The effect of decompressive surgery on lumbar paraspinal and biceps brachii muscle function and movement perception in lumbar spinal stenosis: a 2-year follow-up.

PURPOSE: Chronic low back pain and lumbar spinal stenosis (LSS) seem to deteriorate lumbar muscle function and proprioception but the effect of surgery on them remains unclear. This study evaluates the effect of decompressive surgery on lumbar movement perception and paraspinal and biceps brachii (BB) muscle responses during sudden upper limb loading in LSS. METHODS: Low back and radicular pain intensity (VAS) and Oswestry Disability Index (ODI) were measured together with lumbar proprioception and paraspinal and BB muscle responses prior to and 3 and 24 months after surgery in 30 LSS patients. Lumbar proprioception was assessed by a previously validated motorized trunk rotation unit and muscle responses for sudden upper limb loading by surface EMG. RESULTS: Lumbar perception threshold improved after surgery during 3-month follow-up (from 4.6° to 3.1°, P = 0.015) but tend to deteriorate again during 24 months (4.0°, P = 0.227). Preparatory paraspinal and BB muscle responses prior to sudden load as well as paraspinal muscle activation latencies after the load remained unchanged. CONCLUSION: Impaired lumbar proprioception seems to improve shortly after decompressive surgery but tends to deteriorate again with longer follow-up despite the sustaining favorable clinical outcome. The surgery did not affect either the feed-forward or the feed-back muscle function, which indicates that the abnormal muscle activity in LSS is at least partly irreversible.

Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability.

BACKGROUND: Lumbar spinal stenosis (LSS) is the common term used to describe patients with symptoms related to the anatomical reduction of the lumbar spinal canal size. However, some subjects may have a markedly narrowed canal without any symptoms. This raises the question of what is the actual role of central canal stenosis in symptomatic patients. The purpose of this study was to compare radiological evaluations of LSS, both visually and quantitatively, with the clinical findings of patients with LSS. METHODS: Eighty patients [mean age 63 (11) years, 44% male], with symptoms severe enough to indicate LSS surgery, were included in this prospective single-center study. Lumbar magnetic resonance imaging was performed and one experienced neuroradiologist classified patients into three groups: 0 = normal or mild stenosis, 1 = moderate stenosis, and 2 = severe stenosis. In addition, the same observer measured the minimal dural sac area level by level from the inferior aspect of L1 to the inferior aspect of S1. The association between radiological and clinical findings were tested with Oswestry Disability Index, overall visual analog pain scale, specific low back pain, specific leg pain, Beck Depression Inventory, and walking distance on treadmill exercise test. RESULTS: In the visual classification of the central spinal canal, leg pain was significantly higher and walking distance achieved was shorter among patients with moderate central stenosis than in patients with severe central stenosis (7.33 (2.29) vs 5.80 (2.72); P = 0.008 and 421 (431) m vs 646 (436) m; P = 0.021, respectively). Patients with severe stenosis at only one level also achieved shorter walking distance than patients with severe stenosis of at least two levels. No correlation between visually or quantitatively assessed stenosis and other clinical findings was found. CONCLUSIONS: There is no straightforward association between the stenosis of dural sac and patient symptoms or functional capacity. These findings indicated that dural sac stenosis is not the single key element in the pathophysiology of LSS.

Preoperative MRI findings predict two-year postoperative clinical outcome in lumbar spinal stenosis.

