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Purpose: The objective of this systematic review and metaanalysis is to compare the efficacy and safety of decompression alone versus decompression plus fusion in single-level lumbar spinal stenosis with spondylolisthesis., Methods: A comprehensive search of the PubMed, Embase, Cochrane Library, and Ovid Medline databases was conducted to find randomized control trials (RCTs) or cohort studies that compared decompression alone and decompression plus fusion in single-level lumbar spinal stenosis with spondylolisthesis. Operation time; reoperation; postoperative complications; postoperative Oswestry disability index(ODI) scores and scores related to back and leg pain were collected from eligible studies for meta-analysis., Results: We included 3 randomized controlled trials and 9 cohort studies with 6182 patients. The decompression alone group showed less operative time(P < 0.001) and intraoperative blood loss(p = 0.000), and no significant difference in postoperative complications was observed in randomized controlled trials(p = 0.428) or cohort studies(p = 0.731). There was no significant difference between the other two groups in reoperation(P = 0.071), postoperative ODI scores and scores related to back and leg pain., Conclusions: In this study, we found that the decompression alone group performed better in terms of operation time and intraoperative blood loss, and there was no significant difference between the two surgical methods in rate of reoperation and postoperative complications, ODI, low back pain and leg pain. Therefore, we come to the conclusion that decompression alone is not inferior to decompression and fusion in patients with single-level lumbar spinal stenosis with spondylolisthesis., (© 2024. The Author(s).)

Background: Spinal cord stimulation (SCS) is an efficacious treatment for various refractory chronic pain syndromes. Serious complications including spinal cord compression (SCC) are rare with 19 previous reports which are mainly attributed to fibrotic scar tissue formation at the distal end of the leads at the location of the contacts. We report a case of SCC following SCS implantation at the lead entry location secondary to a delayed progression of spinal canal stenosis., Case Presentation: A patient in her early 70s underwent SCS implantation with adequate therapeutic benefit for approximately 2 years before citing complaints of increasing lower back pain and lower extremity radicular pain. Lumbar spine X-rays excluded lead migration as a causative factor. An MRI of the lumbar spine obtained 30 months following SCS implantation demonstrated a marked interval progression of central canal stenosis secondary to facet and ligamentous hypertrophy manifesting in compression of the spinal cord at the lead entry location. An L1-L2 decompressive laminectomy with hardware removal resulted in the resolution of her symptoms. A literature search conducted with the PubMed database identified previously published cases of SCC following SCS implantation which highlighted the rarity of this complication., Conclusion: Our case report urges physicians of SCS patients, noting a loss of therapeutic benefit with their device, to investigate new pathologies including SCC. Furthermore, our case highlights clinical symptoms and surgical treatments of SCC. Paddle leads are more commonly implicated in published cases of SCC than percutaneous leads. Lastly, MRI conditionality is critical to identifying cases of SCC., Competing Interests: Competing interests: DAP has consulted for Avanos, Boston Scientific, Medtronic, Nevro, and SI Bone. Pain Diagnostics and Interventional Care received research support from Avanos, Medtronic, Nevro, Stimgenics, and Abbott. HXL, DO-S and LD have no conflicts to report., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Individuals with achondroplasia are prone to symptomatic spinal stenosis requiring surgery. Revision rates are thought to be high; however, the precise causes and rates of reoperation are unknown. The primary aim of this study is to investigate the causes of reoperation after initial surgical intervention in individuals with achondroplasia and spinal stenosis. In addition, we report on surgical techniques aimed at reducing the risks of these reoperations., Methods: A retrospective review was conducted over an 8-year period of all patients with achondroplasia at a single institution that serves as a large referral center for patients with skeletal dysplasias. Patients with achondroplasia who underwent spinal surgery for stenosis were identified and the need for revision surgery was studied. Data collected included demographic, surgical, and revision details. Fisher exact test was used to determine if an association existed between construct type and the need for revisions., Results: Thirty-three of the 130 (22%) patients with achondroplasia required spinal stenosis surgery. Twenty-four individuals who met the criteria were selected for analysis. The initial spine surgery was at an average age of 18.7 years (SD: 10.1 y). Nine patients (38%) required revision surgeries, and 3 required multiple revisions. Five of 9 (56%) of the revisions had primary surgery at an outside institution. Revision surgeries were due to caudal pseudarthrosis (the distal instrumented segment) (8), proximal junctional kyphosis (PJK) (7), and new neurological symptoms (7). There was a significant association found between construct type and the need for revision ( P =0.0111). The pairwise comparison found that short fusions were significantly associated with the need for revision compared with the interbody group ( P =0.0180). PJK was associated with short fusions when compared with the long fusion group ( P =0.0294) and the interbody group ( P =0.0300). Caudal pseudarthrosis was associated with short fusions when compared with the interbody group ( P =0.0015). Multivariate logistic regression found long fusion with an interbody was predictive of and protective against the need for revision surgery ( P =0.0246). To date, none of the initial cases that had long fusions with caudal interbody required a revision for distal pseudarthrosis., Conclusions: In patients with achondroplasia, the rate of surgery for spinal stenosis is 22% and the risk of revision is 38% and is primarily due to pseudarthrosis, PJK, and recurrent neurological symptoms. Surgeons should consider discussing spinal surgery as part of the patient's life plan and should consider wide decompression of the stenotic levels and long fusion with the use of an interbody cage at the caudal level in all patients to reduce risks of revision., Level of Evidence: Level IV-Retrospective case series., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Lumbar spinal stenosis (LSS) can cause a range of cauda equina symptoms, including lower back and leg pain, numbness, and intermittent claudication. This disease affects approximately 103 million people worldwide, particularly the elderly, and can seriously compromise their health and well-being. Ligamentum flavum hypertrophy (LFH) is one of the main contributing factors to this disease. Surgical treatment is currently recommended for LSS caused by LFH. For patients who do not meet the criteria for surgery, symptom relief can be achieved by using oral nonsteroidal anti-inflammatory drugs (NSAIDs) and epidural steroid injections. Exercise therapy and needle knife can also help to reduce the effects of mechanical stress. However, the effectiveness of these methods varies, and targeting the delay in LF hypertrophy is challenging. Therefore, further research and development of new drugs is necessary to address this issue. Several new drugs, including cyclopamine and N-acetyl-l-cysteine, are currently undergoing testing and may serve as new treatments for LSS caused by LFH., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Interspinous process devices (IPDs) were developed as minimally invasive alternatives to open decompression surgery for spinal stenosis. However, given high treatment failure and reoperation rates, there has been minimal adoption by spine surgeons. This study leveraged a national claims database to characterize national IPD usage patterns and postoperative outcomes after IPD implantation., Method: Using the PearlDiver database, we identified all patients who underwent 1- or 2-level IPD implantation between 2010 and 2018. Univariate and multivariable logistic regression was performed to identify predictors of the number of IPD levels implanted and reoperation up to 3 years after the index surgery. Right-censored Kaplan-Meier curves were plotted for duration of reoperation-free survival and compared with log-rank tests., Results: Patients (n = 4865) received 1-level (n = 3246) or 2-level (n = 1619) IPDs. Patients who were older (adjusted odds ratio [aOR] 1.02, 95% confidence interval [CI] 1.01-1.03, P < .001), male (aOR 1.31, 95% CI 116-1.50, P < .001), and obese (aOR 1.19, 95% CI 1.05-1.36, P < .01) were significantly more likely to receive a 2-level IPD than to receive a 1-level IPD. The 3-year reoperation rate was 9.3% of patients when mortality was accounted for during the follow-up period. Older age decreased (aOR 0.97, 95% CI 0.97-0.99, P = .0039) likelihood of reoperation, whereas 1-level IPD (aOR 1.37, 95% CI 1.01-1.89, P = .048), Charlson Comorbidity Index (aOR 1.07, 95% CI 1.01-1.14, P = .018), and performing concomitant open decompression increased the likelihood of reoperation (aOR 1.68, 95% CI 1.35-2.09, P = .0014)., Conclusion: Compared with 1-level IPDs, 2-level IPDs were implanted more frequently in older, male, and obese patients. The 3-year reoperation rate was 9.3%. Concomitant open decompression with IPD placement was identified as a significant risk factor for subsequent reoperation and warrants future investigation., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Unilateral biportal endoscopic (UBE) surgery has recently been used as a minimally invasive procedure for the treatment of lumbar spinal stenosis and is associated with less perioperative blood loss. However, perioperative hidden blood loss (HBL) may be neglected during UBE. This study aimed to examine the volume of HBL and discuss the influential risk factors for HBL during unilateral biportal endoscopic surgery., Methods: From January 2022 to August 2022, 51 patients underwent percutaneous unilateral biportal endoscopic surgery for lumbar spinal stenosis at the Department of Spinal Surgery of the Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University and were enrolled in this study. The data included general indicators (age, sex and body mass index [BMI]), underlying disease (hypertension and diabetes), laboratory test results (prothrombin time [PT], activated partial thromboplastin time [APTT], fibrinogen [Fbg]), and preoperative and postoperative hematocrit and hemoglobin), related imaging parameters (severity of intervertebral disc [IVD] degeneration and soft tissue thickness of the interlaminar approach), number of operated vertebrae and operation time. Total blood loss (TBL) and HBL during surgical procedures were measured via the Gross formula. Influential factors were further analyzed by multivariate linear regression analysis and t-tests., Results: The mean HBL was 257.89 ± 190.66 mL for single-operation patients and 296.58 ± 269.75 mL for two-operation patients. Patients with lower PT (p = 0.044), deeper tissue thickness (p = 0.047), and diabetes mellitus were determined to have more HBL during UBE. The operation time might also be an important factor (p = 0.047). However, sex (p = 0.265), age (p = 0.771/0.624), BMI (p = 0.655/0.664), APTT (p = 0.545/0.751), degree of degenerated IVD (p = 0.932/0.477), and hypertension (p = 0.356/0.896) were not related to HBL., Conclusion: This study determined the different influential factors of HBL during UBE. PT, tissue thickness, and diabetes mellitus are the independent risk factors that affect HBL incidence. Long PT may decrease the volume of HBL within a certain range. Tissue thickness and diabetes mellitus can lead to an increased volume of HBL., (© 2024 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Background: Reoperation, sometimes multiple, is common with progressively worse outcomes in patients with degenerative lumbar spine diseases. Lysophosphatidylcholine (LPC), a precursor of lysophosphatidic acid, in the cerebrospinal fluid (CSF) is a possible biomarker for neuropathic pain and discriminating neuropathic pain caused by lumbar spinal canal stenosis (LSCS) from other etiologies. This study aimed to explore this possible use of LPC species in the CSF., Methods: Patients with LSCS (n = 137) and persistent spinal pain syndrome (n = 22) were subjected in this multi-site observational study. The CSF was collected by lumbar puncture. Using liquid chromatography-tandem mass spectrometry, we measured 6 LPC species, (16:0), (18:0), (18:1), (18:2), (20:4), and (22:6), in the CSF. We compared the LPC values between the groups and determined the cutoff levels that could efficiently discriminate the groups with high accuracy., Results: The levels of all measured LPC species were significantly higher in the LSCS group than the persistent spinal pain syndrome group. Four LPC species demonstrated more than 0.80 area under the curve obtained from the receiver operating characteristic curve analysis. Although the specificity of cutoff levels for the 6 LPC species was low to moderate, their sensitivity was consistently high., Conclusions: The existing diagnostic protocols combining physical examinations and morphological imaging studies for lumbar spinal pain have limited sensitivity. Measuring LPC species in the CSF is a promising objective laboratory test and could be suitable for detecting the presence of lumbar spinal stenosis and can help indications for surgery., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To retrospectively investigate the postoperative clinical and radiographic outcomes in elderly patients with degenerative lumbar spinal stenosis (DLSS) and severe global sagittal imbalance who underwent different fusion levels., Methods: A total of 214 patients with DLSS and severe global sagittal imbalance were included. Sagittal imbalance syndrome was defined as the severe decompensated radiographic global sagittal imbalance accompanied with the following symptoms: severe back pain in naturel posture that disappears or significantly relieves in support position, living disability with ODI score > 40% and dynamic sagittal imbalance. Thereinto, 54 patients were found with sagittal imbalance syndrome and were performed the lumbar decompression with a long thoracolumbar fusion (Group A) or a short lumbar fusion (Group B). Thirty patients without sagittal imbalance syndrome who underwent short lumbar decompression and fusion were selected as the control (Group C)., Results: Patients with sagittal imbalance syndrome were detected to have more paraspinal muscle degeneration and less compensatory potentials for sagittal imbalance (smaller thoracic kyphosis and larger pelvic tilt) than those without this diagnosis. Postoperative comparisons revealed significant restoration of global sagittal alignment and balance and improvement of living quality in Groups A and C at the final follow-up. Six patients in Group B and one in Group A were found to have proximal junctional complication during follow-up., Conclusion: Our results indicated that DLSS patients with sagittal imbalance syndrome had inferior surgical outcomes in terms of living quality and proximal junctional complication after lumbar decompression with a short fusion., (© 2024. The Author(s).)

