Correction of Spinal Sagittal Alignment after Posterior Lumbar Decompression: Does Severity of Central Canal Stenosis Matter?

Trenchfield Delano,Lee Yunsoo,Lambrechts Mark J.,D’Antonio Nicholas,Heard Jeremy,Paulik John,Somers Sydney,Rihn Jeffrey A.,Kurd Mark,Kaye David,Canseco Jose,Hilibrand Alan,Vaccaro Alexander Richard,Ke 대한척추외과학회 2023 Asian Spine Journal Vol.17 No.6

Study Design: This study adopted a retrospective study design.Purpose: Our study aimed to investigate the impact of central canal stenosis severity on surgical outcomes and lumbar sagittal correction after lumbar decompression.Overview of Literature: Studies have evaluated sagittal correction in patients with central canal stenosis after lumbar decompression and the association of stenosis severity with worse preoperative sagittal alignment. However, none have evaluated the impact of spinal stenosis severity on sagittal correction.Methods: Patients undergoing posterior lumbar decompression (PLD) of ≤4 levels were divided into severe and non-severe central canal stenosis groups based on the Lee magnetic resonance imaging (MRI) grading system. Patients without preoperative MRI or inadequate visualization on radiographs were excluded. Surgical characteristics, clinical outcomes, and sagittal measurements were compared. Multivariate logistic regression was performed to determine the predictors of pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), and pelvic incidence minus lumbar lordosis (PI–LL).Results: Of the 142 patients included, 39 had severe stenosis, and 103 had non-severe stenosis. The mean follow-up duration for the cohort was 4.72 months. Patients with severe stenosis were older, had higher comorbidity indices and levels decompressed, and longer lengths of stay and operative times (<i>p</i> <0.001). Although those with severe stenosis had lower lordosis, lower SS, and higher PI–LL mismatch preoperatively, no differences in Delta LL, SS, PT, or PI–LL were observed between the two groups (<i>p</i> >0.05). On multivariate regression, severe stenosis was a significant predictor of a lower preoperative LL (estimate=−5.243, <i>p</i> =0.045) and a higher preoperative PI–LL mismatch (estimate=6.192, <i>p</i> =0.039). No differences in surgical or clinical outcomes were observed (<i>p</i> >0.05).Conclusion: Severe central lumbar stenosis was associated with greater spinopelvic mismatch preoperatively. Sagittal balance improved in both patients with severe and non-severe stenosis after PLD to a similar degree, with differences in sagittal parameters remaining after surgery. We also found no differences in postoperative outcomes associated with stenosis severity.

요추 전만 각도 및 요추 추간판 각도와 요추 척추관 협착증의 상관관계에 관한 연구

김종수 ( Jong Su Kim ),손슬기 ( Seul Ki Son ),김세준 ( Se Jun Kim ),김신웅 ( Shin Woong Kim ),정승현 ( Seong Hyun Jeong ),김태호 ( Tae Ho Kim ),정연재 ( Yeon Jae Jeong ),김효섭 ( Hyo Sub Kim ) 한방재활의학과학회 2014 한방재활의학과학회지 Vol.24 No.4

ObjectivesThe purpose of this study is to find out clinical and radiological correlation be-tween lumbar lordotic angle, lumbar intervertebral disc angle and lumbar spinal stenosis.MethodsTotal 250 patients` who had visited Bu-Chun Jaseng Hospital of Korean Medicine lumbar lordotic angle, intervertebral disc angle of L4/5 and dural sac dimension of L4/5 were measured by X-ray and MRI films. We analysed correlation between lumbar lor-dotic angle, intervertebral disc angle of L4/5 and lumbar spinal stenosis in terms of clinical and radiological aspect.Results1. The mean intervertebral disc angle of L4/5 were 10.72±3.98o, the mean lum-bar lordotic angle were 41.97±11.73o and the mean dural sac dimension of L4/5 were 133.18±45.46 mm2. 2. This study shows that dural sac dimension of L4/5 was inversely reated to intervertebral disc angle of L4/5 by statistically (p<0.05). 3. There was visible dif-ference regarding intervertebral disc angle of L4/5 between patients who had been diag-nosed with lumbar spinal stenosis by clinically and patients who had not been diagnosed with lumbar spinal stenosis by clinically; The former`s angle was relatively higher than the latter`s (p<0.05).ConclusionsThere was a statistical significance between intervertebral disc angle of L4/5 and lumbar spinal stenosis in single-segment. (J Korean Med Rehab 2014;24(4): 129-136)

