Distraction of facets with intraarticular spacers as treatment for lumbar canal stenosis: report on a preliminary experience with 21 cases

Clinical article

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Object

The authors report their experience in treating 21 patients by using a novel form of treatment of lumbar degenerative disease that leads to canal stenosis. The surgery involved distraction of the facets using specially designed Goel intraarticular spacers and was aimed at arthrodesis of the spinal segment in a distracted position. The operation is based on the premise that subtle and longstanding facet instability, joint space reduction, and subsequent facet override had a profound and primary influence in the pathogenesis of degenerative lumbar canal stenosis. The surgical technique and the rationale for treatment are discussed.

Methods

Between April 2006 and January 2011, 21 cases of lumbar degenerative disease resulting in characteristic lumbar canal stenosis were treated in the authors' department with the proposed technique. The patients were prospectively analyzed. There were 15 men and 6 women who ranged in age from 48 to 71 years (mean 58 years). Nine patients underwent 1-level and 12 patients underwent 2-level treatment. Surgery involved wide opening of the articular joint, denuding of the articular capsule/endplate cartilage, distraction of the facets, and forced impaction of Goel intraarticular spacers. Bone graft pieces obtained by sectioning the spinous processes were placed within and over the joint and in the midline over the adequately prepared host area of laminae. The Oswestry Disability Index and visual analog scale were used to clinically assess the patients before and after surgery and at follow-up. The alterations in the physical architecture of spinal canal and intervertebral foramen dimensions were evaluated before and after placement of the intrafacet implant and after at least 6 months of follow-up.

Results

All patients had varying degrees of relief from symptoms of local back pain and radiculopathy. Impaction of spacers within the facet joints resulted in an increase in the spinal canal and intervertebral root canal dimensions (mean 2.33 mm), reduction of buckling of the ligamentum flavum, and reduction of the extent of bulge of the disc into the spinal canal. The procedure resulted in firm stabilization and fixation of the spinal segment and provided a ground for arthrodesis. No patient worsened neurologically after treatment. During the follow-up period, all patients had evidence of segmental bone fusion. No patient underwent reexploration or further surgery of the lumbar spine.

Conclusions

Impaction of the spacers within the articular cavity after facet distraction resulted in reversal of several effects of spine degeneration that had caused spinal and root canal stenosis. The safe, firm, and secure stabilization at the fulcrum of lumbar spinal movements provided a ground for segmental spinal arthrodesis. The immediate postoperative and lasting recovery from symptoms suggests the validity of the procedure.

Article Information

Address correspondence to: Atul Goel, M.Ch., Department of Neurosurgery, K. E. M. Hospital and Seth G. S. Medical College, Parel, Mumbai 400012, India. email: atulgoel62@hotmail.com.

Please include this information when citing this paper: published online September 16, 2011; DOI: 10.3171/2011.8.SPINE11249.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Photograph showing the various sizes of the spacers. The flat surface has serrations to make the surface rough. The hole with serrations on the side of the implant is meant for the spacer holder. The hole in the center of the flat surface is meant to assist in arthrodesis.

  • View in gallery

    Images obtained in a 63-year-old man. A: Preoperative T2-weighted MR images showing evidence of lumbar canal stenosis more prominently at L3–4 and L4–5 levels. B: CT scans showing spinal and root canal stenosis. C: Preoperative plain lateral radiograph. D: Postoperative MR images showing marginal reduction in the indentations opposite the L3–4 and L4–5 disc space. E: Postoperative CT scans showing an increase in the disc space height and interlaminar distances. The increase in the spinal canal and foraminal canal dimensions can be observed. Intraarticular spacers can be observed. F: Plain radiographs showing the intraarticular spacers.

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