Background: : Pharmacopuncture therapy and acupotomy are commonly used in combination for Conventional Korean Medicine Treatments (CKMT) for the treatment of patients with lumbar spinal stenosis (LSS). The aim of this study is to evaluate the effect and safety of combining pharmacopuncture therapy and acupotomy in the treatment of LSS., Methods: : This study is designed as a pragmatic, assessor-blinded, randomized controlled trial with two parallel arms in a 1:1 ratio. A total of 104 participants diagnosed with LSS will be randomly assigned to an experimental group (pharmacopuncture therapy and acupotomy in addition to CKMT) or a control group (only CKMT). Patients in both groups will receive treatment two times weekly for 6 weeks. The primary outcome will be the mean change on the 100-mm visual analog scale (VAS) from the baseline to the end of the treatment (week 6). The secondary outcomes will include the mean change in the 100-mm VAS from baseline to week 10 and week 14, respectively. Proportion of patients who achieve the clinically important difference, Zurich Claudication Questionnaire, Roland-Morris disability questionnaire, self-reported maxium walking distance, EuroQol 5-dimension 5-level, and Patients' Global Impression of Change will also be assessed. Adverse events will be assessed at each visit. The outcomes will be measured for a total of 14 weeks, including a treatment period of 6 weeks and follow-up of 4, 8 weeks., Discussion: : The results of this trial will confirm the effect and safety of combining pharmacopuncture therapy and acupotomy in the treatment of patients with LSS.

BACKGROUND Venous hypertensive myelopathy (VHM) is generally closely related to spinal vascular malformations, but a small number of other causes of VHM have been reported. CASE REPORT This rare case report describes a 74-year-old man with a C3 to C7 disc herniation, posterior spondylolisthesis (degree I) with spinal stenosis, exhibiting comparatively swift decline in neurological function as well as abnormal expansion of the high-signal intensity region on T2-weighted magnetic resonance imaging (MRI), which progressed to the medulla oblongata. Whether spinal cord degeneration is caused by cervical spondylotic myelopathy remains uncertain. Lumbar puncture was not performed because of spinal stenosis. An acute inflammatory process was also considered and the patient received hormone therapy. However, the effect was not significant, and his symptoms worsened after his hormone levels decreased. Repeat cervical MRI demonstrated interval development of diffuse intramedullary increased T2 signal in the spinal cord, which gradually increased to the pons, with cord swelling and degeneration more apparent. His medical history, negative laboratory results, evoked potential examination results, and poor effects of hormone therapy indicated a low probability of spinal inflammatory disease. Posterior C3-C6 expansive open-door cervical laminoplasty with lateral mass screw insertion and C2 and C7 decompression surgeries were performed. The neurological symptoms and abnormal T2-weighted MRI signals significantly improved after the operation. CONCLUSIONS VHM can be caused by spondylotic cord compression, leading to spinal cord injury. Therefore, an accurate diagnosis and timely surgery are essential.

Background: Biportal endoscopy spine surgery is an endoscopic procedure that uses 2 portals, 1 for the endoscope and 1 for the instruments. It provides an excellent and very versatile field of view, with the advantage of another portal to approach the most common degenerative lumbar pathologies., Methods: We evaluated a retrospective series of patients who underwent biportal endoscopy with ≥1 year of follow-up. Relevant epidemiological and clinical data, such as the Oswestry disability index and visual analog scale for pain, were also considered. Complications and the effects of the learning curve are also discussed., Results: We included 163 patients treated within a 5-year period with ≥1 year of follow-up available. The main pathologies were disc herniation (53.4%), foraminal stenosis (19%), and central canal stenosis (16.6%). The outcomes regarding disability and pain scores after surgery were very good, with a redistribution of the patient sample to the mild categories of disability. Inferential analysis showed relative and absolute improvements for both disc herniation and canal stenosis in terms of the Oswestry disability index and visual analog scale for pain, especially for disc herniation. The incidence of complications was approximately 7%. The most common approach was interlaminar (89%), and the most common pathology was disc herniation (54.9%). The duration of surgery overall and for the different stages had improved at the end of the learning curve with a reduction of almost 58 minutes., Conclusions: Biportal endoscopy is a minimally invasive procedure that is safe and effective, with a low rate of complications. It has a reproducible learning curve and provides very good outcomes regarding functionality and pain scores., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: New-onset neurological symptoms such as numbness and pain in lower extremities might appear immediately after conventional lumbar interbody fusion (LIF) surgery performed in patients with lumbar spinal stenosis., Methods and Analysis: This is a multicenter, randomized, open-label, parallel-group, active-controlled trial investigating the clinical outcomes of modified LIF sequence versus conventional LIF sequence in treating patients with lumbar spinal stenosis. A total of 254 eligible patients will be enrolled and randomized in a 1:1 ratio to either modified LIF sequence or conventional LIF sequence group. The primary outcome measure is the perioperative incidence of new-onset lower extremity neurological symptoms, including new adverse events of pain, numbness, and foot drop of any severity. Important secondary endpoints include visual analogue scale (VAS) pain score and lumbar Japanese Orthopaedic Association (JOA) recovery rate. Other safety endpoints will also be evaluated. The safety set used for safety data analysis by the actual surgical treatment received and the full analysis set for baseline and efficacy data analyses according to the intent-to-treat principle will be established as the two analysis populations in the study., Conclusion: This study is designed to investigate the clinical outcomes of modified LIF sequences in patients with lumbar spinal stenosis. It aims to provide clinical evidence that the modified "fixation-fusion" sequence of LIF surgery is effective in treating lumbar spinal stenosis., Trial Registration: http://www.chictr.org.cn/index.aspx ID: ChiCTR2100048507., (© 2023. The Author(s).)

