Objective To determine the total blood loss and hidden blood loss associated with surgery for lumbar spinal stenosis and to identify risk factors for blood loss. Methods From September 2002 to July 2006, the cl inical data from 138 patients with lumbar spinal stenosis undergoing initial operation were analysed prospectively. There were 44 males and 94 females, aging 56-78 years (mean 66.7 years). A simple posterior lumbar spinal decompression was used in 26 cases;posterior spinal canal decompression, interbody distraction Cage, and bone graft between transverse process was used in 54 cases; pedicle screw fixation, posterior decompression and bone graft between transverse process was used in 32 cases; posterior decompression, pedicle screw fixation, interbody Cage, and graft between transverse process was used in 26 cases . Before operation, 23 patients took aspirin, and after operation 15 patients had gastrointestinal bleeding. Intraoperative blood loss was calculated by the aspirator and observed blood loss intraoperation. The whole estimated blood loss was calculated according to the level of hemoglobin, blood volume and blood transfusion at the time of admission and after 3 and 4 days of operation. Results The blood loss intraoperation was (485.51 ± 143.75) mL. The estimated blood loss was (1 218.60 ± 306.86) mL, which was significantly higher than the intraoperational blood loss (P lt; 0.001). There was significant difference between the estimated blood loss and observed blood loss during surgeries (P lt; 0.001). There were significant differences in the estimated blood loss and observed blood loss during surgery between patients treated with aspirin and without aspirin (P lt; 0.001), between patients with gastrointestinal bleeding and whiout gastrointestinal bleeding (P lt; 0.001). Conclusion The total blood loss after surgery for lumbar spinal stenosis is much greater than that of observed intra-operation. The type of surgery, treatment with aspirin and gastrointestinal bleeding or ulceration can all independently increase blood loss.
Objective Degenerative lumbar scol iosis and spinal stenosis are more common in elderly patients. Because of many factors, treatment choices are more complex. To investigate the step treatment strategy of degenerative lumbarscol iosis and spinal stenosis. Methods Between January 2005 and December 2009, 117 patients with degenerative lumbar scol iosis and spinal stenosis were treated with step treatment methods, including conservative therapy (43 cases), posterior decompression alone (18 cases), posterior short segment fusion (1-2 segments, 41 cases), and posterior long segment fusion ( ≥ 3 segments, 15 cases). Step treatment options were made according to patient’s will, the medical compl ications, the degree of the symptoms of low back and lower extremity pain, the size of three-dimensional lumbar scol iosis kyphosis rotating deformity, lumbar spine stabil ity (lateral sl ip, degenerative spondylolysis), and the overall balance of the spine. The visual analogue scale (VAS) score of low back and lower extremity pain, Oswestry disabil ity index (ODI), lumbar lordosis angle, and scol iosis Cobb angle were measured and compared before and after treatments. Results Seventy-two cases were followed up more than 12 months, and there was no death or internal fixation failure in all patients. Of them, 19 patients underwent conservative treatment; the mean follow-up period was 19.3 months (range, 1-5 years); no symptom deterioration was observed; VAS score of low back and lower extremity and ODI were significantly decreased at last follow-up (P lt; 0.05); and lordosis angle was decreased and scol iosis Cobb angle was increased, but there was no significant difference (P gt; 0.05). Twelve cases underwentposterior decompression alone; the average follow-up was 36 months (range, 1-5 years); VAS score of lower extremity and ODI were significantly decreased at last follow-up (P lt; 0.05); and scol iosis Cobb angle was increased and lordosis angle was decreased, but there was no significant difference (P gt; 0.05). Thirty-one patients underwent posterior short segment fusion; the mean follow-up period was 21.3 months (range, 1-3 years); postoperative hematoma, poor wound heal ing, cerebrospinal fluid leakage, and superficial infection occurred in 1 case, respectively, and were cured after symptomatic treatment; VAS score of low back and lower extremity and ODI were significantly decreased (P lt; 0.05); and postoperative lumbar scol iosis Cobb angle and lordosis angle were significantly improved at last follow-up (P lt; 0.05). Ten patients underwent posterior long segment fusion; the mean follow-up period was 17.1 months (range, 1-3 years); postoperative symptoms worsened in 1 case and was cured after physical therapy and drug treatment for 3 months, and deep infection occurred in 1 case and was cured after debridement and continuous irrigation drainage; VAS score and ODI were significantly decreased (P lt; 0.05); and postoperative scol iosis Cobb angle and lordosis angle were improved significantly at last follow-up (P lt; 0.05). Conclusion The treatment of degenerative lumbar scol iosis and spinal stenosis should be individual and step. Surgery treatment should be rely on decompression while deformity correction subsidiary. Accurate judgment of the responsible segment of symptoms, scol iosis and lordosis can prevent the operation expansion and increase safety of surgery with active control bleeding.
