|Year : 2019 | Volume
| Issue : 1 | Page : 18-22
Outcomes of surgical management of severe lumbar spinal canal stenosis
Oluwole O Ige, Opeyemi A Lawal, Temiloluwa O Olufemi, Ishaq B Ojodu, Bright A Igbinoba, SO Alao
Department of Orthopaedics and Trauma, University of Medical Sciences Teaching Hospital, Ondo, Nigeria
|Date of Web Publication||26-Jul-2019|
Dr. Oluwole O Ige
Ondo State Trauma and Surgical Services Hospital, Ondo
Source of Support: None, Conflict of Interest: None
Background: Lumbar Spinal Canal Stenosis (LSCS), requiring surgical intervention is a common presentation in Orthopaedic practice in Nigeria. Although it is well established that surgery is very effective in relieving the symptoms of this condition, there is a paucity of reports of surgical treatment outcomes of LSCS in Nigeria. Objective: The study aims to report the early outcomes of surgical treatment of LSCS in the study centre. Methods: Prospective Observational Pretest and Post-test Study at a single centre, the University of Medical Sciences Teaching Hospital, located in Ondo State in Southwest Nigeria, West Africa. The study was done between January 2015 and June 2017. Preoperative and postoperative data collected from 32 patients with a diagnosis of LSCS who had Decompressive Laminectomy with or without instrumented fusion were analyzed for relief of symptoms: pain, functional wellbeing and general health status using Visual Analogue Scale (VAS) for back and leg pain, Oswestry Disability Index (ODI) and Short Form 36 (SF 36). Results: Excellent to good pain relief was reported by 31 (96.9%) and 30 (93.8%) of the patients for leg and back pain respectively at 6 months, 1 (3.1%) reported a fair outcome for leg pain while 2 (6.2%) reported fair outcome for back pain. No patient had a poor pain relief outcome. Functional outcome and general health status were also excellent/good for 28 (87.5%) and 29 (90.6%) respectively. There was no mortality or major cardiorespiratory event recorded. However, there was a minor complication rate of 68.8% (22 patients). These include dural tears 16 (50%), deep vein thrombosis 1 (3.1%), postoperative neurological weakness 2 (6.2%), wound infection 20 (62%), wound dehiscence 10 (31%), reoperation 6 (18.6%). The outcome at 24 weeks was unaffected by these minor complications. Conclusion: Although associated with early perioperative minor complications, Spine surgery is an effective and safe therapeutic option for the relief of LSCS symptoms with short term good clinical outcomes.
Keywords: Clinical outcome, decompressive laminectomy, lumbar canal stenosis
|How to cite this article:|
Ige OO, Lawal OA, Olufemi TO, Ojodu IB, Igbinoba BA, Alao S O. Outcomes of surgical management of severe lumbar spinal canal stenosis. Niger J Orthop Trauma 2019;18:18-22
|How to cite this URL:|
Ige OO, Lawal OA, Olufemi TO, Ojodu IB, Igbinoba BA, Alao S O. Outcomes of surgical management of severe lumbar spinal canal stenosis. Niger J Orthop Trauma [serial online] 2019 [cited 2019 Aug 18];18:18-22. Available from: http://www.njotonline.org/text.asp?2019/18/1/18/263523
| Introduction|| |
Lumbar spinal canal stenosis (LSCS) is narrowing of the lumbar vertebral canal which may lead to compression of the neural and vascular structures.
Clinical symptoms of LSCS include radicular pain in the buttocks, thigh or leg, provoked by walking or standing, with or without back pain and relieved by sitting or bending forwards.
Surgical treatment of symptoms of this condition is the most common indication for spine surgery in the elderly.,
The presence of features suggesting compression on radiological imaging does not necessarily transform tothe clinical manifestation of symptoms. These features may include ligamentum flavum hypertrophy, hypertrophic facet capsule, narrow canal size, disc degeneration with loss of foramina height, disc protrusion into canal, osteophytic bone spurs narrowing the canal, foramina or lateral recess and spondylolisthesis.
Majority of patients with LSCS have favourable long-term outcomes, with or without treatment and catastrophic neurological deterioration is rare. Most patients will, therefore, benefit from a trial of conservative treatment which includes physical therapy, analgesics, anti-inflammatory drugs, epidural steroid injections and other forms of non-surgical care. However, evidence suggests that surgical treatment has a better outcome than conservative treatment in severe LSCS.,,
Severity of symptoms as reported with incapacitating pain, reducing claudication distance, neurologic deficit and myelopathy rather than spinal canal dimensions should dictate aggressiveness of treatment because correlation between spinal anatomy and symptoms is poor. Options of surgical treatment are numerous. The underlying principle is decompression of the neural structures with or without stabilisation.
Surgical management of severe LSCS is not without challenges, with documented complications such as inadequate decompression, inadequate stabilisation with resultant persistence of symptoms, infection, bleeding, neurological injury, dural tear, deep vein thrombosis, wound dehiscence, reoperation, position-related palsies and pseudoathrosis,, Several patient characteristics are significant risk factors and contributors to morbidity and mortality in spine surgery, and these include obesity, diabetes, hypertension, cardiac disease, renal disease, smoking and advanced age. Their correlation to the outcome of treatment of degenerative lumbar canal stenosis is also well studied.