PURPOSE: To study the predictive value of preoperative magnetic resonance imaging (MRI) findings for the two-year postoperative clinical outcome in lumbar spinal stenosis (LSS). METHODS: 84 patients (mean age 63±11 years, male 43%) with symptoms severe enough to indicate LSS surgery were included in this prospective observational single-center study. Preoperative MRI of the lumbar spine was performed with a 1.5-T unit. The imaging protocol conformed to the requirements of the American College of Radiology for the performance of MRI of the adult spine. Visual and quantitative assessment of MRI was performed by one experienced neuroradiologist. At the two-year postoperative follow-up, functional ability was assessed with the Oswestry Disability Index (ODI 0-100%) and treadmill test (0-1000 m), pain symptoms with the overall Visual Analogue Scale (VAS 0-100 mm), and specific low back pain (LBP) and specific leg pain (LP) separately with a numeric rating scale from 0-10 (NRS-11). Satisfaction with the surgical outcome was also assessed. RESULTS: Preoperative severe central stenosis predicted postoperatively lower LP, LBP, and VAS when compared in patients with moderate central stenosis (p<0.05). Moreover, severe stenosis predicted higher postoperative satisfaction (p = 0.029). Preoperative scoliosis predicted an impaired outcome in the ODI (p = 0.031) and lowered the walking distance in the treadmill test (p = 0.001). The preoperative finding of only one stenotic level in visual assessment predicted less postoperative LBP when compared with patients having 2 or more stenotic levels (p = 0.026). No significant differences were detected between quantitative measurements and the patient outcome. CONCLUSIONS: Routine preoperative lumbar spine MRI can predict the patient outcome in a two-year follow up in patients with LSS surgery. Severe central stenosis and one-level central stenosis are predictors of good outcome. Preoperative finding of scoliosis may indicate worse functional ability.

Correlation of lateral stenosis in MRI with symptoms, walking capacity and EMG findings in patients with surgically confirmed lateral lumbar spinal canal stenosis.

BACKGROUND: To evaluate the clinical significance of lateral lumbar spinal canal stenosis (LLSCS), found by magnetic resonance imaging (MRI), through correlating the imaging findings with patient symptoms, walking capacity and electromyography (EMG) measurements. METHOD: 102 patients with symptoms of LSS referred for operative treatment were studied in this uncontrolled study. Of these patients, subjects with distinct only lateral LSS were included. Accordingly, 140 roots in 14 patients (mean age 58, range 48-76 years, male 43%) were evaluated. In MR images the entrance and mid zones of the lateral lumbar nerve root canal were graded as normal, narrowed but not compressed, or compressed. In quantitative analysis, the minimal widths of the lateral recess and mid zone area were measured. Clinical symptoms were recorded with the Oswestry Disability Index (ODI), overall Visual Analogue Scale (VAS), specific low back pain (LBP; NRS-11), specific leg pain (LP NRS-11), Beck Depression Inventory (BDI) and walking distance in the treadmill test. Lumbar paraspinal (L2- L5) and lower limb (L3 - S1) needle EMG studies were performed. The findings were classified root by root as 1 = normal, 2 = abnormal. The associations between radiological, EMG and clinical findings were tested with each other. RESULTS: EMG findings were normal in 92 roots and abnormal in 48 roots. All of the patients had at least one abnormal nerve root finding. Severity of the mid zone stenosis in MRI correlated with abnormal EMG findings (p = 0.015). Patients with abnormal EMG had also higher scores in the VAS (41.9 ± 25.7 vs 31.5 ± 18.1; p = 0.018), NRS leg pain (7.5 ± 1.5 vs 6.3 ± 2.1; p = 0.000) and BDI (9.8 ± 3.8 vs 8.0 ± 3.9; p = 0.014). However, no statistically significant correlations between MRI findings and clinical symptoms or walking capacity were found. CONCLUSIONS: Among persons previously selected for surgery, lateral stenosis seen on MRI correlates with EMG, and thus may be a clinically significant finding. Our EMG findings were also associated with patient symptoms. However, no relationships between the MRI findings and symptoms or walking capacity were found, suggesting their multifactorial etiology.

Lumbar paraspinal and biceps brachii muscle function and movement perception in lumbar spinal stenosis.

