-

Öz

Amaç: Bu çalışmada, dejeneratif lomber dar kanal tanılı hastalara uyguladığımız transvers dekompresyon yöntemiyle beraberinde yapılan posterior enstrümantasyonlu füzyon yönteminin sonuçları değerlendi.Çalışma planı: Çalışmaya 39’u (%86.7) kadın, 6’sı (%13.3) erkek olmak üzere 45 hasta alındı. Ortalama yaş 58.68±8.63, ortalama takip süresi 51.71±20.96 ay. Ameliyat öncesi ve sonrası klinik değerlendirme Oswestry Engellilik İndeksi (OEİ), genel ağrı için görsel analog skala (GAS) uygulandı. Ameliyat öncesi ve sonrası radyografik değerlendirmelerde; spondilolistezis miktarı, skolyoz açısı ve lomber lordoz açısı ölçüldü. Bilgisayarlı tomografi ile ameliyat öncesi faset eklem artrozu olup olmadığı, spinal kanal önarka ve transvers çap değişimi değerlendirildi. Manyetik rezonans görüntülemede ameliyat öncesi disk dejenerasyonu, disk herniasyonu ve spondilolistezisin olup olmadığı değerlendirildi.Bulgular: Hastaların ameliyat öncesi OEİ skoru ortalaması %59.2, GAS ortalaması 7.06 idi. Ameliyat sonrasında OEİ skoru %14.4’e, GAS ise 1.7’e düştü (p=0.001). Ameliyat öncesi santral kanalın önarka çapı 10.43±1.45 mm’den, ameliyat sonrası 19.63±2.01 mm’ye (p=0001), transvers çap ortalaması 13.46±2.18 mm’den, 24.53±2.37 mm’ye yükseldi (p=0.0001). Hastaların ameliyat öncesi spondilolistezis ortalaması 5.81±4.88 mm iken ameliyat sonrası 3.87±4.53 mm (p=0.0001), ameliyat öncesi skolyoz açısı 5.84±10.14 iken ameliyat sonrası 2.04±5.08 (p=0.0002), ameliyat öncesi lordoz ortalaması 22.47±13.98 iken ameliyat sonrası 33.73±10.89 olarak tespit edildi (p=0.0001). Komplikasyon olarak bir (%2.2) hastada pulmoner tromboemboli, bir (%2.2) hastada yüzeyel yara yeri enfeksiyonu, bir (%2.2) hastada derin cerrahi alan enfeksiyonu gelişti. İki (%4.4) hastada dura yırtığı tespit edildi. Bir (%2.2) hastada intraoperatif radiks hasarı gelişti.Çıkarımlar: Transvers dekompresyon ile birlikte posterior enstrümantasyonlu füzyon, lomber dar kanal hastalarında klinik önemi olan bir iyileşme sağlamaktadır

Anahtar Kelimeler

• Dar kanal; komplikasyon; dekompresyon; enstrümante füzyon; laminektomi; cerrahi tedavi

Transverse decompression technique in the surgical treatment of degenerative lumbar canal stenosis

Abstract

Objective: The aim of this study was to assess the outcomes of fusion technique via posterior instrumentation in combination with transverse decompression in the surgical treatment of degenerative lumbar canal stenosis.
Methods: Forty-five patients–39 women (86.7%) and 6 men (13.3%)–were included. Mean age was 58.68±8.63 years with mean follow-up of 51.71±20.96 months. Preoperative and postoperative clinical evaluation was performed using the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for overall pain. Preoperative and postoperative imaging studies were used to measure the degree of spondylolisthesis and the angle of scoliosis and lumbar lordosis. The presence of preoperative facet joint arthrosis and changes in the diameter of anterior, posterior, and transverse spinal canal were assessed by computed tomography (CT). Preoperative disc degeneration, disk herniation, and spondylolisthesis were examined by magnetic resonance imaging (MRI).
Results: Mean preoperative ODI and VAS scores were 59.2% and 7.06, respectively, while postoperative ODI and VAS scores were 14.4% and 1.7%, respectively (p=0.001). Anteroposterior diameter of the central canal increased from 10.43±2.18 mm preoperatively to 19.63±2.01 mm postoperatively (p=0.0001). Mean preoperative and postoperative spondylolisthesis were 5.81±4.88 mm and 3.87±4.53 mm, respectively (p=0.0001). Mean preoperative and postoperative scoliosis angles were 5.84°±10.14° and 2.04°±5.08°, respectively (p=0.0002). Mean preoperative and postoperative lordosis angles were 22.47°±13.98° and 33.73°±10.89°, respectively (p=0.0001). Complications included pulmonary embolism in 1 patient (2.2%), superficial injury site infection in 1 patient (2.2%), and deep surgical site infection in 1 patient (2.2%). Two patients (4.4%) experienced dural tears. One patient (2.2%) had intraoperative radix damage.
Conclusion: The results of the present study suggest that the fusion technique via posterior instrumentation, in combination with transverse decompression, offers a clinical improvement in patients with lumbar canal stenosis.