Objective To evaluate the short-term effectiveness of local laminectomy and interlaminar lumbar instrumented fusion (ILIF) through a small incision for lumbar spinal stenosis. Methods Between November 2009 and January 2011, 16 patients with lumbar spinal stenosis were treated by local laminectomy and ILIF through a small incision. Therewere 7 males and 9 females with an average age of 52.8 years (range, 49-67 years). Sixteen patients had lumbar degenerative stenosis with an average disease duration of 4 years and 7 months (range, 2 years-9 years and 4 months). Four cases complicated by lateral recessus stenosis, 3 by lumbar disc herniation. Involved segments included L3, 4 in 2 cases, L4, 5 in 4 cases, L5, S1 in 4 cases, L3, 4 and L4, 5 (double segments) in 2 cases, L4, 5 and L5, S1 (double segments) in 4 cases. The effectiveness was evaluated with the pre- and post-operative Visual Analogue Scale (VAS) scores, Oswestry Disabil ity Index (ODI). The cross-sectional areas of spinal canal were measured by CT scanning and were compared between pre- and post-operation. Results The average operative time was 47 minutes (range, 35-80 minutes); the average blood loss was 145 mL (range, 120-350 mL); and the average hospital ization days were 7.8 days (range, 4-15 days). Cerebrospinal fluid leakage occurred in 1 case, and healing of incisions by first intention was achieved in the others. The patients were followed up 12-22 months (mean, 14.8 months). CT scanning showed interspinous fusion in 14 cases and possible fusion in 2 cases after operation, with an average fusion time of 4.6 months(range, 3-10 months). The postoperative VAS score, ODI, and cross-sectional area were significantly improved when compared with preoperative values (P lt; 0.05). Conclusion The ILIF can promote fusion between spinous processes, provide spine stabil ization, and protect the spinal cord. The procedure has small incision, simple method of fixation and fusion.
ObjectiveTo investigate the effect of body mass index (BMI) on the outcome of posterior 360° fusion for single-level lumbar degenerative diseases. MethodsA retrospective study was carried on 302 cases of singlelevel lumbar degenerative diseases treated with posterior 360° fusion between September 2009 and September 2013. All patients were divided into 3 groups according to BMI: normal weight (BMI<24 kg/m2) in 105 cases (group A), overweight (24 kg/m2≤BMI< 28 kg/m2) in 108 cases (group B), and obese (BMI≥28 kg/m2) in 89 cases (group C). There was no significant difference in gender, age, disease duration, disease patterns, affected segments, preoperative Japanese Orthopaedic Association (JOA) score and Oswestry disability index (ODI) among 3 groups (P>0.05). The operation time, intraoperative blood loss, postoperative hospital stay, and complications were recorded. The lumbar function was assessed by JOA score and ODI at pre- and post-operation (at 3, 6, and 24 months). ResultsThe operation time, intraoperative blood loss, and postoperative hospital stay of group C were significantly more than those of groups A and B (P<0.05), but no significant difference was found between group A and group B (P>0.05). The patients were followed up 24-45 months. Postoperative JOA score and ODI showed significant improvements in each group when compared with preoperative ones (P<0.05), but there was no significant difference among groups at each time point after operation (P>0.05). There was no significant difference in the incidence of total complications among 3 groups (χ2=3.288, P=0.193). The incidence of incision-related complications (infection and poor healing) in group C was significantly higher than that of groups A and B (P<0.05), but no significant difference was shown between group A and group B (P>0.05). However, there was no significant difference in cerebrospinal fluid leak, pseudarthrosis formation, and revision among 3 groups (P>0.05). ConclusionPosterior 360° fusion for single-level lumbar degenerative diseases can obtain good effectiveness in patients with different BMI, but patients whose BMI was ≥28 kg/m2 have longer operation time, more intraoperative blood loss, longer hospital stay, and higher incidence of postoperative incision-related complications.
