Sagittal- or coronal-plane deformity considerably complicates the diagnosis and treatment of lumbar spinal stenosis. Although decompressive laminectomy remains the standard operative treatment for uncomplicated lumbar spinal stenosis, the management of stenosis with concurrent deformity may require osteotomy, laminectomy, and spinal fusion with or without instrumentation. Broadly stated, the surgery-related goals in complex stenosis are neural decompression and a well-balanced sagittal and coronal fusion. Deformities that may present with concurrent stenosis are scoliosis, spondylolisthesis, and flatback deformity. The presentation and management of lumbar spinal stenosis associated with concurrent coronal or sagittal deformities depends on the type and extent of deformity as well as its impact on neural compression. Generally, clinical outcomes in complex stenosis are optimized by decompression combined with spinal fusion. The need for instrumentation is clear in cases of significant scoliosis or flatback deformity but is controversial in spondylolisthesis. With appropriate selection of technique for deformity correction, a surgeon may profoundly improve pain, quality of life, and functional capacity. The decision to undertake surgery entails weighing risk factors such as age, comorbidities, and preoperative functional status against potential benefits of improved neurological function, decreased pain, and reduced risk of disease progression. The purpose of this paper is to review the pathogenesis, presentation, and treatment of lumbar spinal stenosis complicated by scoliosis, spondylolisthesis, or flat-back deformity. Specific attention is paid to surgery-related goals, decision making, techniques, and outcomes.
Justin F. Fraser, Russel C. Huang, Federico P. Girardi and Frank P. Cammisa Jr.
Carol A. Mancuso, Roland Duculan, Frank P. Cammisa Jr., Andrew A. Sama, Alexander P. Hughes and Federico P. Girardi
Return to work after lumbar surgery is not synonymous with effective job performance, and it is likely that patients who undergo spine surgery experience both positive and negative events attributable to their spine after returning to work. The authors’ objectives were to measure work events attributable to the spine during the 2 years after lumbar surgery and to assess associated demographic and clinical characteristics.
Employed patients scheduled for lumbar surgery were interviewed preoperatively and reported work characteristics, including amount of improvement in job performance that they expected from surgery. Clinical variables, such as comorbidities and surgical complexity, were collected using standard scales. Two years postoperatively patients completed the 22-item work domain of the Psychiatric Epidemiological Research Interview Life Events Scale (PERI) asking about major positive and negative events attributable to the spine that occurred since surgery. Event rates were assessed with logistic regression. Patients also reported the amount of improvement obtained in job performance, which was compared to the amount of improvement expected in bivariate analyses.
Two hundred seven working patients (mean age 53 years, 62% men) were interviewed preoperatively. At 2 years after surgery, 86% were working and 12% reported negative events attributable to the spine (e.g., reduced workload, retirement). In multivariable analysis, high school education or less (OR 4.6, CI 1.7–12.3, p = 0.003), another spine surgery (OR 3.4, CI 1.2–10.1, p = 0.03), and new/worse comorbidity (OR 3.3, CI 1.2–8.8, p = 0.02) remained associated. Seven percent reported positive events attributable to the spine; not having postoperative complications was associated (OR 24, CI 4–156, p = 0.001). Of 162 patients queried preoperatively about expectations, 120 expected improvement in work; postoperatively, 82% reported some improvement (42% reported less improvement than expected and 40% as much as or more improvement than expected), 18% reported no improvement. No improvement was associated with less education (OR 1.5, CI 1.0–2.1, p = 0.04), older age (OR 1.1, CI 1.0–1.1, p = 0.005), more complex surgery (OR 1.1, CI 1.0–1.1, p = 0.07), and another spine surgery (OR 6.1, CI 1.9–19.8, p = 0.003). In descriptive analyses for another sample of preoperatively work-disabled patients, most had physically demanding jobs and only 33% returned to work postoperatively.
Most preoperatively working patients were working postoperatively, reported spine-related improvement in job performance, and reported the occurrence of both positive and negative work events attributable to the spine. This study proposes novel work outcomes (i.e., positive and negative work events) and potential methods to measure them.
Christopher K. Kepler, Amit K. Sharma, Russel C. Huang, Dennis S. Meredith, Federico P. Girardi, Frank P. Cammisa Jr. and Andrew A. Sama
Lateral transpsoas interbody fusion (LTIF) permits anterior column lumbar interbody fusion via a direct lateral approach. The authors sought to answer 3 questions. First, what is the effect of LTIF on lumbar foraminal area? Second, how does interbody cage placement affect intervertebral height? And third, how does the change in foraminal area and cage position correlate with changes in Oswestry Disability Index (ODI) and 12-Item Short Form Health Survey (SF-12) scores?
Included patients underwent LTIF with or without posterior instrumentation and received preoperative and postoperative CT scans. Disc heights, neural foraminal area between adjacent-level pedicles, and anteroposterior cage position were measured from sagittal CT images. Preoperative and postoperative ODI and SF-12 scores were matched with the change in foraminal area from the clinically most severely affected side for analysis of the relationship between outcomes instruments and change in foraminal area.
Average foraminal area increased by 36.2 mm2, or 35% of the preoperative area (p < 0.01), without statistically significant differences by side, level, or anteroposterior cage position. Preoperative anterior and posterior disc heights measured 6.2 mm and 3.7 mm, respectively, compared with postoperative measurements of 9.8 mm (p < 0.01) and 6.3 mm (p < 0.01), respectively, without significant differences by level or cage position. Despite significant overall improvement in ODI and SF-12 scores, there was no correlation with foraminal area increase.
Average foraminal area increased approximately 35% after cage placement without variation based on cage position. While ODI and SF-12 scores increased significantly, there was no significant association with cage position or foraminal area change, likely attributable to the multifactorial nature of preoperative pain.