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The selection of a correct level in lumbar spinal stenosis (LSS) remains a common problem and is critically important to the effectiveness of this surgical treatment. Surgery is invasive, and extended laminectomy may lead to secondary surgical complications. The application of diffuse tensor imagining (DTI) and paraspinal mapping (PM) in addition to conventional magnetic resonance imaging (cMRI) may be helpful in this respect. However, the superiority of cMRI + DTI over cMRI+ (DTI or PM) in reducing decompression has not yet been established.We compared the surgical levels, determined by cMRI + DTI and cMRI+ (DTI or PM) (self-control). Treatment outcome measurements were performed at two weeks, three months, six months, and twelve months postoperatively.The surgical levels determined by cMRI ± DTI showed less than that determined by cMRI± (DTI or PM) with statistically significant differencesThe effectiveness of cMRI ± DTI in the reduction of the surgical levels in degenerative lumbar spinal stenosis is superior than that of cMRI± (DTI or PM).

Objective To compare the clinical efficacy of percutaneous full‐endoscopic transforaminal lumbar interbody fusion (Endo‐TLIF) with percutaneous pedicle screws (PPSs) performed by using a visualization system with that of minimally invasive transforaminal lumbar interbody fusion (MIS‐TLIF) for the treatment of degenerative lumbar spinal stenosis (LSS). Methods From June 2017 to May 2018, the data of a total of 78 patients who met the selection criteria were retrospectively reviewed and were divided into the Endo‐TLIF group (40 cases) and the MIS‐TLIF group (38 cases) according to the surgical method used. The visual analog scale (VAS) and the Japanese Orthopaedic Association (JOA) scale were administered preoperatively and at the 1‐week, 3‐month, and 1–2‐year follow‐ups. The fusion rate and major complications, including revision, were also recorded. Results All the patients were followed up for 24 to 34 months, with an average follow‐up of 30.7 months. The intraoperative blood loss and length of hospital stay for the Endo‐TLIF group (60.56 ± 0.36 mL, 8.12 ± 0.92 days, respectively) were statistically significantly lower than those for the MIS‐TLIF group (65.47 ± 0.91 mL, 9.66 ± 1.34 days, respectively) (P 0.05). There was no significant difference in the intervertebral altitude between the two groups at the 3‐month (11.36 ± 0.23, 11.21 ± 0.42, respectively) or final follow‐up (10.88 ± 0.64, 10.81 ± 0.39, respectively) (P > 0.05). Dural tears, cerebrospinal fluid leakage, infection, and neurologic injury did not occur. Both groups showed good intervertebral fusion at the last follow‐up. The intervertebral fusion rate was 97.5% (39/40) in the Endo‐TLIF group and 94.7% (36/38) in the MIS‐TLIF group, with no statistically significant difference between the two groups (χ 2 = 0.118, P = 0.731). At the final follow‐up, the modified MacNab's criteria were 92.5% and 89.5% between the two groups. Conclusion Endo‐TLIF with percutaneous pedicle screws (PPS) performed by using a visualization system for lumbar degenerative disease may be regarded as an efficient alternative surgery for degenerative lumbar spinal stenosis. It is a safe and minimally invasive way to perform this surgery and has shown satisfactory clinical outcomes., Endo‐TLIF with percutaneous pedicle screws may be regarded as an efficient alternative surgery for degenerative lumbar spinal stenosis. It is a safe and minimally invasive way to perform this surgery and has shown satisfactory clinical outcomes.

The aim of this study is to determine the sagittal inclination of lumbar spinous processes (SPs) in individuals with degenerative lumbar spinal stenosis (DLSS). It is a retrospective computerized tomography (CT) study including 345 individuals divided into two groups: control (90 males, 90 females) and stenosis (80 males and 85 females. The SP inclination was measured in the midsagittal plane from L1 to L5 levels. Stenosis males (L3-L5) and females (L1, L4) manifested significantly greater SP inclination compared to their counterparts in the control group. Males had significantly horizontal SP orientation compared to females (L1, L2). We also found that SP inclination became steeper as we descend caudally. This study indicates that SP inclinations are significantly associated with DLSS.

OBJECTIVEThe use of indirect decompression surgery for severe canal stenosis remains controversial. The purpose of this study was to investigate the efficacy of lateral interbody fusion (LIF) without posterior decompression in degenerative lumbar spinal spondylosis with severe stenosis on preoperative MRI.METHODSThis is a retrospective case series from a single academic institution. The authors included 42 patients (45 surgical levels) who were preoperatively diagnosed with severe degenerative lumbar stenosis on MRI based on the previously published Schizas classification. These patients underwent LIF with supplemental pedicle screw fixation without posterior decompression. Surgical levels were limited to L3–4 and/or L4–5. All patients satisfied the minimum 1-year MRI follow-up. The authors compared the cross-sectional area (CSA) of the thecal sac and the clinical outcome scores (Japanese Orthopaedic Association [JOA] score) preoperatively, immediately postoperatively, and at the 1-year follow-up. Fusion status and disc height were evaluated based on CT scans obtained at the 1-year follow-up.RESULTSThe CSA improved over time, increasing from 54.5 ± 19.2 mm2 preoperatively to 84.7 ± 31.8 mm2 at 3 weeks postoperatively and to 132.6 ± 37.5 mm2 at the last follow-up (average 28.3 months) (p < 0.001). The JOA score significantly improved over time (preoperatively 16.1 ± 4.1, 3 months postoperatively 24.4 ± 4.0, and 1-year follow-up 25.7 ± 2.9; p < 0.001). The fusion rate at the 1-year follow-up was 88.8%, and disc heights were significantly restored (preoperative, 6.3 mm and postoperative, 9.6 mm; p < 0.001). Patients showing poor CSA expansion (< 200% expansion rate) at the last follow-up had a higher prevalence of pseudarthrosis than patients with significant CSA expansion (> 200% expansion rate) (25.0% vs 3.4%, p < 0.001). No major perioperative complications were observed.CONCLUSIONSLIF with indirect decompression for degenerative lumbar disease with severe canal stenosis provided successful clinical outcomes, including restoration of disc height and indirect expansion of the thecal sac. Severe canal stenosis diagnosed on preoperative MRI itself is not a contraindication for indirect decompression surgery.