Preliminary Results of Relationship between Preoperative Walking Ability and Magnetic Resonance Imaging Morphology in Patients with Lumbar Canal Stenosis: Comparison between Trefoil and Triangle Types of Spinal Stenosis

Parisa Azimi,Taravat Yazdanian,Edward C. Benzel 대한척추외과학회 2017 Asian Spine Journal Vol.11 No.4

Study Design: Cross-sectional. Purpose: To examine the relationship between magnetic resonance imaging (MRI) morphology stenosis grades and preoperative walking ability in patients with lumbar canal stenosis (LCS). Overview of Literature: No previous study has analyzed the correlation between MRI morphology stenosis grades and walking ability in patients with LCS. Methods: This prospective study included 98 consecutive patients with LCS who were candidates for surgery. Using features identified in T2-weighted axial magnetic, stenosis type was determined at the maximal stenosis level, and only trefoil and triangle stenosis grade types were considered because of sufficient sample size. Intraobserver and interobserver reliability were assessed by calculating weighted kappa coefficients. Symptom severity was evaluated via the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ). Walking ability was assessed using the Self-Paced Walking Test (SPWT) and JOABPEQ subscales. Demographic characteristics, SPWT scores, and JOABPEQ scores were compared between patients with trefoil and triangle stenosis types. Results: The mean patient age was 58.1 (standard deviation, 8.4) years. The kappa values of the MRI morphology stenosis grade types showed a perfect agreement between the stenosis grade types. The trefoil group (n=53) and triangle group (n=45) showed similar preoperative JOABPEQ subscale scores (e.g., low back pain, lumbar function, and mental health) and were not significantly different in age, BMI, duration of symptoms, or lumbar stenosis levels (all p >0.05); however, trefoil stenosis grade type was associated with a decreased walking ability according to the SPWT and JOABPEQ subscale scores. Conclusions: These findings suggest preoperative walking ability is more profoundly affected in patients with trefoil type stenosis than in those with triangle type stenosis.

The Impact of Joint Mobilization and Transcutaneous Electrical Nerve Stimulation on Pain in Patients With Lumbar Spinal Stenosis

고준혁,안호정 국제물리치료연구학회 2019 Journal of International Academy of Physical Ther Vol.10 No.1

Background: Surgery has been known as an inefficient approach to reduce back pain in patients with lumbar spinal stenosis; therefore, non-surgical treatments are necessary. However, there has been little research to analyze the effect of non-surgical treatments on lumbar spinal stenosis pain. Objective: To identify the effectiveness of 2 physiotherapeutic treatment approaches to relieve pain due to lumbar spinal stenosis. Design: Randomized controlled trial Methods: The participants were 36 lumbar spinal stenosis patients who were randomized in the joint mobilization group (JMG) and transcutaneous electrical nerve stimulation group (TENSG). Joint mobilization (JM) was conducted at the posteroanterior joint in the spinous process of the lumbar spine with stenosis. Transcutaneous electrical nerve stimulation (TENS) was applied on the lumbar spine with stenosis at a high frequency and intensity. Results: Visual analog scale (VAS) pain score significantly decreased in both groups, and the VAS value decreased more after JMG than that after TENSG. The pain thresholds of both groups also significantly increased, and that of JMG increased more compared to TENSG. In both the groups, significant improvements in VAS and pain thresholds were found, and JMG showed better results than TENSG. Conclusions: JM and TENS showed significant relief in both pain threshold and painpain, and JM showed more advanced relief compared to TENS.

