Iatrogenic spondylolisthesis following laminectomy for degenerative lumbar stenosis: systematic review and current concepts

Free access

OBJECT

Decompression without fusion for degenerative lumbar stenosis is an effective treatment for both the pain and disability of neurogenic claudication. Iatrogenic instability following decompression may require further intervention to stabilize the spine. The authors review the incidence of postsurgical instability following lumbar decompression, and assess the impact of surgical technique as well as study design on the incidence of instability.

METHODS

A comprehensive literature search was performed to identify surgical cohorts of patients with degenerative lumbar stenosis, with and without preexisting spondylolisthesis, who were treated with laminectomy or minimally invasive decompression without fusion. Data on patient characteristics, surgical indications and techniques, clinical and radiographic outcomes, and reoperation rates were collected and analyzed.

RESULTS

A systematic review of 24 studies involving 2496 patients was performed, assessing both open laminectomy and minimally invasive bilateral canal enlargement. Postoperative pain and functional outcomes were similar across the various studies, and postoperative radiographie instability was seen in 5.5% of patients. Instability was seen more frequently in patients with preexisting spondylolisthesis (12.6%) and in those treated with open laminectomy (12%). Reoperation for instability was required in 1.8% of all patients, and was higher for patients with preoperative spondylolisthesis (9.3%) and for those treated with open laminectomy (4.1%).

CONCLUSIONS

Instability following lumbar decompression is a common occurrence. This is particularly true if decompression alone is selected as a surgical approach in patients with established spondylolisthesis. This complication may occur less commonly with the use of minimally invasive techniques; however, larger prospective cohort studies are necessary to more thoroughly explore these findings.

ABBREVIATIONSLSS = lumbar spinal stenosis; MIS = minimally invasive surgery; ODI = Oswestry Disability Index.

OBJECT

Decompression without fusion for degenerative lumbar stenosis is an effective treatment for both the pain and disability of neurogenic claudication. Iatrogenic instability following decompression may require further intervention to stabilize the spine. The authors review the incidence of postsurgical instability following lumbar decompression, and assess the impact of surgical technique as well as study design on the incidence of instability.

METHODS

A comprehensive literature search was performed to identify surgical cohorts of patients with degenerative lumbar stenosis, with and without preexisting spondylolisthesis, who were treated with laminectomy or minimally invasive decompression without fusion. Data on patient characteristics, surgical indications and techniques, clinical and radiographic outcomes, and reoperation rates were collected and analyzed.

RESULTS

A systematic review of 24 studies involving 2496 patients was performed, assessing both open laminectomy and minimally invasive bilateral canal enlargement. Postoperative pain and functional outcomes were similar across the various studies, and postoperative radiographie instability was seen in 5.5% of patients. Instability was seen more frequently in patients with preexisting spondylolisthesis (12.6%) and in those treated with open laminectomy (12%). Reoperation for instability was required in 1.8% of all patients, and was higher for patients with preoperative spondylolisthesis (9.3%) and for those treated with open laminectomy (4.1%).

CONCLUSIONS

Instability following lumbar decompression is a common occurrence. This is particularly true if decompression alone is selected as a surgical approach in patients with established spondylolisthesis. This complication may occur less commonly with the use of minimally invasive techniques; however, larger prospective cohort studies are necessary to more thoroughly explore these findings.

Symptomatic lumbar spinal stenosis (LSS) can cause progressive neurogenic claudication, radicular pain, and weakness. Surgical intervention can provide for improvements in pain, disability, and health-related quality of life.49 The pathoanatomy underlying the cross-sectional narrowing of the vertebral canal includes varying degrees of disc herniation and/or bulging, zygoapophyseal facet joint hypertrophy and cyst formation, and ligamentum flavum hypertrophy and buckling. In some cases, the degenerative disc disease permits spondylolisthesis as well.4,24 Neural element compression can cause neurogenic claudication from central canal stenosis or radiculopathy from lateral recess encroachment. Superimposed mechanical back symptoms may occur secondary to dynamic instability.

Although surgical decompression for neurogenic claudication has been shown to be efficacious, the role of fusion remains less clear. In certain subgroups, particularly those with degenerative spondylolisthesis or dynamic instability, there has been suggestion of benefit.18–25,42 Preoperative patient assessment prognosticating for postoperative instability may include overt instability or facet and disc morphology where decompression would be expected to cause iatrogenic instability.43,44 Segmental spinal stability is compromised by the very nature of the surgical approach, with the likelihood of excessive motion augmented when wider decompressions are performed, greater ligamentous disruption occurs, or multiple levels are included.11,31 Indeed, postlaminectomy instability is one of the most common indications for reoperation following decompression.23,36 Minimally invasive surgery (MIS) techniques for the spine purport, among other advantages, to preserve the posterior osseoligamentous structures, and may minimize destabilization while achieving adequate decompression of the neural elements.2,28,30,37,39,47,54 Critics of MIS techniques note the possibility of inadequate decompression with some of these procedures.51

The goal of this review was to evaluate the incidence of postlaminectomy instability among patients with LSS who were symptomatic with neurogenic claudication, and whose condition was managed by decompression without fusion. The objectives were to compare the relative incidences of this complication by surgical technique and also to assess whether the reported rates of instability were affected by study design.

Illustrative Case

A patient was referred to the senior author with symptomatic flexion-induced radicular leg pain and paraspinal muscle spasm following a posterior lumbar decompression for neurogenic claudication. This 45-year-old man presented 3 months after L4–5 laminectomy and discectomy for left L-5 radiculopathy, with positional bilateral claudicant symptoms and disabling mechanical back pain. His symptoms were exacerbated by flexion, with dynamic spinal imaging demonstrating translational instability on supine to upright transition. Further investigations revealed the cause, with Fig. 1A—an axial CT scan—revealing the extensive decompression involving removal of the left L-4 inferior articular process. Revision decompression and transforaminal lumbar interbody fusion (Fig. 1B and C) provided him with a good clinical result for both back and leg symptoms.

FIG. 1.
FIG. 1.

Postlaminectomy axial CT scan (A) reveals extensive lateral decompression with resection of the left inferior articular process of L-4. Postoperative anteroposterior (B) and lateral (C) radiographs show acceptable alignment of instrumentation after a transforaminal lumbar interbody fusion.

