Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany.
Universität Witten-Herdecke, Witten, Germany.
Neurosurg Rev. 2022 Dec;45(6):3739-3748. doi: 10.1007/s10143-022-01875-4. Epub 2022 Oct 4.
Adjacent segment stenosis can occur after lumbar fusion surgery, leading to significant discomfort and pain. If further surgeries are required, the choice of the operative technique is an individual decision. In patients without over instability, it is still uncertain whether patients with adjacent spinal stenosis should be treated like primary lumbar spinal stenosis via decompressive surgery alone or with decompression and fusion. This is a retrospective analysis with prospective collected data. We included patients with adjacent segment stenosis after lumbar fusion. Patients with spinal deformity and/or obvious instability and/or significant neuroforaminal stenosis were excluded. All patients were divided into two groups according to the surgical technique that has been used: (a) treated via microsurgical decompression (MDG), (b) decompression and fusion of the adjacent segment (FG). Treatment decision was at discretion of the surgeon. Primary outcome was the need for further lumbar surgery after 1 year. In addition, patient reported outcome was measured via numerical rating scale (NRS), SF-36, Oswestry disability Index (ODI), Pittsburgh Sleep Quality Index (PSQI), and General Depression Scale before and after 1 year after surgery. In a further follow-up, need for additional lumbar surgery was redetermined. Total study population was 37 patients with a median age of 72 years. A total of 86.1% of patients suffered from a proximal adjacent segment stenosis and most common level was L3/4 (51.4%). A total of 61.1% of included patients developed adjacent segment stenosis after fusion of one single lumbar segment. Eighteen patients were included in MDG and 19 patients in FG. Both groups benefited from surgical interventions and there was no significant difference concerning pain, pain associated disability, sleeping, life quality, and mood after 1 year or the need of follow-up surgeries 1 year after primary fusion (5 in MDG vs. 5 in FG, p = 0.92) and at the second follow-up with a median time after surgery of 30 months (6 in MDG vs. 7 in FG, p = 0.823). Duration of surgery and hospital stay was significant shorter in MDG. There was no difference concerning operative complications rate. Both groups improved significantly in pain associated disability index, pain in motion, and concerning the sleeping quality. The present study indicates that decompression may not be inferior to decompression and fusion in patients suffering from degenerative adjacent segment stenosis without obvious signs of instability, deformation, and neuroforaminal stenosis after lumbar fusion in short-term follow-up. Due to significant shorter time of surgery, a pure microsurgical decompression may be a sufficient alternative to a decompression and fusion, particular regarding old age of this patient cohort.
腰椎融合术后可发生邻近节段狭窄，导致明显的不适和疼痛。如果需要进一步手术，手术技术的选择是一个个体化的决定。在没有过度不稳定的患者中，对于没有原发性腰椎狭窄症表现的邻近节段狭窄症患者，是仅通过减压手术治疗，还是减压融合治疗，目前仍存在争议。这是一项前瞻性收集数据的回顾性分析。我们纳入了腰椎融合术后发生邻近节段狭窄的患者。排除了脊柱畸形和/或明显不稳定和/或明显神经孔狭窄的患者。所有患者均根据所采用的手术技术分为两组：（a）接受显微镜下减压术（MDG）治疗，（b）邻近节段减压融合（FG）。治疗决策由外科医生决定。主要结局是术后 1 年内是否需要进一步腰椎手术。此外，通过数字评分量表（NRS）、SF-36、Oswestry 残疾指数（ODI）、匹兹堡睡眠质量指数（PSQI）和一般抑郁量表在术后 1 年测量患者报告的结果。在进一步随访中，重新确定了是否需要额外的腰椎手术。总研究人群为 37 名中位年龄为 72 岁的患者。86.1%的患者患有近端邻近节段狭窄，最常见的节段为 L3/4（51.4%）。共有 61.1%的患者在单个腰椎节段融合后发生邻近节段狭窄。18 例患者接受 MDG 治疗，19 例患者接受 FG 治疗。两组患者均从手术干预中获益，术后 1 年疼痛、疼痛相关残疾、睡眠、生活质量和情绪以及 1 年后是否需要随访手术（MDG 5 例，FG 5 例，p=0.92）或第二次随访（中位手术时间 30 个月，MDG 6 例，FG 7 例，p=0.823）无显著差异。MDG 组的手术时间和住院时间明显缩短。手术并发症发生率无差异。两组患者疼痛相关残疾指数、运动疼痛和睡眠质量均显著改善。本研究表明，在腰椎融合术后短期内无明显不稳定、变形和神经孔狭窄的退变性邻近节段狭窄患者中，减压术可能并不劣于减压融合术。由于手术时间显著缩短，单纯显微镜下减压术可能是减压融合术的一种有效替代方法，特别是对于这一患者群体的高龄患者。
