We retrospectively examined the prevalence and natural history of asymptomatic lumbar canal stenosis in patients treated surgically for cervical compressive myelopathy in order to assess the influence of latent lumbar canal stenosis on the recovery after surgery. Of 214 patients who had undergone cervical laminoplasty for cervical myelopathy, we identified 69 (32%) with myelographically documented lumbar canal stenosis. Of these, 28 (13%) patients with symptomatic lumbar canal stenosis underwent simultaneous cervical and lumbar decompression. Of the remaining 41 (19%) patients with asymptomatic lumbar canal stenosis who underwent only cervical surgery, 39 were followed up for ≥ 1 year (mean 4.9 years (1 to 12)) and were included in the analysis (study group). Patients without myelographic evidence of lumbar canal stenosis, who had been followed up for ≥ 1 year after the cervical surgery, served as controls (135 patients; mean follow-up period 6.5 years (1 to 17)). Among the 39 patients with asymptomatic lumbar canal stenosis, seven had lumbar-related leg symptoms after the cervical surgery. Kaplan–Meier analysis showed that 89.6% (95% confidence interval (CI) 75.3 to 96.0) and 76.7% (95% CI 53.7 to 90.3) of the patients with asymptomatic lumbar canal stenosis were free from leg symptoms for three and five years, respectively. There were no significant differences between the study and control groups in the recovery rate measured by the Japanese Orthopaedic Association score or improvement in the Nurick score at one year after surgery or at the final follow-up. These results suggest that latent lumbar canal stenosis does not influence recovery following surgery for cervical myelopathy; moreover, prophylactic lumbar decompression does not appear to be warranted as a routine procedure for coexistent asymptomatic lumbar canal stenosis in patients with cervical myelopathy, when planning cervical surgery

Summary Statement. Tandem stenosis is a prevalent condition in an Asian population with the narrowest cervical canal diameters and risk factors include advanced age and increased levels of lumbar canal stenosis. Introduction. Tandem spinal stenosis (TSS) is defined as patient with concomitant spinal canal stenosis found in both cervical (C) and lumbar (L) spinal region. Few studies have reported the incidence of TSS is ranged from 5–25%, but these are all noncomparative, small cohort studies. To the best of author knowledge this is the 1st study aims to compare the prevalence of TSS and its risk factors of development in a large multiracial Asian population. Methods. A retrospective review of all mid-sagittal T2MRI whole spine image was carried out at a University hospital in year 2007. Patients with spinal tumour, fracture and congenital stenosis were excluded. Spinal stenosis was defined as canal diameter of ≤10mm, measured from the posterior cervical vertebral/disc wall to anterior surface of the corresponding lamina. Patients were divided into 4 groups, no stenosis(NS), lumbar stenosis only(LS), cervical stenosis only(CS) and TSS. Patients’ demographics, race, co-morbidities and lumbar radiological report data were examined. Potential risk factors for the development of TSS were analyzed using SPSS software. Results. 926 (479 male, 447 female) patients with average age 50 (20–96) yrs were studied. Cervical canal diameters (mm) in TSS patients were the narrowest among the 4groups with C2/3 disc: 11.6, C3/4: 9.7, C4/5: 9.4, C5/6: 8.9, C6/7: 10.0 and C7T1: 11.4mm. The incidence of TSS was 26.2%. The prevalence of TSS in Chinese was 30.7%, Indian 12.5%, Malay 22.5%. The TSS prevalence in patients with 1 level lumbar canal stenosis was 12.5%, 2 levels lumbar stenosis was 6.4% and 3 levels was 4.1%. Multivariate analysis showed patients aged between 40–59 yrs (p=0.000, Exp(B):5.8, 95%CI 2.8–12.0), aged > 60yrs (p=0.000, Exp(B): 10.5, 95%CI 4.8–22.9), Chinese race (p=0.008, Exp(B): 2.5, 95%CI 1.3–4.9), patients with 1 level lumbar stenosis (p=0.000, Exp(B): 63.3, 95%CI 29.2–137.3), 2 levels lumbar stenosis (p=0.000, Exp(B): 67.7, 95%CI 29.4–155.7) and 3 levels lumbar stenosis (p=0.000, Exp(B): 106.6, 95%CI 43.6–260.5) are statistical significant risk factors for TSS development. Conclusion. The incidence of TSS was 26.2%. TSS patients have the narrowest cervical canal measurements among the studied groups. The prevalence of TSS in Chinese is the highest (30.7%). Patients advancing in age or have increased levels of lumbar canal stenosis are at risk of developing TSS