Background Degenerative lumbar spinal stenosis (DLSS) is a common lumbar disease that requires surgery. Previous studies have indicated that genetic mutations are implicated in DLSS. However, studies on specific gene mutations are scarce. Whole-exome sequencing (WES) is a valuable research tool that identifies disease-causing genes and could become an effective strategy to investigate DLSS pathogenesis. Methods From January 2016 to December 2017, we recruited 50 unrelated patients with symptoms consistent with DLSS and 25 unrelated healthy controls. We conducted WES and exome data analysis to identify susceptible genes. Allele mutations firstly identified potential DLSS variants in controls to the patients’ group. We conducted a site-based association analysis to identify pathogenic variants using PolyPhen2, SIFT, Mutation Taster, Combined Annotation Dependent Depletion, and Phenolyzer algorithms. Potential variants were further confirmed using manual curation and validated using Sanger sequencing. Results In this cohort, the major classification variant was missense_mutation, the major variant type was single nucleotide polymorphism (SNP), and the major single nucleotide variation was C > T. Multiple SNPs in 34 genes were identified when filtered allele mutations in controls to retain only patient mutations. Pathway enrichment analyses revealed that mutated genes were mainly enriched for immune response-related signaling pathways. Using the Novegene database, site-based associations revealed several novel variants, including HLA-DRB1, PARK2, ACTR8, AOAH, BCORL1, MKRN2, NRG4, NUP205 genes, etc., were DLSS related. Conclusions Our study revealed that deleterious mutations in several genes might contribute to DLSS etiology. By screening and confirming susceptibility genes using WES, we provided more information on disease pathogenesis. Further WES studies incorporating larger DLSS patient cohorts are required to comprehend the genetic landscape of DLSS pathophysiology fully.

This study aimed to explore the efficacy of percutaneous transforaminal endoscopic discectomy (PTED) unilateral and bilateral approach for bilateral decompression in the treatment of degenerative lumbar spinal stenosis (DLSS) and their effects on quality of life. Altogether 119 patients with DLSS admitted to our hospital from May 2012 to February 2014 were enrolled in this study. Patients in Group A (62 cases) were treated with PTED bilateral approach for bilateral decompression, while those in Group B (57 cases) were treated with PTED unilateral approach for bilateral decompression. The therapeutic effect and incidence of complications in the two groups were observed. Visual Analogue Scale (VAS) was used to assess the pain degree of the lower limbs. Oswestry Disability Index (ODI) was used to assess the improvement of neurological function. 36-ltem Short Form Health Survey (SF-36) developed by the Institute of Medicine was used to assess the quality of life. There were no significant differences between Group A and Group B in operative time, intraoperative blood loss, hospitalization time, the effective rate of treatment, and the incidence of complications (P>0.05). The recovery time of lumbar function in Group A was significantly shorter than that in Group B (P

Degenerative lumbar spinal stenosis (DLSS) is a common lumbar disease requiring surgery. Previous studies indicate that genetic mutation may play a part in DLSS. However, there is scarcely specific study regarding the genetic study for DLSS. Whole exome sequencing (WES) is an effective strategy to search for disease-causing genes. To identify probable susceptible genes, we performed a WES in a cohort of 50 patients and 25 controls with DLSS. By bioinformatics analyses, we successfully identified several novel variants including HLA-DRB1, PARK2, ACTR8, AOAH, BCORL1, MKRN2, NRG4, NUP205, etc. To the best of our knowledge, this is the first genetic study of susceptibility genes with DLSS by WES in Chinese patients. In conclusion, our findings revealed that deleterious mutations in these genes may contribute to the development of DLSS.

Background Degenerative lumbar spinal stenosis (DLSS) is a common condition secondary to degenerative changes. Acupuncture may be effective for treating DLSS. However, there is a lack of sufficient evidence showing the efficacy of acupuncture. The aim of this study is to assess the efficacy and safety of acupuncture for relieving neurogenic claudication in patients with DLSS. Methods A total of 196 patients will be randomly assigned to an acupuncture group or a sham acupuncture group at a ratio of 1:1. Patients will receive 18 sessions of treatment for 6 continuous weeks. The primary outcome will be the change in the Modified Roland-Morris Disability Questionnaire score from baseline to week 6. The secondary outcomes will include the change in the scores from baseline for the Numerical Rating Scale, Swiss Spinal Stenosis Questionnaire, and Anxiety and Depression Scale. Additionally, the expectancy of acupuncture, blinding, and safety will also be assessed. All analysis will be performed based on intention-to-treat. Discussion The aim of this study is to evaluate the efficacy and safety of acupuncture for the treatment of neurogenic claudication in patients with DLSS. A limitation of this study is that acupuncturists cannot be blinded according to the characteristics of acupuncture, which may introduce some bias. Trial registration ClinicalTrials.gov NCT03784729 and protocol ID 2018-161-KY. Registered on 18 December 2018.

BACKGROUND The aim of this study was to determine whether timing of lumbar spinal fusion (LSF) before revision total hip arthroplasty (THA) would impact dislocation and rerevision rates. METHODS This retrospective analysis includes a total of 505 patients who underwent revision THA with concomitant diagnosis of degenerative lumbar spinal stenosis with spondylolisthesis. Patients were stratified into the following two cohorts: (1) 328 patients who underwent revision THA with previous LSF and (2) 177 patients who underwent revision THA, followed by LSF. Postoperative complications including dislocation and rerevision rates were evaluated. RESULTS Patients who underwent revision THA with previous LSF demonstrated significantly higher dislocation rates and rerevision rates compared with patients who underwent revision THA, followed by LSF, at the 1-year follow-up (6.7% versus 5.1%, P < 0.01; 8.5% versus 7.0%, P = 0.02). Patients who underwent revision THA, followed by LSF within 1 year demonstrated significantly higher dislocation and rerevision rates (5.6% versus 4.1%; 7.6% versus 6.4%). DISCUSSION This study demonstrates that patients who underwent revision THA with previous LSF demonstrated notably higher dislocation rates and rerevision rates compared with patients who underwent revision THA, followed by LSF, with the greater the intervals between revision THA and LSF, the lower the postoperative dislocation rates and rerevision rates.

