Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.
Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
Acta Neurochir (Wien). 2023 Aug;165(8):2121-2129. doi: 10.1007/s00701-023-05693-5. Epub 2023 Jul 5.
We aim to investigate associations between preoperative radiological findings of lumbar foraminal stenosis with clinical outcomes after posterior microsurgical decompression in patients with predominantly central lumbar spinal stenosis (LSS).
The study was an additional analysis in the NORDSTEN Spinal Stenosis Trial. In total, 230 men and 207 women (mean age 66.8 (SD 8.3)) were included. All patients underwent an MRI including T1- and T2-weighted sequences. Grade of foraminal stenosis was dichotomized into none to moderate (0-1) and severe (2-3) category using Lee's classification system. The Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), and numeric rating scale (NRS) for back and leg pain were collected at baseline and at 2-year follow-up. Primary outcome was a reduction of 30% or more on the ODI score. Secondary outcomes included the mean improvement on the ODI, ZCQ, and NRS scores. We performed multivariable regression analyses with the radiological variates foraminal stenosis, Pfirrmann grade, Schizas score, dural sac cross-sectional area, and the possible plausible confounders: patients' gender, age, smoking status, and BMI.
The cohort of 437 patients presented a high degree of degenerative changes at baseline. Of 414 patients with adequate imaging of potential foraminal stenosis, 402 were labeled in the none to moderate category and 12 in the severe category. Of the patients with none to moderate foraminal stenosis, 71% achieved at least 30% improvement in ODI. Among the patients with severe foraminal stenosis, 36% achieved at least 30% improvement in ODI. A significant association between severe foraminal stenosis and less chance of reaching the target of 30% improvement in the ODI score after surgery was detected: OR 0.22 (95% CI 0.06, 0.83), p=0.03. When investigating outcome as continuous variables, a similar association between severe foraminal stenosis and less improved ODI with a mean difference of 9.28 points (95%CI 0.47, 18.09; p=0.04) was found. Significant association between severe foraminal stenosis and less improved NRS pain in the lumbar region was also detected with a mean difference of 1.89 (95% CI 0.30, 3.49; p=0.02). No significant association was suggested between severe foraminal stenosis and ZCQ or NRS leg pain.
In patients operated with posterior microsurgical decompression for LSS, a preoperative severe lumbar foraminal stenosis was associated with higher proportion of patients with less than 30% improvement in ODI.
The study is registered at ClinicalTrials.gov (22.11.2013) under the identifier NCT02007083.
本研究旨在探讨腰椎侧隐窝狭窄的术前影像学表现与以中央型腰椎椎管狭窄症为主的患者行后路显微减压术后临床结果之间的关系。
本研究是 NORDSTEN 脊柱狭窄症试验的附加分析。共纳入 230 名男性和 207 名女性（平均年龄 66.8（SD 8.3））。所有患者均接受 MRI 检查，包括 T1 加权和 T2 加权序列。使用 Lee 分类系统将椎间孔狭窄程度分为无到中度（0-1）和重度（2-3）两类。采用 Oswestry 功能障碍指数（ODI）、苏黎世跛行问卷（ZCQ）和数字评分量表（NRS）分别评估腰痛和腿痛，于基线和 2 年随访时进行评估。主要结局是 ODI 评分降低 30%或更多。次要结局包括 ODI、ZCQ 和 NRS 评分的平均改善情况。我们采用多变量回归分析，对椎间孔狭窄、Pfirrmann 分级、Schizas 评分、硬脊膜囊横截面积等影像学变量以及可能的混杂因素（患者性别、年龄、吸烟状况和 BMI）进行了分析。
437 例患者在基线时表现出高度的退行性改变。在 414 例有潜在椎间孔狭窄适当影像学表现的患者中，402 例被归类为无到中度，12 例为重度。在无到中度椎间孔狭窄的患者中，71%的患者 ODI 至少改善了 30%。在严重椎间孔狭窄的患者中，36%的患者 ODI 至少改善了 30%。研究发现，严重的椎间孔狭窄与术后 ODI 评分达到 30%改善目标的机会较低显著相关：OR 0.22（95%CI 0.06，0.83），p=0.03。当将结局作为连续变量进行研究时，发现严重的椎间孔狭窄与 ODI 改善程度较低之间存在类似的关联，平均差异为 9.28 分（95%CI 0.47，18.09；p=0.04）。还发现严重的椎间孔狭窄与腰椎区域 NRS 疼痛改善程度较低之间存在显著关联，平均差异为 1.89（95%CI 0.30，3.49；p=0.02）。严重的椎间孔狭窄与 ZCQ 或 NRS 腿痛之间无显著关联。
在接受后路显微减压术治疗的以中央型腰椎椎管狭窄症为主的患者中，术前严重的腰椎侧隐窝狭窄与 ODI 改善不足 30%的患者比例较高有关。
该研究在 ClinicalTrials.gov 注册（2013 年 11 月 22 日），标识符为 NCT02007083。
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