INTRODUCTION: Impaired muscle function and lumbar proprioception have been observed in lumbar spinal stenosis (LSS) but those have not been studied in LSS patients with age-matched controls. We assessed lumbar movement perception and paraspinal and biceps brachii (BB) muscle responses during sudden upper limb loading in age-matched healthy subjects and patients with LSS. METHODS: The study included 30 patients selected for an operation due to LSS and 30 age-matched controls without chronic back pain. The paraspinal and BB muscle responses for upper limb loading during unexpected and expected conditions were measured by surface EMG. The ability to sense lumbar rotation was assessed in a previously validated motorized trunk rotation unit in a seated position. Pain, disability and depression scores were recorded. RESULTS: Patients had poorer lumbar perception (mean difference 2.3 ± 0.6°, P < 0.001) and longer paraspinal muscle response latencies [mean difference 4.6 ± 0.6 ms (P = 0.033)] than age-matched healthy controls. Anticipation increased paraspinal and BB muscle activation prior to the load perturbation (P < 0.001) but less in LSS patients than in controls [9 vs. 30 %, P = 0.016 (paraspinals); 68 vs. 118 %, P = 0.047 (BB)]. CONCLUSIONS: The observed impairments in lumbar proprioception and activation of paraspinal and upper limb muscles indicate an extensive loss of both sensory and motor functions in LSS. The main new finding was decreased anticipatory muscle activation during expected upper limb loading reflecting involvement of central movement control mechanisms.

Accuracy and reproducibility of a retrospective outcome assessment for lumbar spinal stenosis surgery.

BACKGROUND: Retrospective assessment of surgery outcome is considered problematic. The aims of this study were to evaluate the reproducibility and accuracy of a retrospective outcome assessment of lumbar spinal stenosis surgery with reference to prospective outcome scale measurements. METHOD: Outcome of surgery from 100 lumbar spinal stenosis (LSS) patients was evaluated retrospectively from patient files of a 3-month outpatient visit performed according to a standard clinical protocol by two independent researchers. In the retrospective analysis, outcome was graded as 2 = good if the clinical condition had clearly improved, 1 = moderate if it had just slightly improved, 0 = poor if it had not improved or was even worse than before the surgical treatment (Retrospective 3- point scale). A prospectively assessed Oswestry Disability Index questionnaire (ODI), Visual analogue pain scale (VAS) and a patient satisfaction questionnaire were used as references of standards. Reproducibility of the measurements was evaluated. RESULTS: The retrospective 3-point scale correlated with ODI (r = 0.528; P < 0.001) and VAS (r = 0.368; P < 0.001). The agreement was better in the good and poor outcome than in the moderate outcome. Retrospective 3-point scale demonstrated substantial intra-rater and inter-rater repeatability (κ = 0.682, P < 0.001 and κ = 0.630, P < 0.001, respectively). CONCLUSIONS: Retrospective assessment of spinal surgery outcome is highly reproducible. Accuracy is highest in the patients with poor and good surgical result.

Lumbar instrumented posterolateral fusion in spondylolisthetic and failed back patients: a long-term follow-up study spanning 11-13 years.

UNLABELLED: INTRODUCTION AND MATERIALS: We examined lumbar transpedicular instrumented posterolateral fusion patients operated on between 1992 and 1997 presenting: degenerative spondylolisthesis with spinal stenosis; adult isthmic spondylolisthesis; failed back syndrome after one to five discectomies; and failed back syndrome after one to three laminectomy operations (groups 1-4, respectively). METHODS: They were examined by an independent orthopedic surgeon, completed the Oswestry Disability Index (ODI) and visual analog scale (VAS) questionnaires and their outcome was evaluated. RESULTS: The overall patient satisfaction at follow-up (mean 11.7 years) was 82.1%. The reoperation rate was 15.1% (7.5% due to adjacent segment disease). CONCLUSION: Group 1 showed the greatest improvements in ODI and VAS values, Group 2 the lowest and Group 3 the highest preoperative values, and Group 4 the second highest improvements. Patient satisfaction scores were 90.3, 69.7, 63.6 and 80.0%, respectively, and unplanned reoperation rates were 6.5, 9.1, 31.8 and 20.0%. Thus, long-term outcomes of lumbar instrumented posterolateral fusion (rarely previously studied) were satisfactory for >80% of patients, but varied among groups.