Effects of Lumbar Mobilization on the Paravertebral Muscle Activity and Muscle Tone in Patients with Lumbar Spinal Stenosis

Go, Junhyeok,An, Hojung International Academy of Physical Therapy Research 2021 Journal of International Academy of Physical Ther Vol.12 No.1

Background: Patients with lumbar spinal stenosis show abnormal changes in muscle activity due to pain and limited range of motion of the lumbar spine. Excessive increased muscle tone and decreased muscle activity patterns threaten the patients' quality of life. However, there have been a few studies showing how to improve muscle performance in patients with lumbar spinal stenosis. Among these, joint mobilization is one way of improving muscle performance through pain relief and increasing the range of motion. Objectives: To investigate the effect of lumbar mobilization by orthopedic manual physical therapy on paravertebral muscle activity and tone in patients with lumbar spinal stenosis. Design: A randomized controlled trial. Methods: In this study, 24 patients with lumbar spinal stenosis were randomized (1:1 ratio) into two groups. The experimental group underwent lumbar posteroanterior mobilization, and the control group underwent conventional physical therapy (conventional transcutaneous electrical nerve stimulation) for 15 minutes each. For outcome measures, Myoton^®PRO was used to evaluate muscle tone when resting of the paravertebral muscle in the pain area. For muscle activity evaluation, the reference voluntary contraction of the paravertebral muscle was evaluated using surface electromyography. Results: Muscle tone and activity were significantly improved after intervention in both the experimental and control groups. In addition, the experimental group showed more significant decrease in muscle tone and activity than the control group. Conclusion: These results suggest that lumbar mobilization improving muscle performance in patients with lumbar spinal stenosis.

The Impact of Joint Mobilization and Transcutaneous Electrical Nerve Stimulation on Pain in Patients With Lumbar Spinal Stenosis

Jun Hyeok Go,Ho Jung An 국제물리치료연구학회 2019 Journal of International Academy of Physical Ther Vol.10 No.1

Background: Surgery has been known as an inefficient approach to reduce back pain in patients with lumbar spinal stenosis; therefore, non-surgical treatments are necessary. However, there has been little research to analyze the effect of non-surgical treatments on lumbar spinal stenosis pain. Objective: To identify the effectiveness of 2 physiotherapeutic treatment approaches to relieve pain due to lumbar spinal stenosis. Design: Randomized controlled trial Methods: The participants were 36 lumbar spinal stenosis patients who were randomized in the joint mobilization group (JMG) and transcutaneous electrical nerve stimulation group (TENSG). Joint mobilization (JM) was conducted at the posteroanterior joint in the spinous process of the lumbar spine with stenosis. Transcutaneous electrical nerve stimulation (TENS) was applied on the lumbar spine with stenosis at a high frequency and intensity. Results: Visual analog scale (VAS) pain score significantly decreased in both groups, and the VAS value decreased more after JMG than that after TENSG. The pain thresholds of both groups also significantly increased, and that of JMG increased more compared to TENSG. In both the groups, significant improvements in VAS and pain thresholds were found, and JMG showed better results than TENSG. Conclusions: JM and TENS showed significant relief in both pain threshold and painpain, and JM showed more advanced relief compared to TENS.