Patients with severe LSCS commonly present in orthopaedic practice in Nigeria. Spine surgery is expensive and out of reach of most patients. This is further compounded by the fact that patients who require treatment have to pay out of pocket. Those who can afford spine surgery would rather seek treatment outside the country due to lack of confidence in spine care in Nigeria. The number of patients undergoing surgery is, however, increasing steadily. The impact of availability of surgical management of spinal conditions in Nigeria is yet to be analysed globally.
This study intends to determine, document and report the outcome of surgical management of severe degenerative lumbar canal stenosis in a tertiary health institution in Nigeria.
A study of the surgical outcome of patients with the severe form of LSCS, with symptoms of incapacitating pain, reducing claudication distance, neurologic deficit, myelopathy and overall reduction in quality of life, which makes them a burden to self, family and communities, will strengthen the need for surgical decompression of patients presenting with such symptoms, hence the need for this study in our hospital.
| Methodology|| |
The study was carried out at the Ondo State Trauma and Surgical Centre, located within the Medical Village in Ondo town, Ondo State. It is about 24 km from the city of Akure and 116 km from Benin. It is a rapidly evolving surgical-based centre aimed at providing world-class tertiary comprehensive surgical services to the people of Ondo State, surrounding environs and Nigeria in general. It has over 78 consultants and several medical doctors under its employment. It also has a bed space capacity of 120.
A prospective cohort study was conducted. The study population were patients who had undergone spine surgical decompression for features in keeping with lumbar spinal canal stenosis in respect of their outcomes for a period of 24 weeks.
No sample size calculation was done.
A total of 32 patients were studied during the study period from January 2015 to June 2017.
All consenting patients who underwent surgical decompression for LSCS were included in the study.
All patients who did not have surgical decompression for LSCS were excluded from the study.
Approval for the study was obtained from the Ethics and Research Committee of Ondo State Trauma and Surgical Centre, Ondo State.
This was done by structured pre-test and post-test questionnaire incorporating general health and disease-specific questions which included both patient and physician-reported outcome.
The questionnaires were filled by the patient assisted by a physician. This included the baseline pre-operative data, at 6, 12 and 24 weeks, which were assessed for relief of symptoms that included: pain, functional well-being and general health status, using the Visual Analogue Scale (VAS) for leg and back pain, Oswestry Disability Index (ODI) and Short Form-36 (SF 36).
Primary outcome measures
- VAS: Ranges from a score of 0–10, 10 representing worst score
- ODI: Ten questions relating to limitations in performing the following activities: getting dressed, lifting objects from the floor, walking and running, sitting, standing, sleeping, social and recreational activities were asked. Each response has six graded responses that range from unlimiting pain to total incapacitation due to pain. Lower scores indicate better outcome
- SF 36 Health Status Questionnaire: Consists of 36 quantities that are aggregated to form eight domains: physical function, mental health, general health perception, pain, role limitation physical and emotional.
On each scale, a higher score indicates a better outcome.
Statistical analysis was done using the Wilcoxon signed-rank test to determine the difference in average scores of SF-36 and ODI at pre- and post-operation.
Marginal homogeneity test was done for VAS.
| Results|| |
A total of 32 patients were followed up over the 24-week study period.
The baseline characteristics of patients showed a mean age of 64.3 ± 8.4.
Fifteen of the participants were male (46.5%), while the remaining 17 were female (53.1%).
About 68.8% of the study population had formal education; the entire population were married as may be expected.
Hypertension was the most common co-morbidity as observed in 31 patients (96.9%), while 5 (15.6%) patients had diabetes [Table 1].
All the study population had severe leg pain and spinal claudication at presentation, average VAS score for leg was 8.5. Only two patients had severe back pain at presentation.
Functional disability assessment using mean ODI at presentation was 72.
General health status as reported by patients using mean SF-36 was 28.6 ± 4.4.
The mean duration of symptoms before presentation was 17 weeks.
Magnetic resonance imaging (MRI) findings of the patients are outlined in [Table 2]. Stenosis was seen at two levels, 15 (46.9%) of the study population and the involvement of L4/L5 level in 25 (75.1%) were the most common findings.
All patients had non-steroidal anti-inflammatory drugs as a form of conservative treatment before presentation.
Only 5 (15.6%) of the study population has had translaminal epidural steroid injection.
The mean age of respondents was 64.3 ± 8.4. Out of the respondents, 46.9% were female and 68.8% had formal occupation. All the respondents were married as depicted in [Table 1].
All the respondents had at least one form of co-morbidity as shown in [Table 2], with 96.9% having hypertension. The mean duration of symptoms was 17 months, and all the patients had leg pain and claudication pre-operatively, while the majority of the respondents had stenosis at L4/L5 level. Almost half of the respondents (46.9%) had stenosis at two levels on MRI.
[Table 3] showed that 46.9% of the respondents had moderate back pain using VAS, while all the respondents had severe leg pain (100%).
