Pre-operative planning in surgical treatment of patients with lumbar spinal stenosis of degenerative etiology

Aim. Develop a pre-operative planning algorithm to treat patients with lumbar spinal stenosis of degenerative etiology.

Material and Methods. The results of surgical treatment of 522 patients at the age of 23–78 years with degenerative lumbar stenosis were analyzed. Patients with osteoporosis, with a sagittal spinal profile disorder or deviations in the frontal plane of more than 20 degrees, with spondylolistesis of more than 1 Meyerding degree, with accompanying pathology aggravating the Charlson Commorbidity Index of more than 8 points, were not included in this group. All patients underwent decompressive-stabilizing operations using TPF for 1 to 8 vertebral-motor segments. Decompression and interbody stabilization were performed by the method PLIF, TLIF, or by the method of reconstruction of the lumbar vertebral-motor segment (patent no. 2527150), or the ventral fusion was performed.

Results. Immediate and distant results over a period of 24–36 months were studied by regression in major clinical manifestations. The VAS, McCulloch and Young scales, the Oswestry questionnaire, and the modified Macnab scale were applied. The quality of decompression, correction in operated PDS and intertose splicing were evaluated. The effect of the initial state of patients on the obtained results and the number of complications were studied as well. For this purpose, the correlation analysis was carried out between clinical parameters characterizing initial condition of patients (length of lumbar spinal stenosis, degree of functional maladaptation, duration of anamnesis and severity of premorbid background) and achieved results of treatment, as well as number of complications. A correlation analysis was also performed between the technique of performed operations and surgical tactics on the one hand and the achieved results and the number of complications on the other.

Discussion. Differences in results and number of complications depending on the applied technical and tactical treatment options and statistical treatment with determination of the correlation coefficient of Spirman and Fisher's criterion determined clinical and spondylometric signs in the pre-operative state of patients, that influenced the probability of complications when using the specified technical and tactical treatment options. It has been found that the state of the premorbid background reliably affects the probability of the most dangerous intraoperative and early complications. The length of decompressive stabilizing operations affects the probability of evidence for audits in the distant period. When performing TLIF, the spondylolistesis presence increases the likelihood of intraoperative liquvorea. The method of lumbar vertebral-motor segment reconstruction in lumbar lordosis deficiency improves the possibility of correction in operated vertebral-motor segments in comparison with TLIF technique.

Conclusion. Taking into account the revealed statistically confirmed effect of a number of clinical and spondylometric signs of the pre-operative condition in patients on the probability of complications using various technical and tactical versions of treatment, an algorithm of pre-operative planning of surgical intervention in patients with lumbar stenosis of degenerative etiology is presented.

1. Afaunov A.A., Basankin I.V., Kuzmenko A.V., Shapovalov V.K. Analysis of the reasons for revision operations in surgical treatment of patients with lumbar stenosis of degenerative etiology. Spine surgery. 2014;1:86-93. (In Russ.)

2. Basankin I.V., Afaunov A.A., Shapovalov V.K., Kuzmenko A.V., Takhmazyan K.K. Reconstruction Technique of Lumbar Spinal Motion Segment. Lic. 2527150 the Russian Federation, MPK А 61В 17/00/, Notice 24.05.13; publ. 27.08.14, Newsletter №24. 14 p.: ill. 4. (In Russ.)

3. Bronheim RS, Kim JS, Di Capua J, Lee NJ, Kothari P, Somani S, Phan K, Cho SK. High-risk subgroup membership is a predictor of 30-day morbidity following anterior lumbar fusion. Global Spine J. 2017;7(8):762-9. PMID: 29238640. PMCID: PMC5721989. doi:10.1177/2192568217696691

4. Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion. Spine. 2003;28:S26-S35. PMID: 12897471. doi:10.1097/01.BRS.0000076895.52418.5E

5. Choudhri TF, Mummaneni PV, Dhall SS, Eck JC, Groff MW, Ghogawala Z, Watters WC 3rd, Dailey AT, Resnick DK, Sharan A, Wang JC, Kaiser MG. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 4: Radiographic assessment of fusion status. J Neurosurg Spine. 2014;21(1):23-30. PMID: 24980581. DOI: 10.3171/2014.4.SPINE14267

6. Cobo Soriano J, Sendino Revuelta M, Fabregate Fuente M, Cimarra Diaz I, Martinez Urena P, Deglane Meneses R. Predictors of outcome after decompressive lumbar surgery and instrumented posterolateral fusion. Eur Spine J. 2010;19(11):1841-8. PMID: 20135333. PMCID: PMC2989260. doi:10.1007/s00586-010-1284-2

7. Foley KT, Lefkowitz MA. Advances in minimally invasive spine surgery. Clin Neurosurg. 2002;49:499-517. PMID: 12506566.