Postoperative rehabilitation does not improve functional outcome in lumbar spinal stenosis: a prospective study with 2-year postoperative follow-up.

The aim was to study if postoperative rehabilitation improves functional outcome in lumbar spinal stenosis (LSS). Surgically treated LSS patients (n = 102) were randomized to rehabilitation-group (A) and "standard postoperative treatment"--group (B). Intervention for A-group started 3 months postoperatively, consisting of once a week outpatient visits for 12 weeks (1.5 h per visit; 1-6 patients per one physiotherapist). Physiotherapist guided stretching and strengthening exercises. A-group performed individually estimated exercises at those visits with guiding and at home up to 24-month postoperative follow-up. Physiotherapeutic guidance (12 times) was repeated after 12 months, in order to update exercises and motivate patients to keep training. For B-group, the "standard treatment" thus included normal postoperative treatment, or no treatment/self-management. Outcome measures were measured at the start and the end of the first physiotherapeutic intervention (3 and 6 months postoperatively), and at 12- and 24-month postoperative follow-ups. Oswestry Disability Index (ODI, 0-100%) was the main outcome measure. The other outcome measures were back- and leg pain separately (NRS-11); satisfaction (7-point scale) and treadmill test (0-1,000 m; not at 6 month). The intervention consisting of 12 + 12 physiotherapeutic sessions with further home exercises did not influence the course ODI in the 24-month postoperative follow-up (p = 0.95 for ODI; "as-rehabilitated" analysis). No influence on any other outcome measures was observed. After LSS surgery, routinely performed outpatient rehabilitation did not improve functional outcome compared to standard treatment. In addition, it had no impact on the back and leg pain, satisfaction and walking ability.

Long-term results of surgery for lumbar spinal stenosis: a randomised controlled trial.

We randomised a total of 94 patients with long-standing moderate lumbar spinal stenosis (LSS) into a surgical group and a non-operative group, with 50 and 44 patients, respectively. The operative treatment comprised undercutting laminectomy of stenotic segments, augmented with transpedicular-instrumented fusion in suspected lumbar instability. The primary outcome was the Oswestry disability index (ODI), and the other main outcomes included assessments of leg and back pain and self-reported walking ability, all based on questionnaire data from 85 patients at the 6-year follow-up. At the 6-year follow-up, the mean difference in ODI in favour of surgery was 9.5 (95% confidence interval 0.9-18.1, P-value for global difference 0.006), whereas the intensity of leg or back pain did not differ between the two treatment groups any longer. Walking ability did not differ between the treatment groups at any time. Decompressive surgery of LSS provided modest but consistent improvement in functional ability, surpassing that obtained after non-operative measures.

Lumbar spinal stenosis patients are satisfied with short-term results of surgery - younger age, symptom severity, disability and depression decrease satisfaction.

PURPOSE: To study the lumbar spinal stenosis (LSS) patients' (n = 98) satisfaction with surgery outcome and associated factors at three months post-operative stage. METHOD: LSS-related physical functioning and pain were assessed with Oswestry disability index, Stucki questionnaire, Visual Analogue Scale and pain drawings. Depression was assessed with 21-item Beck Depression Inventory. Psychological well-being was assessed with the Life satisfaction scale, Toronto Alexithymia Scale and Sense of Coherence Scale. All questionnaires were administered before and 3 months after surgical treatment of LSS. Satisfaction with surgery outcome was assessed with a separate scale. RESULTS: Considerable improvement was evident in all the functional and pain-related variables. Two-thirds (66%) of the patients were at least clearly satisfied with the surgery outcome. Younger age, symptom severity, disability and depression were independently associated with dissatisfaction with surgery outcome. CONCLUSION: The lack of physical, functional and emotional well-being is associated with the patients' dissatisfaction with the surgery outcome. Patient satisfaction is a valid outcome to be measured in LSS patients undergoing surgery. It is recommended that patients should be provided with realistic pre-operative patient information and that depression be assessed pre-operatively.