Methods

We conducted a systematic search in MEDLINE, EM-BASE, Scopus, Web of Science, and Google Scholar for literature published through May 2015, limiting the search results to human studies published in the English language. Search terms included “neurogenic claudication,” “lumbar spinal stenosis,” “decompression,” “laminectomy,” and “surgery,” as well as derivatives therefrom. Reference lists of key articles were also systematically checked to identify additional eligible articles. The specific question asked focused on the incidence of postlaminectomy instability and whether it was variable by surgical technique, the presence of preoperative spondylolisthesis, and how instability was variably reported by retrospective and prospective studies. Case reports or case series that consisted of fewer than 10 patients were excluded. Other works that were excluded were animal, cadaveric, and biomechanical studies. Figure 2 summarizes this selection process.

FIG. 2.
FIG. 2.

Study selection flowchart of the search for articles pertaining to surgical management of LSS and incidence of postoperative instability.

Studies were included if a minimum mean follow-up of 12 months was achieved and reporting of pre- and postoperative sagittal lumbar alignment and reoperation rates was included. When multiple studies were found from the same cohort, only the report with the longer follow-up was included. Patients who were treated with fusion at the index operation were excluded from analysis.

Data Extraction

We extracted the following data from the included articles: study design, patient demographic information, diagnosis, and surgical procedure. From these studies, we also compiled the reported outcomes of new or progressive spondylolisthesis (radiographic findings), and of reoperation for postoperative instability (clinical findings). Furthermore, clinical outcomes extracted from the studies included those used by 3 or more studies: the Physical Function and Bodily Pain components of the 36-Item Short Form Health Survey, the Japanese Orthopaedic Association lumbar score,26 the Oswestry Disability Index (ODI), and the visual analog scale for back and leg pain. Bias was assessed at the study level by using the Cochrane Risk of Bias tool, with each study thereafter assigned a grade of evidence reported in Table 1 alongside study characteristics.

TABLE 1.

Literature review of studies on degenerative lumbar stenosis

Authors & YearStudy DesignNo. of PtsM/F (%)Mean Age (yrs)Mean FU (mos)Definition of InstabilityGrade of Evidence*
Lurie et al., 2015Prospective35862:3863.996.0Not definedHigh (High)
Nomura et al., 2014Retrospective12459:4171.031.0Increased translationVery Low (Low – 1)
Chang et al., 2014Prospective16557:4368.740.0Increased translation (>2 mm)Moderate (High – 1)
Arai et al., 2014Prospective9462:3868.824.0Increased translation (>2 mm)Moderate (High – 1)
Minamide et al., 2013Prospective31048:5268.724.0Increased translationLow (High - 2)
Blumenthal et al., 2013Prospective4025:7568.243.0Not definedHigh (High)
Morgalla et al., 2011Retrospective10847:5371.012.0Not definedVery Low (Low – 1)
Hong et al., 2011Retrospective5353:4762.449.3Flex/ext translation (>8%)Low (Low)
Celik et al., 2010Prospective7146:5460.060.0Flex/ext translation (>4 mm)Moderate (High – 1)
Kelleher et al., 2010Retrospective7552:4868.047.5Increased translation (>6%)Low (Low)
Yagi et al., 2009Prospective4134:6672.118.2Not definedLow (High - 2)
Castro-Menendez et al., 2009Prospective5058:4256.048.0Not definedModerate (High – 1)
Fu et al., 2008Prospective15246:5457.640.0Not definedModerate (High – 1)
Ikuta et al., 2008Prospective3735:6569.038.0Flex/ext translation (>5%) or angulation (>5°)Moderate (High – 1)
Ofluoğlu et al., 2007Retrospective3441:5957.523.0Flex/ext angulation (>15°)Low (Low)
Costa et al., 2007Retrospective37449:5164.730.3Not definedVery Low (Low – 1)
Oertel et al., 2006Retrospective10255:4563.467.2Not definedLow (Low)
Lin et al., 2006Prospective1850:5067.014.0Not definedModerate (High – 1)
Thomé et al., 2005Prospective12044:5668.015.5Flex/ext translation (>5 mm)Moderate (High – 1)
Ghogawala et al., 2004Prospective2032:6868.812.0Flex/ext translation (>3 mm)Moderate (High – 1)
Mariconda et al., 2002Prospective2227:7362.647.0Panjabi/White criteriaModerate (High – 1)
Iguchi et al., 2000Retrospective3751:4960.9157.2Increased translation (>3 mm)Low (Low)
Thomas et al., 1997Prospective26NR68.036.7Not definedHigh (High)
Fox et al., 1996Retrospective9552:4867.569.6Flex/ext translation (>2 mm)Low (Low)

Flex/ext = flexion/extension; FU = follow-up; NR = not reported; pts = patients.

Grade—i.e., quality of evidence—is stated; the initial quality assessment and any modifiers are stated in parentheses.

Data Analysis

Because of the variable mechanisms of neurological outcome reporting, clinical outcomes were described in a systematic review format, with pooled estimates for dichotomous outcomes where feasible. Summary statistics regarding overall reported complication rates of instability and reoperation for stabilization were generated by pooled estimates based on study size. Two-factor weighted nominal logistic regression analysis was performed to define the dependence of both radiographic translational listhesis and repeated spinal operation for stabilization on the presence of preoperative spondylolisthesis versus stenosis alone and the use of MIS versus open surgical intervention. The 0.05 level of significance was used with post hoc Tukey’s analysis.

Results

Study Characteristics

The search strategy yielded 241 relevant citations, of which 198 were excluded based on title and/or abstract. Forty-three were selected for full-text review, of which 18 more were excluded due to lack of postoperative radiographic data in 11 studies, inclusion of only patients undergoing fusion in 6, or follow-up period less than 12 months in 1. Twenty-five papers were considered appropriate, of which 2 publications reported on differing follow-ups of the same cohort,33,49 so only the study with the longer follow-up was included. The flow of this process defining the final 24 studies is shown in Fig. 2, and the fundamental characteristics are shown in Table 1.

Fifteen of the studies were conducted prospectively1,5–8,15,16,21,32,33,35,37,46,47,52 and 9 were conducted retrospectively.10,14,19,20,27,38–41 Postoperative instability was defined variably across studies, including increase in sagittal translation between flexion-extension radiographs by 2 mm,1,8,14 3 mm,16 5 mm,47 5%,21 or 8%,19 or an increase in sagittal angulation by more than 15° between flexion and extension.41 Reoperation rates were considered positive if the procedure was explicitly cited to be a fusion for instability, although studies rarely stated the specific indication motivating such fusion. Furthermore, reoperation for residual stenosis was not consistently reported across the studies reviewed herein.