Background This study compares the use of radiographic K-Rod dynamic stabilization to the rigid system for the treatment of multisegmental degenerative lumbar spinal stenosis (MDLSS). Methods A total of 40 patients with MDLSS who underwent surgical treatment using the K-Rod (n = 25) and rigid systems (n = 15) from March 2013 to March 2017 were assessed. The mean follow-up period was 29.1 months. JOA, ODI, VAS and modified Macnab were assessed. Radiographic evaluations included lumbar lordosis angle, ISR value, operative and proximal adjacent ROM. Changes in intervertebral disc signal were classified according to Pfirrmann grade and UCLA system. Results JOA, ODI and VAS changed significantly after the operation to comparable levels between the groups. However, the lumbar lordosis significantly decreased at final follow-up between both groups. The ROM of the proximal adjacent segment increased at final follow-up, but the number of fixed segment ROMs in the K-Rod group were significantly lower at the final follow-up than observed prior to the operation. In both groups, the ISR of the proximal adjacent segment decreased, most notably in the rigid group. The ISR of the non-fusion fixed segments in the K-Rod group increased post-operation and during final follow-up. The levels of adjacent segment degeneration were higher in the rigid group vs. the K-Rod group according to modified Pfirrmann grading and the UCLA system. Conclusions Compared with the rigid system for treatment of MDLSS, dynamic K-Rod stabilization achieves improved radiographic outcomes and improves the mobility of the stabilized segments, minimizing the influence on the proximal adjacent segment.

Study design A retrospective case-control study. Objective This study aimed to elucidate the association between facet joint orientation and degenerative lumbar spinal stenosis (DLSS). Summary of background data Many studies have demonstrated the relationship between sagittal facet orientation and degenerative lumbar spondylolisthesis. However, the associations between facet orientation and DLSS have rarely been studied. Methods Ninety-one age-matched and sex-matched patients with DLSS (LSS group) and 91 control participants were consecutively enrolled. Their lumbar facet angles and the dural sac cross-sectional area at L2-L3, L3-L4, L4-L5, and L5-S1 were measured using axial magnetic resonance imaging. The intersection angle of the midsagittal line of the vertebra to the facet line represents the orientation of the facet joint. Results The facet angles on the left side or right side of the LSS group were significantly smaller than the respective ones of the control group. Outcomes of the groups revealed significantly and consistently increasing facet angles from L2-L3 to L5-S1. The dural sac cross-sectional area of the LSS group had significantly smaller measurements values than that of the control group at L2-L3, L3-L4, L4-L5, and L5-S1. Conclusion Sagittalization of lumbar facet joints was considered to be a risk factor for DLSS and may play a role in the pathology of DLSS. Level of evidence 3.

Introduction This study aimed to investigate the perception of Korean medicine (KM) doctors regarding the treatment of degenerative lumbar spinal stenosis (LSS) and explore their opinions on the core clinical questions (CQs) of KM clinical practice guidelines (CPGs) for patients with degenerative LSS. Methods An online cross-sectional survey distributed via e-mail was conducted in December 2016. The study population included registered KM doctors (KMDs) in South Korea. The e-mail contained 13 questionnaire items regarding the doctors’ demographic characteristics and perceptions of the core CQs that should be addressed in CPGs for patients with degenerative LSS. Descriptive analyses were performed to summarize the data. Results A total of 680 KMDs responded to the survey. Kidney qi deficiency was the most commonly used diagnostic name for degenerative LSS. Acupuncture ranked first in the treatment used for degenerative LSS and in the treatment desired to be included in the development of CPG recommendations. Ojeok-san (积散, 積散, Wuji-san, Goshaku-san) was the number one herbal medicine, and 5% bee venom pharmacopuncture was the number one pharmacopuncture technique used for degenerative LSS. Drug therapy was the most selected control treatment considered appropriate to assess treatment effectiveness and safety. Pain relief was the most chosen indicator among the indicators considered reasonable to assess therapeutic effectiveness. Conclusion Results of this study are expected to inform the development of key CQs of the KM standard CPG for degenerative LSS. The involvement of KMDs in the CPG development process can help develop useful and available CPGs.

Study Design: Retrospective study. Objective: To compare the clinical efficacy of posterior lumbar laminectomy decompression under full endoscopic technique (Endo-LOVE) and percutaneous endoscopic medial foraminal decompression (PE-MFD) in the treatment of degenerative lumbar spinal stenosis (DLSS). Methods: Between April 2017 and April 2018, 96 patients with DLSS underwent Endo-LOVE or PE-MFD, including 58 with Endo-LOVE and 38 with PE-MFD. After propensity score matching (PSM), patient characteristics, operation time, intraoperative fluoroscopy times, postoperative bedridden time, hospital stay and postoperative complications were recorded and compared. The clinical efficacy was evaluated according to Oswestry disability index (ODI), visual analogue scale (VAS), lumbar disease JOA and modified MacNab criteria. Results: A total of 96 patients with DLSS were included in the study. After PSM, the 2 groups were comparable in patient demographic and baseline characteristics. The operation time and intraoperative fluoroscopy times in PE-MFD group were significantly more than those in Endo-LOVE group ( P < .05). The operation time in PE-MFD group was significantly less than that in Endo-LOVE group ( P < .05). The intraoperative fluoroscopy times in PE-MFD group were significantly more than that in Endo-LOVE group ( P < .05). The ODI, VAS and lumbar disease JOA in the 2 groups were significantly improved comparing with those before operation ( P < .05). According to the modified MacNab criteria, the excellent and good rates of the 2 groups were 93.5% in Endo-LOVE group and 87.1% in PE-MFD group ( P > .05). Conclusion: Endo-LOVE and PE-MFD technique can both effectively treat DLSS, and the short-term follow-up results are positive. Endo-LOVE technique has the advantages of fast puncture positioning, less radiation exposure and wider indications. However, PE-MFD needs more radiation exposure and has the possibility of incomplete decompression for complex multiplanar spinal stenosis.

