Comparison of Single-Level and Multilevel Decompressive Laminectomy for Multilevel Lumbar Spinal Stenosis

doi:10.1016/j.wneu.2017.12.033

World Neurosurgery

Volume 111, March 2018, Pages e235-e240

https://doi.org/10.1016/j.wneu.2017.12.033 Get rights and content

Objective

This study aimed to clarify whether multiple compressions of nerve roots resulted in poorer surgical outcome when patients were treated with single-level decompressive laminectomy or multilevel decompressive laminectomy. To reach this we compared preoperative and postoperative Oswestry Disability Index (ODI) scores, Visual Analogue Scale (VAS) scores, and walking duration of multilevel lumbar spinal stenosis (LSS) patients treated with single-level and multilevel decompressive laminectomy.

Methods

This retrospective study included 112 consecutive patients undergoing lumbar decompressive surgery without arthrodesis for LSS between March 2010 and September 2013. Forty-eight patients were treated with single-level laminectomy and 64 patients were treated with multilevel laminectomy. ODI scores, VAS scores, and walking duration were measured for all patients preoperatively and 30 months after decompressive surgery.

Results

The mean age of the patients was 64.41 ± 13.4 years. The ODI scores, VAS scores, and walking duration difference between patients treated with single-level laminectomy and multilevel laminectomy were statistically significant and higher for the first group (P < 0.05). There were more operative complications in patients treated with multilevel decompressive laminectomy; however, there was no statistically significant difference between single-level and multilevel decompressed patients regarding complications (P = 0.119). Four of the patients treated with multilevel decompressive laminectomy experienced postoperative spondylolisthesis needing posterior instrumented fusion.

Conclusion

Recovery in terms of ODI scores, VAS scores, and walking duration was better in LSS patients undergoing single-level laminectomy than in those undergoing multilevel laminectomy. Also, the rates of operative complications and postoperative follow-up spondylolisthesis were higher in patients treated with multilevel laminectomy.

Introduction

Lumbar spinal stenosis (LSS) is the most frequent indication for spinal surgery in elderly patients. A sensory or motor deficit occurs in approximately half of the patients with symptomatic lumbar stenosis.¹ Patients usually present with a variety of symptoms, including back and leg pain, with frequent sensory and voiding disturbances and motor weakness. The classic presentation of LSS is neurogenic claudication.² Substantial reduction in walking tolerance owing to neurogenic claudication is often the cause of medical intervention.³ LSS is defined as a narrowing of the spinal canal, the lateral nerve root canals, or the intervertebral neural foramina due to progressive hypertrophy of any of the surrounding osteocartilaginous and ligamentous elements and may result in neurogenic or vascular compression of the contents of the spinal canal at 1 or more levels. Anatomically, spinal stenosis is classified as 1) central, when it affects the spinal canal and dural sac; 2) foraminal, when it affects the spinal foramina; or 3) lateral, when it affects the lateral recess. In addition to its structural aspects, the pathology of LSS also has a dynamic component. Extension of the spine and axial loading contribute to further narrowing of both the central and the lateral canals.⁴

The literature is not clear as to which surgical technique is the best course of action, particularly on whether an arthrodesis should be added to the procedure. Some studies indicate that fusion should be combined with lumbar decompression in the setting of LSS.5, 6 Postoperative spinal instability is a major complication associated with performing decompression alone in the presence of LSS. Different decompression techniques may also have different outcomes. This study aimed to clarify whether multiple compressions of nerve roots resulted in poorer surgical outcome when patients were treated with single=level decompressive laminectomy or multilevel decompressive laminectomy.

Section snippets

Materials and Methods

This retrospective study included 112 consecutive patients undergoing lumbar decompressive surgery without arthrodesis for LSS between March 2010 and September 2013 at the Neurosurgery Clinic, Yüksek Ihtisas Research and Training Hospital, Bursa, Turkey. Patients were reexamined 30 months after decompressive surgery and retrospectively evaluated.