Patient Characteristics

Table 2 summarizes the pooled characteristics of all the study patients. The mean patient age was 65.7 years, and 51% were male. The radiographic pattern was reportedly stenosis only in 42% of cases, stenosis and spondylolisthesis in 11% of cases, and the remainder was not defined between the two. Following surgical intervention, the mean follow-up across all studies was 43.5 months; 37.1 months for prospective studies and 54.1 months for retrospective studies.

TABLE 2.

Summary of characteristics in patients with degenerative lumbar stenosis

VariableValue
Age in yrs, mean ± SD65.7 ± 4.7
% M/F51:49
Surgical indication
 Stenosis1039 (42%)
 Stenosis & spondylolisthesis285 (11%)
 Undefined1172 (47%)
Surgical technique
 Laminectomy777 (31%)
 Spinous process-splitting laminectomy189 (7.5%)
 Open ULBD947 (37%)
 Endoscopie ULBD417 (17%)
 Bilat laminotomy196 (7.8%)

ULBD = unilateral laminotomy with bilateral decompression.

Clinical Outcomes

Pooled clinical outcomes are summarized in Table 3. More than 50% improvement after surgery was seen in all metrics across the total cohort. Patients with stenosis exhibited greater improvement in ODI scores than those with both stenosis and spondylolisthesis, although both groups reached the minimum clinically important difference for improvement. Outcomes between open laminectomy and minimally invasive procedures were similar across all outcome measures.

TABLE 3.

Summary of clinical outcomes in patients with degenerative lumbar stenosis*

SubgroupSF-36 PFSF-36 BPODIJOAVAS Leg Pain (cm)VAS Back Pain (cm)
PreopPostop%APreopPostop%APreopPostop%APreopPostop%APreopPostopPreopPostop
Stenosis32.4 ± 1.261.2 ± 2.388.930.2 ± 2.157.6 ± 3.190.742.2 ± 10.76.3 ± 7.885.115.0 ± 0.024.7 ± 0.064.76.0 ± 2.31.3 ± 1.878.33.0 ± 2.61.8 ± 2.240.0
Stenosis & spondylolisthesis29.1 ± 3.666.4 ± 7.2128.225.3 ± 4.766.4 ± 6.8162.439.6 ± 7.223.3 ± 3.541.214.7 ± 0.823.8 ± 0.461.9NRNRNR7.3 ± 0.03.0 ± 0.058.9
Laminectomy31.1 ± 6.551.4 ± 9.765.318.1 ± 0.044.9 ± 0.0148.144.2 ± 2.98.4 ± 17.081.015.1 ± 0.524.1 ± 0.659.66.4 ± 1.92.0 ± 1.868.83.0 ± 4.12.0 ± 1.933.3
MIS decompression29.0 ± 7.359.5 ± 11.8105.223.6 ± 5.858.2 ± 8.1146.643.8 ± 16.915.5 ± 12.664.614.8 ± 0.723.6 ± 0.459.47.9 ± 1.33.2 ± 1.259.55.2 ± 2.72.6 ± 1.450.0
Total cohort30.3 ± 5.958.5 ± 9.993.127.4 ± 6.256.4 ± 9.3105.843.5 ± 12.014.4 ± 10.666.914.4 ± 0.623.4 ± 0.9262.57.7 ± 1.53.0 ± 1.361.04.5 ± 2.92.4 ± 1.446.7

JOA = Japanese Orthopaedic Association (lumbar pain score); SF-36 PF/BP = 36-ltem Short Form Health Survey, Physical Functioning/Bodily Pain component; VAS = visual analog scale.

% Δ denotes percent change between pre- and postoperative scores; positive values indicate improvement in clinical outcome. All other values are expressed as the mean ± SD.

Radiographic Progression and Reoperation

Table 4 delineates the radiographic outcome of progressive deformity and the incidence of reoperation. The overall incidence of new or increased postoperative spondylolisthesis was 5.5%, with a reoperation rate for instability of 1.8%, roughly one-third of patients in whom radiographic slip was detected. The radiographic progression was seen nearly twice as frequently in patients with preoperative Grade I—II spondylolisthesis compared with those having stenosis alone.

TABLE 4.

Summary of patient outcomes for radiographic progression and need for stabilization surgery

SubgroupNew/Increased Spondylolisthesis at Mean FU (% of pts)Reop for Postop Instability (% of pts)
Stenosis6.8%0.72%
Stenosis & spondylolisthesis12.6%9.3%
Laminectomy12.0%4.1%
MIS decompression2.6%0.81%
Total cohort5.5%1.8%

Retrospective studies reported the incidence of radiographic progression at 6.8% compared with 6.5% for prospective studies. There was a higher incidence of progression among patients with preexisting spondylolisthesis (17%) versus stenosis alone (5.3%, p < 0.001) and among patients in whom open decompression was performed (13%) compared with minimally invasive decompression (3.2%, p < 0.001). Reoperation rates were likewise similar between retrospective (1.2%) and prospective (2.3%) studies. There was a higher incidence of reoperation among patients with preexisting spondylolisthesis (8.9%) versus stenosis alone (1.1%, p < 0.001) and among patients in whom open decompression was performed (11%) compared with a minimally invasive decompression (0.7%, p < 0.001).