Depression is associated with poorer outcome of lumbar spinal stenosis surgery.

The objective of this observational prospective study was to investigate the effect of depression on short-term outcome after lumbar spinal stenosis (LSS) surgery. Surgery was performed on 99 patients with clinically and radiologically defined LSS, representing ordinary LSS patients treated at the secondary care level. They completed questionnaires before surgery and 3 months postoperatively. Depression was assessed with the 21-item Beck Depression Inventory (BDI). Physical functioning and pain were assessed with Oswestry disability index, Stucki Questionnaire, self-reported walking ability, visual analogue scale (VAS) and pain drawing. Preoperatively, 20% of the patients had depression. In logistic regression analyses, significant associations were seen between preoperative depression and postoperative high Oswestry disability and Stucki severity scores and high intensity of pain (VAS score). In subsequent analyses, the patients with continuous depression, measured with BDI (60% of the patients who had preoperative depression), showed fewer improvements in symptom severity, disability score, pain intensity and walking capacity than the patients who did not experience depression at any phase. In those patients who recovered from depression, according to BDI-scores (35% of the patients with preoperative depression), the postoperative improvement was rather similar to the improvement seen in the normal mood group. In the surgical treatment of LSS, we recommend that the clinical practice should include an assessment of depression.

Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial.

STUDY DESIGN: A randomized controlled trial. OBJECTIVES: To assess the effectiveness of decompressive surgery as compared with nonoperative measures in the treatment of patients with lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: No previous randomized trial has assessed the effectiveness of surgery in comparison with conservative treatment for spinal stenosis. METHODS: Four university hospitals agreed on the classification of the disease, inclusion and exclusion criteria, radiographic routines, surgical principles, nonoperative treatment options, and follow-up protocols. A total of 94 patients were randomized into a surgical or nonoperative treatment group: 50 and 44 patients, respectively. Surgery comprised undercutting laminectomy of the stenotic segments in 10 patients augmented with transpedicular fusion. The primary outcome was based on assessment of functional disability using the Oswestry Disability Index (scale, 0-100). Data on the intensity of leg and back pain (scales, 0-10), as well as self-reported and measured walking ability were compiled at randomization and at follow-up examinations at 6, 12, and 24 months. RESULTS: Both treatment groups showed improvement during follow-up. At 1 year, the mean difference in favor of surgery was 11.3 in disability (95% confidence interval [CI], 4.3-18.4), 1.7 in leg pain (95% CI, 0.4-3.0), and 2.3(95% CI, 1.1-3.6) in back pain. At the 2-year follow-up, the mean differences were slightly less: 7.8 in disability (95% CI, 0.8-14.9) 1.5 in leg pain (95% CI, 0.3-2.8), and 2.1 in back pain (95% CI, 1.0-3.3). Walking ability, either reported or measured, did not differ between the two treatment groups. CONCLUSIONS: Although patients improved over the 2-year follow-up regardless of initial treatment, those undergoing decompressive surgery reported greater improvement regarding leg pain, back pain, and overall disability. The relative benefit of initial surgical treatment diminished over time, but outcomes of surgery remained favorable at 2 years. Longer follow-up is needed to determine if these differences persist.

Somatic comorbidity and younger age are associated with life dissatisfaction among patients with lumbar spinal stenosis before surgical treatment.