All patients received oral and written information regarding the treatment of LSS, and informed consents were obtained. The major preoperative symptoms

Results

This study included 112 patients (69 male and 43 female). Demographic and operational details are summarized in Table 1. The mean age was 64.41 ± 13.4 years. The mean duration of the symptoms before surgery was 5 ± 3.21 years. The mean postoperative follow-up period was 42.8 ± 83.9 months. The number of decompressed levels was a single level in 48 patients, 2 levels in 50 patients and 3 levels in 14 patients. We performed decompressive surgery on L1 lamina in 4 instances, on L2 lamina in 8

Discussion

Previous studies have indicated that surgery in patients with LSS is superior to nonoperative care.9, 10 Previous studies have also indicated that operations for LSS can be broadly divided into some form of decompression alone or decompression combined with arthrodesis. The results of the Swedish Spine Registry, published by Försth et al.,¹¹ involved 5390 patients with LSS and showed a statistically significant improvement with both these surgical groups (with no difference between the 2

Conclusion

Most patients with multilevel LSS reported relief of their symptoms after decompression surgery. Although most of our patients were satisfied with the outcome of the operation, recovery in terms of ODI and VAS scores and walking duration was better in patients who underwent single-level decompressive laminectomy than in those who underwent multilevel decompressive laminectomy. The complication rate was lower in patients who underwent single-level decompressive laminectomy, but this was not

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Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis?

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Cited by (21)