Discussion

Lumbar spinal stenosis is predominantly a disease of the elderly, and the most common indication for spine surgery in patients older than 65 years.9 Surgical decompression for symptomatic disease has been shown to improve quality-of-life outcomes in multiple randomized and nonrandomized trials;3,34,50 however, there remains no consensus on the optimal surgical technique. In the US alone there is significant regional variation in technique, specifically whether to perform an arthrodesis.48 Despite relative stability of the overall number of operations performed, there is a nationwide trend in the US increasingly toward complex fusion, which is associated with 2–3 times the upfront cost and often higher subsequent reoperation rates than decompression alone.12,13,29 Reflective of the lack of consensus, surgeon preference often outweighs patient clinical and radiographic factors as the primary determinant for whether fusion is performed.22,25

Postoperative instability after lumbar decompression remains one of the primary motivators of arthrodesis performed during the index procedure, or in reoperations after decompression.23 The incidence of postdecompression instability varies widely in the literature, ranging from 0% to 63%,1,14 due partly to the lack of standardized radiographic criteria.53 In our review alone, 10 of 24 studies reported incidences of postoperative instability without specifying its definition; the remaining studies varied widely in their stated criteria. Patient heterogeneity also contributes to the variability in postoperative instability. Multiple observational studies have combined patients with and without preexisting degenerative spondylolisthesis, although the influence of preexisting spondylolisthesis on subsequent instability remains debatable.16

Biomechanical work has demonstrated increased segmental mobility following disruption of the posterior osseoligamentous structures in bilateral laminectomy.17,45 Several MIS procedures intended to preserve the posterior tension band have been developed over the past 2 decades. The few existing studies directly comparing an MIS technique to open laminectomy have demonstrated superiority in pain and functional status, along with reduced blood loss, length of hospital stay, and cost, at relatively short follow-up intervals.15,46,47,52 Our review suggests no significant differences in clinical outcomes between MIS techniques and open laminectomy, although postoperative instability and reoperation rates were consistently reported to be lower for the less invasive techniques. What remains unclear is whether MIS approaches are associated with higher rates of reoperation for residual stenosis that was not adequately addressed in the indexed operation. Regrettably, the studies included in this analysis do not address acutely residual stenosis and cannot answer the question of surgical quality beyond the equivalence of reported clinical outcomes.

No significant differences in postoperative instability or reoperation rate were found between studies conducted prospectively or retrospectively in our review. Retrospective studies had a longer mean follow-up duration of 54.1 months, relative to 37.1 months for prospective studies, during which additional reoperative cases might be expected. However, the quality of follow-up in these retrospective series was often poor, with postoperative radiographs usually performed only in symptomatic patients. Because randomized controlled trials are also difficult with a heterogeneous patient group, studies of large, population-based, prospectively observed cohorts are required to identify significant predictors of radiographic and clinical outcomes in the neurogenic claudication population.29

Study Limitations

This is a narrative review of retrospective and prospective clinical studies, in which the patient management was nonrandomized, subject to surgeon assessment of patient candidacy for secondary surgical intervention, and with unpredictable recording of complications. It is nevertheless reassuring that many of the complication rates for these studies are in line with magnitudes observed in reported national databases. The cost burden of this complication has not been rigorously addressed by any of the reviewed literature, and should be included in future prospective work so that both the patient outcome and economic burden are understood in the context of lumbar decompressive surgery. In parallel, though, the potential for postlaminectomy instability must be ruled in or out in the workup of every patient who has persistent postoperative pain following structurally decompressive spinal surgery before the diagnosis of failed back surgery syndrome or persistent postoperative neuropathic pain can be assigned.

Conclusions

Iatrogenic instability following decompression for symptomatic LSS occurs in 5%–6% of patients. Interestingly, the rates reported have been consistent between both prospective and retrospective studies. Patients with preoperative spondylolisthesis undergoing decompression are nearly 10 times more likely to undergo a subsequent additional stabilization procedure than their stenosis-only counterparts. Minimally invasive surgical procedures may help protect patients from this complication, although more prospective studies with longer follow-up durations are necessary to better define whether this theoretical benefit will be realized in the longer term.

Author Contributions

Conception and design: all authors. Acquisition of data: Shamji, Guha. Analysis and interpretation of data: Shamji, Guha. Drafting the article: Shamji, Guha. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors.

References

  • 1

    Arai YHirai TYoshii TSakai KKato TEnomoto M: A prospective comparative study of 2 minimally invasive decompression procedures for lumbar spinal canal stenosis: unilateral laminotomy for bilateral decompression (ULBD) versus muscle-preserving interlaminar decompression (MILD). Spine (Phila Pa 1976) 39:3323402014

    • Search Google Scholar
    • Export Citation
  • 2

    Aryanpur JDucker T: Multilevel lumbar laminotomies: an alternative to laminectomy in the treatment of lumbar stenosis. Neurosurgery 26:4294331990

    • Search Google Scholar
    • Export Citation
  • 3

    Atlas SJDeyo RAKeller RBChapin AMPatrick DLLong JM: The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine (Phila Pa 1976) 21:178717951996

    • Search Google Scholar
    • Export Citation
  • 4

    Bae HWRajaee SSKanim LE: Nationwide trends in the surgical management of lumbar spinal stenosis. Spine (Phila Pa 1976) 38:9169262013

    • Search Google Scholar
    • Export Citation
  • 5

    Blumenthal CCurran JBenzel ECPotter RMagge SNHarrington JF Jr: Radiographic predictors of delayed instability following decompression without fusion for degenerative grade I lumbar spondylolisthesis. J Neurosurg Spine 18:3403462013

    • Search Google Scholar
    • Export Citation
  • 6

    Castro-Menendez MBravo-Ricoy JACasal-Moro RHernandez-Blanco MJorge-Barreiro FJ: Midterm outcome after microendoscopic decompressive laminotomy for lumbar spinal stenosis: 4-year prospective study. Neurosurgery 65:100110A122009

    • Search Google Scholar
    • Export Citation
  • 7

    Celik SECelik SGöksu KKara AInce I: Microdecompressive laminatomy with a 5-year follow-up period for severe lumbar spinal stenosis. J Spinal Disord Tech 23:2292352010

    • Search Google Scholar
    • Export Citation
  • 8

    Chang HSFujisawa NTsuchiya TOya SMatsui T: Degenerative spondylolisthesis does not affect the outcome of unilateral laminotomy with bilateral decompression in patients with lumbar stenosis. Spine (Phila Pa 1976) 39:4004082014

    • Search Google Scholar
    • Export Citation
  • 9

    Ciol MADeyo RAHowell EKreif S: An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations. J Am Geriatr Soc 44:2852901996

    • Search Google Scholar
    • Export Citation
  • 10

    Costa FSassi MCardia AOrtolina ADe Santis ALuccarell G: Degenerative lumbar spinal stenosis: analysis of results in a series of 374 patients treated with unilateral laminotomy for bilateral microdecompression. J Neurosurg Spine 7:5795862007

    • Search Google Scholar
    • Export Citation
  • 11

    Dai LCheng PTu KXu YZhang W: The effect of posterior element resection on the stress distribution in the lumbar spine. Chin Med Sci J 10:1131151995