Сomputed tomography (CT) is widely used in the diagnosis of degenerative pathology of the lumbar spine, but the relationship between clinical manifestations of lumbar stenosis and its anatomical prerequisites has not been sufficiently studied to date.The objective: to determine the significance of the morphometric parameters of lumbar stenosis according to CT scans and to establish their relationship with the prevailing symptoms of the disease.Material and methods. Seventy-five consecutive patients with clinically significant lumbar stenosis who underwent CT scan before surgery were enrolled in this study. The average values of thirteen different morphometric parameters were calculated at LIII–SI levels of the intervertebral discs and of the pedicels in the axial and sagittal views. The possibility of classification of clinical observations and the correlation of morphometric parameters with the clinical forms of lumbar stenosis were investigated using discriminant and logistic regression analysis. Results. CT scan with high probability allocates patients with predominant symptoms of neurogenic claudication or bilateral radiculopathy. The most significant morphometric predictors of this clinical group are the depth of the lateral recesses and the cross-sectional area of the spinal canal.Conclusion. CT scan significantly expands the informative value of magnetic resonance imaging and can be used in planning the decompressive stage of the surgery intervention in patients with lumbar spinal canal stenosis.

Background Acupuncture is commonly used to treat degenerative lumbar spinal stenosis in Asian countries. However, rigorous data regarding the efficacy and safety of acupuncture for aging patients are currently lacking. Methods Eighty patients older than 50 years were assigned randomly to the acupuncture group or the noninsertive sham acupuncture for 24 treatments over an 8-week period. Measurements were obtained at baseline and 4 and 8 weeks of treatment; and 3 and 6 months after completion of treatment. The primary outcome was a change in the 24-point Roland Morris Disability Questionnaire scores at the end of treatment. The secondary outcomes included disability, pain intensity, symptoms, and dysfunction. Results At the end of treatment, mean changes in the Roland Morris Disability Questionnaire were −4.1 (95% CI, −4.9 to −3.3) in the acupuncture group and −1.5 (95% CI, −2.3 to −0.7) in the sham group, with a statistically significant between-group difference: −2.6 (95% CI, −3.7 to −1.4). Acupuncture was superior to sham acupuncture in reducing pain intensity (between-group difference: −2.9 [95% CI, −3.8 to −2.0] in leg and buttock pain, vs −2.3 [95% CI, −3.0 to −1.5] in back pain), symptoms and dysfunction (between-group difference: −0.9 [95% CI, −1.2 to −0.6] in symptom subscale, and −0.8 [95% CI, −1.1 to −0.5] in dysfunction subscale). Conclusions Acupuncture provides immediate functional recovery and pain relief for degenerative lumbar spinal stenosis. However, current evidence is insufficient to support the suggestion that acupuncture could offer clinical benefits as compared with noninsertive sham acupuncture for degenerative lumbar spinal stenosis.

Background Low back pain is a common condition and carries substantial socioeconomic implications. Magnetic resonance imaging (MRI) is the imaging modality of choice with lumbar neural foraminal stenosis being one of the most common causes of lower back pain syndromes. Studies have shown a lack of correlation between patients’ severity of disability and radiologically determined nerve root constriction. Therefore, the goal of this study will be to determine the frequency of severity of disability in patients with severe (i.e., grade III) lumbar neural foraminal stenosis on MRI to ascertain the impact of MRI diagnosis on clinical outcomes. Materials and methods Two hundred fifty patients of either gender with a history of backache referred for MRI were included by purposive sampling. Of these 250 patients, 27 patients had grade II lumbar neural foraminal stenosis, and 21 had grade I neural foraminal stenosis on MRI and were excluded. Thirty-two patients had a spinal infection (e.g., tuberculosis), and 24 patients had a history of trauma. Further, 31 patients were having follow-up scans for previously diagnosed lumbar neural foraminal stenosis. Hence, after excluding these cases, 115 patients were enrolled in this cross-sectional study with grade III lumbar neural foraminal stenosis on MRI. Results The mean age was 51 years (range: 20 to 82 years). Most of the patients (55.6%) were older than 50 years. The most common site of grade III lumbar neural foraminal stenosis was L4-L5 (56.5%). According to the Oswestry disability index, 47 patients (40.9%) had a severe disability, 32 (27.8%) had a moderate disability, 16 (13.9%) were diabled, 14 (12.2%) had a mild disability, and six (5.2%) were bedridden. Conclusions While MRI is the imaging modality of choice in degenerative lumbar spinal stenosis, clinical disabilities can be more extensive than what radiological findings may indicate in approximately 40% of the cases. Therefore, lumbar spinal stenosis should be a neuro-radiological diagnosis, and surgical decisions should be based on clinical scenarios in addition to MRI findings.

A comprehensive description of the literature regarding interspinous process devices (IPD) mainly focused on comparison with conservative treatment and surgical decompression for the treatment of degenerative lumbar spinal stenosis. Recent meta-analysis and articles are listed in the present article in order to establish IPD pros and cons.

Priapism is a relatively uncommon clinical presentation. The well-recognised causes are sickle cell anaemia and the use of medications, such as vasoactive erectile agents. Infrequently, it could be the result of lumbar spinal stenosis. The authors reported an elderly man with 1-year history of isolated intermittent priapism aggravated by walking. MRI showed lumbosacral spondylosis with severe stenosis at the level of L4–L5. Total laminectomy of L4 and L5 was done, resulting in a rapid and complete resolution of symptom without recurrence during the follow-up time of 10 years.

IntroductionSurgical and invasive procedures are widely used in adults with degenerative lumbar spinal stenosis when conservative treatments fail. However, little is known about the comparative efficacy and safety of these interventions. To address this, we will perform a network meta-analysis (NMA) and systematic review to compare the efficacy and safety of surgical and invasive procedures for adults with degenerative lumbar spinal stenosis.Methods and analysisWe will include randomised controlled trials assessing surgical and invasive treatments for adults with degenerative lumbar spinal stenosis. We will search AMED, CINAHL, EMBASE, the Cochrane Library and MEDLINE. Only English studies will be included and no restriction will be set for publication status. For efficacy, our primary outcome will be physical function. Secondary outcomes will include pain intensity, health-related quality of life, global impression of recovery, work absenteeism and mobility. For safety, our primary outcome will be all-cause mortality. Secondary outcomes will include adverse events (number of events or number of people with an event) and treatment withdrawal due to adverse effect. Two reviewers will independently select studies, extract data and assess the risk of bias (Revised Cochrane risk-of-bias tool for randomized trials) of included studies. The quality of the evidence will be evaluated through the Grading of Recommendations Assessment, Development and Evaluation framework. Random-effects NMA will be performed to combine all the evidence under the frequentist framework and the ranking results will be presented through the surface under the cumulative ranking curve and mean rank. All analyses will be performed in Stata and R.Ethics and disseminationNo ethical approval is required. The research will be published in a peer-reviewed journal.PROSPERO registration numberCRD42018094180.