Do patients with lumbar spinal stenosis benefit from decompression of levels with adjacent moderate stenosis? A prospective cohort study from the NORDSTEN study
2024, Spine Journal
Lumbar spinal stenosis (LSS) is characterized by pain that radiates to the buttocks and/or legs, aggravated by walking and relieved by forward flexion. There is poor correlation between clinical symptoms and severity of stenosis on MRI, and multi-level stenosis has not been described to present worse symptoms or treatment outcomes, compared with patients with single-level stenosis. In patients with one level with severe stenosis combined with an adjacent level with moderate stenosis, the surgeon must decide whether to decompress only the narrowest level or both, to achieve the best possible outcome. The potential benefits of performing surgery on an adjacent moderate stenosis is debated, and the scientific evidence in scarce.
The aim of the present study was to investigate whether patients with a level of adjacent moderate stenosis, along with an index stenosis, benefitted from a dual-level decompression (DLD) compared with a single-level decompression (SLD). Furthermore, to investigate whether DLD patients had longer duration of surgery and hospital stay, higher rates of complications and/or lower rate of reoperations compared with SLD patients.
Prospective cohort study.
We analyzed data from the Norwegian Degenerative Spondylisthesis and Spinal Stenosis study- Spinal Stenosis Trial (NORDSTEN-SST). In this randomized multicenter study, 437 patients were included, evaluating clinical outcomes of three different surgical treatment options for LSS. Patients with degenerative spondylolisthesis were excluded.
Based on preoperative MRI, the present analysis included all patients who had a moderate stenosis (defined as Schizas B or C) in addition to a predefined index stenosis (the level with the smallest cross-sectional area). We compared patients who, based on the surgeons` choice, received a dual-level decompression, with those receiving a single-level decompression.
The primary outcome was mean change in the Oswestry Disability Index (ODI) score from baseline to 2-year follow up. Secondary outcomes were proportion of success (30% reduction in ODI score), the Numeric Rating Scales for back and leg pain (NRS), the EuroQol 5-dimensional questionnaire utility index (EQ-5D), the Zurich Claudication Questionnaire (ZCQ), the Global Perceived Effect (GPE)-scale, duration of surgery, duration of hospital stay, perioperative complications and reoperation rates.
Among the 222 patients, included in the analysis, 108 underwent DLD and 114 underwent SLD. There was no difference in change scores for any of the investigated patient-reported outcomes between the groups after 2 years. However, the DLD group had longer duration of surgery and longer length of hospital stay. There was no difference in reoperation rates or perioperative complications.
This study, alongside the NORDSTEN-LSS trial on patients with adjacent moderate stenosis as well as an index stenosis, showed no superior clinical effectiveness for dual-level surgery compared with single-level surgery.
Predictors of Skip Laminotomy for Placement of Paddle Leads for Spinal Cord Stimulation
2024, Neuromodulation
Placement of a standard paddle lead for spinal cord stimulation (SCS) requires a laminotomy for positioning of the lead within the epidural space. During initial placement, an additional laminotomy or laminectomy, termed a “skip” laminotomy, may be necessary at a higher level to pass the lead to the appropriate midline position. Patient and radiographic factors that predict the need for a skip laminotomy have yet to be identified.
Participants who underwent SCS paddle placement at Albany Medical Center between 2016 and 2017 were identified. Operative reports were reviewed to identify the paddle type, level of initial laminotomy, target level, and skip laminotomy level. Preoperative thoracic magnetic resonance images (MRIs) were reviewed, and spinal canal diameter, interpedicular distance, and dorsal cerebral spinal fluid thickness were measured for each participant when available.
A total of 106 participants underwent thoracic SCS placement. Of these, 97 had thoracic MRIs available for review. Thirty-eight participants required a skip laminotomy for placement of the paddle compared with 68 participants who did not. There was no significant difference in demographic features including age, sex, body mass index, and surgical history. Univariate analyses that suggested trends were selected for further analysis using binary logistic regression. Level of initial laminotomy (odds ratio [OR] = 1.51, p = 0.028), spinal canal diameter (OR = 0.71, p = 0.015), and dorsal cerebrospinal fluid thickness (OR = 0.61, p = 0.011) were correlated with skip laminotomy. Target level (OR = 1.27, p = 0.138) and time from trial (1.01, p = 0.117) suggested potential association. The multivariate regression was statistically significant, X²(10) = 28.02, p = 0.002. The model explained 38.3% of the variance (Nagelkerke R²) and predicted skip laminectomy correctly in 73.3% of cases. However, for the multivariate regression, only a decrease in spinal canal diameter (OR = 0.59, p = 0.041) was associated with a greater odds of skip laminotomy.
This study aims to characterize the patient and radiographic factors that may predict the need to perform a skip laminotomy during the initial placement of SCS paddles. Here, we show that radiographic and anatomic variables, primarily spinal canal diameter, play an important role in predicting the need for a skip laminotomy. Furthermore, we suggest that target level for placement and level of initial laminotomy also may contribute. Further investigation of the predictive factors for performing a skip laminotomy would help optimize surgical planning and preoperative patient selection and counseling.
Progression to fusion after lumbar laminectomy for degenerative lumbar spondylolisthesis: Rate and risk-factors. A national database study
2023, Clinical Neurology and Neurosurgery
Lumbar laminectomy is often utilized in the treatment of degenerative lumbar spondylolisthesis. Risk factors that contribute to reoperation rates, in particular to progression to fusion, are poorly understood. We aimed to identify rate and risk factors of lumbar fusion surgery following lumbar laminectomy for the treatment of degenerative lumbar spinal spondylolisthesis.
Our sample was obtained from the national MarketScan Commercial Claims and Encounters Database. We reviewed patients undergoing lumbar laminectomy for stable degenerative lumbar spondylolisthesis (Grade-1) at one or two levels between January 2007 and December 2016.
A total of 33,681 patients were included. By 2 years after the index operation, 2.48 % of patients had required lumbar fusion surgery. Female sex was associated with lower odds (OR 0.8, 95 %CI 0.7–0.9) of reoperation for fusion. Diabetes (OR 1.2, 95 %CI 1.1–1.4), rheumatoid arthritis (OR 1.5, 95 %CI 1.2–1.7) and clinical presentation with LBP (OR 2.1, 95 %CI 1.6–2.9), lower extremity weakness (OR 1.4, 95 %CI 1.1–1.5), as well as occurrence of a postoperative neurological complications (OR 2.0, 95 %CI 1.1–3.4) increased the odds ratio for requiring fusion surgery within two years after lumbar laminectomy.
