*George H L, Anwar Marthya, Kumaran C M, Gopinathan P. 

Address for Correspondence

Abstract

This study was done to evaluate the symptomatic and functional outcome of surgical management in Lumbar Spinal Canal Stenosis. A prospective study for evaluating the symptoms and surgical outcome in patients with symptomatic Lumbar Spinal canal Stenosis was conducted in 90 patients during the period 2001-2004.   Mean duration of follow up in these patients was 24 months.
The surgical techniques used were laminectomy, laminectomy & discectomy, laminectomy, discectomy with foraminal decompression, laminectomy with posterior instrumentation, laminectomy with in situ fusion and posterior instrumentation.
Of the 90 patients studied, 37 patients (41%) showed improvement in motor functions.  Sensory improvement was seen in 20 patients (21.6%).  During the follow-up 16 patients (17.6%) regained normal deep tendon reflex. Out of the 51 patients who had a positive straight leg raising test before the surgery, 27 (29.2%) improved during the follow-up.  Claudication distance seems to vary when examined at different times in the same person.  However, 44 patients (48.4%) showed improvement in claudication distance during the follow-up.  49 patients (49.5%) had improvement in radicular pain.  The average pre-operative Oswestry score of 90 patients before surgical intervention was 62 and after surgery the score came down to 18. Follow-up of functional outcome by modified MacNab criteria showed that, 43 patients had excellent outcome, 29 patients had good outcome, 10 had fair and 8 patients had poor outcome.
We conclude that surgical procedures had good functional outcome as shown by Oswestry score and MacNab criteria during the follow-up.

J.Orthopaedics 2007;4(1)e5

Introduction:

Spinal canal is the osteoligemantous canal which contains the spinal cord. This canal with its contents can be compared to a passage and passenger.  A functional canal compromise occur either due to decrease in size of the passage or due to increase in size of the passenger.

Lumbar spinal canal stenosis is defined as an anatomical or functional narrowing of the osteoligamentous vertebral canal and or intervertebral foramina causing direct compression or indirect compromise of dural sac, the caudal nerve root and their vasculature, enough to cause symptoms or signs.

It was found that some adults develop progressive neurological deficits and low back pain in the latter  part of life.  It was found to be due to degenerative spinal changes leading to acquired spinal canal stenosis.   Further studies have also shown that soft issue compromise of dural sac determines the severity of clinical presentation.

Surgery is indicated when conservative treatment fails or in case of progressive neurological deficit. Over the time, improvement in surgical techniques has decreased the rate of complications.

The aim of the study was to evaluate the clinical features and outcome of surgical management in Lumbar Spinal Canal Stenosis.

Spinal stenosis refers to a reduction in the caliber of the spinal canal. Resultant symptoms depend on the level of involvement. Spinal stenosis may be either primary or acquired. The most common cause of acquired stenosis is degenerative change. Degenerative spinal stenosis arises from changes occurring in three major locations: the disc space, the facet joints, and the ligamentum flavum.  Other rare causes of acquired spinal canal stenosis include epidural lipomatosis and ossification of the posterior longitudinal ligament and/or the ligamentum flavum.

Ablolute stenosis was defined as AP diameter < 10mm on plane radiograph or dural sac cross-sectional area < 76mm2 in MRI.  Lumbar spinal canal AP diameter £ 12 – 10 mm in plain x-ray or dural sac cross-sectional area < 100 – 75 mm2 at narrowest point in MRI were taken as relative stenosis. 

Material and Methods :

A prospective study involving 90 patients was done at Medical College Hospital Calicut, during 2001-2004. Mean duration of follow up was 24 months.

Inclusion criteria: patients with characteristic clinical features like low back ache with or without radicular pain, neurogenic claudication defined as –unilateral or bilateral pain and disesthesisas spreading from low back in to extremities on walking and standing, and disappearing with recumbency were included in the study. Exclusion criteria: Patients with peripheral neuropathies, patients with spinal cord tumours , patients with POVD, patients with history of acute spinal injury, patients with lumbar spinal canal, AP diameter > 12mm/drual sac diameter >100mm2 imaging were excluded. The surgical techniques used were laminectomy, laminectomy & discectomy, laminectomy, discectomy with foraminal decompression, laminectomy with posterior instrumentation, laminectomy with in situ fusion and posterior instrumentation.

All the patients were clinically assessed for neurological deficiency and for other associated illness.  The patients were assessed radiologically by X-ray and MRI. 

Results :

A total of 90 patients participated in the study. The male: female ratio was 1.1:1.  The minimum symptom duration was 3 months and the maximum duration was 12 years.  Back pain was the most important symptom that brought the patient to medical consultation.  In our study 81 patients had history of back ache either in low back or in the buttocks and 66 patients had radicular pain. The Youngest patient in our study was 20 years old, oldest patient was 62 year old. Most common age group affected was 40-49 yrs.

Sex distribution

 Duration of Symptoms

The most important symptom neurogenic claudication was present in 78 patients.  The symptoms were aggravated by maneuvers like extension in 68 patients.The claudication distance was found to be different in the same patient at various points of time. Claudication distance does not correlate with severity of stenosis.

Weakness was the presenting symptoms in 22 patients and objectively weakness were demonstrated in 59 patients.  Sensory symptoms were present in 52 patients.  Most common dermatome affected was L5S1.

Muscle wasting was found in 32 causes unilaterally, of which 14 patients had calf muscle wasting and 8 patients had quadriceps wasting.  Bladder incontinence was present in 9 patients in our study.  Examination of deep tendon reflexes shows involvement of ankle jerk in 25 patients and knee jerk in 16 patients. 