Benefits and Weaknesses of Interspinous Devices in Elderly Patients with Lumbar Spinal Stenosis - Comparative Study of Interspinous U and Decompression Surgery Alone

박용숙,김영백,김경태 대한척추신경외과학회 2009 Neurospine Vol.6 No.1

Objective: Several types of interspinous process (ISP) devices have the common goal of limiting lumbar extension. In this study, we selected patients aged older than 60 years with lumbar spinal stenosis and assessed whether ISP devices are more beneficial in elderly patients with lumbar spinal stenosis than simple decompression. Methods: Eighteen patients were treated with the Interspinous U device, and 17 patients were treated with decompression alone during the same period. Clinical results were assessed using the pre- and postoperative visual analogue scale (VAS) and activities of daily living (ADL). Radiologic results were assessed according to pre-and postoperative anterior disc height, posterior disc height, foraminal height, spondylolisthesis, segmental coronal angle and lordotic angle at the treated level. Results: The mean age of the patients in the interspinous device group was 66.9 years (range 60-78 years), and the mean age of the patients in the decompression group was 70.6 years (range 60-80 years). The mean pre- and postoperative VAS scores were 8.5 and 3.8, respectively, in interspinous devices group and 7.7 and 2.5 in the decompression group. Both groups of patients showed significant improvement in their VAS and ADL scores in comparison with their preoperative scores. Radiologically, there were no significant differences in anterior and posterior disc height or foraminal height in the interspinous devices group. Coronal and lordotic angles were reduced postoperatively in the device group but not in the decompression group. Listhesis at the treated level was significantly aggravated in both groups. Conclusions: The ISP device was helpful in alleviating pain and improving ADL performance in elderly patients with lumbar spinal stenosis. It corrected segmental scoliosis and restricted extension. However Interspinous U may induce spondylolisthesis and do not prevent further displacement of preexisting spondylolisthesis. There should be careful selection to apply of this device in elderly patients. Objective: Several types of interspinous process (ISP) devices have the common goal of limiting lumbar extension. In this study, we selected patients aged older than 60 years with lumbar spinal stenosis and assessed whether ISP devices are more beneficial in elderly patients with lumbar spinal stenosis than simple decompression. Methods: Eighteen patients were treated with the Interspinous U device, and 17 patients were treated with decompression alone during the same period. Clinical results were assessed using the pre- and postoperative visual analogue scale (VAS) and activities of daily living (ADL). Radiologic results were assessed according to pre-and postoperative anterior disc height, posterior disc height, foraminal height, spondylolisthesis, segmental coronal angle and lordotic angle at the treated level. Results: The mean age of the patients in the interspinous device group was 66.9 years (range 60-78 years), and the mean age of the patients in the decompression group was 70.6 years (range 60-80 years). The mean pre- and postoperative VAS scores were 8.5 and 3.8, respectively, in interspinous devices group and 7.7 and 2.5 in the decompression group. Both groups of patients showed significant improvement in their VAS and ADL scores in comparison with their preoperative scores. Radiologically, there were no significant differences in anterior and posterior disc height or foraminal height in the interspinous devices group. Coronal and lordotic angles were reduced postoperatively in the device group but not in the decompression group. Listhesis at the treated level was significantly aggravated in both groups. Conclusions: The ISP device was helpful in alleviating pain and improving ADL performance in elderly patients with lumbar spinal stenosis. It corrected segmental scoliosis and restricted extension. However Interspinous U may induce spondylolisthesis and do not prevent further displacement of preexisting spondylolisthesis. There should be careful selection to apply of this device in elderly patients.

The Impact of Joint Mobilization and Transcutaneous Electrical Nerve Stimulation on Pain in Patients With Lumbar Spinal Stenosis

Go, Jun Hyeok,An, Ho Jung International Academy of Physical Therapy Research 2019 Journal of International Academy of Physical Ther Vol.10 No.1

