|Year : 2019 | Volume
| Issue : 4 | Page : 99-103
Lumbar spine decompression with or without instrumentation in a limited resource setting
Adetunji M Toluse1, Mustapha F Alimi1, Sulaimon A A Gbadegesin1, Olorunfemi O Ogundele2
1 Department of Orthopaedic Surgery and Trauma, National Orthopaedic Hospital, Lagos, Nigeria
2 Department of Community Health, State Specialist Hospital, Ondo, Nigeria
|Date of Submission||14-Apr-2020|
|Date of Acceptance||05-Jun-2020|
|Date of Web Publication||11-Nov-2020|
Dr. Adetunji M Toluse
Department of Orthopaedic Surgery and Trauma, National Orthopaedic Hospital, P.M.B 2009, Yaba, Lagos State
Source of Support: None, Conflict of Interest: None
Background: Lumbar degenerative spine disease is a leading cause of chronic low back pain and disability. Surgery is indicated to improve clinical condition when non operative measures fail. The objective of this study is to determine the outcome of lumbar spine decompression with or without instrumented fusion in the management of lumbar spine degenerative disease.
Objectives: To determine the outcome of lumbar spine decompression with or without instrumented fusion in the management of lumbar spine degenerative disease.
Patients and Methods: Study was retrospective in design and carried out at the Orthopedic Department of the National Orthopaedic Hospital, Lagos. Records of patients who had surgery for lumbar spine degenerative disease between 2007 and 2016 were retrieved. Variables of interest extracted included indication for surgery, type of surgery, complications, neurologic outcome, and length of follow-up. Descriptive and Chi-square analysis were done using SPSS version 16.0.
Results: Eighty-eight patients had surgery of which sixty-five were analyzed. Duration of follow-up was 12–96 months (mean 31.7 ± 21.4 months). The age range was 32–75 years (mean 58 ± 9 years) with male:female ratio of 1:1.3. Fifty-three (81.5%) had improved pain relief, of which 7 (10.8%) had pain relapse at mean of 27.5 months post operative. Twenty-six (40%) had pre operative limb weakness of which 16/26 (61.5%) improved, 10/26 (38.5%) had no changes, while 2/26 (7.8%) had worse neurology after surgery. The complications included wound infection (7.7%), implant-related (6.2%) and dural tear (3.1%). Surgical technique (“decompression alone” vs “decompression and instrumented fusion”) and complications (none/any complication) are significantly associated with a likelihood ratio of P = 0.023. Reoperation rate was 7.7%.
Conclusion: The addition of pedicle screw instrumented fusion does not seem to offer additional benefit with respect to long-term back pain and leg pain control; however, complication rate is notably higher.
Keywords: Degenerative spine disease, lumbar spine decompression, pedicle screw instrumented fusion, posterolateral fusion, spinal stenosis
|How to cite this article:|
Toluse AM, Alimi MF, Gbadegesin SA, Ogundele OO. Lumbar spine decompression with or without instrumentation in a limited resource setting. Arch Int Surg 2019;9:99-103
|How to cite this URL:|
Toluse AM, Alimi MF, Gbadegesin SA, Ogundele OO. Lumbar spine decompression with or without instrumentation in a limited resource setting. Arch Int Surg [serial online] 2019 [cited 2021 May 12];9:99-103. Available from: https://www.archintsurg.org/text.asp?2019/9/4/99/300558
| Introduction|| |
Lumbar degenerative spine disease is a leading cause of chronic low back pain and disability. It is often characterized by a compression of the neural elements, resulting in radicular pain and neurogenic claudication, weakness, numbness/tingling, and (often) pain in the lower back or buttocks. Surgery is indicated to improve clinical condition when non operative measures fail. The indications for surgery are usually based on the relationship between clinical findings, imaging studies, and pain symptoms.,,
The surgical management for degenerative lumbar spinal stenosis includes single or multilevel decompressive laminectomy with or without lumbar fusion. Decompression surgery without fusion has been proven to be beneficial to patients with lumbar spinal stenosis.,,, However, some studies have shown that the addition of instrumented fusion is desirable for patients, because this procedure had acceptable surgical results, especially where there is spinal instability., This study analyzes the patient demographics, presenting symptoms, operative procedure, complications, and neurologic outcomes of patients who underwent elective spine decompression with or without instrumented fusion for lumbar spinal stenosis with a minimum follow-up of 12 months. The objective is to evaluate the benefits of lumbar spine decompression vis-à-vis amelioration of back pain, leg pain, and improved muscle power in the lower limbs. We aim to see if addition of pedicle screw instrumented fusion confers additional benefits compared to patients who had lumbar decompression as standalone procedure after a minimum follow-up of 12 months.