Objective: To evaluate the safety and efficacy of modified facet joint fusion (MFF) for the treatment of multilevel (three-level or more) lumbar spinal stenosis (LSS)., Patients and Methods: In this retrospective study, 135 consecutive patients who underwent initial MFF for multilevel LSS were included. Clinical outcomes included fusion rate, change of visual analogue scale pain scores for low back pain (VAS-LBP) and leg pain (VAS-LP), Japanese Orthopedic Association scores (JOA), Oswestry Disability Index (ODI) and MacNab classification before and after MFF. The complications were also analyzed., Results: The fusion rates were 46.7% (63/135) at 6-month and 89.6% (121/135) at 1-year. The mean VAS-LBP, VAS-LP, and ODI significantly decreased from 5.2 ± 0.6, 5.7 ± 0.8 and 65 ± 7.9 to 1.58 ± 0.4, 0.58 ± 0.3 and 20.8 ± 5.8, respectively (all p  < 0.001). The mean JOA markedly improved from 10.0 ± 1.3 to 26.1 ± 1.5 ( p  < 0.001). Excellent/good results of MacNab classification were achieved in 88.9% (120/135) of the patients. The overall rate of complications after MFF was 5.9%, including poor wound healing (2.2%), calf muscular venous thrombosis (0.74%), deep venous thrombosis (0.74%), superficial wound infection (1.48%), transient foot drop (0.74%). All the complications were transient and improved without prolonged hospital stay and sequelae., Conclusion: MFF may be safe and efficient for multilevel LSS with high fusion rate and significant symptom relief, which is worthy of further study.

Purpose: Thoracic myelopathy caused by ossification of the posterior longitudinal ligament (OPLL) in the thoracic spine is usually progressive and responds poorly to conservative therapy, making surgery the only effective treatment option. A variety of surgical procedures have been developed to treat thoracic OPLL. However, the optimal surgical approach for removal of thoracic OPLL remains unclear. In the present study, we described a newly modified posterior approach for the removal of OPLL: circular decompression via dural approach, and complete removal of OPLL can be achieved under direct vision and without neurological deficit., Materials and Methods: Three patients with beak-type thoracic OPLL presented with progressive thoracic myelopathy and leg weakness. Magnetic resonance imaging showed the spinal cord severely compressed. The surgical management of the three patients involved the 'cave-in' circular decompression and transdural resection of OPLL., Results: Transdural circumferential decompression was successfully performed in all three patients. Clinical outcome measures, including pre- and postoperative radiographic parameters, were assessed. All of the patients were followed up for an average of 12 months (ranging from 10 to 15 months), and no surgery-related complications occurred. Weakness relief and neural function recovery were satisfactorily achieved in all patients by the final follow-up., Conclusions: Transdural circumferential decompression was an effective method for thoracic spinal stenosis caused by concurrent beak-type OPLL, by which OPLL could be safely removed. It is especially useful when there is a severe adhesion between the dura OPLL.

Objective: To investigate the clinical significance and screen the risk factors of redundant nerve roots(RNRs) in patients with lumbar spinal stenosis., Methods: The clinical data of 196 patients with lumbar spinal stenosis in the department of Spinal Surgery, Yijishan Hospital, Wannan Medical College from April 1, 2015 to November 30, 2020 were retrospectively analyzed. All patients were divided into RNRs positive group and RNRs negative group according to the presence of RNRs. The differences in general clinical data, imaging parameters, visual analogue scale(VAS), Oswestry disability index(ODI), and other indicators between the two groups were compared. The risk factors which are highly correlated with RNRs were screened by binary Logistic regression analysis., Results: There were 59 cases in the RNRs positive group, with an occurrence rate of 29.95% (59/137), and 137 cases in the RNRs negative group. The incidence rate of RNRs in 196 patients with lumbar spinal stenosis was 30.10% (59/196). VAS and ODI scores of patients in the two groups were statistically significant ( P <0.05), and clinical symptoms of patients in the RNRs positive group were more severe than those in the RNRs negative group. There were significant differences in age, number of stenosis segments, average area of lumbar dural sac, area of the narrowest segment and the narrowest segment( P <0.05). Binary logistic regression analysis showed that the number of stenosis segments, the average median sagittal diameter of spinal canal, and the average area of dural sac in lumbar intervertebral space were correlated with the generation of RNRs ( P <0.05). The regression coefficient of the number of stenosis segments was -1.115, the regression coefficient of the median sagittal diameter of the spinal canal was -1.707, and the regression coefficient of the mean dural sac area of the lumbar intervertebral space was 7.556., Conclusion: The clinical symptoms of patients with lumbar spinal stenosis accompanied by RNRs are more severe than those without them. The number of narrow segments, median sagittal diameter of the spinal canal, and the area of the lumbar intervertebral dural sac are the high-risk factors for RNRs, with the area of the lumbar intervertebral dural sac has the highest correlation.

Study Design: Finite Element Study., Objective: To determine the risk of spinal cord injury with pre-existing cervical stenosis during a whiplash injury., Summary of Background Data: Patients with cervical spinal stenosis are often cautioned on the potential increased risk of spinal cord injury (SCI) from minor trauma such as rear impact whiplash injuries. However, there is no consensus on the degree of canal stenosis or the rate of impact that predisposes cervical SCI from minor trauma., Methods: A previously validated three-dimensional finite element model of the human head-neck complex with the spinal cord and activated cervical musculature was used. Rear impact acceleration was applied at 1.8 m/s and 2.6 m/s. Progressive spinal stenosis was simulated at the C5 to C6 segment, from 14 mm to 6 mm, at 2 mm intervals of ventral disk protrusion. Spinal cord von Mises stress and maximum principal strain were extracted and normalized with respect to the 14 mm spine at each cervical spine level from C2 to C7., Results: The mean segmental range of motion was 7.3 degrees at 1.8 m/s and 9.3 degrees at 2.6 m/s. Spinal cord stress above the threshold for SCI was noted at C5 to C6 for 6 mm stenosis at 1.8 m/s and 2.6 m/s. The segment (C6-C7) inferior to the level of maximum stenosis also showed increasing stress and strain with a higher rate of impact. For 8 mm stenosis, spinal cord stress exceeded SCI thresholds only at 2.6 m/s. Spinal cord strain above SCI thresholds were only noted in the 6 mm stenosis model at 2.6 m/s., Conclusion: Increased spinal stenosis and rate of impact are associated with greater magnitude and spatial distribution of spinal cord stress and strain during a whiplash injury. Spinal canal stenosis of 6 mm was associated with consistent elevation of spinal cord stress and strain above SCI thresholds at 2.6 m/s., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To share long-term clinical outcomes and our experience with full-endoscopic interlaminar decompression (FEI) for lateral recess stenosis (LRS)., Methods: We included all patients who underwent FEI for LRS from 2009 to 2013. VAS for leg pain, ODI, neurological findings, radiographic findings, and complications were analyzed at one week, one month, three months, and one year postoperation. The telephone interview for local patients with simple questions was done approximately ten years after the operation. International patients receive an email with the same questionnaire as local patients during the same follow-up period., Results: One hundred and twenty-nine patients underwent FEI for LRS with complete data during 2009-2013. Most of the patients (70.54%) had LRS radiculopathy for less than one year, mainly L4-5 (89.92%), followed by L5-S1 (17.83%). Early outcomes three months after surgery showed that most patients (93.02%) reported significant pain relief, and 70.54% reported no pain at their ODI scores were significantly reduced from 34.35 to 20.32% (p = 0.0052). In contrast, the mean VAS for leg pain decreased substantially by 3.77 points (p < 0.0001). There were no severe complications. At ten years of follow-up, 62 patients responded to the phone call or email. 69.35% of the patients reported having little or no back or leg pain, did not receive any further lumbar surgery, and were still satisfied with the result of the surgery. There were six patients (8.06%) who underwent reoperation., Conclusion: FEI for LRS was satisfactory at 93.02%, with a low complication rate during the early follow-up period. Its effect seems to decline slightly in the long term at a 10-year follow-up. 8.06% of the patients subsequently underwent reoperation., (© 2023. The Author(s).)