Purpose of the study: Missing a cervical stenosis in patients with lumbar canal stenosis can lead to an inadequate surgical strategy and delay in treatment of overt cord compression. Material and methods: Among 100 patients with lumbar canal stenosis, we identified patients with symptoms related to cervical stenosis. These four patients had to undergo surgical decompression of the cervical and lumbar spine to achieve full symptom relief. Careful analysis of the clinical expression is essential to identify cervical stenosis with few or no signs. Presence of gait disorders related to balance disorders, widening of the balance polygone, or use of a crutch, are suggestive of an associated lesion. MRI facilitates diagnosis of cervical compression. EMG and somesthetic evoked potentials are the gold standard examinations to confirm clinical and radiographic suspicion. Results: Gait disorders, other than simple claudication and/or radiculalgia warranted MRI and electric explorations in these patients. In these four patients, compression of the posterior cord explained well the gait disorders via a deep sensorial mechanism. Discussion: MRI evidence of cervical osteoarthritis is not sufficient to confirm the origin of the patient’s complaints. There must be a perfect correlation with the electrical results, particularly evoked potentials associated with MRI to confirm the organic origin of disorders resulting from cervical stenosis. Positive diagnosis of such an association requires a specific treatment algorithm as was used in three of our four patients. In the fourth case, the lumbar compression appeared to predominate over the cervical compression leading to decompression of the lumbar canal followed later by decompression of the cervical canal. Between the two procedures, the patient’s status had considerably declined. This strategy which had appeared adequate was thus found to be quite inadequate and even dangerous. Conclusion: Presence of gait disorders other than simple claudication or single-level or multiple-level radiculalgia in patients with lumbar canal stenosis should lead to search for an associated cervical stenosis. The perfect correlation between the radiographic and electrical findings is indispensable to establish certain diagnosis. The cervical stenosis should be treated before the lumbar stenosis

Aim: To assess the clinical effectiveness of X stop interspinous decompression device in patients with neurogenic claudication due to lumbar canal stenosis at 24 months post surgery. Design: Prospective Observational Study of 57 patients with X stop procedure. Methods: Fifty-seven patients with unilateral or bilateral leg pain due to lumbar canal stenosis, who had significant relief from sitting or flexing the lumbar spine, were treated with X stop. Clinical outcome was assessed by Zurich claudication questionnaire (ZCQ), visual analogue score (VAS), Oswestery disability index (ODI) and SF36 questionnaires preoperatively and at 2 years. ZCQ has three components- symptom severity, physical function and patient satisfaction. ZCQ is considered the most precise, reliable and condition specific questionnaire for lumbar canal stenosis. Out of 57 patients, 2 died due to unrelated causes, 3 withdrew from study and 3 had the device removed within 2 years. Forty-five, 44, 42 and 48 completed ZCQ, ODI, SF-36 and VAS respectively at 24 months. Results: The mean age was 71(53–94) and M: F ratio 29:28. X stop device was inserted at single level in 32 (56%) and double levels in 25(44%) patients. In single level cases, 72% reported improvement in symptom severity, 65% in physical function, 68% were satisfied with the procedure, and overall 55% made a clinically significant improvement at 24 months. In double level cases, the figures were 62%, 68%, 78% and 40% respectively. The threshold for changes in symptom severity was 0.46, physical function was 0.42 and patient satisfaction 2.42. Overall clinically significant improvement requires that a patient achieves at least 2 criteria. The mean ODI improved by 6.5 in single level and 10.8 in double level cases. The SF-36 showed improvement in physical function, role physical, bodily pain and vitality social domain. Average hospital stay for the procedure was 1.6 days. One patient stayed for 10 days for investigation unrelated to the procedure. There were no major complications. Conclusions: The results of our study show that the X stop interspinous decompression device remains clinically effective at the end of 2 years. X stop is a relatively less invasive procedure, especially suitable for patients with other co-morbidities, which can be performed as a day case procedure without major complications