To determine whether fat infiltration in the multifidus muscle would predict surgical prognosis in patients with degenerative lumbar spinal stenosis (DLSS).This ambispective cohort study enrolled 118 consecutive patients undergoing surgery for L4-5 single-segment DLSS. Fat infiltration rate (FIR) on magnetic resonance images of the multifidus muscle at L5-S1 were measured using ImageJ software. The enrolled patients were divided into FIR25% and FIR ≥25% groups according to their FIR of the multifidus muscle at L5-S1. The 2 groups of patients who finished follow-up were further matched for the baseline covariates based on propensity scores. Patients' reported outcomes including the visual analog scale score for back pain and leg pain, and the Oswestry Disability Index (ODI) score were compared between groups at follow-up and further adjusted using generalized linear models.Patients in the FIR25% group showed statistically significantly greater reduction in ODI at 6 and 18 months after surgery than did patients in the FIR ≥25% group in either cohort regardless of adjustment; however, the 2-point between-group difference was smaller than the predefined minimum clinically important difference. In addition, more patients in the FIR25% group achieved clinically significant improvement in ODI than those in the FIR ≥25% group in either complete cohort or matching cohort (63.8% vs. 21.1%, P0.001; 70.3% vs. 24.1%, P 0.001, respectively) before and after adjustment (63.3% vs. 27.8%, P0.001; 69.1% vs. 31.0%, P0.001, respectively).Fat infiltration in multifidus muscle at L5-S1 could be a potential predictor of functional improvement after surgery in patients with L4-5 single-segment DLSS.

Aims The purpose of this study was to investigate the prevalence of sarcopenia and to examine its impact on patients with degenerative lumbar spinal stenosis (DLSS). Patients and Methods This case-control study included two groups: one group consisting of patients with DLSS and a second group of control subjects without low back or neck pain and related leg pain. Five control cases were randomly selected and matched by age and gender (n = 77 cases and n = 385 controls) for each DLSS case. Appendicular muscle mass, hand-grip strength, sit-to-stand test, timed up and go (TUG) test, and clinical outcomes, including the Oswestry Disability Index (ODI) scores and the EuroQol EQ-5D were compared between the two groups. Results The prevalence of sarcopenia, as defined by hand-grip strength, was significantly higher in the DLSS group (24%) when compared with the age- and gender-matched control group (12%) (p = 0.004). In the DLSS group, the sarcopenia subgroup demonstrated inferior results for the TUG test and ODI scores when compared with the non-sarcopenia subgroup (p = 0.006 and p = 0.039, respectively) after adjusting for age and gender. Conclusion This study demonstrated a higher prevalence of sarcopenia in patients with DLSS and highlighted its negative effect on clinical outcomes. Cite this article: Bone Joint J 2016;98-B:1093–8.

Introduction: Spinal stenosis mostly occur in lumbar spine and causes back pain, leg pain & neurogenic claudication. Although conservative treatment is mainstay, decompression with or without fusion (with or without instrumentation) can be considered in non-responsive cases. However, long term outcome of the surgery is controversial. The aim of our study was to analyze the outcome of surgery in lumbar spinal stenosis in terms of post-operative pain and claudication distance.Methods: A prospective analysis of patients who underwent decompression or decompression with fusion (with or without instrumentation), after failure of 3-6 months conservative treatment, for lumbar spinal stenosis were conducted. Only those who were operated and followed up for at least two years were included.Their preop and postop VAS score and walking distance compared.Results: Of 22 cases enrolled in this study, VAS score was improved in 21 patients and walking distance increased. Only one patient complained of increase in pain score at 24 months.Conclusion: Operative management is a good option for selected patients, 21 out of 22 have improved VAS and claudication distance in our study

Background: Most degenerative lumbar spinal stenosis (DLSS) patients primitively received the conservative treatment to control symptoms. In order to develop an optimal surgical treatment strategy, it is very significant to understand how the degenerative lumbar spondylolisthesis (DS) affects the effect of decompression in the DLSS. Thus, the aim of this current study was to explore whether the concomitant DS would affect the effect of decompression alone in the patients with DLSS. Methods: The current study was carried out at our hospital and it was approved through our institutional review committee of General Hospital of Ningxia Medical University. During the period from January 2015 to December 2017, in our study, we identified consecutive patients who received the minimally invasive laminectomy to treat the DLSS. The inclusion criterion included radicular leg pain or neurogenic claudication with the neurological symptoms associated with DLSS syndrome, magnetic resonance imaging of the lumbar spine reveals at least 1 level of serious stenosis, the conservative treatment failed for at least 3 months, and patients agreed to provide the postoperative details. The major outcomes of this present research was Oswestry Disability Index. Secondary outcomes of this current study involved visual analog score, short form-36, surgical revision rate as well as complications. Results: We assumed that previous DS possessed a negative effect on the postoperative results of the DLSS patients. Trial registration: researchregistry5943.