| Materials and Methods|| |
The study was retrospective in design and carried out at the Orthopedic Department of the National Orthopaedic Hospital, Lagos. Case records of patients who had surgery for lumbar spine degenerative disease between January 2007 and December 2016 were retrieved. Details such as socio demographics, indication for and type of surgery, complications, neurologic outcome, and length of follow-up were extracted and recorded. Included in the study were all adult patients who had spine surgery for degenerative lumbar spine disease with not less than 1 year follow-up. Intraoperative C-arm fluoroscopy was utilized for all procedures to confirm correct level of surgery and also screw placement in cases in which instrumented fusion was done. Patients with less than one year of outpatient follow-up were excluded from the study. Patients were examined for follow-up at 3 weeks, 6 weeks, 3 months, and then 6 monthly intervals. The improvement of muscle power in the lower limbs was measured using the Medical Research Council (MRC) grading system. Patients' satisfaction with the outcome of surgery was assessed based on the 5-point Likert scale, which was dichotomized into “good” (helped a lot, helped) and “poor” (helped only little, did not help, made things worse).
Descriptive analysis was used for the socio demographic characterization of the patients. The Chi-square (χ2) test/likelihood ratio Chi-square test was used to assess the statistical significance of the bivariate associations at P < 0.05. Statistical Package for Social Sciences (SPSS Inc., Chicago) version 16.0 was used for data analysis. A total of 88 case records were retrieved using patient register for this period.
| Results|| |
Eighty-eight patients had surgery during the study period of which sixty-five met the inclusion criteria and were analyzed. Duration of follow-up was 12–96 months (mean 31.7 ± 21.4 months). The age range was 32–75 years (mean 58 ± 9 years) with male: female ratio of 1:1.3. Thirty-nine (60.0%) had decompression alone while twenty six (40.0%) had decompression + pedicle screw instrumented posterolateral fusion. L4/5 was mostly affected and decompressed in 61 (93.8%) patients [Table 1].
Twenty-six (40%) had pre operative limb weakness of which 16/26 (61.5%) improved, 10/26 (38.5%) had no changes, while 2/26 (7.8%) had worse neurology after surgery. None of them had symptoms and signs of cauda equina syndrome pre-operatively or post-operatively. Fifty-three (81.5%) had improved pain relief, of which seven (10.8%) had pain relapse at mean of 27.5 months (range 13–36 months) post operative. Ten (15.4%) reported no improvement in pain symptoms while two (3.1%) said symptoms were worse post-op. Based on the 5-point Likert scale, which was dichotomized into “good” (helped a lot, helped) and “poor” (helped only little, did not help, made things worse), surgical technique and pain improvement showed no significant association with a likelihood ratio P = 0.896 [Table 2].
|Table 2: Cross-tabulation of surgical technique and Likert scale outcome|
Click here to view
The complications recorded include wound infection (7.7%), implant-related (6.2%), dural tear (3.1%). Complication rate was higher in instrumented decompression. Surgical technique (“decompression alone” vs “decompression and instrumented fusion”) and complications (none/any complication) are significantly associated with a likelihood ratio of P = 0.023 [Table 3]. Re operation rate was 7.7%. The indications for re operation included re adjustment of malpositioned screw and revision for implant loosening.
| Discussion|| |
Lumbar degenerative spine disease is a leading cause of chronic low back pain and disability. Epidemiological reports in the study by Levy found a male preponderance, whereas Mijiyawa et al. had a female preponderance. The male to female ratio in our study shows no significant gender association and this compares with the reports of Andrews et al. So far, gender has not been proven in literature as a risk factor for lumbar degenerative spine disease. However, it is widely known that prevalence of degenerative joint diseases (of which the spine is no exception) increases with age. Lumbar degenerative spine disease manifesting as chronic low back pain with or without radicular symptoms constitutes enormous socioeconomic burden; hence, the need for surgical intervention when non operative measures fail.