Background: Surgery has been known as an inefficient approach to reduce back pain in patients with lumbar spinal stenosis; therefore, non-surgical treatments are necessary. However, there has been little research to analyze the effect of non-surgical treatments on lumbar spinal stenosis pain. Objective: To identify the effectiveness of 2 physiotherapeutic treatment approaches to relieve pain due to lumbar spinal stenosis. Design: Randomized controlled trial Methods: The participants were 36 lumbar spinal stenosis patients who were randomized in the joint mobilization group (JMG) and transcutaneous electrical nerve stimulation group (TENSG). Joint mobilization (JM) was conducted at the posteroanterior joint in the spinous process of the lumbar spine with stenosis. Transcutaneous electrical nerve stimulation (TENS) was applied on the lumbar spine with stenosis at a high frequency and intensity. Results: Visual analog scale (VAS) pain score significantly decreased in both groups, and the VAS value decreased more after JMG than that after TENSG. The pain thresholds of both groups also significantly increased, and that of JMG increased more compared to TENSG. In both the groups, significant improvements in VAS and pain thresholds were found, and JMG showed better results than TENSG. Conclusions: JM and TENS showed significant relief in both pain threshold and painpain, and JM showed more advanced relief compared to TENS.

요추 Y-각 협착증 : 요추간 협착증의 새로운 개념 New Concept of Lumbar Stenosis

김영수,조용은,박형천,윤도흠,노성우 대한신경외과학회 1993 Journal of Korean neurosurgical society Vol.22 No.1

Authors measured the Y-shaped angle made by both yellow ligaments and both laminae named Y-angle at the spinal CT scan in normal and lumbar stenosis group. The normal range of Y-angle is between 60˚and 95˚. Lumbar stenosis is classified into narrow Y-angle stenosis(<60°) and wide Y-angle stenosis(>95°) by Y-angle. Narrow Y-angle stenosis is most common in degenerative spondylotic stenosis. Wide Y-angle is most common in congenital stenosis. The Y-angle is a simple and useful diagnostic indicator in the diagnosis of lumbar spinal stenosis on CT scan and MEU scan.

척추관 협착증에 대한 연구 : 요추관 협착증 환자에서 협착 부위에 따른 수술적 치료의 결과 Results of the Operative Treatments by the Level of Lumbar Spinal Stenosis

이준규,안재성,양준영 충남대학교 의과대학 지역사회의학연구소 1998 충남의대잡지 Vol.25 No.2

Spinal stenosis is any type of narrowing of the main spinal canal, nerve canal or foramina from structural abnormality of bony components. Posterior decompression only provide relief of pain and restoration of neurologic function, and simultaneous posterolateral fusion is needed for prevention of spinal instability after wide posterior decompression. The degree of decompression (focal or wide), instrumentation and bone graft is dependent to the level of stenosis and instability. The purpose of this study is to compare the operative results clinically and radiologically by the level of spinal stenosis. We reviewed 73 patients of lumbar spinal stenosis who had undergone operations with posterior decompression or posterolateral fusion with spinal instrumentation at our hospital, From January 1987 to October 1997. We classified the level of stenosis into one level, two level and multi-level(above three level) stenosis, and on the last follow up, radiological bony union, clinical results, and complications were compared. The following results were obtained. I. The one level was 42 cases(57.6%), two level 24 cases(32.9%), and multi-level stenosis 7 cases(9.6%) and the most common stenotic level was at LA-5, 31 cases(42.5%). 2. Posterior decompression only were carried out on 20 patients(27.4%), and simultaneous posterolateral fusion with instrumentation were 53 patients(72.6%), CD 4 cases, CCD 11 cases, PWB 2 cases, and Diapason 36 cases. 3. The radiologic union rate was 41 cases(97.6%) in one level, 22 cases(87.5%) in two level, 6cases(85.7%) in multi-level spinal stenosis. 4. The excellent or good clinical results(by the Kikaldy-Willis criteria) were 40 cases (95.2%) in one level, 22 cases(91.8%) in two level, 6 cases(85.7%) in multi-level spinal stenosis. 5. The postoperative complications such as infection, metal failure, neurologic deficit or death were 6 cases(14.3%) in one level, 4 cases(21%) in two level, 3 cases(44.3%) in multi-level stenosis.