BACKGROUND CONTEXT: Due to poor bone stock in the elderly, a noninstrumented fusion is commonly performed in Scandinavia when instability is present. Allograft bone is often used as graft extender with consequent low fusion rates. The use of 15 amino acid residue (ABM/P-15) has shown superior fusion rates in dental and cervical spinal surgery but no clinical studies have been conducted in noninstrumented lumbar fusion surgery.PURPOSE: To evaluate patient reported outcomes (PROs) and the intertransverse fusion rate in noninstrumented posterolateral fusion with either ABM/P-15 or allograft.STUDY DESIGN: Double-blind randomized clinical trial.PATIENT SAMPLE: Patients 60 years or older with degenerative spondylolisthesis undergoing decompression and noninstrumented posterolateral fusion.OUTCOME MEASURES: Visual analog scales for back and leg pain, Oswestry Disability Index and EuroQoL-5D.METHODS: One hundred one patients were enrolled in the study and randomized 1:1 to either ABM/P-15 (mixed 50/50, 5cc/level) or allograft bone (30 g/level), both mixed with local bone graft. PROs were collected at baseline and at 12 and 24 months after surgery. The patients underwent 1-year postoperative fine cut computed tomography-scans (0.9 mm) with reconstructions, independently evaluated by three reviewers. Fusion status was concluded by consensus of two of the three as "fusion" or "no fusion."RESULTS: There were 49 patients available for analysis in both cohorts. The two groups were similar in terms of sex distribution, age, and number of levels fused. The fusion rate was significantly higher in the ABM/P-15 group with 50% fused compared with 20% in the allograft group. PROs at baseline and at all follow-up time points were similar between the two groups.CONCLUSIONS: Patients undergoing noninstrumented posterolateral fusion augmented with ABM/P-15 had a statistically significantly higher fusion rate compared with allograft when evaluated with postoperative fine cut computed tomography-scans (0.9 mm) with reconstructions. However, this did not translate to better clinical outcomes.

Background In lumbar spinal stenosis (LSS), at most times, several levels are impaired and selecting the correct level remains a common problem for surgeons, as surgery remains invasive, and extended laminectomy may lead to secondary surgical complications. Therefore, helping to select the correct level may be useful for surgeons. The use of diffuse tensor imaging (DTI) and paraspinal mapping (PM) in addition to conventional magnetic resonance imaging (MRI) may be helpful (Chen et al., J Orthop Surg Res 11:47, 2016). However, with decompression levels determined by conventional magnetic resonance imaging (MRI) increasing, whether the benefits of reducing decompression level of conventional MRI + (DTI or PM) will be more obvious is unknown. Methods Reduced surgical levels that were different between levels determined by conventional MRI + (DTI or PM) and conventional MRI + neurogenic examination (NE) between groups were compared. Treatment outcome measures were performed at 2 weeks, 3 months, 6 months, and 12 months postoperatively. Results The reduced levels of three groups showed no statistically significant differences between each other except for two levels and four levels (two levels/three levels, p = 0.085; two levels/four levels, p = 0.039; three levels/ four levels, p = 0.506, respectively). Conclusions With surgical levels determined by conventional MRI increasing, the benefits of DTI and PM will be uncertainly more obvious.

Background: Neurogenic intermittent claudication (NIC) is the main symptom of degenerative lumbar spinal stenosis. Percutaneous interspinous process decompression devices (IPDs) have been designed as an alternative therapy to conservative treatment and to open decompressive surgery for patients suffering from NIC. Initial short-term results were encouraging. We present the long-term results of a group of patients that we followed to provide insight on long-term outcomes and effectiveness of this technique compared to other decompression methods. Methods: Fifteen patients operated for NIC by implantation of percutaneous IPDs have been prospectively monitored for reoperations or complications. Follow-up (FU) was interrupted if the patient was reoperated. Results were considered poor if the patient had to be reoperated at any stage of the FU or if the treatment failed to alleviate the pain after 6 months. Results were considered average if the patient still suffered some pain but did not require reoperation. Results: The patients were followed up to 7 years after the initial surgery. The mean length of the FU was 3.53 years and all patients could be followed. At the end of the FU, the results were good in only 20.0% (3/15), average in 13.3% (2/15) and poor in 66.7% (10/15). Conclusions: Despite initial satisfactory results, long-term FU is disappointing, with 80% poor or average results. The long-term reoperation rate is high (66.6%), increases over time and is higher than after implantation of IPDs for decompression augmentation. Although this technique is simple and safe, its effectiveness seems short-lived. We recommend cautious use and informing patients about the risk of relatively early failure and recurrence.

Although a number of prognostic factors have been demonstrated to be associated with surgical outcome of degenerative lumbar spinal stenosis (DLSS), no study has investigated the relation between hand grip strength (HGS) and treatment outcome of DLSS.The purpose of the present study was to examine the influence of HGS on surgical outcomes after surgery for patients with DLSS.This is an observational study.Patients who underwent spine surgery for DLSS were included in the study.Oswestry Disability Index (ODI), EuroQOL (EQ-5D), and visual analog scale (VAS) scores for back or leg pain were assessed.A total of 172 consecutive patients who underwent spine surgery for DLSS were included in the present study. Patients were assigned to either high HGS group (≥26 kg for men and ≥18 kg for women, n=124) or low HGS group (26 kg for men and18 kg for women, n=48) based on their preoperative HGS performance. Oswestry Disability Index, EQ-5D, and VAS scores for back and leg pain were assessed and compared between two groups preoperatively, 3 and 6 months after surgery. The primary outcome measure was baseline-adjusted ODI scores 6 months after surgery. The secondary outcome measures, including the overall ODI score, EQ-5D score, VAS score for back and leg pain, were assessed at each time point during the 6-month follow-up period.As primary outcome, baseline-adjusted ODI scores were significantly lower in the high HGS group than in the low HGS group 6 months after surgery. In the secondary outcome measurements, the ODI, EQ-5D, and VAS scores for back and leg pain improved significantly with time after surgery in both groups. The effects of HGS group on the overall changes in the ODI and EQ-5D scores during the 6-month period were significantly different between the two groups; however, they were not significantly different on VAS score for back and leg pain. The pattern of change in the ODI during the follow-up period was significantly different between the two groups.Patients with preoperative high HGS display better surgical outcome in terms of disability and health status 6 months after spine surgery. Preoperative HGS can act as a predictor of surgical outcome in patients with DLSS.

Degenerative lumbar spinal stenosis and spondylolisthesis are a common diagnosis seen in the primary care office. Symptoms of both conditions include neurogenic claudication and/or lower extremity radiculopathy. A thorough workup will help differentiate etiologies with overlapping symptoms, such as vascular claudication. For both conditions, the mainstay of treatment is nonsurgical in the absence of a neurologic deficit. A shared decision for surgical treatment is made with the patient and surgeon based on the impact on a patient’s quality of life.