The objective of the study was to examine self-reported life satisfaction and associated factors in patients (n=100) with lumbar spinal stenosis (LSS) in secondary care level, selected for surgical treatment. Life satisfaction was assessed with the four-item Life Satisfaction scale. Depression was assessed with a 21-item Beck Depression Inventory (BDI). Psychological well-being was assessed with Toronto Alexithymia Scale and Sense of Coherence Scale. LSS related physical functioning and pain were assessed with Oswestry disability index, Stucki questionnaire, Visual Analogue Scale and pain drawings. All questionnaires were administered before surgical treatment of LSS. Results showed that 25% of the patients with LSS were found to be dissatisfied with life. In a univariate analysis, smoking, elevated subjective disability scores and extensive markings in the pain drawings were more common in the dissatisfied patients. The dissatisfied patients also showed lower coping resources, elevated alexithymia and depression scores, and were more often depressed. In multiple logistic regression analyses, only younger age and somatic comorbidity were associated with life dissatisfaction. This association remained significant even when the BDI score was added into the model. No other significant associations emerged. In conclusion, life dissatisfaction was rather common among preoperative LSS patients. Pain and constraints on everyday functioning were important correlates of life dissatisfaction. However, only younger age and somatic comorbidity were independently associated with life dissatisfaction. These results emphasize the importance of recognizing and assessing the effect of coexisting medical conditions and they need to be addressed in any treatment program.

Preoperative predictors for postoperative clinical outcome in lumbar spinal stenosis: systematic review.

STUDY DESIGN: Systematic review. OBJECTIVE: To define preoperative factors predicting clinical outcome after lumbar spinal stenosis (LSS) surgery. SUMMARY OF BACKGROUND DATA: LSS is the most common reason requiring lumbar spine surgery in adults older than 65 years. There are no published systematic reviews on this topic. METHODS: A literature search was done until April 30, 2005. Included were randomized controlled or controlled trials or prospective studies dealing with operated LSS. The preoperative predictors had to be presented. Included articles were assessed as high-quality (HQ) and low-quality studies. The predictors in HQ studies were considered as the main results. RESULTS: A total of 21 articles were included. Depression and walking capacity were predictors according to 2 HQ studies. Predictors reported in 1 HQ study were cardiovascular/overall comorbidity, disorder influencing walking ability, self-rated health, income, severity of central stenosis, and scoliosis. CONCLUSION: Depression, cardiovascular comorbidity, disorder influencing walking ability, and scoliosis predicted poorer subjective outcome. Better walking ability, self-rated health, higher income, less overall comorbidity, and pronounced central stenosis predicted better subjective outcome. Male gender and younger age predicted better postoperative walking ability. The predictive value may be outcome specific; thus, the use of all relevant outcome measures is recommended when studying predictors of LSS.

Depression and associated factors in patients with lumbar spinal stenosis.

PURPOSE: To investigate the prevalence of depression and associated factors in patients (n = 100) with lumbar spinal stenosis selected for surgical treatment. METHOD: Depression was assessed with the 21-item Beck Depression Inventory. Psychological well-being was assessed with Life Satisfaction Scale, Toronto Alexithymia Scale and Sense of Coherence Scale. Physical functioning and pain were assessed with the Oswestry disability index, the questionnaire devised by Stucki and the Visual Analogue Scale. All questionnaires were administered before surgical treatment of lumbar spinal stenosis. RESULTS: Twenty percent of the patients with LSS were found to have clinically important depression. In univariate analyses, subjective disability measured with the Oswestry disability index, low sense of coherence and poor life satisfaction were common in depressed patients. In the multiple logistic regression analyses, being dissatisfied with life was associated with depression. When sense of coherence score was included in the model, then only low sense of coherence was independently associated with depression. Neither socio-demographic nor pain-related factors associated with depression. CONCLUSIONS: Clinically important depression is rather common among preoperative patients with lumbar spinal stenosis. The factors associated with depression are subjective disability of everyday living and decreased life satisfaction. A low sense of coherence is an important correlate of depression. The results underline the importance of assessing depression in clinical practice dealing with these patients.