Presenting symptoms

Causes of LSCS

Plain x-rays AP and lateral views were performed in all 90 patients and 33 patients were found to have multiple level narrowing. All patients had a MRI scan .  There were 33 cases of absolute spinal canal stenosis defined as AP diameter of <10mm and or dural sac diameter < 76mm2.  Relative spinal canal stenosis was found in 57 patients, of which 5 had single level stenosis and 42 had multiple level stenosis.  15 cases showed lateral canal stenosis.

MRI

Post surgical evaluation of patients with lumbar spinal canal stenosis during a mean follow-up period of 24 months gave the following results.

Of the 90 patients studied, 37 patients showed improvement in motor functions i.e., 41% of the study population had improvement in motor weakness.  Sensory improvement was seen in 20 patients, which come to 21.6% of the study population.  During the follow-up 16 patients regained normal deep tendon reflex which amount to 17.6% of the study population.    Claudication distance seems to vary when examined at different times in the same person.  However, 44 of them showed improvement in claudication distance during the follow-up which was 48.4% of the study population.  49 (49.5% ) patients had improvement in radicular pain

Type of surgery

Motor function

r-value = <0.05

Sensory improvement

r-value = <0.05

Deep Tendon Reflex

r-value = <0.05

Claudication distance

r-value = <0.05

Radicular pain

r-value= <0.05 

The average pre-operative Oswestry score of 90 patients before surgical intervention was 62 and after surgery the score came down to

During the follow-up by modified MacNab criteria 43 patients had excellent outcome, 29 patients had good outcome, 10 had fair and 8 patients had poor outcome.

Oswestry back pain disability questionnaire

MacNab criteria

Discussion :

The term lumbar spinal canal was coined by Verbiest et al[20,21] in 1949.  Initially it was described in patients with congenital bony abnormalities like achondroplasia.  Later Verbiest found that similar syndromes also occurred in normal population.

We can see various studies with different outcomes after surgery, for lumbar spinal canal stenosis in literature. Postacchini [10] described a satisfactory outcome of 80% of the patients in the short term. In a study on 4-year outcomes after decompressive laminectomy performed by Katz and co-workers [7,8], satisfaction had decreased to 48% and a poor outcome was observed in 43%, with severe pain present in 30% of the patients. The factors associated with a poor outcome included coexisting illness, the duration of follow-up, and an initial laminectomy involving a single interspace. Schulitz [26] observed 46 patients after decompressive laminectomy for 3–10 years. Thirty percent developed translational instability, and a correlation between low back pain and instability was not found. Herno [27,28] reported 68% good-to-excellent results at a mean followup time of 12.8 years, even describing an improvement of symptoms since the previous follow-up at 6.8 years. Eight years after decompressive laminectomy, Katz et al.[7,8] reported 33% of his patients having severe back pain and 53% being unable to walk two blocks. Twenty-three percent had been reoperated upon. However, 75% were somewhat or very satisfied with the results of surgery. After 4.3 years, Airaksinen et al. [29] reported 38% poorresults in 438 consecutive patients who had received decompressive laminectomy. Herkowitz and Kurz [28] evaluated 50 patients with single-level degenerative spondylolisthesis who underwent laminectomy with or without uninstrumented fusion. Ninety-six percent had good or excellent results with arthrodesis after 2.4–4 years follow-up compared with 44% without arthrodesis. Turner et al. [30] found no difference in the outcome between patients with or without fusion in a comprehensive literature review, with a satisfaction rate of about 70% in all procedures. Grob et al. [31] showed no advantage of instrumented fusion over laminectomy without arthrodesis in a randomized controlled trial of 45 patients with degenerative spinal stenosis and no spondylolisthesis. Yone et al. [32] reported significantly better results after decompression and fusion when instability was present than with decompression alone. Thirty-four patients were included in the study. In a prospective non-randomized study Katz et al. [7,8] found superior relief of low back pain at 6 and 24 months after non-instrumented arthrodesis compared with laminectomy alone or with instrumented fusion; 68–83% of the groups were satisfied with the treatment. In a meta-analysis of the literature Niggemeyer et al. [33] found the duration of symptoms to be decisive for the success of surgery – up to 8 years decompression without fusion showed the best results, and longer than 15 years decompression with instrumented fusion had the best outcomes. Decompression without instrumented fusion was the least successful procedure in both groups.

The current study including 90 patients shows that surgical procedures have good out come in short term when assessed with Oswestry back pain disability questionnaire  and MacNab criteria, and this supports the available literature. However long term follow up needs to be done in these patients.           

Conclusion:

Lumbar spinal canal stenosis was an under recognized but potentially treatable cause of low back pain. Acquired lumbar canal stenosis is by far more common than congenital lumbar canal stenosis.  Most common causes of acquired lumbar canal stenosis include degenerative causes and posterior disc prolapse , spondylolysthesis and trauma. Commonest age groups affected were 40-49 years and male: female ratio was 1.1:1. Low backache and neurogenic claudication were the commonest symptoms. Claudication distance was not constant and does not correlate with severity of disease.  Surgical procedures like had good functional outcome as by Oswestry score and MacNab criteria during the follow-up. 

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This is a peer reviewed paper 

Please cite as : George H L:Lumbar Spinal Canal Stenosis – An Evaluation Of Surgical Treatment

J.Orthopaedics 2007;4(1)e5

URL: http://www.jortho.org/2007/4/1/e5

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