The aim of the present study was to examine the curative effect of dynamic fixation Coflex treatment for patients with degenerative lumbar spinal stenosis. In the present study, 78 patients with degenerative lumbar spinal stenosis were recruited and divided equally into the control and observation groups. The control group was treated with traditional decompression fusion and the observation group received dynamic fixation Coflex system. Surgery and hospitalization were shorter in the observation group than in the control group. Intraoperative blood loss and drainage volume after surgery were significantly lower in the observation group compared to the control group. The treatment effective rate for the observation group was significantly higher. Visual analogue scale, Oswestry disability index and Japanese Orthopaedic Association pain and functional scores as well as postoperative vertebral canal area and adjacent segment quantitative scores improved after surgery in the two groups, but the observation group showed greater improvement. The curative effect of dynamic fixation Coflex treatment for degenerative lumbar spinal stenosis demonstrates advantages over traditional surgery, including less trauma and bleeding, pain reduction, improved postoperative rehabilitation, and lower incidence of adjacent segment degeneration.

Aim: The aim of our study was to compare clinical outcomes and examined the effect of simple decompression without additional fusion in patients with preoperative degenerative spondylolisthesis (DS) versus patients without preoperative degenerative spondylolisthesis (non-DS) on one or two adjacent levels. Methods: For this retrospective analysis we did use data from the Lumbar Stenosis Outcome Study (LSOS). The LSOS is conducted as a prospective cohort study at eight medical centers in Switzerland. The main outcomes of this study were change in SSM symptoms, SSM function, and EQ-5D-EL sum score over time. These outcomes were measured at baseline, six, and 12-month follow-up. To obtain an unbiased effect of DS versus non-DS we chose matching techniques relying on propensity scores. Results: For this study, 853 potentially eligible patients agreed to participate between December 2010 and December 2015. Of these, 350 patients underwent decompression alone surgery within the first six months after baseline. Out of these, 133 patients met the inclusion criteria, with accompanying DS (n = 32) or without DS (n = 101). The estimated effects of DS versus non-DS for change in SSM symptoms from baseline to 6 and 12 months were 0.08 (95% CI −0.34 to 0.49) and 0.16 (−0.23 to 0.55), respectively. For change in SSM function, the estimated effects were −0.01 (−0.39 to 0.37), and 0.08 (−0.33 to 0.50). Changes in between group difference of EQ-5D-EL sum score were estimated to be −7.19 (−15.24 to 0.86) and −4.88 (−13.29 to 3.54) from baseline to 6 and 12 months. None of the group differences between the non-DS and the DS group were statistically significant. All matched patients improved over time in all secondary outcomes. Conclusion: Among the patients with degenerative lumbar spinal stenosis our study demonstrates that in the two groups, degenerative spondylolisthesis and non-degenerative spondylolisthesis, patients distinctively take advantage of simple decompression without fusion. Our results indicate that the presents of a preoperative degenerative spondylolisthesis does not worsen outcome in comparison to non-olisthesis cases when treated by simple decompression. Conversely, our results could indicate that adding fusion in preoperative olisthesis cases might only be reserved for certain patients.

dLSS is a clinical definition which describes a small spinal canal diameter commensurate with standing and walking limitations due to back and/or leg pain.

Objective. To analyze the reasons for revision surgery after decompression and stabilization in patients with degenerative lumbar spinal stenosis. Material and Methods. A total of 308 patients with degenerative lumbar spinal stenosis were operated on. They underwent decompression and stabilization surgery using transpedicular fixation involving from 1 to 8 spinal motion segments. Results. Clinical manifestations of radiculopathy and back pain were completely eliminated in 166 (53.9 %) patients. Another 86 (27.9 %) patients reported the absence of radicular pain syndrome with sustained mild low back pain during physical exertion. Significant reduction in radicular and low back pain was achieved in 49 (15.9 %) patients. Poor long-term results of surgical treatment requiring revision surgery in the long-term period were detected in 30 (16.1 %) patients. Conclusion. Multi-level surgery for lumbar spinal stenosis increases the risk and probability of indications for revision in the long-term period. When performing extended decompression and stabilization procedure at four or more spinal motion segments including the L5-S1segment stabilization, it is advisable to insert caudal pedicle screws into posterior portions of the os illium instead of the S1 vertebral body. Hir. Pozvonoc. 2014;(1):86-93.

Degenerative lumbar spinal stenosis (LSS) and lumbar spondylolisthesis (DS) can lead to significant disability and impaired quality of life. In select patients with predominantly leg-dominant symptoms that have exhausted nonoperative treatment, surgical treatment can provide significant improvement in symptoms. The present paper reviews the clinical evaluation, radiographic findings, and surgical decision making of both spinal stenosis and degenerative spondylolisthesis using the current best available evidence.

Lumbar spinal canal stenosis (LSCS) associated with degenerative scoliosis has being increasingly aware by the public and studied by many researchers. Degenerative changes leading to spinal stenosis can precede a spinal deformity which will develop into the de novo scoliosis. There are few studies focusing on the risk factors contributing to the degenerative lumbar scoliosis (DLS) in lumbar spinal stenosis patients. From September, 2017 to December, 2017, 181 patients who were diagnosed with LSCS in the outpatient department of our hospital were enrolled in this retrospective investigation. The patients were divided into 2 groups: DLS group (Cobb angle >10°) and LSCS group. Sex, age, smoking status (yes or no), occupation (heavy or light labor), body mass index (BMI), bone mineral density (BMD) and radiographic parameters including the lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), thoracic kyphosis (TK), coronal vertical axis, and sagittal vertical axis (SVA) are all evaluated as potential risk factors. Multivariate logistic regression analysis and receiver-operating characteristic curves were used to identify potential risk factors. Forty-five of 181 patients were diagnosed with DLS and involved in the DLS group. There were significant differences between the 2 groups in BMI (P 25.57 kg/m2 (AOR 1.270, 95% CI 1.040–1.551, P = .019), and SVA >3.98 cm (AOR 3.651, 95% CI 2.226–5.990, P 25.57 kg/m2, and SVA >3.98 cm were the potential risk factors for the formation of degenerative lumbar scoliosis based on degenerative lumbar spinal stenosis.