Purpose of the study: Discal herniation is an exceptional cause of lumbar canal stenosis. When surgery for this disorder was first performed in the sixties, discectomy was not exceptional because discal protrusions were frequent. It was rather rapidly observed however that these protrusions were actually osteoarthitic discal rims that do not cause root compression. Discectomy was thus almost completely abandoned for lumbar stenosis surgery. Consequently, the development of true discal herniation after surgery for lumbar canal stenosis is highly exceptional. To our knowledge, this situation has not been reported in the literature. Among several hundred procedures for decompression of the lumbar canal practised in our unit over the last thirty years, we have observed seven cases. Material and methods: The patients were aged 43 to 74 years at the time of reoperation (mean 61 years). The stenosis was at the L4-L5 level in all patients and extended to L3-L4 in three and to L5-S1 in two and was bilateral in one patient. The L4-L5 disk had been removed at the prior surgery in three patients. Delay to recurrent pain was variable, from six months to eleven years. The sciatic pain was associated with motor disorders in one patient. Discal herniation was observed at the L4-L5 level in all patients and was often voluminous, excluded in three patients. Reossification was present in one patient but did not have a compressive effect. Treatment after recurrence was chemonucleolysis in three patients, with two successes and one failure. Surgical treatment by discal excision was used in four cases associated with instrumented fusion in one patient. Results: The patients were reviewed at one to ten years after the second operation. Nucleolysis was successful in two and a failure in one. The patient with failure of nucleolysis was treated by a new decompression with fusion and achieved an excellent result at ten years. Pain relief was achieved after surgery in all patients though only partial in one. Discussion and conclusion: Discal herniation is rare in elderly subjects and can cause problems late after surgical decompression of lumbar canal stenosis. It is important to search for discal herniation which is not always easy to confirm radiologically due to postoperative remodeling. Chemonucleolysis is an effective and economical solution when the disk has not been resected during the first procedure. When an operation is necessary, spinal fusion is not useful except in case of associated instability

The multimodal management of canal stenosis is increasing, and inhibitors of central sensitization are playing a crucial role in central sensitization processes. Pregabalin and gabapentin are antiepileptic drugs that reduce presynaptic excitability. The objective of this study was to investigate whether the use of pregabalin and gabapentin is effective in the symptomatic management of canal stenosis. A literature search was conducted in four databases. The inclusion criteria were studies that compared pregabalin or gabapentin with a control group in lumbar canal stenosis. Randomized clinical trials and a comparative retrospective cohort study were included. The main clinical endpoints were VAS/NRS, ODI, and RDQ (Roland Morris Disability Questionnaire) at 2, 4, 8 weeks, and 3 months, adverse events, and walking distance were also collected. Data were combined using Review Manager 5.4 software. Six studies and 392 patients were included. The mean age was 60.25. No significant differences were observed in VAS at 2, 4, and 8 weeks: (MD: 0.23; 95% CI: −0.63-1.09), (MD: −0.04; 95% CI: −0.64 to −0.57), and (MD: −0.6; 95% CI: −1.22 to 0.02). Significant differences were observed in favor of pregabalin with respect to VAS at three months: (MD: −2.97; 95% CI: −3.43 to −2.51). No significant differences were observed in ODI (MD: −3.47; 95% CI: −7.15 to −0.21). Adverse events were significantly higher in the pregabalin/gabapentin group (OR 5.88, 95%CI 1.28-27.05). Walking distance and RDQ could not be compared, although the results were controversial. Gabapentinoids have not been shown to be superior to other drugs used in the treatment of LSS or to placebo. However, they have shown a higher incidence of adverse effects, improved results in VAS at 3 months, and a slight improvement in ambulation at 4 months in combination with NSAIDs compared to NSAIDs in monotherapy

Study Purpose. To examine the presence of radicular pain and its relationship to the degree of lumbar nerve root compression in patients with a degenerative lumbar spine condition about to undergo surgery for either lumbar disc prolapse or lumbar canal stenosis. Background. The pathophysiology underlying radicular pain is not completely understood but it is thought that nerve root compression is a key factor and from a surgical perspective, decompressing the nerve root is considered to be the key therapeutic step. However, despite often severe root compression in patients with lumbar stenosis, radicular pain is not a typical feature. Methods. Thirty-nine pre-surgical patients with either lumbar disc prolapse or lumbar canal stenosis were studied using the Standardised Evaluation of Pain (StEP), a clinical assessment tool known to predict with a high degree of sensitivity and specificity the presence or absence of lumbar radicular pain. A nerve root compression score was given from lumbar MRI for each patient by a neuroradiologist blinded to the patients history. Results. The StEP assessment tool was able to distinguish the presence or absence of radicular pain with high sensitivity and specificity. This correlated well with the pre-operative diagnosis of disc prolapse or canal stenosis. The relationship between radicular pain and nerve root compression was less clear and will be discussed. Conclusion. This study confirms StEP as a useful bedside tool for identifying the presence of radicular pain in patients with a degenerative lumbar spine condition. Nerve root compression per se does not necessarily produce radicular pain. Conflicts of Interest. None. Source of Funding. None. This study has not been published or presented at a previous meeting

