative treatments can be effective in providing temporary symptom relief, LSS is a progressive disease successfully treated by surgical decompression once conservative measures fail.  There is good medical evidence that patients with symptomatic spinal stenosis, who are addressed surgically, have higher functional outcomes than those who receive non-operative treatment.

What type of treatment is effective for Spinal Stenosis?

The largest prospective study, the Spine Outcomes Research Trial (SPORT) has solidly established Open Direct Decompression to be an effective treatment method, with superior outcomes to non-operative care in both the short and midterm follow up (with results currently established out to 4 years).  The SPORT trials additionally showed a relatively low complication profile with a reoperation rate of 8% at 2 years and 13% at 4 years.

(Reference: Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial )

Describe what happens during spinal stenosis surgery?

Direct decompression through removal of the offending bone or soft tissue remains a common effective method of reducing encroachment on the involved neural elements. The key to an adequate decompression while preserving the stability of the motion segment is by undercutting the facet joint and preserving the pars interarticularis. The most frequent approach utilizes a direct posterior incision and newer techniques being developed, which utilize a minimally invasive approach or tubular retractor coupled with microscope or endoscopic camera visualization.

Direct open decompression has been established to be effective for treatment of LSS in several retrospective and prospective trials comparing direct surgical decompression with non-operative care, including physiotherapy and nonsteroidal anti-inflammatory medications, among 94 patients with spinal stenosis. Improvement was found in both groups, with a larger improvement in Oswestry Disability Index (ODI) at 1 year in the surgical group and a slight loss in gains at 2 year follow up.

When is a fusion with screws and rods included in Spinal Stenosis surgery?

Studies evaluating outcomes in patients with spinal stenosis, along with a spondylolisthesis (slipping forward of one vertebral body upon the one below), found approximately one-third of patients experienced subjective improvement in back pain and 55% described improved leg pain symptoms at 3 years follow up, with significantly better results in patients in whom spinal fusion with instrumentation (screws and rods) was also performed.

(Reference: Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. )

What are the benefits of Posterior Lumbar Decompression and Fusion?

There are several benefits when it comes to being treated with Posterior Lumbar Decompression and Fusion:

• Pain relief
• Improved nerve function
• Increased spinal stability
• Enhanced quality of life

What type of complications can happen during Spinal Stenosis surgery?

The most common complications of a lumbar decompression surgery for lumbar spinal stenosis include:

• Nerve root damage
• Dural tear
• Infection
• Bleeding
• Post-operative instability at the operative levels.

Conclusion

I encourage patients to discuss all treatment options with their doctor to determine the best course of action. To make an appointment with myself or a fellow Rothman Spine specialist, visit our Appointments page.