Background: Lumbar spinal stenosis (LSS) is the most common reason for spine surgery in older people. However, surgery rates vary widely both internationally and nationally. This study compared patient and sociodemographic characteristics, geographical location and comorbidity between surgically and non-surgically treated Danish patients diagnosed with LSS from 2002 to 2018 and described variations over time., Methods: Diagnostic ICD-10 codes identifying patients with LSS and surgical procedure codes for decompression with or without fusion were retrieved from the Danish National Patient Register. Patients ≥ 18 years who had been admitted to private or public hospitals in Denmark between 2002 and 2018 were included. Data on age, sex, income, retirement status, geographical region and comorbidity were extracted. A multivariable logistic regression model was used to calculate the relative risk for surgically versus non-surgically treated LSS patients using the total population and subsequently divided into three time periods. Variations over time were displayed graphically., Results: A total of 83,783 unique patients with an LSS diagnosis were identified, and of these, 38,362 (46%) underwent decompression surgery. Compared to those who did not receive surgery, the surgically treated patients were more likely to be aged 65-74 years, were less likely to have comorbidities, had higher income and were more likely to reside in the northern part of Denmark. Patients aged 65-74 years remained more likely to receive surgery over time, although the difference between age groups eventually diminished, as older patients (aged ≥ 75) were increasingly more likely to undergo surgery. Large variations and differences in the relative risk of surgery were observed within and between the geographical regions. The likelihood of receiving surgery varied up to threefold between regions., Conclusion: Danish patients with LSS who receive surgery differ in a number of respects from those not receiving surgery. Patients aged 65 to 74 years were more likely to receive surgery than other age groups, and LSS surgical patients were healthier, more often retired and had higher incomes than those not undergoing surgery. There were considerable variations in the relative risk of surgery between and within geographical regions., (© 2023. The Author(s).)

Background Context: Proper patient selection is crucial for the outcome of surgically treated degenerative lumbar spinal stenosis (DLSS). Nevertheless, there is still not a clear consensus regarding the optimal treatment option for patients with DLSS., Purpose: To investigate the treatment failure rate and introduce a simple, preoperative score to aid surgical decision-making., Study Design/setting: Retrospective observational study., Patient Sample: Four hundred forty-five patients who underwent surgical decompression for DLSS., Outcome Measures: Treatment failure (defined as conversion to a fusion of a previously decompressed level) of lumbar decompression., Materials and Methods: Several risk factors associated with worse outcomes and treatment failures, such as age, body mass index, smoking status, previous surgery, low back pain (LBP), facet joint effusion, disk degeneration, fatty infiltration of the paraspinal muscles, the presence of degenerative spondylolisthesis and the facet angulation, were investigated., Results: At a mean follow-up of 44±31 months, 6.5% (29/445) of the patients underwent revision surgery with spinal fusion at an average of 3±9 months following the lumbar decompression due to low back or leg pain. The baseline LBP (≥7) [odds ratio (OR)=5.4, P <0.001], the presence of facet joint effusion (>2 mm) in magnetic resonance imaging (OR=4.2, P <0.001), and disk degeneration (Pfirrmann >4) (OR=3.2, P =0.03) were associated with an increased risk for treatment failure following decompression for DLSS. The receiver operating characteristic curve analysis demonstrated that a score≥6 points yielded a sensitivity of 90% and specificity of 64% for predicting a treatment failure following lumbar decompression for DLSS in the present cohort., Conclusions: The newly introduced score quantifying amounts of LBP, facet effusions, and disk degeneration, could predict treatment failure and the need for revision surgery for DLSS patients undergoing lumbar decompression without fusion. Patients with scores >6 have a high chance of needing fusion following decompression surgery., Level of Evidence: Retrospective observational study, Level III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To assess and compare 5-year outcomes following uninstrumented spinal decompression and decompression with interlaminar device (ILD). To determine whether improvement in clinical outcomes correlated with changes in the radiological indices studied. This is because comparative literature between the above two procedures is limited past the 2-year timeframe., Methods: We conducted a retrospective review of prospectively collected data from a single surgeon across 116-patients who underwent spinal decompression with or without ILD insertion between 2007 and 2015. Patients with symptomatic LSS who met the study criteria were offered spinal decompression with ILD insertion. Patients who accepted ILD were placed in the D + ILD group (n = 61); while those opting for decompression alone were placed in the DA group (n = 55). Clinical outcomes were assessed preoperatively and up to 5-years postoperatively using the ODI, Eq. 5d, VAS back and leg pain, and SF-36. Radiological indices were assessed preoperatively and up to 5-years postoperatively., Results: Both groups showed statistically significant (p < 0.001) improvement in all clinical outcome indicators at all timepoints as compared to their preoperative status. The D + ILD group achieved significant improvement in radiological parameters namely foraminal height and posterior disc height in the immediate postoperative period that was maintained while the DA group did not., Conclusion: Our study found that in the management of LSS, clinical outcomes between those patients undergoing decompression alone compared to decompression with ILD showed statistically significant improvement in VAS back pain and radiological parameters namely foraminal height and posterior disc height at the 5-year mark. ILD does not predispose to increased reoperation rates., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: To explore the characteristics and clinical management of thoracic spinal stenosis with diffuse idiopathic skeletal hyperostosis (DISH)., Methods: The patients diagnosed with thoracic spondylotic myelopathy who underwent spinal decompression and fusion surgery in a single center between 2012 and 2020 were retrospectively analyzed. All the patients were followed up for at least 2 years. Patients were classified into DISH and non-DISH groups. Demographic, radiographic and clinical parameters were compared between the two groups., Results: A total of 100 thoracic spondylotic myelopathy patients were included in the study. 22 patients were diagnosed with DISH. The proportion of male patients in the DISH group was higher, and the average BMI was larger. The incidence of upper thoracic vertebrae with ossification of posterior longitudinal ligament (OPLL) (P < 0.05) and lumbar spine with ossification of ligamentum flavum (OLF) was higher (P < 0.05) in DISH the group. The proportion of patients received staged surgery is higher in the DISH group (P < 0.1). There were no significant differences between the two groups in the amount of surgical bleeding, the ratio of cerebrospinal fluid leakage, the time duration of drainage tube placement and the JOA scores., Conclusion: Thoracic spinal stenosis with DISH occurred more in male patients with larger BMI. The posterior decompression and fusion surgery could achieve comparable satisfying clinical outcomes between DISH and non-DISH patients. More proportion of patients received staged surgery in the DISH group; the underline mechanism may be DISH caused more OPLL in the upper thoracic spine and more OLF in the lumbar spine because of mechanical stress., (© 2023. The Author(s).)

Study Design: Prospective randomized Food and Drug Administration investigational device exemption clinical trial., Objective: The purpose of the present study is to report the 1-year clinical and radiographic outcomes and safety profile of patients who underwent lumbar facet arthroplasty through implantation of the Total Posterior Spine System (TOPS) device., Summary of Background Data: Lumbar facet arthroplasty is one proposed method of dynamic stabilization to treat grade-1 spondylolisthesis with stenosis; however, there are currently no Food and Drug Administration-approved devices for facet arthroplasty., Methods: Standard demographic information was collected for each patient. Radiographic parameters and patient-reported outcome measures were assessed preoperatively and at regular postoperative intervals. Complication and reoperation data were also collected for each patient., Results: At the time of this study, 153 patients had undergone implantation of the TOPS device. The mean surgical time was 187.8 minutes and the mean estimated blood loss was 205.7cc. The mean length of hospital stay was 3.0 days. Mean Oswestry Disability Index, Visual Analog Score leg and back, and Zurich Claudication Questionnaire scores improved significantly at all postoperative time points ( P >0.001). There were no clinically significant changes in radiographic parameters, and all operative segments remained mobile at 1-year follow-up. Postoperative complications occurred in 11 patients out of the 153 patients (7.2%) who underwent implantation of the TOPS device. Nine patients (5.9%) underwent a total of 13 reoperations, 1 (0.6%) of which was for device-related failure owing to bilateral L5 pedicle screw loosening., Conclusions: Lumbar facet arthroplasty with the TOPS device demonstrated a statistically significant improvement in all patient-reported outcome measures and the ability to maintain motion at the index level while limiting sagittal translation with a low complication rate., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Cervical myelopathy is a condition that is rarely reported in pediatric patients who have movement or neuromuscular disorders. We, herein, present a rare case of cervical myelopathy observed in a 14-year-old patient, who was previously a healthy boy treated with cervical laminoplasty, which was caused by cervical spinal canal stenosis based on multiple level disc herniation. The patient presented to the clinic with spastic and ataxic gait with previous diagnostic challenges. Magnetic resonance imaging showed cervical degenerative changes mainly marked at the C3-C4 and C4-C5 levels, along with canal narrowing and a central high signal cord abnormality on T2-weighted images. A C3-C4 open-door laminoplasty surgery technique was performed. The neurological symptoms and signs improved dramatically following surgery. Subsequently, cervical computed tomography and magnetic resonance imaging showed good decompression of the cervical spinal cord during the 5 years of follow-up with the preservation of the range of movement. We concluded that though it is pretty rare, cervical myelopathy should be considered in diagnosing adolescent patients with gait and balance disorders.