    • Search Google Scholar
    • Export Citation
  • 12

    Deyo RAMartin BIKreuter WJarvik JGAngier HMirza SK: Revision surgery following operations for lumbar stenosis. J Bone Joint Surg Am 93:197919862011

    • Search Google Scholar
    • Export Citation
  • 13

    Deyo RAMirza SKMartin BIKreuter WGoodman DCJarvik JG: Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 303:125912652010

    • Search Google Scholar
    • Export Citation
  • 14

    Fox MWOnofrio BMOnofrio BMHanssen AD: Clinical outcomes and radiological instability following decompressive lumbar laminectomy for degenerative spinal stenosis: a comparison of patients undergoing concomitant arthrodesis versus decompression alone. J Neurosurg 85:7938021996

    • Search Google Scholar
    • Export Citation
  • 15

    Fu YSZeng BFXu JG: Long-term outcomes of two different decompressive techniques for lumbar spinal stenosis. Spine (Phila Pa 1976) 33:5145182008

    • Search Google Scholar
    • Export Citation
  • 16

    Ghogawala ZBenzel ECAmin-Hanjani SBarker FG IIHarrington JFMagge SN: Prospective outcomes evaluation after decompression with or without instrumented fusion for lumbar stenosis and degenerative Grade I spondylolisthesis. J Neurosurg Spine 1:2672722004

    • Search Google Scholar
    • Export Citation
  • 17

    Gillespie KADickey JP: Biomechanical role of lumbar spine ligaments in flexion and extension: determination using a parallel linkage robot and a porcine model. Spine (Phila Pa 1976) 29:120812162004

    • Search Google Scholar
    • Export Citation
  • 18

    Herkowitz HNKurz LT: Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 73:8028081991

    • Search Google Scholar
    • Export Citation
  • 19

    Hong SWChoi KYAhn YBaek OKWang JCLee SH: A comparison of unilateral and bilateral laminotomies for decompression of L4–L5 spinal stenosis. Spine (Phila Pa 1976) 36:E172E1782011

    • Search Google Scholar
    • Export Citation
  • 20

    Iguchi TKurihara ANakayama JSato KKurosaka MYamasaki K: Minimum 10-year outcome of decompressive laminectomy for degenerative lumbar spinal stenosis. Spine (Phila Pa 1976) 25:175417592000

    • Search Google Scholar
    • Export Citation
  • 21

    Ikuta KTono OOga M: Clinical outcome of microendoscopic posterior decompression for spinal stenosis associated with degenerative spondylolisthesis--minimum 2-year outcome of 37 patients. Minim Invasive Neurosurg 51:2672712008

    • Search Google Scholar
    • Export Citation
  • 22

    Irwin ZNHilibrand AGustavel MMcLain RShaffer WMyers M: Variation in surgical decision making for degenerative spinal disorders. Part I: lumbar spine. Spine (Phila Pa 1976) 30:220822132005

    • Search Google Scholar
    • Export Citation
  • 23

    Javalkar VCardenas RTawflk TAKhan IRBollam PBanerjee AD: Reoperations after surgery for lumbar spinal stenosis. World Neurosurg 75:7377422011

    • Search Google Scholar
    • Export Citation
  • 24

    Katz JNHarris MB: Clinical practice. Lumbar spinal stenosis. N Engl J Med 358:8188252008

  • 25

    Katz JNLipson SJLew RAGrobler LJWeinstein JNBrick GW: Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Patient selection, costs, and surgical outcomes. Spine (Phila Pa 1976) 22:112311311997

    • Search Google Scholar
    • Export Citation
  • 26

    Kawaguchi YKanamori MIshihara HOhmori KFujiuchi YMatsui H: Clinical symptoms and surgical outcome in lumbar spinal stenosis patients with neuropathic bladder. J Spinal Disord 14:4044102001

    • Search Google Scholar
    • Export Citation
  • 27

    Kelleher MOTimlin MPersaud ORampersaud YR: Success and failure of minimally invasive decompression for focal lumbar spinal stenosis in patients with and without deformity. Spine (Phila Pa 1976) 35:E981E9872010

    • Search Google Scholar
    • Export Citation
  • 28

    Khoo LTFessler RG: Microendoscopic decompressive laminotomy for the treatment of lumbar stenosis. Neurosurgery 51:5 SupplS146S1542002

    • Search Google Scholar
    • Export Citation
  • 29

    Kim CHChung CKPark CSChoi BHahn SKim MJ: Reoperation rate after surgery for lumbar spinal stenosis without spondylolisthesis: a nationwide cohort study. Spine J 13:123012372013

    • Search Google Scholar
    • Export Citation
  • 30

    Kleeman TJHiscoe ACBerg EE: Patient outcomes after minimally destabilizing lumbar stenosis decompression: the “port-hole” technique. Spine (Phila Pa 1976) 25:8658702000

    • Search Google Scholar
    • Export Citation
  • 31

    Lee KKTeo ECQiu TXYang K: Effect of facetectomy on lumbar spinal stability under sagittal plane loadings. Spine (Phila Pa 1976) 29:162416312004

    • Search Google Scholar
    • Export Citation
  • 32

    Lin SMTseng SHYang JCTu CC: Chimney sublaminar decompression for degenerative lumbar spinal stenosis. J Neurosurg Spine 4:3593642006

    • Search Google Scholar
    • Export Citation
  • 33

    Lurie JDTosteson TDTosteson AAbdu WAZhao WMorgan TS: Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 40:63762015

    • Search Google Scholar
    • Export Citation
  • 34

    Malmivaara ASlätis PHeliövaara MSainio PKinnunen HKankare J: Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976) 32:182007

    • Search Google Scholar
    • Export Citation
  • 35

    Mariconda MFava RGatto ALongo CMilano C: Unilateral laminectomy for bilateral decompression of lumbar spinal stenosis: a prospective comparative study with conservatively treated patients. J Spinal Disord Tech 15:39462002

    • Search Google Scholar
    • Export Citation
  • 36

    Martin BIMirza SKComstock BAGray DTKreuter WDeyo RA: Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine (Phila Pa 1976) 32:3823872007

    • Search Google Scholar
    • Export Citation
  • 37

    Minamide AYoshida MYamada HNakagawa YKawai MMaio K: Endoscope-assisted spinal decompression surgery for lumbar spinal stenosis. J Neurosurg Spine 19:6646712013

