Lumbar Decompression Surgery for Spinal Canal Stenosis [Neurosurgery Wiki]

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====== Lumbar Decompression Surgery for Spinal Canal Stenosis ======

The classic treatment for [[Degenerative lumbar spinal stenosis]] is traditional total laminectomy decompression, bilateral laminotomy decompression, unilateral laminectomy bilateral decompression, and fusion, which are only considered in cases of [[lumbar spine instability]]
((Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis. BMJ. 2016 Jan 4;352:h6234. doi: 10.1136/bmj.h6234. PMID: 26727925; PMCID: PMC6887476.))
((Shen J, Wang Q, Wang Y, Min N, Wang L, Wang F, Zhao M, Zhang T, Xue Q. Comparison Between Fusion and Non-Fusion Surgery for Lumbar Spinal Stenosis: A Meta-analysis. Adv Ther. 2021 Mar;38(3):1404-1414. doi: 10.1007/s12325-020-01604-7. Epub 2021 Jan 24. PMID: 33491158.)).

[[Lumbar Decompression]] for [[lumbar spinal canal stenosis]], is the most common indication for operative treatment in elderly.

It is a frequently performed [[procedure]] and was the fastest growing type of surgery in the US from 1980 to 2000. 
----
In a a randomized clinical trial adding fusion to a decompression increased the rate of new stenosis on two-year MRI, even when a spondylolisthesis was present preoperatively. This supports decompression alone as the preferred method of surgery for spinal stenosis, whether or not a degenerative spondylolisthesis is present preoperatively
((Karlsson T, Försth P, Skorpil M, Pazarlis K, Öhagen P, Michaëlsson K, Sandén B. Decompression alone or decompression with fusion for lumbar spinal stenosis: a randomized clinical trial with two-year MRI follow-up. Bone Joint J. 2022 Dec;104-B(12):1343-1351. doi: 10.1302/0301-620X.104B12.BJJ-2022-0340.R1. PMID: 36453045; PMCID: PMC9680197.))

===== Indications =====

[[Lumbar Decompression Surgery for Spinal Canal Stenosis Indications]] 


===== Techniques =====

[[Lumbar Decompression Surgery for Spinal Canal Stenosis Techniques]].


===== Outcome =====

see [[Lumbar decompression surgery for spinal canal stenosis outcome]].

===== Case series =====

A successive series of 102 patients with [[lumbar spinal stenosis]] from [[Aachen]] (with and without previous lumbar surgery) were treated with [[decompression]] alone during a 3-year period. Data on pre- and postoperative [[back pain]] and [[leg pain]] ([[numerical rating scale]] [NRS] scale) were retrospectively collected from [[questionnaire]]s with a return rate of 65% (n = 66). The complete [[cohort]] as well as patients with first-time surgery and re-decompression were analyzed separately. Patients were dichotomized to short-term follow-up (< 100 weeks) and long-term follow-up (> 100 weeks) postsurgery.

Overall, both [[back pain]] (NRS 4.59 postoperative versus 7.89 preoperative; p < 0.0001) and [[leg pain]] (NRS 4.09 versus 6.75; p < 0.0001) improved postoperatively. The short-term follow-up subgroup (50%, n = 33) showed a significant reduction in back pain (NRS 4.0 versus 6.88; p < 0.0001) and leg pain (NRS 2.49 versus 6.91: p < 0.0001). Similar results could be observed for the long-term follow-up subgroup (50%, n = 33) with significantly less back pain (NRS 3.94 versus 7.0; p < 0.0001) and leg pain (visual analog scale 3.14 versus 5.39; p < 0.002) postoperatively. Patients with previous [[decompression surgery]] benefit significantly regarding back pain (NRS 4.82 versus 7.65; p < 0.0024), especially in the long-term follow-up subgroup (NRS 4.75 versus 7.67; p < 0.0148). There was also a clear trend in favor of leg pain in patients with previous surgery; however, it was not significant.