Objectives: The aim of our study was to investigate facet tropism and its impact on the development of lumbar spinal canal stenosis (LSCS) in patients with LSCS. MATERIALS AND METHODS Bilateral facet joint angles at the L3-4, L4-5, and L5-S1 levels were measured on axial plane in the lumbar magnetic resonance imaging (MRI) scans of 82 patients aged between 32 and 75 with LSCS, and 82 healthy individuals aged between 30 and 66 without LSCS, who were considered as the normal group. RESULTS Both groups in our study consisted of both males and females. The mean age was 51.4 for patients with LSCS and 44.7 for the healthy group, with no signifi cant difference (p>0.05). A total of 984 facet joint angles were measured, with 164 patients at three intervertebral disc levels each. The presence of facet tropism was found to be a signifi cant risk factor in the LSCS group compared to the healthy group, with an increased risk of 2.125 times at L3-4, 3.389 times at L4-5, and 2.496 times at L5-S1 (p<0.05). CONCLUSIONS In our study, we determined that facet joint tropism is statistically signifi cant in patients with LSCS compared to the control group (p<0.05). We believe that facet tropism plays a predisposing role as a contributing factor in the etiology of LSCS., Key Words: lumbar spinal stenosis, facet tropism, magnetic resonance ımaging.

The authors report retroperitoneal echinococcosis with destruction of the bodies and left transverse processes of L4-5 vertebrae, recurrence and pathological fracture of L4-5 vertebrae with secondary spinal stenosis and left-sided monoparesis. Retroperitoneal echinococcectomy, pericystectomy, decompressive laminectomy L5 and foraminotomy L5-S1 on the left were performed. Therapy with albendazole was prescribed in postoperative period.

Objectives: To identify age-related radiographic risk factors for degenerative lumbar spinal stenosis (DLSS) and analyze correlations among them., Methods: A total of 180 cases were enrolled in this study, and lumbar magnetic resonance was performed. Among them, 93 cases suffered DLSS and lumbar dynamic X-ray was examined. And following parameters were measured and evaluated: intervertebral disk height (IDH), the ratio of IDH(IDH L4-5/L3-4 ), initial IDH of L4-5(iIDH L4-5 ) in the DLSS group, disk degeneration (DD), cartilaginous endplate failure (CEF), Modic changes, the thickness of ligamentum flavum (LF), range of intervertebral motion (ROM), facet joint opening (FJO), facet joint angle (FJA), the standard cross-sectional area (SCSA) of the multifidus, erector spinae, and psoas major muscles. The data of two groups were compared, and the possible risk factors of DLSS were analyzed., Results: Compared with the control group, the DLSS group had higher IDH except for L4-5 and larger iIDH L4-5 (P < 0.05). Significant differences were shown in CEF and the thickness of LF at L1-S1 and DD at L4-5 (P < 0.05). The DLSS group had smaller SCSA of multifidus, erector spinae, and psoas major muscles but greater FJA, FJO (P < 0.05). And the risk of DLSS increased when iIDH L4-5  ≥ 10.73 mm, FJA ≥ 52.03° , or FJO ≥ 3.75 mm. IDH positively correlated with SCSA of multifidus and psoas major muscles and ROM at L1-S1 (P < 0.05). DD showed negative linear relations with SCSA of multifidus and psoas muscle and positive linear relation with CEF at L1-2, L2-3, and L5-S1 (P < 0.05)., Conclusion: Larger initial disk height and excessive CEF may induce DLSS by increasing intervertebral mobility to promote DD, and atrophied paravertebral muscles by weakening the stability of lumbar spine., (© 2022. The Author(s).)

Introduction: The long-term risk of conversion to lumbar fusion is ill-defined for patients with cauda equina syndrome (CES) treated with decompression. This study aimed to identify the rates of fusion in patients with CES and compare those rates with a matched lumbar spinal stenosis (LSS) group., Methods: Patients with CES who underwent decompression were identified in a national database and matched to control patients with LSS. The rates of conversion to fusion were identified and compared. Multivariate logistic regression analysis identified independently associated risk factors. A subanalysis was conducted after stratifying by timing between CES diagnosis and decompression., Results: The rate of lumbar fusion in the CES cohort was 3.6% after 1 year, 6.7% after 3 years, and 7.8% after 5 years, significantly higher than the LSS control group at all time points (1 year: 1.6%, P = 0.001; 3 years: 3.0%, P &lt; 0.001; 5 years: 3.8%, P &lt; 0.001). CES was independently associated with increased risk of conversion to fusion (odds ratio: 2.13; 95% confidence interval: 1.56 to 2.97; P &lt; 0.001). Surgical timing was not associated with risk of conversion to fusion., Conclusions: After 5 years, 7.8% of patients with CES underwent fusion, a markedly higher rate compared with patients with LSS. Counseling patients with CES on this increased risk of future surgery is important for patient education and satisfaction., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background Context: Tandem spinal stenosis (TSS) refers to a narrowing of the spinal canal in distinct, noncontiguous regions. TSS most commonly occurs in the cervical and lumbar regions. Decompressive surgery is indicated for those with cervical myelopathy or persistent symptoms from lumbar stenosis despite conservative management. Surgical management typically involves staged procedures, with cervical decompression taking precedence in most cases, followed by lumbar decompression at a later time. However, several studies have shown favorable outcomes in simultaneous decompression., Purpose: The aim of this study is to provide a literature review and compare surgical outcomes in patients undergoing staged vs simultaneous surgery for TSS., Study Design/setting: Systematic literature review., Methods: A systematic review using PRISMA guidelines to identify original research articles for tandem spinal stenosis. PubMed, Cochrane, Ovid, Scopus, and Web of Science were used for electronic literature search. Original articles from 2005 to 2021 with more than eight adult patients treated surgically for cervical and lumbar TSS in staged or simultaneous procedures were included. Articles including pediatric patients, primarily thoracic stenosis, stenosis secondary to neoplasm or infectious disease, minimally invasive surgery, and non-English language were excluded. Demographic, perioperative, complications, functional outcome, and neurologic outcome data including mJOA (modified Japanese Orthopaedic Association), Nurick grade (NG), and ODI (Oswestry disability index), were extracted and summarized., Results: A total of 667 articles were initially identified. After preliminary screening, 21 articles underwent full-text screening. Ten articles met our inclusion criteria. A total of 831 patients were included, 571 (68%) of them underwent staged procedures, and 260 (32%) underwent simultaneous procedures for TSS. Mean follow-ups ranged from 12 to 85 months. There was no difference in estimated blood loss (EBL) between staged and simultaneous groups (p=.639). Simultaneous surgeries had shorter surgical time than staged surgeries (p<.001). Mean changes in mJOA, NG, and ODI was comparable between staged and simultaneous groups. Complications were similar between the groups. There were more major complications reported in simultaneous operations, although this was not statistically significant (p=.301)., Conclusion: Staged and simultaneous surgery for TSS have comparable perioperative, functional, and neurologic outcomes, as well as complication rates. Careful selection of candidates for simultaneous surgery may reduce the length of stay and consolidate rehabilitation, thereby reducing hospital-associated costs., Competing Interests: Declaration of competing interest This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. We have no conflicts of interest or conflict of interest-associated biases to report., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: 1) To investigate if implant-related factors such as cage size and cage position are associated with radiologic improvement after indirect decompression with oblique lateral interbody fusion (OLIF). 2) To investigate the risk factors associated with indirect decompression failure (IDF) at the surgical levels after OLIF., Methods: From February 2015 to December 2019, 92 consecutive patients (188 levels) with lumbar spinal stenosis who underwent indirect decompression via OLIF with or without posterior instrumentation were studied retrospectively. Radiographic variables were measured preoperatively and postoperatively. The radiographic results were compared for cages with different heights and positions. IDF was defined as revision surgery within 6 months or persistent compressive symptoms 6 months after surgery., Results: Postoperative improvements were observed in all measured radiographic parameters except for segmental lordosis. Taller cages were associated with more shrinkage of the bulging disc and greater increase in dural sac diameter. Cages placed posteriorly showed larger postoperative subarticular diameters. Twelve patients (16 levels) had IDF. Multivariate logistic regression showed that after adjusting for age, sex, and body mass index, smaller preoperative dural sac cross-sectional area and anterior positioning of cages were both independent risk factors for IDF., Conclusions: OLIF is an effective procedure for indirect decompression. To avoid reoperation for lumbar spinal stenosis, surgeons should aim to place the center of the cage at the posterior half of the lower endplate. Surgical levels with a preoperative dural sac cross-sectional area <44 mm 2 may not be suitable for indirect decompression., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: We developed a novel multi-torsional mechanical stretch stress loading device for ligamentum flavum cells and evaluated its influence on the development of ligamentum flavum hypertrophy, a common cause of lumbar spinal canal stenosis., Materials and Methods: Stretch strength of the device was optimized by applying 5% and 15% MSS loads for 24, 48, and 72 h. A cytotoxicity assay of human ligamentum flavum cells was performed and the results were compared to control (0% stress). Inflammatory markers (interleukin [IL]-6, IL-8), vascular endothelial growth factor [VEGF], and extracellular matrix (ECM)-regulating cytokines (matrix metalloproteinase [MMP]-1, MMP-3 and MMP-9, and tissue inhibitor of metalloproteinase [TIMP]-1 and TIMP-2) were quantified via enzyme-linked immunosorbent assay., Results: Using our multi-torsional mechanical stretch stress loading device, 5% stress for 24 hour was optimal for ligamentum flavum cells. Under this condition, the IL-6 and IL-8 levels, VEGF level, and MMP-1, MMP-3, and TIMP-2 were significantly increased, compared to the control., Conclusion: Using the novel multi-torsional mechanical stretch stress loading device we confirmed that, mechanical stress enhances the production of inflammatory cytokines and angiogenic factors, and altered the expression of ECM-regulating enzymes, possibly triggering ligamentum flavum hypertrophy., Competing Interests: The authors have declared that no competing interests exist.