Background: X stop interspinous decompression device has been used effectively in symptomatic patients with lumbar canal stenosis. The positional MRI scanner images patients in the erect weight bearing position and is used here to evaluate the efficacy of the X stop in maintaining increase in dural sac and foraminal areas. Aim: To assess the clinical effectiveness of X stop in patients with lumbar canal stenosis and measure its effect in decompressing the spinal canal two years postoperatively. Design: Prospective Observational Study. Methods: Clinical outcome was assessed by ZCQ, VAS, ODI and SF36 questionnaires. Clinical and radiological outcomes were measured preoperatively and at 2 years. Foraminal area was measured in flexion and extension whereas dural sac area was measured in erect, neutral, flexion and extension. Osiris 4.17 software program was used for the measurements. The data was analysed using paired t test on SPSS ver.15.01. Results: With ZCQ overall 57% of patients had clinically significant improvement at 24 months. The mean ODI and VAS scores showed improvement. The SF-36 improved in four domains. Radiologically we noted increase in mean dural sac area in all positions. There was a small increase in foraminal areas and statistically significant increase in dural sac areas at 24 months. Conclusion: The X stop device remains clinically effective at the end of 2 years. It is a relatively less invasive procedure without major complications and can be performed as a day case procedure. X stop maintains increase in dural sac and foraminal areas at 24 months postoperatively

Purpose: To measure outcome in patients undergoing decompression for lumbar canal stenosis (LCS) by lami-nectomy. Methods: 100 patients (57 men, 43 women) under one consultant surgeon presenting with neurogenic claudication and MRI confirmed LCS were studied . 23 patients had pre –existing spondylolisthesis (21 Grade 1, 2 Grade-2) and were managed by laminectomy without fixation. Patients completed a set of outcome measure questionnaires (SF-36, Visual analogue scores for back pain, leg pain, leg sensory symptoms and the Roland-Morris back disability score) pre-operatively, 3 months post surgery and at longer term follow up (median 2 years). Outcome scores were analysed and for SF-36 compared to age matched normative data. Statistical significance was calculated using Wilcoxon’s matched pairs and correlations using Spearman’s rank test. Statistical analysis was performed using the SPSS statistical package. Results: Average age 68 years (inter-quartile range 60 – 77). For the cohort visual analogue scores and Roland scores showed significant improvement (p < 0.01) at both 3 months and at long term follow up compared to pre-operative scores. For the physical functioning domain of SF-36, outcome scores improved significantly (p< 0.01) at short and long term follow up with 80% of patients having better long term scores compared to pre-operative scores. The physical functioning domain of SF-36 was significantly correlated with the changes seen in the visual analogue pain scores and the Roland back pain score (p < 0.01). Outcome for the spondylo-listhesis subgroup was similar to the outcome in patients without pre existing spondylolisthesis. Conclusions: Laminectomy for lumbar canal stenosis is an effective treatment resulting in significant health gains which are maintained in the longer term. Our data validates SF-36 as a measurement of disease severity and outcome in this condition

Purpose of the study: Surgery for lumbar canal stenosis is classically an intracanalar procedure with the risk of injury of the dura mater or nerve roots or of postoperative haematoma with secondary sequelae. Extracanalar surgery could be useful for the treatment of lumbar canal stenosis in older patients. Material and methods: The Farcy procedure is based on the observation that the root is compressed in the recessus by the tip of the upper facet. The foramen is too small. The tip can be cut with a chisel along a horizontal line plumb with the pedicle landmark on the upper border of the lateral mass. The tip of the facet and its osteophyte can be removed laterally to medially with a curette and separated from the capsule and the yellow ligament without exposing the root. Release of the foramen is verified with an elevator. From August 1999 to July 2000, 15 patients (ten women and five men) underwent the Farcy procedure in association with fusion-osteosynthesis. Mean age was 60.4 years (55–71). The patients had suffered a mean 8.5 years (1–30). All had lumbalgia. Radiculalgia involved one root in seven patients, two in four and three in four. The Beaujon score was 6.73 (0–14) before surgery. The procedure was performed at one level in five patients, at two in four, at three in four and at four in two. Laminectomy was associated in two patients early in our experience. Results: Postoperative Beaujon score was 15.2 (9–12) with cure of lumbalgia in eleven patients and cure of radiculalgia in ten patients. five patients had a 100% relative gain and only four had a gain of less than 50%. There were two failures explained by a history of stroke in two women (67 and 71 years). The only complications were one haematoma that was reoperated and one superficial infection. Discussion: These results are comparable with those obtained with intracanalar surgery. The procedure is equally effective and is more rapid without the risk of the classical complications. The one extradural haematoma observed was related to laminectomy which later was noted to be unnecessary. Conclusion: The Farcy procedure is a useful technique for the treatment of lumbar spine stenosis. Further experience is needed to determine whether this extracanalar technique should replace classical techniques with the risk of complications related to exposure of the canal