Objective To evaluate the clinical outcomes ofa surgical approach for decompression of lumbar spinal stenosis, which was featured with reconstruction of posterior spinal structures and epidural space by spinous process-splitting, less osteotomy, laminar flap and keeping spinal process, lamina, outer ligmentum flavum intact. Methods From October 2001 to April 2003, 39 patients (19 males and 20 females, aging 36 to 77 years with a mean age of 49.6 years with lumbar stenosis underwent the surgical decompression procedure with reconstruction of posterior canal structures and epidural space. The involved locations were L3,4 to L5S1(5 cases),L4,5 to L5S1(18 cases), L4,5(11 cases) and L5S1(5 cases). The course of disease was 3 months to 16 years (40.4 months on average). The clinical outcomes after 1 year of operation Results All patients were followed up from 18 to 36 months. No intraoperative and postoperative complications were observed and all patients were satisfactory with the surgery. Computerized tomography showed that spinal and nerve root canal were satisfactorily enlarged 1 week postoperatively in all cases. Fusion of lamina and spinous process were detected on CT in 87.2% patients (34/39) 3 months after operation. No patients presented re-stenosis of lumbar spine and all patients presented bony fusion 1 year after surgery. Conclusion The approach of the current study was a reliable and effective method in the management of lumbar stenosis, it preserved thecontinuity of spinal process, interspinous ligaments, lamina and ligmentumn flavum and integrality of posterior spinal structures and epidural space. The integrity of the psoterior spinal structures can prevent the scar formation and improve the stability of lmbar spine postoperatively.
ObjectiveTo compare the effectiveness between unilateral laminotomy and bilateral decompression (ULBD) with unilateral biportal endoscopy (UBE) and uniportal interlaminar endoscopy (UIE) in the treatment of lumbar spinal stenosis. Methods A clinical data of 52 patients with lumbar spinal stenosis, who met the selection criteria and treated with ULBD between March 2021 and November 2022, was retrospectively analyzed. The patients were allocated into UBE group (23 cases) and UIE group (29 cases) according to the surgical methods. There was no significant difference (P>0.05) in age, gender, body mass index, surgical segment, type of lumbar stenosis, and preoperative visual analogue scale (VAS) score of low back pain, VAS score of leg pain, Oswestry disability index (ODI), disc height, and dural sac area between the two groups. Perioperative indexes (incision length, operation time, hospital stay, and surgical complications), clinical indicators (VAS score of low back pain, VAS score of leg pain, and ODI before operation and at 3 days, 1 month, 6 months, and 12 months after operation), and imaging indicators (disc height and dural sac area before operation and at 1, 12 months after operation, and dural sac expansion area) were recorded and compared between the two group. Results All operations in both groups were successfully completed. Compared with the UIE group, the UBE group had shorter operation time and longer incision length, with significant differences (P<0.05). But there was no significant difference in hospital stay and incidence of complications between the two groups (P>0.05). All patients were followed up 12-20 months (mean, 14 months). The VAS scores of low back pain and leg pain and ODI after operation significantly improved when compared with preoperative values (P<0.05), and there was no significant difference in the above indicators between different time points after operation (P>0.05). There was no significant difference between the two groups at different time points (P>0.05). Imaging examination showed that there was no significant difference in disc height between the two groups at different time points after operation (P>0.05). However, the dural sac area and dural sac expansion area were significantly larger in the UBE group than in the UIE group (P<0.05). Conclusion ULBD with UBE and UIE can achieve satisfactory effectiveness in the treatment of lumbar spinal stenosis. But the former has more thorough decompression and better dural sac expansion than the latter.