Lumbar spine surgery is an option in the management of lumbar degenerative spine disease especially following failure of conservative measures. Several surgical approaches and options have been described with good results. For a posterior surgery, the options include standalone decompression or in combination with pedicle screw plus rod instrumentation and posterolateral fusion. The choice of instrumentation in patients with chronic low back pain is still controversial. There is no consensus on the single best treatment option for these patients. Endler et al. noted in their publication that all patient reported outcomes improved after surgery, but were without statistically significant differences at 1-, 2-, and 6.9-year follow-ups whether non-instrumented or instrumented. Several other authors also reported similar findings.,,, However, Ghogawala et al. reported that posterolateral instrumented fusion was associated with slightly greater but clinically meaningful improvement in overall physical health-related quality of life than decompression alone.
The goal of decompression surgery, which entails relieving pressure on compressed neural tissues by laminectomy, foraminotomy, and osteophyte removal is to relieve back and leg pains. The majority of the patients in our study reported improvement in back pain and leg pain post operatively. This finding has also been reported in studies., In the study by Cornefjord et al. a significant improvement regarding both low back pain and leg pain was found postoperatively compared to preoperatively. They also noted in their report that there was no statistical difference by all the evaluated parameters in the clinical outcome between patients who had pedicle screw instrumented fusion and those who had lumbar spine decompression alone. The finding in this present study is similar to what they reported. It is however noteworthy that improvement in both pain sites tends to worsen with time in a number of patients. Several reasons have been expounded for this phenomenon, including progression of the underlying spondylosis condition, inactivity combined with ageing, and adjacent segment degeneration. Psychological and sociological factors have also been implicated. As last follow-up visits, most of the patients with relapse of pain in our study were content with non operative pain management modalities that is analgesics and physical therapy. At follow-up, Cornefjord et al. reported that 25% of their patients used analgesics daily, while 35% took analgesics occasionally.
Another important goal of decompression is improvement of neurologic deficits. It is expected that once the compression lesion has been dealt with, there should be improved blood supply and nutrition of the neural tissues with consequent resolution of inflammation and reversal of neurologic deficits. Our study shows neurologic improvement rate of 61.5%. This is comparable with studies that have reported recovery rates between 61% and 84%.,, Girardi et al. found no statistically significant prognostic factor for neurologic recovery. They found no significant relationship between extent of recovery and age, diagnosis (herniated disc, lumbar spinal stenosis), duration of symptoms, or severity of preoperative weakness. Some studies, found duration of deficit (<4 weeks) to be a significant predictor of recovery. They postulated that the duration of neural inflammation as a result of compression may be responsible, presuming that acute inflammation resolves better. However, they also acknowledged in their report that the perceived benefit may also depend on patient factors. All the patients in our study presented with deficits of duration longer than 3 months. This may account for the recovery rate seen to be closer to lower limit of the range reported in literature.