    • Search Google Scholar
    • Export Citation
  • 38

    Morgalla MHNoak NMerkle MTatagiba MS: Lumbar spinal stenosis in elderly patients: is a unilateral microsurgical approach sufficient for decompression?. J Neurosurg Spine 14:3053122011

    • Search Google Scholar
    • Export Citation
  • 39

    Nomura HYanagisawa YArima JOga M: Clinical outcome of microscopic lumbar spinous process-splitting laminectomy: clinical article. J Neurosurg Spine 21:1871942014

    • Search Google Scholar
    • Export Citation
  • 40

    Oertel MFRyang YMKorinth MCGilsbach JMRohde V: Long-term results of microsurgical treatment of lumbar spinal stenosis by unilateral laminotomy for bilateral decompression. Neurosurgery 59:126412702006

    • Search Google Scholar
    • Export Citation
  • 41

    Ofluoğlu AEKarasu AEkinci BToplamaoğlu H: The effect of laminectomy on instability in the management of degenerative lumbar stenosis surgery: a retrospective radiographic assessment. Turk Neurosurg 17:1781822007

    • Search Google Scholar
    • Export Citation
  • 42

    Resnick DKWatters WC IIISharan AMummaneni PVDailey ATWang JC: Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 9: lumbar fusion for stenosis with spondylolisthesis. J Neurosurg Spine 21:54612014

    • Search Google Scholar
    • Export Citation
  • 43

    Robertson PAGrobler LJNovotny JEKatz JN: Postoperative spondylolisthesis at L4–5. The role of facet joint morphology. Spine (Phila Pa 1976) 18:148314901993

    • Search Google Scholar
    • Export Citation
  • 44

    Sharma MLangrana NARodriguez J: Role of ligaments and facets in lumbar spinal stability. Spine (Phila Pa 1976) 20:8879001995

  • 45

    Tai CLHsieh PHChen WPChen LHChen WJLai PL: Biomechanical comparison of lumbar spine instability between laminectomy and bilateral laminotomy for spinal stenosis syndrome—an experimental study in porcine model. BMC Musculoskelet Disord 9:842008

    • Search Google Scholar
    • Export Citation
  • 46

    Thomas NWRea GLPikul BKMervis LJIrsik RMcGregor JM: Quantitative outcome and radiographic comparisons between laminectomy and laminotomy in the treatment of acquired lumbar stenosis. Neurosurgery 41:5675751997

    • Search Google Scholar
    • Export Citation
  • 47

    Thomé CZevgaridis DLeheta OBäzner HPöckler-Schö-niger CWöhrle J: Outcome after less-invasive decompression of lumbar spinal stenosis: a randomized comparison of unilateral laminotomy, bilateral laminotomy, and laminectomy. J Neurosurg Spine 3:1291412005

    • Search Google Scholar
    • Export Citation
  • 48

    Weinstein JNLurie JDOlson PRBronner KKFisher ES: United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine (Phila Pa 1976) 31:270727142006

    • Search Google Scholar
    • Export Citation
  • 49

    Weinstein JNTosteson TDLurie JDTosteson ABlood EHerkowitz H: Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976) 35:132913382010

    • Search Google Scholar
    • Export Citation
  • 50

    Weinstein JNTosteson TDLurie JDTosteson ANBlood EHanscom B: Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 358:7948102008

    • Search Google Scholar
    • Export Citation
  • 51

    Wong APSmith ZALall RRBresnahan LEFessler RG: The microendoscopic decompression of lumbar stenosis: a review of the current literature and clinical results. Minim Invasive Surg 2012:3250952012

    • Search Google Scholar
    • Export Citation
  • 52

    Yagi MOkada ENinomiya KKihara M: Postoperative outcome after modified unilateral-approach microendoscopic midline decompression for degenerative spinal stenosis. J Neurosurg Spine 10:2932992009

    • Search Google Scholar
    • Export Citation
  • 53

    Yone KSakou T: Usefulness of Posner’s definition of spinal instability for selection of surgical treatment for lumbar spinal stenosis. J Spinal Disord 12:40441999

    • Search Google Scholar
    • Export Citation
  • 54

    Young SVeerapen RO’Laoire SA: Relief of lumbar canal stenosis using multilevel subarticular fenestrations as an alternative to wide laminectomy: preliminary report. Neurosurgery 23:6286331988

    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Correspondence Mohammed F. Shamji, Division of Neurosurgery, Toronto Western Hospital, WW4-446 - 399 Bathurst St., Toronto, ON M5T 2S8, Canada. email: mohammed.shamji@uhn.ca.

INCLUDE WHEN CITING DOI: 10.3171/2015.7.FOCUS15259.

Disclosure Dr. Shamji is a consultant for Medtronic Sofamor Danek with no relevant conflicts of interest in this work. There was no funding received by the authors for this systematic review.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Postlaminectomy axial CT scan (A) reveals extensive lateral decompression with resection of the left inferior articular process of L-4. Postoperative anteroposterior (B) and lateral (C) radiographs show acceptable alignment of instrumentation after a transforaminal lumbar interbody fusion.

  • View in gallery

    Study selection flowchart of the search for articles pertaining to surgical management of LSS and incidence of postoperative instability.

References

  • 1

    Arai YHirai TYoshii TSakai KKato TEnomoto M: A prospective comparative study of 2 minimally invasive decompression procedures for lumbar spinal canal stenosis: unilateral laminotomy for bilateral decompression (ULBD) versus muscle-preserving interlaminar decompression (MILD). Spine (Phila Pa 1976) 39:3323402014

    • Search Google Scholar
    • Export Citation
  • 2

    Aryanpur JDucker T: Multilevel lumbar laminotomies: an alternative to laminectomy in the treatment of lumbar stenosis. Neurosurgery 26:4294331990

    • Search Google Scholar
    • Export Citation
  • 3

    Atlas SJDeyo RAKeller RBChapin AMPatrick DLLong JM: The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine (Phila Pa 1976) 21:178717951996

    • Search Google Scholar
    • Export Citation
  • 4

    Bae HWRajaee SSKanim LE: Nationwide trends in the surgical management of lumbar spinal stenosis. Spine (Phila Pa 1976) 38:9169262013

