Surgical decision-making in lumbar spinal stenosis
involves assessment of clinical parameters and the severity of the
radiological stenosis. We suspected that surgeons based surgical
decisions more on dural sac cross-sectional area (DSCA) than on
the morphology of the dural sac. We carried out a survey among members
of three European spine societies. The axial T2-weighted MR images
from ten patients with varying degrees of DSCA and morphological
grades according to the recently described morphological classification
of lumbar spinal stenosis, with DSCA values disclosed in half the
assessed images, were used for evaluation. We provided a clinical
scenario to accompany the images, which were shown to 142 responding
physicians, mainly orthopaedic surgeons but also some neurosurgeons
and others directly involved in treating patients with spinal disorders.
As the primary outcome we used the number of respondents who would
proceed to surgery for a given DSCA or morphological grade. Substantial
agreement among the respondents was observed, with severe or extreme
stenosis as defined by the morphological grade leading to surgery.
This decision was not dependent on the number of years in practice, medical
density or specialty. Disclosing the DSCA did not alter operative
decision-making. In all, 40 respondents (29%) had prior knowledge
of the morphological grading system, but their responses showed
no difference from those who had not. This study suggests that the
participants were less influenced by DSCA than by the morphological
appearance of the dural sac. Classifying lumbar spinal stenosis according to morphology rather
than surface measurements appears to be consistent with current
clinical practice.
In a prospective observational study we compared the two-year outcome of lumbar fusion by a simple technique using translaminar screws (n = 57) with a more extensive method using transforaminal lumbar interbody fusion and pedicular screw fixation (n = 63) in consecutive patients with degenerative disease of the lumbar spine. Outcome was assessed using the validated multidimensional Core Outcome Measures Index. Blood loss and operating time were significantly lower in the translaminar screw group (p <
0.01). The complication rates were similar in each group (2% to 4%). In all, 91% of the patients returned their questionnaire at two-years. The groups did not differ in Core Outcome Measures Index score reduction, 3.6 ( The two fusion techniques differed markedly in their extent and the cost of the implants, but were associated with almost identical patient-orientated outcomes. Extensive three-point stabilisation is not always required to achieve satisfactory patient-orientated results at two years.