Spine surgery, like every operative intervention, is not devoid of complications. Overall complication rate is higher in instrumented surgeries. Reasons that can be attributed for this include increased surgical time, operative technicality, and complexity. Wound infection is a significant complication of posterior spine surgery. It is quite distressing to both patient and surgeon, and remains among the leading causes of morbidity and mortality. Aside patient related factors, the proximity of the incision to peri-anal region, extensive dissection, and retraction of posterior spinal musculature are predisposing factors. Incidence of postoperative surgical site infection has been reported between 0.1 and 6.7%., Other reports have also cited incidence as high as 16.7%, following posterior spine surgery. Incidence of surgical site infection in our study is less than 10%. Dessy et al. observed that instituting enhanced antibiotic prophylactic protocol is beneficial in reducing the incidence of surgical site infections. In their report, antibiotic prophylaxis was continued until drain removal in patients who had posterior instrumentation and a decline of infection rate from 2.28% to 0 was recorded. The surgical site infections in our study progressed to heal following serial wound dressing, antibiotic therapy. Wound debridement was done in the patients that had deep surgical site infection. Anjarwalla et al. in their report of outcome of spinal decompression surgery had zero re-operation in all of their patients that returned for follow-up assessments at 5 years. Though the initial pain improvement diminished over the period, it was not sufficient to warrant re operation. Mannion et al. reported re operation rate of 24% at an average of 29.1 ± 20.9 months (range 0.3–59.6 months) after the primary surgery. Our finding was a re-operation rate of 7.7%. Only one of our patients with significant pain relapse consented to re-operation at 18 months for hardware revision, on account of loosening. We recorded an instance of incidental durotomy in each group, and this were repaired intra-operatively with autogenous fat patch. There was no post operative sequelae.
| Conclusion|| |
There is good surgical outcome in carefully selected patients with lumbar spine degenerative disease. The addition of pedicle screw instrumented fusion does not seem to offer additional benefit with respect to long-term back pain and leg pain control; however, complication rate is notably higher.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Goh KJ, Khalifa W, Anslow P, Cadoux-Hudson T, Donaghy M. The clinical syndrome associated with lumbar spinal stenosis. Eur Neurol 2004;52:242-9.
Djurasovic M, Carreon LY, Crawford 3rd
CH, Zook JD, Bratcher KR, Glassman SD. The influence of preoperative MRI findings on lumbar fusion clinical outcomes. Eur Spine J 2012;21:1616-23.
Goni VG, Hampannavar A, Gopinathan NR, Singh P, Sudesh P, Logithasan RK, et al.
Comparison of the oswestry disability index and magnetic resonance imaging findings in lumbar canal stenosis: An observational study. Asian Spine J 2014;8:44-50.
Weber C, Giannadakis C, Rao V, Jakola AS, Nerland U, Nygaard OP, et al.
Is there an association between radiological severity of lumbar spinal stenosis and disability, pain, or surgical outcome? A multicenter observational study. Spine (Phila Pa 1976) 2016;41:E78-83.
Weinstein JN, Lurie JD, Olson PR, Bronner KK, Fisher ES. United States' trends and regional variations in lumbar spine surgery: 1992-2003. Spine (Phila Pa 1976) 2006;31:2707-14.
Atlas SJ, Delitto A. Spinal stenosis: Surgical versus nonsurgical treatment. Clin Orthop Relat Res 2006;443:198-207.
Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the Maine lumbar spine study. Spine (Phila Pa 1976) 2005;30:936-43.
Weinstein JN, Lurie JD, Tosteson TD, Hanscom B, Tosteson AN, Birkmeyer NJ et al
. Surgical versus nonsurgical treatment for lumbar degenerative spondylolisthesis. New Engl J Med 2007;356:2257-70.
Malmivaara A, Slätis P, Heliövaara M, Sainio P, Kinnunen H, Kankare J. Finnish Lumbar Spinal Research Group. Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine (Phila Pa 1976) 2007;32:1-8.
Yone K, Sakou T, Kawauchi Y, Yamaguchi M, Yanase M. Indication of fusion for lumbar spinal stenosis in elderly patients and its significance. Spine (Phila Pa 1976). 1996;21:242-8.
Zucherman J, Hsu K, Picetti G 3rd
, White A, Wynne G, Taylor L. Clinical efficacy of spinal instrumentation in lumbar degenerative disc disease. Spine (Phila Pa 1976). 1992;17:834-7.
Levy LF. Lumbar intervertebral disc disease in Africans. J. Neurosurg 1967;26:31-4.
Mijiyawa M, Oniankitan O, Kolani B, Koriko T. Low back pain in hospital outpatients in Lome (Togo). Joint Bone Spine 2000;67:533-8.