Introduction: The demographic change results in an ever increasing number of older patients with pre-existing medical conditions who require spinal surgery, and recovery is often severely impaired by procedure-related complications. The purpose of this retrospective study was to determine patients at risk of medical and surgical complications., Method: Using our database, we reviewed 1244 patients with lumbar degenerative disk disease, spinal stenosis, and instability, who had undergone surgery at our department between 2009 and 2014. We screened for medical complications (thromboembolic and cardiac events, pneumonia, and sepsis) and surgical complications (hemorrhage, wound infection, and CSF fistula). Furthermore, a matched 1:1 control group consisted of 103 patients without any surgical and medical complications in the randomly selected period of May 2009 to October 2014., Results: 93 patients (46 women, 47 men), mean age 70 years (range 33-86 years, median 67.4 years), with complications were identified (overall morbidity 7.6 %): 22.6 % (n = 26) had medical complications and 77.4 % (n = 89) surgical complications. In 93 patients (46 females, 47 males), mean age 70 years (range 33-86 years, median 67.4 years), a total of 115 complications were noted (overall morbidity of the 93 patients 7.6 %): 22.6 % (n = 26) medical complications and 77.4 % (n = 89) surgical complications. Age and pre-existing conditions were independently associated with medical complications (p &lt; 0.001). Infections (pneumonia and sepsis) were correlated with multi-segmental interventions (p = 0.009), duration of surgery (p = 0.009), and pre-existing conditions (p = 0.014). Surgical complications were significantly correlated with age (p = 0.016) and duration of surgery (p = 0.014) and occurred significantly more often in patients with instability (p &lt; 0.001). Wound healing disorders were associated with coagulopathy (p = 0.013) and transfusion (p &lt; 0.001)., Conclusions: We identified predictors that help identify patients at risk of medical and surgical complications. These correlations should be taken into account when advising older patients with pre-existing conditions on lumbar spine surgery., Competing Interests: Conflict of interest No conflict of interest., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Standard procedure in patients with lumbar spinal canal stenosis is decompression to relieve the neural structures. Clinical results generally show superiority compared to nonoperative therapy after an observation period of several years. However, there is still a question of postsurgical segmental stability and correlation to clinical findings. Therefore, the aim of this prospective study was to evaluate the clinical outcome in patients who underwent microsurgical decompression in lumbar spine and particularly to analyze intervertebral movement by use of upright, kinetic-positional magnetic resonance imaging (MRI) over a period of 12 months and then to correlate the clinical and imaging data with each other., Methods: Complete clinical data of 24 consecutive participants with microsurgical decompression of the lumbar spine were obtained by questionnaires including visual analogue scale (VAS) for back and leg, Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RMDQ), Short-Form-36 (SF-36), walking distance and use of analgesics with assessment preoperatively and after 6 weeks and 12 months. At the same points of time all patients underwent upright, kinetic-positional MRI to measure intersegmental motion of the operated levels with determination of intervertebral angles and translation and to correlate the clinical and imaging data with each other., Results: VAS for leg, ODI, RMDQ and physical component scale of SF-36 improved statistically significantly without statistically significant differences regarding intersegmental motion and horizontal displacement 6 weeks and 12 months after operation. Regression analysis did not find any linear dependencies between the clinical scores and imaging parameters., Conclusions: In awareness of some limitations of the study, our results demonstrate no increase of intersegmental movement or even instability after microsurgical decompression of the lumbar spine over a follow-up period of 12 months, which is equivalent to preservation of intervertebral stability. Furthermore, the magnitude of intervertebral range of motion showed no correlation to the clinical score parameters at all three examination points of time., (© 2022. The Author(s).)

Objectives: To compare the short-term outcomes of unilateral biportal endoscopic lumbar interbody fusion (BLIF) and uniportal endoscopic lumbar interbody fusion (ULIF)., Methods: Sixty patients diagnosed with L4/5 spinal stenosis who underwent BLIF and ULIF were included (30 in each group). Clinical evaluation was performed preoperatively and postoperatively in the 1st week, 1st month, and 1st year. Factors such as the visual analogue score (VAS), Oswestry Disability Index (ODI), operative time, surgical complications, and radiological outcomes (fusion rate, screw loosening, and cage subsidence) were compared between the two groups., Results: All patients showed improved mean VAS and ODI at all three postoperative follow-ups, and no statistically significant differences were detected between the BLIF and ULIF groups. The mean operative time in the BLIF group was shorter than that in the ULIF group. Nerve root injury occurred in two patients in the BLIF group, while leakage of cerebrospinal fluid occurred in one patient in the ULIF group. All adverse events were treated adequately prior to discharge. The fusion rates with definite and probable grades were significantly higher in the BLIF group than that in the ULIF group. One case of cage subsidence with no screw loosening occurred in each group., Conclusion: Both BLIF and ULIF are safe and effective surgical techniques. Compared with ULIF, BLIF has the advantages of shorter operative time and a higher fusion rate. Other merits of BLIF include a wider surgical field, greater maneuverability of instruments, visibility during cage implantation, and transverse orientation of the cage., (© 2022. The Author(s).)

Previous studies have reported evidence that thoracolumbar articular process hyperplasia and degenerative joint disease may be a cause of stenotic myelopathy in large breed dogs; however, detailed descriptions of imaging characteristics are currently lacking. The aim of this retrospective, multi-center, case series report was to describe imaging findings in six large breed dogs diagnosed with thoracolumbar articular process hyperplasia and degenerative joint disease causing vertebral canal stenosis. All dogs presented with progressive paraparesis, proprioceptive ataxia of the pelvic limbs, and neuroanatomical localization of T3-L3 myelopathy. All dogs underwent magnetic resonance imaging (MRI) of the thoracolumbar spine and had articular process malformations at T13-L1 (three German Shepherd dogs (GSD) and a Boxer dog) or T12-T13 (two mixed-breed dogs). Five cases were managed surgically. Findings provided more detailed imaging descriptions and supported previously published studies indicating that maldevelopment of articular processes and secondary degenerative changes can be a cause of thoracolumbar spinal stenosis and myelopathy in large breed dogs. While uncommon, this condition should be included as a differential diagnosis for large breed dogs presenting with a T3-L3 myelopathy., (© 2022 American College of Veterinary Radiology.)