8. Strömqvist F, Jönsson B, Strömqvist B. Dural lesions in decompression for lumbar spinal stenosis: incidence, risk factors and effect on outcome. Eur Spine J. 2012;21(5):825-8. PMID: 22146791. PMCID: PMC3337897. doi:10.1007/s00586-011-2101-2

9. Ghahreman A, Ferch RD, Rao PJ, Bogduk N. Minimal access versus open posterior lumbar interbody fusion in the treatment of spondylolisthesis. Neurosurgery. 2010;66:296-304; discussion 304. PMID: 20087129. doi:10.1227/01.NEU.0000363600.24074.D0

10. Genevay S, Atlas S. Lumbar spinal stenosis. Best Pract Res Clin Rheumatol. 2010;24:253-65. PMID: 20227646. PMCID: PMC2841052. doi:10.1016/j.berh.2009.11.001

11. Jansson KA, Németh G, Granath F, Blomqvist P. Spinal stenosis re-operation rate in Sweden is 11% at 10 years – a national analysis of 9,664 operations. Eur Spine J. 2005;14(7):659-63. PMID: 15754213. PMCID: PMC3489214. doi:10.1007/s00586-004-0851-9

12. Kalff R, Ewald C, Waschke A, Gobisch L, Hopf C. Degenerative lumbar spinal stenosis in older people: current treatment options. Dtsch Arztebl Int. 2013;110:613-24. PMID: 24078855. PMCID: PMC3784039. doi:10.3238/arztebl.2013.0613

13. Knutsson B, Michaëlsson K, Sandén B. Obesity is associated with inferior results after surgery for lumbar spinal stenosis: a study of 2633 patients from the Swedish spine register. Spine. 2013;38(5):435-41. PMID: 22941097. doi:10.1097/BRS.0b013e318270b243

14. Kobayashi K, Ando K, Kato F, Kanemura T, Sato K, Hachiya Y, Matsubara Y, Kamiya M, Sakai Y, Yagi H, Shinjo R, Nishida Y, Ishiguro N, Imagama S. Reoperation within 2 years after lumbar interbody fusion: a multicenter study. Eur Spine J. 2018;27:1972-80. PMID: 29423887. doi:10.1007/s00586-018-5508-1 [Epub ahead of print]

15. Kobayashi K, Ando K, Kato F, Kanemura T, Sato K. Predictors of prolonged length of stay after lumbar interbody fusion: a multicenter study. Global Spine J. 2019;9(5):466-72. PMID: 31431867. PMCID: PMC6686383. doi:10.1177/2192568218800054

16. Lindsey D, Swanson K, Fuchs P. The effects of an interspinous implant on the kinematics of the instrumented and adjacent levels in the lumbar spine. Spine. 2003;128(19):2192-7. PMID: 14520030. doi:10.1097/01.BRS.0000084877.88192.8E

17. Mayer HM, Heider F. Selektive, mikrochirurgische «Cross-over»-Dekompression mehrsegmentaler lumbaler Spinalstenosen. Oper Orthop Traumatol. 2013;25(1):47-62. PMID: 23400667. doi:10.1007/s00064-012-0196-1

18. Morgalla MH, Noak N, Merkle M, Tatagiba MS. Lumbar spinal stenosis in elderly patients: is a unilateral microsurgical approach sufficient for decompression? J Neurosurg Spine. 2011;14(3):305-12. PMID: 21235300. doi:10.3171/2010.10.SPINE09708

19. Munting E, Roder C, Sobottke R, Dietrich D, Aghayev E. Patient outcomes after laminotomy, hemilaminectomy, laminectomy and laminectomy with instrumented fusion for spinal canal stenosis: a propensity score-based study from the Spine Tango registry. Eur Spine J. 2015;24(2):358-68. PMID: 24840246. doi:10.1007/s00586-014-3349-0

20. Slätis P, Malmivaara A, Heliövaara M, Sainio P, Herno A, Kankare J, Seitsalo S, Tallroth K, Turunen V, Knekt P, Hurri H. Long-term results of surgery for lumbar spinal stenosis: a randomised controlled trial. Eur Spine J. 2011;20(7):1174-81. PMID: 21240530. PMCID: PMC3175822. doi:10.1007/s00586-010-1652-y

21. Sandén B, Forsth P, Michaëlsson K. Smokers show less improvement than nonsmokers two years after surgery for lumbar spinal stenosis: a study of 4555 patients from the Swedish spine register. Spine. 2011;36(13):1059-64. PMID: 21224770. doi:10.1097/BRS.0b013e3181e92b36

22. Sidhu GS, Henkelman E, Vaccaro AR, Albert TJ, Hilibrand A, Anderson DG, Rihn JA. Minimally invasive versus open posterior lumbar interbody fusion: a systematic review. Clin Orthop Relat Res. 2014;472(6):1792-9. PMID: 24748069. PMCID: PMC4016428. doi:10.1007/s11999-014-3619-5

23. Wang MY, Widi G, Levi AD. The safety profile of lumbar spinal surgery in elderly patients 85 years and older. Neurosurg Focus. 2015;39(4):E3. PMID: 26424343. doi:10.3171/2015.7.FOCUS15180

24. Wang MY, Cummock MD, Yu Y, Trivedi RA. An analysis of the differences in the acute hospitalization charges following minimally invasive versus open posterior lumbar interbody fusion. J Neurosurg Spine. 2010;12(6):694-9. PMID: 20515357. doi:10.3171/2009.12.SPINE09621