Objective To compare the effectiveness of unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) and endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) in the treatment of single-segment degenerative lumbar spinal stenosis with lumbar spondylolisthesis. Methods Between November 2019 and May 2023, a total of 81 patients with single-segment degenerative lumbar spinal stenosis with lumbar spondylolisthesis who met the selection criteria were enrolled. They were randomly divided into UBE-TLIF group (39 cases) and Endo-TLIF group (42 cases). There was no significant difference in baseline data between the two groups (P>0.05), including gender, age, body mass index, surgical segment, and preoperative visual analogue scale (VAS) scores for low back and leg pain, Oswestry Disability Index (ODI), and serum markers including creatine kinase (CK) and C reactive protein (CRP). Total blood loss (TBL), intraoperative blood loss, hidden blood loss (HBL), postoperative drainage volume, and operation time were recorded and compared between the two groups. Serum markers (CK, CRP) levels were compared between the two groups at 1 day before operation and 1, 3, and 5 days after operation. Furthermore, the VAS scores for low back and leg pain, and ODI at 1 day before operation and 1 day, 3 months, 6 months, and 12 months after operation, and intervertebral fusion rate at 12 months after operation were compared between the two groups. Results All surgeries were completed successfully without occurrence of incision infection, vascular or nerve injury, epidural hematoma, dural tear, or postoperative paraplegia. The operation time in UBE-TLIF group was significantly shorter than that in Endo-TLIF group, but the intraoperative blood loss, TBL, and HBL in UBE-TLIF group were significantly more than those in Endo-TLIF group (P<0.05). There was no significant difference in postoperative drainage volume between the two groups (P>0.05). The levels of CK at 1 day and 3 days after operation and CRP at 1, 3, and 5 days after operation in UBE-TLIF group were slightly higher than those in the Endo-TLIF group (P<0.05), while there was no significant difference in the levels of CK and CPR between the two groups at other time points (P>0.05). All patients were followed up 12 months. VAS score of low back and leg pain and ODI at each time point after operation significantly improved when compared with those before operation in the two groups (P<0.05); there was no significant difference in VAS score of low back and leg pain and ODI between the two groups at each time point after operation (P>0.05). There was no significant difference in the intervertebral fusion rate between the two groups at 12 months after operation (P>0.05). ConclusionUBE-TLIF and Endo-TLIF are both effective methods for treating degenerative lumbar spinal stenosis with lumbar spondylolisthesis. However, compared to Endo-TLIF, UBE-TLIF requires further improvement in minimally invasive techniques to reduce tissue trauma and blood loss.