The median ODI score was 72 pre-operatively, which reduced post-operatively to 45, 50 and 20 at 6, 12 and 24 weeks, respectively, as shown in [Table 4].
|Table 4: Outcome of scores for Short Form-36 and Oswestry Disability Index among respondents|
Click here to view
From [Table 5], 62.5% of the respondents had wound infection, 50% had dural tear and 25% had re-operation post-operatively.
There is a statistically significant association between the severity of pain pre-operatively and post-operatively among the patients studied (P < 0.001) as shown in [Table 6].
|Table 6: The association between leg Visual Analogue Scale of pain pre-operatively and post-operatively|
Click here to view
[Figure 1] depicted that all the patients had severe leg pain pre-operatively (100%), 6 weeks post-operatively, only 3.1% reported severe leg pain, while at 12 and 24 weeks post-operative, none of the patients reported severe leg pain.
|Figure 1: Leg Visual Analogue Scale of pain pre-operatively and post-operatively in the respondents|
Click here to view
| Discussion|| |
Patients entertain a lot of reservation about spine surgery in Nigeria, as a result, even when suffering incapacitating symptoms, they are unwilling to undergo surgery. There are no local studies to dispute or validate this fear. The reasons above have prompted the execution of this study.
The condition is seen mainly in the elderly with the mean age of 64.3 as demonstrated in this study, which is similar to a study by Gunzburg and Szpalski in 2003. High rate of co-morbidities, such as hypertension and diabetes mellitus, was seen in 97% of the population. The presence of co-morbidities in this age group is debilitating; therefore, any of such patient with features of severe LSCS should have an effective treatment option of surgical decompression to prevent further decline in their quality of life.
The study showed that there was statistically significant reduction in both leg and back pain pre- and post-operatively using the VAS. All the patients presented with severe leg pain initially, but reduction in leg pain was noted in 59.4% of patients as early as 6 weeks post-operative, with none having severe pain at 24 weeks post-operative.
Quality of life was increased from 28.6 at pre-operation to 93.0 at 24 weeks using the SF-36, and the test result showed statistical significant reduction in ODI score (median) from 78 to 20.
Majority of patients in this study had long-standing symptoms before presentation.
Patients, who suffer long period of severe symptoms without surgical intervention, have been reported to have worse prognosis than patients who present early for surgical intervention as noted by Johnson et al. Their study showed that patients with a pre-operative duration of symptoms of <4 years and patients with no pre-operative back pain tend to have better surgical outcomes. However, considering that most of the patients in this study had long-standing symptoms and most had back pain, most of them had relief of symptoms With only 31% reported cases of fair outcome of leg pain, while 6.2% reported a fair outcome for back pain. The report by Jönsson et al. was not demonstrated in our study.
Functional outcome and general health status were also excellent and good for 28 (87.5%) and 29 (90.6%), respectively.
Our study is not without its limitations, such as low volume of recruitment of the study population and high rate of minor intra- and post-operative complications similar to the study by Ragab et al. Although some other reviews reported low complications, these might not be unconnected with the experience on the part of the operating team. The cases that were operated much later in the series had lesser intraoperative complication.
| Conclusion|| |
We conclude that surgical treatment of LSCS is an effective and safe therapeutic option with good short-term clinical outcome, as shown in this index study.
Presence of predominance of back pain over leg pain and claudication should warrant more proper evaluation before surgical intervention.
Surgery for the relief of symptoms of LSCS is very effective in well-selected patients.
Even though spine surgery is just developing in Nigeria, the result of surgical treatment of LSCS is good in spite of the high incidence of minor complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gunzburg R, Szpalski M. The conservative surgical treatment of lumbar spinal stenosis in the elderly. Eur Spine J 2003;12 Suppl 2:S176-80.
Lee SY, Kim TH, Oh JK, Lee SJ, Park MS. Lumbar stenosis: A recent update by review of literature. Asian Spine J 2015;9:818-28.
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al.
Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol 2015;36:811-6.
Johnson KE, Rosen I, Uden A. The natural course of lumbar spinal stenosis. Clin Orthop Relat Res 1992;(279):82-6.
Covaro A, Vilà-Canet G, de Frutos AG, Ubierna MT, Ciccolo F, Caceres E, et al.
Management of degenerative lumbar spinal stenosis: An evidence-based review. EFORT Open Rev 2016;1:267-74.
Pumberger M, Chiu YL, Ma Y, Girardi FP, Vougioukas V, Memtsoudis SG. Perioperative mortality after lumbar spinal fusion surgery: An analysis of epidemiology and risk factors. Eur Spine J 2012;21:1633-9.
Jönsson B, Annertz M, Sjöberg C, Strömqvist B. A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part II: Five-year follow-up by an independent observer. Spine (Phila Pa 1976) 1997;22:2938-44.
Ragab AA, Fye MA, Bohlman HH. Surgery of the lumbar spine for spinal stenosis in 118 patients 70 years of age or older. Spine (Phila Pa 1976) 2003;28:348-53.
Ciol MA, Deyo RA, Howell E, Kreif S. An assessment of surgery for spinal stenosis: Time trends, geographic variations, complications, and reoperations. J Am Geriatr Soc 1996;44:285-90.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]