Aim: To measure the effect of X-stop interspinous decompression device on the dural sac and foraminal area at 6 and 24 months post operatively at the instrumented level in patients with symptomatic lumbar canal stenosis. Design: Prospective Observational Study of 48 patients. Methods: Patients due to have an X stop procedure were included and had a positional MRI scan preoperatively and 6 & 24 months post operatively. Foraminal area was measured in flexion and extension position whereas dural cross sectional area was measured in erect, neutral, flexion and extension positions. Osiris 4.17 software program was used to measure the canal and foraminal dimensions. The data was analysed using paired t test on SPSS ver.15.01. Results: Forty-eight patients (25 male and 23 female) underwent scans preoperatively and at six months. Twenty-nine patients had single level and 19 had double level procedures. Three patients had removal of X stop and 5 did not have scan at 24 months leaving 40 patients scanned at 24 months. Of these 38 scans were complete and were included. We noted increase in mean dural sac area in all positions. The mean dural sac area increased from 131 mm2 to 143 mm2 (p=0.144) at 6 months and from 137 mm2 to 202 mm2 (p= 000) at 24 months in standing position. The difference in pre-operative measurements in the six and 24-month measurements is because of the different patient numbers scanned. There were similar increased dural sac areas in the other positions. The mean foraminal areas were measured in flexion and extension and the measurements in extension were increased from 66.58 mm2 to 79.51 mm2 (p=. 001) at 6 months and from 68.10 to 69.57 mm2 (p=0.752) at 24 months on left side; and increased from 63.75 mm2 to 71.65 mm2 (p=0.036) at 6 months, from 65.54 mm2 to 68.01mm2 (p=0.440) at 24 months on right side. Thus there is a small increase in foraminal areas and statistically significant increase in dural sac areas at 24 months. Conclusion: X-stop interspinous device remains effective in decompressing the stenosed spinal segment by increasing the anatomic dural cross sectional areas and foraminal areas of spinal canal at 24 months post operatively, thus providing symptomatic relief from lumbar canal stenosis

Background. Acute lumbar radiculopathy is a very painful condition sometimes requiring admission for strong analgesia. Purpose. To evaluate the efficacy of distal nerve root blocks as an outpatient procedure for immediate pain relief. Methods. Local anaesthetic was injected in the distal nerve root areas of the leg and foot in the clinic in patients with lumbar radiculopathy who consented to the procedure. Results. There were 29 patients, 18 females and 11 males, aged 25 to 76 years. 13 patients had acute lumbar disc prolapse, 11 had lumbar canal stenosis, 2 had annular tears and one a facet joint cyst. The VAS pain scores ranged from 3 to 11 (patient's description), with an average VAS score of 7.5. The improvement in VAS scores was between 2 and 9 with average improvement of 6. 19 patients had associated back pain which improved in 14. Walking improved in all 29 patients. Pain relief was immediate in all patients. This lasted from 30 min to 11 days with one patient having no recurrence. 27 patients had at least 24 hours pain relief. All patients could be sent home immediately after the procedure. 12 patients had recent onset of foot weakness which improved one MRC grade immediately after the injection. The analgesic effect was most significant in acute disc prolapse. There were no complications. Conclusion. This technique is simple and would be valuable in the acute setting to provide immediate pain relief allowing immediate discharge from accident and emergency. Conflicts of interest: None. Sources of funding: None