ObjectiveTo assess the reliability, effectiveness, and the safety of full endoscopic transforaminal decompression (FETD) under local anesthesia guided by the classification of lateral region of the lumbar spinal canal (CLLSC) in treating lumbar spinal stenosis (LSS) in geriatric patients.MethodsThe clinical data of 63 geriatric patients with LSS met the inclusion criteria underwent FETD surgery between June 2015 and July 2017 were retrospectively analyzed. There were 37 males and 26 females, with a median age of 76 years [interquartile range (IQR), 73-80 years], and a median symptomatic duration of 55 months (IQR, 16-120 months). There were 17 cases of grade B and 46 cases of grade C based on the Schizas morphological grading system. CLLSC was used for imaging evaluation for the stenotic condition, and intra-class correlation coefficients (ICC) were used to test intra-observer and inter-observer reliability of CLLSC. The stenotic condition of patients was re-evaluated by the surgeon after operation, and the results were compared with the findings of preoperative CLLSC. The visual analogue scale (VAS) score for low back pain and leg pain recorded before operation, and at 1 day, 3 months, and 6 months after operation, and last follow-up were used to assess the pain relieving; the functional improvement was evaluate by Oswestry disability index (ODI); the modified Macnab criteria were used to self-evaluate the surgical satisfaction.ResultsThe operation were successfully performed for all patients, with a median operation time of 75 minutes (IQR, 65-85 minutes), postoperative hospitalization stay of 48 hours (IQR, 48-72 hours), and the time to ambulation after operation of 24 hours (IQR, 24-24 hours). Sixty-three patients were followed-up and with a median follow-up time of 18 months (IQR, 13-20 months). Based on preoperative CLLSC classification, there were 72 stenotic zones, distributed 16 in zone 1, 6 in zone 2, 3 in zone 3, 2 in zone 4, 7 in zone 5, 34 in zones 1+2, 2 in zones 3+4, and 2 in zones 4+5. Perioperative complications occurred in 4 cases (6.3%), including 2 cases of intraoperative dural sac tear, 1 of preoperative numbness symptom aggravation, and 1 of postoperative urinary retention. VAS score of leg pain and ODI score at each time point after operation were significantly improved compared with those before operation (P<0.05). VAS scores of low back pain showed no significant difference between pre- and post-operation (P>0.05). At last follow-up, based on the modified Macnab criteria, 19 cases were excellent, 37 were good, 6 were fair, and 1 was poor, and the excellent and good rate was 88.9%. The reliability analysis showed that CLLSC had substantial intra-observer reliability in the geriatric population, with an average ICC of 0.78. There was also a substantial inter-observer reliability, with an average ICC of 0.73. While comparing the preoperative CLLSC results with the postoperative CLLSC results, 53 patients (73.6%) were in full agreement, 15 patients (20.8%) were in partial agreement, and 4 patients (5.6%) were not.ConclusionCLLSC has high reliability in the diagnosis of LSS in the geriatric patients. Combined FETD with CLLSC, accurate diagnosis, and minimal invasion can be performed to achieve safe and effective result.
ObjectiveTo investigate the clinical results and complication prevention of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of single-segment severe lumbar spinal stenosis (LSS).MethodsThe clinical data of 112 patients with severe LSS treated with MIS-TLIF between January 2010 and January 2017 were retrospectively analyzed. There were 43 males and 69 females, aged 52-81 years, with an average age of 65.3 years. The disease duration ranged from 4 to 126 months, with an average of 10.5 months. Clinical manifestations: 104 cases of low back pain, 91 cases of nervous intermittent claudication of both lower limbs, 21 cases of unilateral nerve root pain and/or numbness, and 5 cases of cauda equina nerve injury. The 112 cases were all severe central spinal stenosis, including 32 cases with lateral recess stenosis, 20 cases with foramen stenosis, 9 cases with ossification of ligamentum flavum, 38 cases with disc herniation; 14 cases with two complications and 5 cases with three. Stenosis segment: L3, 4 in 6 cases, L4, 5 in 89 cases, and L5, S1 in 17 cases. Surgical methods included bilateral decompression through bilateral approach (60 cases), bilateral decompression through unilateral approach (15 cases), and unilateral decompression (37 cases). The operation time, intraoperative blood loss, visual analogue scale (VAS) score of low back pain and leg pain, Oswestry disability index (ODI) score, fusion rate, and surgical complications were recorded. At last follow-up, the lumbar fusion was evaluated by Bridwell method, grades Ⅰ and Ⅱ were expressed as fusion.ResultsThe operation time was 83-186 minutes (mean, 126.8 minutes), and the intraoperative blood loss was 65-630 mL (mean, 163.1 mL). All the 112 patients were followed up 25-49 months, with an average of 35.1 months. The VAS score of low back pain and leg pain and ODI score at each time point after operation were significantly improved when compared with preoperative scores (P<0.05). There was no significant difference between the VAS score of low back pain and leg pain and ODI score at the other time points except 1 month after operation (P<0.05). At last follow-up, 2 cases of cauda equina nerve injury recovered and 3 cases partially recovered. According to Bridwell classification criteria, 58 cases were grade Ⅰ, 47 cases were grade Ⅱ, and 7 cases were grade Ⅲ. The fusion rate was 93.8%. Perioperative complications included 5 cases of incision complications (superficial infection in 3 cases, hematoma formation in 2 cases), 19 cases of internal fixator complications (intraoperative end plate fracture in 8 cases, fusion cage sinking in 11 cases at last follow-up), and 15 cases of neurological complications (dural sac tear in 10 cases, transient neurological symptoms of lower extremities aggravated in 5 cases). Conclusion MIS-TLIF treatment of single-level severe LSS can achieve good clinical results, while there is a risk of serious complications. Full understanding of the clinical and imaging features of the disease and reasonable and careful operation are helpful to control the occurrence of cauda equina nerve damage.