Andrews NB, Lawson HJ, Darko D. Decompressive laminectomy for lumbar stenosis: Review of 65 consecutive cases from Tema, Ghana. West Afr J Med 2007;26:283-7.
Machado GC, Ferreira PH, Yoo, RI, Harris IA, Pinheiro MB, Koes BW, et al
. Surgical options for lumbar spinal stenosis. Cochrane Database Syst Rev 2016;11:CD012421. doi: 10.1002/14651858.CD012421.
Eck JC, Sharan A, Ghogawala Z, Resnick DK, Watters WC, Mummaneni PV et al
. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 7: Lumbar fusion for intractable low-back pain without stenosis or spondylolisthesis. J Neurosurg Spine 2014;21:42-7.
Endler P, Ekman P, Berglund I, Möller H, Gerdhem P. Long-term outcome of fusion for degenerative disc disease in the lumbar spine. Bone Joint J 2019;101-B: 1526-33.
Sunderland G, Foster M, Dheerendra S, Pillay R. Patient-reported outcomes following lumbar decompression surgery: A review of 2699 cases. Global Spine J 2020. doi: 10.1177/2192568219896541.
Tye EY, Anderson J, Haas A, Percy R, Woods ST, Ahn N. Decompression versus decompression and fusion for degenerative lumbar stenosis in a workers' compensation setting. Spine 2017;42:1017-23.
Donnarumma P, Tarantino R, Nigro L, Rullo M, Messina D, Diacinti D, et al
. Decompression versus decompression and fusion for degenerative lumbar stenosis: Analysis of the factors influencing the outcome of back pain and disability. J Spine Surg 2016;2:52-8.
Försth P, Michaëlsson K, Sandén B. Does fusion improve the outcome after decompressive surgery for lumbar spinal stenosis? A two-year follow-up study involving 5390 patients. Bone Joint J 2013;95:960-5.
Ghogawala Z, Dziura J, Butler WE, Dai, F, Terrin, N, Magge, SN, et al
. Laminectomy plus fusion versus laminectomy alone for lumbar spondylolisthesis. New Engl J Med 2016;374:1424-34.
Cornefjord M, Byrod G, Brisby H, Rydevik B. A long-term (4- to 12-year) follow-up study of surgical treatment of lumbar spinal stenosis. Eur Spine J 2000;9:563-70.
Bhargava D, Sinha P, Odak S, Tyagi A, Towns G, Pal D. Surgical outcome for foot drop in lumbar degenerative disease. Global Spine J 2012;2:125-8.
Ghahreman A, Ferch RD, Rao P, Chandran N, Shadbolt B. Recovery of ankle dorsiflexion weakness following lumbar decompressive surgery. J Clin Neurosci 2009;16:1024-7.
Girardi FP, Cammisa FP Jr, Huang RC, Parvataneni HK, Tsairis P. Improvement of preoperative foot drop after lumbar surgery. J Spinal Disord Tech 2002;15:490-4.
Dessy AM, Yuk FJ, Maniya AY, Connolly JG, Nathanson JT, Rasouli JJ, et al
. Reduced surgical site infection rates following spine surgery using an enhanced prophylaxis protocol. Cureus 2017;9:e1139. doi: 10.7759/cureus. 1139.
Bekelis K, Desai A, Bakhoum, SF, Mission S. A predictive model of complications after spine surgery: The National surgical quality improvement program (NSQIP) 2005-2010. Spine J 2014;14:1247-55.
Ojo OA, Owolabi BS, Oseni AW, Kanu OO, Bankole OB. Surgical site infection in posterior spine surgery. Niger J Clin Pract 2016;19:821-6.
] [Full text]
Barnes M, Liew S. The incidence of infection after posterior cervical spine surgery: A 10 year review. Global Spine J 2012;2:3-6.
Anjarwalla NK, Brown LC, McGregor AH. The outcome of spinal decompression surgery 5 years on. Eur Spine J 2007;16:1842-7.
Mannion AF, Denzler R, Dvorak J, Grob D. Five-year outcome of surgical decompression of the lumbar spine without fusion. Eur Spine J 2010;19:1883-91.
[Table 1], [Table 2], [Table 3]