Background Minimally invasive decompressive procedures have evolved into the modern standard surgical solution for degenerative lumbar spinal stenosis (DLSS) patients, such as the bilateral laminotomy and the unilateral laminotomy for bilateral decompression (ULBD) that is characterized by ipsilateral and contralateral microdecompression under the midline posterior structures and has been successfully used with proven efficacy. Objective To compare the effect of the size of the skin incision and the method of handling the multifidus muscle on the clinical outcomes of the endoscopic laminotomy versus the standard microscopic laminotomy for DLSS. Patients and methods Primary outcome data included the numerical rating scale for back and leg symptoms and Oswestry Disability Index to quantify pain and disability, respectively. Secondary outcome data included operative time, blood loss, and modified Mcnab criteria. Results At the end of the follow-up period, the rate of successful outcome of the endoscopic group was 87.2 and 77.8% for the control group after initial improvement by 87% at 3-month follow-up. The incidence of complications was 13% in both groups. Conclusion For DLSS, the endoscopic ULBD in experienced hands would have a better outcome than the microscopic ULBD regarding the postoperative clinical outcome and patient satisfaction.

The evidence-based clinical guideline on the diagnosis and treatment of degenerative lumbar spinal stenosis by the North American Spine Society (NASS) provides evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of degenerative lumbar spinal stenosis. The guideline is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spinal stenosis as reflected in the highest quality clinical literature available on this subject as of July 2010. The goals of the guideline recommendations are to assist in delivering optimum efficacious treatment and functional recovery from this spinal disorder.Provide an evidence-based educational tool to assist spine care providers in improving quality and efficiency of care delivered to patients with degenerative lumbar spinal stenosis.Systematic review and evidence-based clinical guideline.This report is from the Degenerative Lumbar Spinal Stenosis Work Group of the NASS's Evidence-Based Clinical Guideline Development Committee. The work group consisted of multidisciplinary spine care specialists trained in the principles of evidence-based analysis. The original guideline, published in 2006, was carefully reviewed. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases to identify articles published since the search performed for the original guideline. The relevant literature was then independently rated by a minimum of three physician reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final recommendations to answer each clinical question were arrived at via work group discussion, and grades were assigned to the recommendations using standardized grades of recommendation. In the absence of Levels I to IV evidence, work group consensus statements have been developed using a modified nominal group technique, and these statements are clearly identified as such in the guideline.Sixteen key clinical questions were assessed, addressing issues of natural history, diagnosis, and treatment of degenerative lumbar spinal stenosis. The answers are summarized in this document. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence.A clinical guideline for degenerative lumbar spinal stenosis has been updated using the techniques of evidence-based medicine and using the best available clinical evidence to aid both practitioners and patients involved with the care of this condition. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, will be available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.

Degenerative spinal stenosis is a common lumbar condition in the elderly population. Clinical decision-making in the physiotherapy settings is based on assessments of the patients physical status. The purpose of this study was to examine how self-reported measures on symptoms and physical function relate to responses on physical performance tests.A total of 103 patients with LSS completed a comprehensive questionnaire and physical performance tests (functional leg-strength and dynamic balance). Associations between the subscales Symptom Severity (SYMP) and Physical Function (FUNC) from the Spinal Stenosis Questionnaire, and the performance tests were examined. Univariate correlation and multivariable linear regression analyses were applied.The associations between SYMP or FUNC and the performance tests were moderate (?0.3 rho 0.6). The multivariable analyses showed that One-leg-Stand, 30s sit-to-stand were significantly associated with SYMP ( 0.001 p 0.03), whereas Stairclimb, was significantly associated with FUNC ( 0.001 p 0.005). The explained variance was fair for both adjusted models (RThe present study indicates that both self-reported symptoms and walking limitation are associated with leg strength, while only symptoms are associated with balance. The results suggest that a combination of simple performance tests will add information needed to map the patients disability and guide interventions. Implications for Rehabilitation One-leg-standing, 30-s sit-to-stand and stair climb test are easy to use and applicable for examining physical function in patients with lumbar spinal stenosis (LSS). Simple performance tests add information needed to map the patients' disability and guide interventions. Leg strength is a key factor for both symptoms and walking ability. Also, balance is of importance for the symptoms in LSS patients.

Objectives To analyze whether multifidus degeneration has a relationship with degenerative lumbar spinal stenosis (LSS). Materials and methods Clinical data of 40 patients with LSS were analyzed retrospectively. Moreover, 40 healthy people were selected as controls. Subjects of both groups underwent a 1.5-T lumbar spinal magnetic resonance imaging scan in our hospital, and then the multifidus muscularity, fatty infiltration ratio, and bilateral asymmetry at L4/5 level on magnetic resonance imaging were measured with ImageJ software to analyze and compare the multifidus parameters between the 2 groups. Results Compared with the control group, the multifidus muscularity was lower, fatty infiltration ratio was greater, and muscle asymmetry was more significant at the L4/5 level in patients with LSS, and the difference between the 2 groups was statistically significant. Conclusions Multifidus degeneration, including reduced volume, increased fatty infiltration, and bilateral muscle asymmetry, has an association with LSS.

COMMENTARY ON: Lee S, Kim CH, Chung CK, Park SB, Yang SH, et al. Risk factor analysis for postoperative urinary retention after surgery for degenerative lumbar spinal stenosis. Spine J 2017:17:469–77 ( in this issue ).

The incidence of symptomatic osteoarthritis of the hip and degenerative lumbar spinal stenosis is increasing in our aging population. Because the subjective complaints can be similar, it is often difficult to differentiate intra- and extra-articular hip pathology from degenerative lumbar spinal stenosis. These conditions can present concurrently, which makes it challenging to determine the predominant underlying pain generator. A thorough history and physical examination, coupled with selective diagnostic testing, can be performed to differentiate between these clinical entities and help prioritize management. Determining the potential benefit from surgical intervention and the order in which to address these conditions are of utmost importance for patient satisfaction and adequate relief of symptoms.

The U.S. population is living longer and staying increasingly more active. Symptoms of degenerative lumbar spinal stenosis are being seen with increasing frequency in older age groups. Many of the more symptomatic patients do not respond to nonoperative care and seek potential surgical solutions. The current article offers an evidence-based review of the literature for surgical treatment of degenerative lumbar spinal stenosis with a focus on the role of lumbar fusion. The author evaluates the evidence for surgical treatment of this condition so that appropriate, patient-centered care can be provided in the safest and most cost-effective manner possible.