    • Search Google Scholar
    • Export Citation
  • 5

    Blumenthal CCurran JBenzel ECPotter RMagge SNHarrington JF Jr: Radiographic predictors of delayed instability following decompression without fusion for degenerative grade I lumbar spondylolisthesis. J Neurosurg Spine 18:3403462013

    • Search Google Scholar
    • Export Citation
  • 6

    Castro-Menendez MBravo-Ricoy JACasal-Moro RHernandez-Blanco MJorge-Barreiro FJ: Midterm outcome after microendoscopic decompressive laminotomy for lumbar spinal stenosis: 4-year prospective study. Neurosurgery 65:100110A122009

    • Search Google Scholar
    • Export Citation
  • 7

    Celik SECelik SGöksu KKara AInce I: Microdecompressive laminatomy with a 5-year follow-up period for severe lumbar spinal stenosis. J Spinal Disord Tech 23:2292352010

    • Search Google Scholar
    • Export Citation
  • 8

    Chang HSFujisawa NTsuchiya TOya SMatsui T: Degenerative spondylolisthesis does not affect the outcome of unilateral laminotomy with bilateral decompression in patients with lumbar stenosis. Spine (Phila Pa 1976) 39:4004082014

    • Search Google Scholar
    • Export Citation
  • 9

    Ciol MADeyo RAHowell EKreif S: An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations. J Am Geriatr Soc 44:2852901996

    • Search Google Scholar
    • Export Citation
  • 10

    Costa FSassi MCardia AOrtolina ADe Santis ALuccarell G: Degenerative lumbar spinal stenosis: analysis of results in a series of 374 patients treated with unilateral laminotomy for bilateral microdecompression. J Neurosurg Spine 7:5795862007

    • Search Google Scholar
    • Export Citation
  • 11

    Dai LCheng PTu KXu YZhang W: The effect of posterior element resection on the stress distribution in the lumbar spine. Chin Med Sci J 10:1131151995

    • Search Google Scholar
    • Export Citation
  • 12

    Deyo RAMartin BIKreuter WJarvik JGAngier HMirza SK: Revision surgery following operations for lumbar stenosis. J Bone Joint Surg Am 93:197919862011

    • Search Google Scholar
    • Export Citation
  • 13

    Deyo RAMirza SKMartin BIKreuter WGoodman DCJarvik JG: Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 303:125912652010

    • Search Google Scholar
    • Export Citation
  • 14

    Fox MWOnofrio BMOnofrio BMHanssen AD: Clinical outcomes and radiological instability following decompressive lumbar laminectomy for degenerative spinal stenosis: a comparison of patients undergoing concomitant arthrodesis versus decompression alone. J Neurosurg 85:7938021996

    • Search Google Scholar
    • Export Citation
  • 15

    Fu YSZeng BFXu JG: Long-term outcomes of two different decompressive techniques for lumbar spinal stenosis. Spine (Phila Pa 1976) 33:5145182008

    • Search Google Scholar
    • Export Citation
  • 16

    Ghogawala ZBenzel ECAmin-Hanjani SBarker FG IIHarrington JFMagge SN: Prospective outcomes evaluation after decompression with or without instrumented fusion for lumbar stenosis and degenerative Grade I spondylolisthesis. J Neurosurg Spine 1:2672722004

    • Search Google Scholar
    • Export Citation
  • 17

    Gillespie KADickey JP: Biomechanical role of lumbar spine ligaments in flexion and extension: determination using a parallel linkage robot and a porcine model. Spine (Phila Pa 1976) 29:120812162004

    • Search Google Scholar
    • Export Citation
  • 18

    Herkowitz HNKurz LT: Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 73:8028081991

    • Search Google Scholar
    • Export Citation
  • 19

    Hong SWChoi KYAhn YBaek OKWang JCLee SH: A comparison of unilateral and bilateral laminotomies for decompression of L4–L5 spinal stenosis. Spine (Phila Pa 1976) 36:E172E1782011

    • Search Google Scholar
    • Export Citation
  • 20

    Iguchi TKurihara ANakayama JSato KKurosaka MYamasaki K: Minimum 10-year outcome of decompressive laminectomy for degenerative lumbar spinal stenosis. Spine (Phila Pa 1976) 25:175417592000

    • Search Google Scholar
    • Export Citation
  • 21

    Ikuta KTono OOga M: Clinical outcome of microendoscopic posterior decompression for spinal stenosis associated with degenerative spondylolisthesis--minimum 2-year outcome of 37 patients. Minim Invasive Neurosurg 51:2672712008

    • Search Google Scholar
    • Export Citation
  • 22

    Irwin ZNHilibrand AGustavel MMcLain RShaffer WMyers M: Variation in surgical decision making for degenerative spinal disorders. Part I: lumbar spine. Spine (Phila Pa 1976) 30:220822132005

    • Search Google Scholar
    • Export Citation
  • 23

    Javalkar VCardenas RTawflk TAKhan IRBollam PBanerjee AD: Reoperations after surgery for lumbar spinal stenosis. World Neurosurg 75:7377422011

    • Search Google Scholar
    • Export Citation
  • 24

    Katz JNHarris MB: Clinical practice. Lumbar spinal stenosis. N Engl J Med 358:8188252008

  • 25

    Katz JNLipson SJLew RAGrobler LJWeinstein JNBrick GW: Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Patient selection, costs, and surgical outcomes. Spine (Phila Pa 1976) 22:112311311997

    • Search Google Scholar
    • Export Citation
  • 26

    Kawaguchi YKanamori MIshihara HOhmori KFujiuchi YMatsui H: Clinical symptoms and surgical outcome in lumbar spinal stenosis patients with neuropathic bladder. J Spinal Disord 14:4044102001

    • Search Google Scholar
    • Export Citation
  • 27

    Kelleher MOTimlin MPersaud ORampersaud YR: Success and failure of minimally invasive decompression for focal lumbar spinal stenosis in patients with and without deformity. Spine (Phila Pa 1976) 35:E981E9872010

    • Search Google Scholar
    • Export Citation
  • 28

    Khoo LTFessler RG: Microendoscopic decompressive laminotomy for the treatment of lumbar stenosis. Neurosurgery 51:5 SupplS146S1542002

    • Search Google Scholar
    • Export Citation
  • 29

    Kim CHChung CKPark CSChoi BHahn SKim MJ: Reoperation rate after surgery for lumbar spinal stenosis without spondylolisthesis: a nationwide cohort study. Spine J 13:123012372013