Background. Gore and Nadkarni described a ‘Gore sign’ of reproducing radiating leg pain by palpation of distal nerve root endings in the foot for L5 and S1 nerve roots in lumbar radiculopathy due to disc prolapse. Purpose. This sign was explored and observation of symptoms recorded. Results. There were 31 patients, 20 females and 11 males, aged 25 to 76 years. 13 patients had acute disc prolapse, 14 had lumbar canal stenosis, 3 had annular tears and one had a facet cyst. Radiating leg pain was reproduced in all patients by palpation of distal nerve root endings and was immediately relieved by local anaesthetic injection around distal nerve root endings in all patients (second part of Gore test). New clinical signs were observed which have not been described before:. Back pain was reproduced in 21 patients. L4 nerve root pain was reproduced in 13 patients by palpation of the proximal tibia. Crossed leg pain was reproduced in 5 patients. Reproduction of pain by palpation of more than one distal nerve root ending was observed in 16 patients. Cessation of radiating leg pain by palpation of distal nerve root endings in two patients. These test were positive in patients with varied pathology producing radiculopathy, not just disc prolapse. Conclusion. Provocative nerve root tension signs can be difficult in severe pain. The tests described above can be performed without having to move the patient's lower limb. These observations open up discussion on the mechanism of radiculopathy and new ways of treatment. Conflicts of interest: None. Sources of funding: None

Meticulous haemostasis not only improves the operative field facilitating spinal surgery, but also diminishes chances of post-operative neurological complications from a compressive haematoma. Since being introduced in the 1940’s, implantable haemostats have proven a useful adjunct in achieving haemostasis with relatively few complications. However, their use in spaces bounded by bony architecture can lead to compressive effects on neurological structures. We present three cases of post-operative cauda equina syndrome – two cases following surgery for lumbar disc herniation and one case following surgery for lumbar canal stenosis. In each case, implantable haemostats were utilised to control haemorrhage for complications during the surgery. All three patients underwent urgent exploration, which revealed cauda equina compression from clot organised around the haemostat. Neurological recovery was variable. We recommend careful attention to intra-operative haemostasis. Although haemostats can assist in achieving haemostasis, we caution against leaving them in situ

Patients with neurogenic claudication from lumbar canal stenosis non-responsive to non-surgical treatment are usually managed with spinal decompression with or without fusion. Flexion at stenotic segments relieves symptoms by increasing canal cross-sectional area, intervertebral foraminal height. Interspinous spacers work by causing flexion at the treated segement. We used COFLEX¯ [Paradigm Spine] a titanium interspinous spacer along with interlaminar decompression where indicated. To compare the clinical and radiological results of patients undergoing interlaminar decompression with or without use of COFLEX¯. Pre and post-operative assessment and comparison of clinical outcomes of Oswestry disability index(ODI), Visual analog Scale(VAS), Short Form-36(SF-36) and radiological outcomes of disc heights of operated and adjacent levels, intervertebral foraminal heights, sagittal angles of the operated segment. All consecutive patients undergoing spinal decompression at one or more levels from Jan to Dec 2008 were included. Patients with clinically symptomatic back pain for a duration longer than claudication pain were offered interspinous spacer at L4/5 level or above. In first group(n-20), patients were treated with inter-laminar decompression and COFLEX¯ with a standard posterior approach. In second group(n-25) inter-laminar decompression for the involved segment was performed. All patients are on follow-up. Clinical and radiological outcomes were compared at 6 months and 1 year. Statistically significant(p<0.001) improvements in ODI, VAS(back), VAS(leg) and SF-36 in patients in whom COFLEX¯ was used. Radiological parameters also showed significant improvements(p<0.05). Use of COFLEX¯ spacer is justified in patients with symptomatic disc degeneration with neurogenic claudication when treated operatively