ObjectiveTo evaluate early effectiveness of posterior 180-degree decompression via unilateral biportal endoscopy (UBE) in the treatment of lumbar spinal stenosis (LSS) combined with Michigan State University (MSU)-1 lumbar disc herniation (LDH). MethodsA retrospective analysis was conducted on clinical data from 33 patients with LSS combined with MSU-1 LDH, who met selection criteria and were treated between March 2022 and January 2024. All patients underwent UBE-assisted 180-degree spinal canal decompression. The cohort comprised 17 males and 16 females, aged 37-82 years (mean, 67.1 years). Preoperative presentations included bilateral lower limbs intermittent claudication and radiating pain, with disease duration ranging from 5 to 13 months (mean, 8.5 months). Affected segments included L3, 4 in 4 cases, L4, 5 in 28 cases, and L5, S1 in 1 case. LSS was rated as Schizas grade A in 4 cases, grade B in 5 cases, grade C in 13 cases, and grade D in 11 cases. LDH was categorized as MSU-1A in 24 cases, MSU-1B in 2 cases, and MSU-1AB in 7 cases. Intraoperative parameters (operation time, blood loss) and postoperative hospitalization length were recorded. The visual analogue scale (VAS) score and Oswestry Disability Index (ODI) were used to assess the lower limb pain and functional outcomes after operation. Clinical efficacy was evaluated at last follow-up via modified MacNab criteria. Quantitative radiological assessments included dural sac cross-sectional area (DSCA) measurements and spinal stenosis grading on lumbar MRI. Morphological classification of lumbar canal stenosis was determined according to the Schizas grading, categorized into four grades. Results The operation time was 60.4-90.8 minutes (mean, 80.3 minutes) and intraoperative blood loss was 13-47 mL (mean, 29.9 mL). The postoperative hospitalization length was 3-5 days (mean, 3.8 days). All patients were followed up 12-16 months (mean, 13.8 months). The VAS score and ODI improved at immediate and 3, 6, and 12 months after operation compared to before operation, and the differences between different time points were significant (P<0.05). At last follow-up, the clinical efficacy assessed by the modified MacNab criteria were graded as excellent in 23 cases, good in 9 cases, and poor in 1 case, with an excellent and good rate of 96.97%. Postoperative lumbar MRI revealed the significant decompression of the dural sac in 32 cases, with 1 case showing inadequate dural expansion. DSCA measurements confirmed progressive enlargement and stenosis reduction over time. The differences were significant (P<0.05) before operation, immediately after operation, and at 6 months after operation. At 6 months after operation, Schizas grading of spinal stenosis improved to grade A in 27 cases and grade B in 6 cases. ConclusionPosterior 180-degree decompression via UBE is a safe and feasible strategy for treating LSS combined with MSU-1 LDH, achieving effective neural decompression while preserving intervertebral disc integrity.