    • Search Google Scholar
    • Export Citation
  • 30

    Kleeman TJHiscoe ACBerg EE: Patient outcomes after minimally destabilizing lumbar stenosis decompression: the “port-hole” technique. Spine (Phila Pa 1976) 25:8658702000

    • Search Google Scholar
    • Export Citation
  • 31

    Lee KKTeo ECQiu TXYang K: Effect of facetectomy on lumbar spinal stability under sagittal plane loadings. Spine (Phila Pa 1976) 29:162416312004

    • Search Google Scholar
    • Export Citation
  • 32

    Lin SMTseng SHYang JCTu CC: Chimney sublaminar decompression for degenerative lumbar spinal stenosis. J Neurosurg Spine 4:3593642006

    • Search Google Scholar
    • Export Citation
  • 33

    Lurie JDTosteson TDTosteson AAbdu WAZhao WMorgan TS: Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 40:63762015

    • Search Google Scholar
    • Export Citation
  • 34

    Malmivaara ASlätis PHeliövaara MSainio PKinnunen HKankare J: Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976) 32:182007

    • Search Google Scholar
    • Export Citation
  • 35

    Mariconda MFava RGatto ALongo CMilano C: Unilateral laminectomy for bilateral decompression of lumbar spinal stenosis: a prospective comparative study with conservatively treated patients. J Spinal Disord Tech 15:39462002

    • Search Google Scholar
    • Export Citation
  • 36

    Martin BIMirza SKComstock BAGray DTKreuter WDeyo RA: Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine (Phila Pa 1976) 32:3823872007

    • Search Google Scholar
    • Export Citation
  • 37

    Minamide AYoshida MYamada HNakagawa YKawai MMaio K: Endoscope-assisted spinal decompression surgery for lumbar spinal stenosis. J Neurosurg Spine 19:6646712013

    • Search Google Scholar
    • Export Citation
  • 38

    Morgalla MHNoak NMerkle MTatagiba MS: Lumbar spinal stenosis in elderly patients: is a unilateral microsurgical approach sufficient for decompression?. J Neurosurg Spine 14:3053122011

    • Search Google Scholar
    • Export Citation
  • 39

    Nomura HYanagisawa YArima JOga M: Clinical outcome of microscopic lumbar spinous process-splitting laminectomy: clinical article. J Neurosurg Spine 21:1871942014

    • Search Google Scholar
    • Export Citation
  • 40

    Oertel MFRyang YMKorinth MCGilsbach JMRohde V: Long-term results of microsurgical treatment of lumbar spinal stenosis by unilateral laminotomy for bilateral decompression. Neurosurgery 59:126412702006

    • Search Google Scholar
    • Export Citation
  • 41

    Ofluoğlu AEKarasu AEkinci BToplamaoğlu H: The effect of laminectomy on instability in the management of degenerative lumbar stenosis surgery: a retrospective radiographic assessment. Turk Neurosurg 17:1781822007

    • Search Google Scholar
    • Export Citation
  • 42

    Resnick DKWatters WC IIISharan AMummaneni PVDailey ATWang JC: Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 9: lumbar fusion for stenosis with spondylolisthesis. J Neurosurg Spine 21:54612014

    • Search Google Scholar
    • Export Citation
  • 43

    Robertson PAGrobler LJNovotny JEKatz JN: Postoperative spondylolisthesis at L4–5. The role of facet joint morphology. Spine (Phila Pa 1976) 18:148314901993

    • Search Google Scholar
    • Export Citation
  • 44

    Sharma MLangrana NARodriguez J: Role of ligaments and facets in lumbar spinal stability. Spine (Phila Pa 1976) 20:8879001995

  • 45

    Tai CLHsieh PHChen WPChen LHChen WJLai PL: Biomechanical comparison of lumbar spine instability between laminectomy and bilateral laminotomy for spinal stenosis syndrome—an experimental study in porcine model. BMC Musculoskelet Disord 9:842008

    • Search Google Scholar
    • Export Citation
  • 46

    Thomas NWRea GLPikul BKMervis LJIrsik RMcGregor JM: Quantitative outcome and radiographic comparisons between laminectomy and laminotomy in the treatment of acquired lumbar stenosis. Neurosurgery 41:5675751997

    • Search Google Scholar
    • Export Citation
  • 47

    Thomé CZevgaridis DLeheta OBäzner HPöckler-Schö-niger CWöhrle J: Outcome after less-invasive decompression of lumbar spinal stenosis: a randomized comparison of unilateral laminotomy, bilateral laminotomy, and laminectomy. J Neurosurg Spine 3:1291412005

    • Search Google Scholar
    • Export Citation
  • 48

    Weinstein JNLurie JDOlson PRBronner KKFisher ES: United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine (Phila Pa 1976) 31:270727142006

    • Search Google Scholar
    • Export Citation
  • 49

    Weinstein JNTosteson TDLurie JDTosteson ABlood EHerkowitz H: Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976) 35:132913382010

    • Search Google Scholar
    • Export Citation
  • 50

    Weinstein JNTosteson TDLurie JDTosteson ANBlood EHanscom B: Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med 358:7948102008

    • Search Google Scholar
    • Export Citation
  • 51

    Wong APSmith ZALall RRBresnahan LEFessler RG: The microendoscopic decompression of lumbar stenosis: a review of the current literature and clinical results. Minim Invasive Surg 2012:3250952012

    • Search Google Scholar
    • Export Citation
  • 52

    Yagi MOkada ENinomiya KKihara M: Postoperative outcome after modified unilateral-approach microendoscopic midline decompression for degenerative spinal stenosis. J Neurosurg Spine 10:2932992009

    • Search Google Scholar
    • Export Citation
  • 53

    Yone KSakou T: Usefulness of Posner’s definition of spinal instability for selection of surgical treatment for lumbar spinal stenosis. J Spinal Disord 12:40441999

    • Search Google Scholar
    • Export Citation
  • 54

    Young SVeerapen RO’Laoire SA: Relief of lumbar canal stenosis using multilevel subarticular fenestrations as an alternative to wide laminectomy: preliminary report. Neurosurgery 23:6286331988

    • Search Google Scholar
    • Export Citation

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 312 312 29
PDF Downloads 1550 1550 68
EPUB Downloads 0 0 0

PubMed

Google Scholar