In this large cross-sectional sample of a national claims database consisting of lumbar laminectomy patients for the treatment of spondylolisthesis, approximately 2.5 % required subsequent lumbar fusion. Several modifiable risk factors for fusion progression were identified, which may guide clinicians in shared decision-making and to help identify patients with elevated post-operative risk providing potential leverage point for prevention.
A novel technology named as selective fenestration and axial decompression for the surgical management of lumbar degenerative diseases
2023, Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
A retrospective study.
To firstly introduce a new surgical technique named as selective fenestration and axial decompression (SFAD) to improve the surgical treatment effects of lumbar degenerative diseases.
Posterior lumbar laminectomy and interbody fusion (LIF) is a standard surgical method for the treatment of lumbar degenerative diseases. However, its application has some limitations, and the incidence of spinal cord nerve injury is relatively high.
This retrospective clinical study was conducted from January 2018 to February2020. A total of 101 eligible patients including 62 men and 39 women with lumbar disc herniation (LDH) or lumbar spinal stenosis (LSS) underwent LIF or SFAD were enrolled in this study. The average postoperative follow-up period of the LIF and SFAD groups were 20.1 ± 3.7 months and 19.7 ± 4.1 months, respectively. The clinical effects, imaging manifestation, and postoperative complications in LIF and SFAD groups were analyzed.
The operative time, blood loss and hospital stay in SFAD group were significantly lower than those in LIF group (P < 0.05). Significant clinical improvements in VAS and ODI were achieved in both LIF and SFAD groups after surgery, respectively (P < 0.05). There was no statistical difference in improvements of VAS and ODI between the LIF and SFAD groups (P > 0.05). Similarly, improvements of cobb angle of operated segment, intervertebral space height (ISH), intervertebral space foramen (IFH) and lumbar lordosis (LL) showed no statistical difference between the two groups (P > 0.05). Finally, the prevalence of complication rates in LIF group were significantly higher than the SFAD group during the follow-up period (P < 0.05)
The application of SFAD to the surgical treatment of lumbar degenerative diseases can realize the three-dimensional and precise decompression of spinal cord nerve, which is one of the ideal alternatives to traditional LIF.
Degenerative Lumbar Stenosis Surgery: Predictive Factors of Clinical Outcome—Experience with 1001 Patients
2021, World Neurosurgery
Citation Excerpt :
Of the significant predictors, the number of intervertebral levels treated yielded the second weakest correlation with outcome. In agreement with our findings, a number of studies have found that patients with multilevel stenosis have tended to have a poorer clinical outcome compared with those with 1 level of stenosis.35-37 Keorochana et al.38 also found an association between multilevel surgery and poor long-term symptom relief.
Degenerative lumbar spinal stenosis (DLSS) carries a high risk of morbidity and represents a financial burden to society. A late diagnosis can lead to severe disability. Although lumbar decompressive surgery has been widely used worldwide, the proper preoperative factors to define the ideal candidates for decompression are missing.
A total of 1001 patients who had undergone decompressive surgery from 2012 to 2019 for DLSS were screened for the presence of 9 clinical and radiological parameters. For all cases, the differences between the baseline and postoperative Oswestry disability index were calculated and the results categorized as 5 different classes (ranging from very poor outcomes to excellent outcomes) according to the specific scores. Generalized ordinal logistic regression was then used to analyze the significance of the 9 parameters (coded as dummy variables) in predicting the outcome as measured by Oswestry disability index improvement after surgery.
Of the 9 parameters, 8 were found to be significant predictors. The radiological grade of compression was the strongest, followed by polyneuropathy, obesity, symptom duration, gait autonomy, radicular deficits, American Society of Anesthesiologists score, and level of surgery. In contrast, previous back surgery was not predictive of the outcome.
Our findings have indicated that the ideal candidate for surgery will have the following preoperative characteristics: Schizas grade D, no signs of peripheral polyneuropathy, body mass index <30 kg/m², symptom duration of <2 years, gait autonomy <100 m, no radicular deficits, 1 level of stenosis, and an American Society of Anesthesiologists score of 1, 2, or 3.
Building block osteotomy, a new back muscle-preserving laminoplasty for lumbar spinal stenosis
2020, Medical Hypotheses
Citation Excerpt :
Laminectomy is the most commonly used method for treatment of spinal stenosis [1,2].
In order to preserve paravertebral muscles and posterior ligaments complex (PLC), this paper proposes a new lumbar laminoplasty surgery for lumbar spinal stenosis (LSS). According to the anatomy of back muscles insertions, building block osteotomy (BBO) which aimed to achieve precise osteotomy and reconstruction based on modular design theory was firstly put forward, and supposed to be achieved by an ultrasound bone scalpel (UBS). In details, lumbar spinous processes are longitudinally split, then supraspinous and interspinous ligaments are sharply cut off longitudinally. After converting to lumbar flexion, lamina osteotomy is innovatively finished by an UBS through interspinous space. After decompression, hollow screws are firstly suggested to be used on each side to fix lamina and spinous processes, and PLC is reconstructed by interrupted suture. Feasibility of this method is evaluated in details. Challenges, advantages and disadvantages are also discussed.

View all citing articles on Scopus

: Conflict of interest statement: The author declares that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Original ArticleComparison of Single-Level and Multilevel Decompressive Laminectomy for Multilevel Lumbar Spinal Stenosis

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Materials and Methods

Results

Discussion

Conclusion

Degenerative lumbar spinal stenosis: diagnostic value of the history and physical examination

Arthritis Rheum

Lumbar spinal stenosis in the elderly: an overview

Eur Spine J

Spinal stenosis and neurogenic claudication

Spine

Dynamic changes in the dimensions of the lumbar spinal canal: an experimental study in vitro

J Orthop Res

Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective study comparing decompression with decompression and intertransverse process arthrodesis

J Bone Joint Surg Am

Surgical or nonoperative treatment for lumbar spinal stenosis?: a randomized controlled trial

Spine

The Oswestry low back pain disability questionnaire

Physiotherapy

A critical review of visual analogue scales in the measurement of clinical phenomena

Res Nurs Health

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

Spine

Surgical versus nonsurgical therapy for lumbar spinal stenosis

N Engl J Med

Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis?

Bone Joint J

Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults

JAMA

Original Article
Comparison of Single-Level and Multilevel Decompressive Laminectomy for Multilevel Lumbar Spinal Stenosis