Introduction: Accounting for an estimated 1.10-1.76% of all lumbar herniations, lumbar intradural disc herniation (IDH) occurs primarily in males during the fourth to fifth decades of life. While not validated, congenital lumbar spinal stenosis (CLSS) is implicated as one precipitating factor for IDH., Case Report: We report 28-year-old Hispanic female with CLSS, severe obesity, and degenerative disk disease, with a history of minimally invasive surgical (MIS) decompression for a large paracentral L4-5 disc herniation at 25. After three years, the patient developed sudden burning dysesthesias in the L4-5 dermatomes bilaterally and temporary leg weakness. Lumbar magnetic resonance imaging exhibited severe L4-5 spinal stenosis, and the patient underwent repeat MIS decompression, which again provided her with adequate symptom resolution. However, 20 days postoperatively she developed cauda equina syndrome with anal dysfunction, and bilateral leg and foot weakness. Upon open surgical exploration we discovered a tense L4-5 dural protrusion. After a dorsal durotomy, a large IDH with a ventral dural tear was identified. Subsequent to adequate debulking of the IDH, the ventral tear was repaired, and an expansile duraplasty was performed. Overall, the patient's bladder and bowel function, pain, hypoesthesia, and motor strength all improved. Two weeks after surgery she presented with a lumbar pseudomeningocele that was managed conservatively., Conclusion: This report not only highlights an atypical presentation of IDH and is the first case of CLSS linked with IDH, lending support to the hypothesis that CLSS can lead to IDH, but also provides a comprehensive review of IDHs., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Context: Patients with X-linked hypophosphatemia (XLH) experience multiple musculoskeletal manifestations throughout adulthood., Objective: To describe the burden of musculoskeletal features and associated surgeries across the lifespan of adults with XLH., Methods: Three groups of adults were analyzed: subjects of a clinical trial, participants in an online survey, and a subgroup of the online survey participants considered comparable to the clinical trial subjects (according to Brief Pain Inventory worst pain scores of ≥ 4). In each group, the adults were categorized by age: 18-29, 30-39, 40-49, 50-59, and ≥ 60 years. Rates of 5 prespecified musculoskeletal features and associated surgeries were investigated across these age bands for the 3 groups., Results: Data from 336 adults were analyzed. In all 3 groups, 43% to 47% had a history of fracture, with the proportions increasing with age. The overall prevalence of osteoarthritis was > 50% in all 3 groups, with a rate of 23% to 37% in the 18- to 29-year-old group, and increasing with age. Similar patterns were observed for osteophytes and enthesopathy. Hip and knee arthroplasty was reported even in adults in their 30s. Spinal stenosis was present at a low prevalence, increasing with age. The proportion of adults with ≥ 2 musculoskeletal features was 59.1%, 55.0%, and 61.3% in the clinical trial group, survey group, and survey pain subgroup, respectively., Conclusion: This analysis confirmed high rates of multiple musculoskeletal features beginning as early as age 20 years among adults with XLH and gradually accumulating with age., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society.)

Aim: To define a novel autologous bone graft insertion technique, and to evaluate its effects on bone fusion in patients with lumbar stenosis who underwent laminoplasty., Material and Methods: Fifty-six patients and 142 vertebrae that underwent autologous bone graft insertion technique between 2009 and 2018 were analysed retrospectively. Demographic data, comorbidities, and perioperative findings of patients were recorded. The midline anteroposterior (AP) diameter was measured at the bone graft insertion levels, and fusion formation was evaluated with computed tomography (CT) and dynamic X-Ray images. Pain scores were assessed preoperatively with the visual analogue scale (VAS) for both legs and Oswestry Disability Index (ODI) for overall life quality. Scores were re-evaluated on 1 < sup > st < /sup > day, at 3 < sup > rd < /sup > , and 12 < sup > th < /sup > months, postoperatively., Results: Degenerative spinal stenosis was present in 56 patients who underwent autologous bone graft insertion technique. It was found that the diameter of the spinal canal increased by 37% in CT measurements. In postoperative radiological followups, fusion developed in 49 (87.5%) patients. There was a statistically significant decrease in both VAS and ODI scores in the postoperative period when compared to the preoperative evaluations., Conclusion: Bone graft insertion technique supports posterior fusion and protects against dural injuries during revision surgery by creating a barrier over the dura. The prevention of epidural fibrosis formation reduces the symptoms of the postlaminectomy syndrome. The fact that this technique does not require fixation material. Therefore, it reduces expenditure and eliminates the risk of complications related to synthetic materials.

Rationale: Acute aortic occlusion is an uncommon disease with a high morbidity and high mortality. Clinical symptoms typically include acute lower limb pain, acute paralysis, and absent pulses. We report a very rare case of acute aortic occlusion causing complete paralysis of bilateral lower limbs following microendoscopic laminectomy., Patient Concerns: A 64-year-old man with hypertension, hyperlipidemia, diabetes, and atrial fibrillation underwent microendoscopic laminectomy for lumbar spinal stenosis. After the operation, intermittent claudication improved significantly without neurological deficit. However, 7 days later, he developed complete paralysis of the bilateral lower limbs, extreme pain of the bilateral lower limbs, and mottling of the left extremity., Diagnosis: An emergency magnetic resonance imaging examination revealed no epidural hematoma behind the spinal cord, proscribing spinal cord compression. Computed tomography revealed occlusion of the infrarenal abdominal aorta. Blood tests revealed high values of total plasminogen activator inhibitor-1 before surgery., Interventions: The acute aortic occlusion was verified and underwent thrombectomy and right axillary-bifemoral bypass., Outcomes: Following the revascularization, the neurological deficit of the lower limbs improved. On follow-up after 1 year, the muscle strength of the bilateral lower limbs had returned to normal., Lessons: This case presentation highlights the necessity of early diagnosis and early revascularization. Moreover, a preoperative high value of plasminogen activator inhibitor-1 may indicate vascular complications including Acute Aortic Occlusion., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: This report describes a minimally invasive lumbar foraminotomy technique that can be applied in patients who underwent complex spine decompression procedures or in patients with severe foraminal stenosis., Methods: Awake, endoscopic decompression surgery was performed in 538 patients over a 5-year period between 2014 and 2019. Transforaminal endoscopic foraminal decompression surgery using a high-speed endoscopic drill was performed in 34 patients who had previously undergone fusions at the treated level., Results: At 2-year follow-up, the mean (± SD) preoperative visual analog scale score for leg pain and the Oswestry Disability Index improved from 7.1 (± 1.5) and 40.1% (± 12.1%) to 2.1 (± 1.9) and 13.6% (± 11.1%)., Conclusions: A minimally invasive, awake procedure is presented for the treatment of severe lumbar foraminal stenosis in patients with lumbar radiculopathy after lumbar fusion.

Tantalizing connections between type 2 diabetes and degenerative lumbar spine disorders have become increasingly evident. However, the association of type 2 diabetes with degenerative lumbar spine disorders remains unclear. We sought to clarify the association between type 2 diabetes and lumbar spine disorders using nationwide data in Korea. Furthermore, we explored the association of diabetes with the prevalence of spinal procedures. The data in this study was obtained from Korean health claim database. Between 2016 and 2019, totals of 479,680 diabetes and 479,680 age- and sex-matched control subjects were enrolled. Patients with diabetes had more likely to have degenerative lumbar spine disorders and spinal procedures than controls. Using multivariate-adjusted analysis, patients with diabetes were at increased risk of being concomitantly affected by lumbar disc disorder [adjusted odds ratio 1.11 (95% confidence interval 1.10-1.12)], lumbar spondylotic radiculopathy [1.12 (1.11-1.13)], spondylolisthesis [1.05 (1.02-1.08)] and spinal stenosis [1.16 (1.15-1.18)], compared to controls. Furthermore, diabetic patients had an increased risk of undergoing lumbar spinal injection [1.13 (1.12-1.14)], laminectomy [1.19 (1.15-1.23)], and fusion surgery [1.35 (1.29-1.42)]. We demonstrated that type 2 diabetes was significantly associated with lumbar spine disorders and frequent spinal procedures. Our results suggest diabetes as a predisposing factor for lumbar spine disorders., (© 2021. The Author(s).)