Decompression of [[lumbar spinal stenosis]] without [[fusion]] led to a significant and similar reduction of [[back pain]] and leg pain in a short-term and a long-term follow-up group. Patients without previous surgery benefited significantly better, whereas patients with previous decompression benefited regarding back pain, especially for long-term follow-up with a clear trend in favor of leg pain
((Geiger MF, Bongartz N, Blume C, Clusmann H, Müller CA. Improvement of Back and
Leg Pain after Lumbar Spinal Decompression without Fusion. J Neurol Surg A Cent
Eur Neurosurg. 2018 Dec 5. doi: 10.1055/s-0038-1669473. [Epub ahead of print]
PubMed PMID: 30517963.
)).

===2017===
A retrospective matched-pair cohort study included a total of 144 patients who underwent surgery for bisegmental spinal stenosis at the levels L3-4 and L4-5 between 2008 and 2012. There were 72 matching pairs that corresponded in sex, year of birth, and width of the stenosed segments. The patients' impairments were reported before, immediately after, and 6 and 12 months after surgery using the Oswestry Disability Questionnaire (ODQ-D) and the EuroQol-5D (EQ-5D). The data were evaluated statistically. 

The comparison of both surgical procedures (Bisegmental Fenestration versus Hemilaminectomy)regarding walking ability (walking a distance with and without a walking aid) revealed a significant difference. Patients who underwent hemilaminectomy had better postoperative results. The individual criteria of the ODQ-D and EQ-5D revealed no significant differences between 2-level fenestration and hemilaminectomy; however, there is always significant postoperative improvement in comparison with preoperative status. Age, sex, body mass index, comorbidities, smoking, and alcohol consumption had no influence on the surgical results. The reoperation rate was between 13% and 15% for both surgical techniques, not being significantly different. 

Fenestration and hemilaminectomy are equivalent therapies for bisegmental lumbar spinal canal stenosis. Regarding walking, the study revealed better results for hemilaminectomy than for fenestration in this cohort of patients. Pain intensity, personal care, lifting and carrying of objects, sitting, social life, and travel all improved significantly postoperatively as compared with preoperatively. In both groups, health status as the decisive predictor improved considerably after surgery. We could show that both surgical methods result in significant postoperative improvement of all the individual criteria of the ODQ-D and the EQ-5D
((Schüppel J, Weber F. Retrospective Matched-Pair Cohort Study on Effect of
Bisegmental Fenestration versus Hemilaminectomy for Bisegmental Spinal Canal
Stenosis at L3-L4 and L4-L5. J Neurol Surg A Cent Eur Neurosurg. 2017 Jan 9. doi:
10.1055/s-0036-1597617. [Epub ahead of print] PubMed PMID: 28068753.
)).

===2015===
Patients who underwent lumbar decompression between 2008 and 2014. Inclusion necessitated a minimum follow-up of six months.

Postoperative change in the EuroQol 5-Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire 9 (PHQ-9) at last follow-up. The secondary outcome variable was postoperative change in QOL measures exceeding the MCID.

QOL data were collected using the institutional prospectively-collected database of patient-reported health status measures. Simple and multivariable logistic regressions were used to assess the impact of diabetes upon normalized change in QOL and improvement exceeding the MCID.

There were 212 patients who met inclusion criteria. While non-diabetics experienced significant improvements in EQ-5D, PDQ, and PHQ-9 (p<0.01), diabetics experienced no significant changes in any measures. More non-diabetics achieved the EQ-5D MCID compared with diabetics (55% v. 23%, p<0.01). Following multivariable regression, chronic kidney disease (CKD, β=-0.15, p=0.04) and diabetes (β=-0.05, p=0.04) were identified as significant independent predictors of diminished improvement in EQ-5D postoperatively. Furthermore, diabetes was also identified as a significant independent predictor of failure to achieve an EQ-5D MCID (OR 0.20, p<0.01), while CKD trended toward predicting diminished improvement (OR <0.01, p=0.09).

The burden of comorbidities may impact the QOL benefit of decompression spine surgery. In the present study, diabetes was found to independently predict diminished improvement in QOL after lumbar decompression
((Silverstein MP, Miller JA, Xiao R, Lubelski D, Benzel EC, Mroz TE. The impact 
of diabetes upon quality of life outcomes after lumbar decompression. Spine J.
2015 Dec 15. pii: S1529-9430(15)01626-5. doi: 10.1016/j.spinee.2015.10.041. [Epub
ahead of print] PubMed PMID: 26704860.
)).