Keywords

• Canal stenosis
• complication
• decompression
• instrumental fusion
• laminectomy
• surgical treatment

References

1. Karaeminoğulları O, Aydınlı U. Dejeneratif Lomber Spi- nal Stenoz. TOTBİD Dergisi 2004;3:3–4.
2. Genevay S, Atlas SJ. Lumbar spinal stenosis. Best Pract Res Clin Rheumatol 2010;24:253–65.
3. Issack PS, Cunningham ME, Pumberger M, Hughes AP, Cammisa FP Jr. Degenerative lumbar spinal steno- sis: evaluation and management. J Am Acad Orthop Surg 2012;20:527–35.
4. Aykaç B, Copuroğlu C, Ozcan M, Ciftdemir M, Yalnız E. Postoperative evaluation of quality of life in lumbar spinal stenosis patients following instrumented posterior decom- pression. Acta Orthop Traumatol Turc 2011;45:47–52.
5. Rompe JD, Eysel P, Zöllner J, Nafe B, Heine J. Degenera- tive lumbar spinal stenosis. Long-term results after un- dercutting decompression compared with decompressive laminectomy alone or with instrumented fusion. Neuro- surg Rev 1999;22:102–6.
6. Verbiest H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal. J Bone Joint Surg Br 1954;36-B:230–7.
7. Gelalis ID, Arnaoutoglou C, Christoforou G, Lykissas MG, Batsilas I, Xenakis T. Prospective analysis of surgical out- comes in patients undergoing decompressive laminectomy and posterior instrumentation for degenerative lumbar spi- nal stenosis. Acta Orthop Traumatol Turc 2010;44:235–40.
8. Martin WCT, Andrew CPH, Ka-Kin CA. Prospective Study on the Outcome of Degenerative Lumbar Spinal Stenosis Treated With Open Laminotomy. J Orthop Trauma Rehabil 2012;16:62–5.

9. Pao JL, Chen WC, Chen PQ. Clinical outcomes of micro- endoscopic decompressive laminotomy for degenerative lumbar spinal stenosis. Eur Spine J 2009;18:672–8.
10. Wiltse LL, Kirkaldy-Willis WH, McIvor GW. The treatment of spinal stenosis. Clin Orthop Relat Res 1976;115:83–91.
11. Postacchini F, Cinotti G, Perugia D, Gumina S. The surgi- cal treatment of central lumbar stenosis. Multiple laminot- omy compared with total laminectomy. J Bone Joint Surg Br 1993;75:386–92.
12. Rosen DS, O’Toole JE, Eichholz KM, Hrubes M, Huo D, Sandhu FA, et al. Minimally invasive lumbar spinal de- compression in the elderly: outcomes of 50 patients aged 75 years and older. Neurosurgery 2007;60:503–10.
13. Lin SM, Tseng SH, Yang JC, Tu CC. Chimney sublaminar decompression for degenerative lumbar spinal stenosis. J Neurosurg Spine 2006;4:359–64.
14. Khoo LT, Fessler RG. Microendoscopic decompressive laminotomy for the treatment of lumbar stenosis. Neuro- surgery 2002;51(5 Suppl):146–54.
15. Cavuşoğlu H, Kaya RA, Türkmenoglu ON, Tuncer C, Co- lak I, Aydin Y. Midterm outcome after unilateral approach for bilateral decompression of lumbar spinal stenosis: 5-year prospective study. Eur Spine J 2007;16:2133–42.
16. Niggemeyer O, Strauss JM, Schulitz KP. Comparison of surgical procedures for degenerative lumbar spinal steno- sis: a meta-analysis of the literature from 1975 to 1995. Eur Spine J 1997;6:423–9.
17. Booth KC, Bridwell KH, Eisenberg BA, Baldus CR, Len- ke LG. Minimum 5-year results of degenerative spondy- lolisthesis treated with decompression and instrumented posterior fusion. Spine (Phila Pa 1976) 1999;24:1721–7.
18. Kornblum MB, Fischgrund JS, Herkowitz HN, Abraham DA, Berkower DL, Ditkoff JS. Degenerative lumbar spon- dylolisthesis with spinal stenosis: a prospective long-term study comparing fusion and pseudarthrosis. Spine (Phila Pa 1976) 2004;29:726–34.
19. Cornefjord M, Byröd 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.
20. Katz JN, Lipson SJ, Larson MG, McInnes JM, Fossel AH, Liang MH. The outcome of decompressive laminectomy for degenerative lumbar stenosis. J Bone Joint Surg Am 1991;73:809–16.
21. Spivak JM. Degenerative lumbar spinal stenosis. J Bone Joint Surg Am 1998;80:1053–66.
22. Iguchi T, Kurihara A, Nakayama J, Sato K, Kurosaka M, Yamasaki K. Minimum 10-year outcome of decompres- sive laminectomy for degenerative lumbar spinal stenosis. Spine (Phila Pa 1976) 2000;25:1754–9.
23. Jolles BM, Porchet F, Theumann N. Surgical treatment of lumbar spinal stenosis. Five-year follow-up. J Bone Joint Surg Br 2001;83:949–53.
24. Grob D, Humke T, Dvorak J. Degenerative lumbar spinal stenosis. Decompression with and without arthrodesis. J Bone Joint Surg Am 1995;77:1036–41.
25. Feffer HL, Wiesel SW, Cuckler JM, Rothman RH. De- generative spondylolisthesis. To fuse or not to fuse. Spine (Phila Pa 1976) 1985;10:287–9.
26. Fischgrund JS, Mackay M, Herkowitz HN, Brower R, Montgomery DM, Kurz LT. 1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthe- sis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation. Spine (Phila Pa 1976) 1997;22:2807–12.
27. Mardjetko SM, Connolly PJ, Shott S. Degenerative lumbar spondylolisthesis. A meta-analysis of literature 1970-1993. Spine (Phila Pa 1976) 1994;19(20 Suppl):2256–2265.
28. Fu KM, Smith JS, Polly DW Jr, Perra JH, Sansur CA, Berven SH, et al. Morbidity and mortality in the surgi- cal treatment of 10,329 adults with degenerative lumbar stenosis. J Neurosurg Spine 2010;12:443–6.