Abstract: Despite the increasing prevalence of spinal surgery in super-elderly (SE) patients, the outcomes and complication rates have not been fully elucidated. The purpose of this study was to compare the outcomes and complications of lumbar spinal fusion for degenerative lumbar spinal stenosis (DLSS) in SE patients aged 80 years and over with those in patients aged 65 years and over, and under 80 years.This study analyzed 160 patients who underwent spinal fusion for DLSS between January 2011 and November 2019. Thirty patients in the SE group (group SE, ≥80 years) and 130 patients in the elderly group (group E, ≥65 years and <80 years) were enrolled. The performance status was evaluated by preoperative American society of anesthesiologists (ASA) score. Visual analog scales for back pain (VAS-BP) and leg pain (VAS-LP), and Korean Oswestry disability index (K-ODI) were used to assess clinical outcomes preoperatively and 1 year postoperatively. Percent changes of VAS-BP, VAS-LP and K-ODI were also analyzed. Fusion rates were evaluated by computed tomography 6 months and 1 year postoperatively. Furthermore, bone mineral density, operative time, estimated blood loss, blood transfusion, hospital days, hospitalization in intensive care unit and postoperative complications were compared.The average age of group SE was 82.0 years and that of group E was 71.6 years. There were no differences in preoperative ASA score, preoperative or postoperative VAS BP and VAS-LP, bone mineral density, operative time, estimated blood loss, blood transfusion, hospital days, hospitalization in intensive care unit and fusion rates between the groups. Preoperative and postoperative K-ODI were higher in group SE than group E (all P < .05). However, percent changes of VAS-BP, VAS-LP and K-ODI showed no significant differences. Overall early and late complications were not significantly different between the groups; however postoperative delirium was more common in group SE than group E (P = .027). SE status was the only risk factor for postoperative delirium with odds ratio of 3.4 (P = .018).Spinal fusion surgery is considerable treatment to improve the quality of life of SE patients with DLSS, however careful perioperative management is needed to prevent postoperative delirium., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Transthyretin (TTR) cardiac amyloidosis is a systemic disease caused by amyloid deposits in several systemic organs. The thickening of the yellow ligament because of amyloid deposits results in spinal canal stenosis. This study reports a case of mutant-type TTR cardiac amyloidosis in a patient with recurrent spinal canal stenosis. To our knowledge, this is the first study to report pathologic amyloid involvement in both spinal and cardiac tissues of a patient with hereditary TTR amyloidosis. It is important to be aware of underlying amyloidosis as a cause of spinal canal stenosis, especially regarding refractory diseases in older adults., (Copyright © 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Ligamentum flavum hypertrophy (LFH) leads to lumbar spinal stenosis (LSS) caused by LF tissue inflammation and fibrosis. Emerging evidence has indicated that dysregulated microRNAs (miRNAs) have an important role in inflammation and fibrosis. Mechanical stress (MS) has been explored as an initiating step in LFH pathology progression; the inflammation-related miRNAs induced after mechanical stress have been implicated in fibrosis pathology. However, the pathophysiological mechanism of MS-miRNAs-LFH remains to be elucidated. Using miRNAs sequencing analysis and subsequent confirmation with qRT-PCR assays, we identified the decreased expression of miR-10396b-3p and increased expression of IL-11 (interleukin-11) as responses to the development of LSS in hypertrophied LF tissues. We also found that IL-11 is positively correlated with fibrosis indicators of collagen I and collagen III. The up-regulation of miR-10396b-3p significantly decreased the level of IL-11 expression, whereas miR-10396b-3p down-regulation increased IL-11 expression in vitro. Luciferase reporter assay indicates that IL-11 is a direct target of miR-10396b-3p. Furthermore, cyclic mechanical stress inhibits miR-10396b-3p and induces IL-11, collagen I, and collagen III in vitro. Our results showed that overexpression of miR-10396b-3p suppresses MS-induced LFH by inhibiting collagen I and III via the inhibition of IL-11. These data suggest that the MS-miR-10396b-3p-IL-11 axis plays a key role in the pathological progression of LFH., (© 2021 Federation of American Societies for Experimental Biology.)

Objective: We aimed to evaluate reliability, radiological outcomes, and the impacts of anterior cervical hybrid construction on the adjacent segments for the multilevel cervical degenerative disc disease (mCDDD) and spondylotic spinal stenosis (SSS)., Methods: A retrospective analysis was performed using data extracted from the medical files of 195 patients (105 males, 90 females; mean age: 47.7 years). From 2008 to 2018, these patients underwent anterior cervical hybrid construction for symptomatic contiguous at least 2-level cervical degenerative disc diseases and cervical spondylosis. Clinical and radiological data including Neck Disability Index (NDI), visual analogue scale (VAS), local cervical degenerative disk disease in adjacent segments on magnetic resonance imaging (MRI) views, and complications were reviewed., Results: The mean clinical and radiological follow-up was 45.2 months (range 24 to 102). Radiculopathy and/or myelopathy were the main clinical problems in all patients. The mean VAS scores of HC for arm pain were 7.4 ± 0.8 preoperatively; 2.8 ± 0.6, 1 month after surgery; 2.3 ± 0.6, 6 months after surgery; 1.8 ± 0.6, 12 month after surgery; and 1.6 ± 0.6, 24 months after surgery. The mean NDI scores (mean ± SD) of HC significantly improved after surgery (on admission, 57.2 ± 5.5%; 1 month after surgery, 27.35 ± 5.3%; 6 month after surgery, 21.43 ± 2.8%; 12 months after surgery, 21.9 ± 2.3%; 24 months after surgery, 20.6 ± 2.6%, p = 0.006). Hoarseness and dysphagia were the most common complications and osteophyte formation was the most frequent radiographic change., Conclusion: Anterior cervical hybrid construction appears to be an acceptable option in the management of multilevel cervical degenerative disc diseases and spondylotic spinal stenosis.

Objective: This study was designed to investigate the relationship between the laminar slope angle (LSA) and the lumbar disc degenerative grade, the cross-section area (CSA) of multifidus muscle, the muscle-fat index, and the thickness of the ligamentum flavum., Methods: Retrospective analysis of 122 patients who were scheduled to undergo a lumbar operation for diagnoses associated with degenerative lumbar disease between January and December 2017. The L4-L5 disc grade was evaluated from preoperative sagittal T2-weighed magnetic resonance imaging of the lumber region; the CSA of the multifidus and muscle-fat index were measured at the L4 level, while the thickness of the ligamentum flavum was measured at the L4-L5 facet level from axis T2-weighed magnetic resonance imaging. The slope of the laminar was evaluated from preoperative three-dimensional computer tomography at the tip level of the facet joints and selected by the axis plane. Independent-sample T-tests were used to assess the association between age and measurement indices., Results: Our results showed that age was positively connected with the LSA of L4 and L5 in different patients, although there was no significant difference between age and the difference of the two segment LSA. Partial correlation analysis, excluding the interference of age, revealed a strong negative relationship between the LSA of L4 and the thickness of the ligamentum flavum, irrespective of whether we considered the left or right. However, there was no correlation with lumbar disc degenerative grade, the CSA of the multifidus, and the muscle-fat index., Conclusion: The thickness of the ligamentum flavum showed changes with anatomical differences in the LSA, but not the lumbar disc degenerative grade, the CSA of the multifidus, and the muscle-fat index. A small change in LSA may cause large mechanical stress; this may be one of the causative factors responsible for lumbar spinal stenosis.

Objective: This study aimed to investigate the possible relationship between Scheuermann disease (SD) and the pathophysiological factors of thoracic spinal stenosis (TSS), including ossification of the ligamentum flavum (OLF), ossification of the posterior longitudinal ligament (OPLL), and thoracic disc herniation (TDH) in patients with symptomatic TSS., Methods: Demographic and radiological data from 66 consecutive patients diagnosed with symptomatic TSS from 2013 to 2018 were retrospectively collected and divided into 3 groups depending on the underlying pathomechanism of TSS: TDH group (18 patients; 6 women; mean age ± standard deviation [Sd] = 59.89 ± 11.34), OPLL group (12 patients; 8 women; mean age ± Sd = 56.08 ± 14.74), and OLF group (36 patients; 20 women; mean age ± Sd = 58.69 ± 9.77). A total of 41 age-matched healthy individuals (19 women; mean age ± Sd = 54.88 ± 13.63) were designated as the control group. In each group, both typical and atypical SD criteria were radiologically examined. The demographic data and presence of SD between the control group and 3 subgroups of TSS pathomechanisms were evaluated., Results: SD characteristics were identified in 83.33% (15/18) of patients in the TDH group, 44.44% (16/36) in the OLF group, 25% (3/12) in the OPLL group, and 17.07% (7/41) of the control individuals. When analyzed by the chi-squared test and logistic regression analysis, the presence of SD was significantly associated with TDH (P < 0.01) and OLF (P < 0.05) but not OPLL (P > 0.05). Patients with TDH and OLF showed peak involvement of T10/11, and patients with OPLL did not. Furthermore, we determined that age, sex, body-mass index, and smoking status were not the risk factors for TDH, OPLL, and OLF (P > 0.05). SD was found to be a risk factor for TDH (P < 0.01) and OLF (P < 0.05) but not for OPLL (P > 0.05)., Conclusion: Evidence from this study indicated that SD might be a risk factor for OLF and TDH but not for OPLL.

Background: Spinal epidural lipomatosis is a rare cause of lumbar spinal stenosis. While conservative therapy is applicable for most of cases, surgical intervention is necessary for severe ones. This is the first time we apply this modified technique to this disease., Case Presentation: The case is a 53-year-old man. He is 175 cm tall and weighs 102 kg (body mass index 33.3 kg/cm 2 ), presenting with low back pain and bilateral legs pain and numbness. Radiological examination showed severe lumbar spinal stenosis resulting from adipose hyperplasia, combined with hyperosteogeny and hypertrophy of ligaments, which are common etiological factors. Posterior decompression, internal fixation and a modified articular fusion technique was performed on this patient, and regular follow-up that up o 22 months showed outstanding clinical outcomes., Conclusions: A suitable style of posterior lumbar fusion should be considered to especially severe case with lumbar spinal stenosis and idiopathic spinal epidural lipomatosis.

Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.