Purpose of the study: It is currently accepted (particularly since the work by Katz et al.) that a number of factors can potentially influence the functional outcome obtained after surgical treatment of lumbar canal stenosis (LCS). Among these factors are comorbid conditions and the notion of perceived health appear to be predominant. Little work has however been focused on the influence of these same factors on the qualitative and quantitative expression of functional impairment expressed by patients before their treatment. This possible link might have an intrinsic impact on the assessment of the outcome obtained after medical or surgical treatment of LCS. We wanted to examine this question. Material and methods: Two hundred twenty patients referred to our orthopaedic surgery consultations were included in this prospective observation study, irrespective of the type f treatment eventually proposed (medical or surgical) or the type of lumbar stenosis. Patients who had had prior spinal surgery and those treated for LCS due to spinal deformity were excluded. The degree of the functional symptoms was determined with the SF36 and a self-administered questionnaire specifically designed and validated for the evaluation of LCS. Comorbidity factors were studied individually and with the following scores: the ASA score, the FCI (Functional Comorbidity Index), the CIRS (Cumulative Illness Rating Scale, and the ICED (Index of co-existent Diseases). Univariate and multivariate analysis was used to search for correlations between expressed functional impairment and comorbid factors. Results: Expression of a functional impairment was significantly associated with a high number of comorbidity factors. This correlation was tighter when there was no additional compressive discal factor and when the functional neurological symptoms were longstanding. The type of comorbid factor analysed did not have an impact on these results. Conclusion: The presence of comorbid factors is significantly associated with more severe expression of functional impairment related to LCS. This effect could also influence the functional outcome after treatment of LCS and should be taken into consideration

Background. Unexplained pain is one of the most common complications after Oxford UKAs. We have retrospectively reviewed the patients who underwent Oxford UKAs and investigated those patients with prolonged pain and found that many of these patients had strong tenderness over the Hunter canal and they were well treated with Hunter canal block or administration of Pregabalin. We have checked the details of these prolonged pain and key to the treatment will be discussed. Methods. Between May 2006 and September 2014 we have performed 316 Oxford UKAs. There were 47 males and 269 females with average age of 70.4 years old (46–90). The patients were followed up for at least 6 months (6 months to 8.0 years, mean follow-up period of 3.1 years). The patients were examined both clinically and radiologically. Result. There were 30 knees (9.5%) that showed prolonged pain continuing more than 3 month after the operation(Fig.1). Of these 30 knees, 17 knees had strong tenderness over the Hunter canal, and many patients had numbness and radiating pain toward medial side of the lower extremities. They were diagnosed as having Hunter canal syndrome clinically. Of these 17 knees 5 were treated successfully with Hunter canal block with Lidocaine. Remaining 12 knees were treated with Pregabalin or with Tramadol. All but 1 knee, pain disappeared within 3 months after starting the treatment as we stated. There were 3 cases that were finally diagnosed as having lumbar canal stenosis and L3 root block was effective. For the 10 knees not diagnosed as having Hunter canal syndrome without any tenderness over the Hunter canal, the pain disappeared spontaneously in 2 knees, and the pain disappeared with administration of Pregabalin or Tramadol in 6 knees. Two patients didn't respond to any treatment, they were referred to psychiatrist and diagnosed as having mental problems. There was no abnormal radiolucency, which suggested loosening of the component. As a result, true unexplained pain that continued more than a year was only 1. Discussion. 17 knees out of 30 unexplained pain knees after Oxford UKAs had strong tenderness over the Hunter canal, and the pain disappeared after the saphenous nerve block or adminestration of Pregabalin except for 1 knee. Patients without the diagnosis of Hunter canal syndrome also responded well to either Pregabalin or Tramadol. The pain continuing for more than 3 months after Oxford UKA is usually self-limited and well treated conservatively. With these results, when you see the prolonged pain after Oxford UKA, we strongly recommend just wait and see by conservative treatment with Pregabalin, Tramadol or saphenous nerve block, and do not revise the implant

Background: Guidelines for the management of Low Back Pain (LBP) consistently recommend that the initial assessment focuses on the detection of serious spinal pathologies. In 1994 the UK Clinical Standards Advisory Group introduced the concept of “red flags”. One of these red flags is the first presentation of LBP in people over the age of 55 years. The aim of this study was to investigate the incidence of serious spinal pathologies in patients presenting with new onset of LBP over the age of 55 years. Method/Results: This was a prospective analysis of all patients presenting to a secondary care spinal triage service over a 3 year period (2005–2008). During the study period, in excess of 3000 patients were seen. Of these, a total of 70 patients presented with a first onset of LBP aged over 55 years and had no other red flags. Analysis of this group of patients revealed 2 serious spinal pathologies. Both of which were osteoporotic vertebral compression fractures. Both patients were over age 75. In addition 1 patient had severe central lumbar canal stenosis. Therefore, 2.3% of patients presented with the first onset of LBP > 55 years, of which 2.9% has serious pathology. Patients > 55 years with cancer or infection had other red flags in addition. Conclusion: In isolation the first onset of LBP over the age > 55 accounts for a small percentage of this secondary care population, of which 2.9% had vertebral compression fractures. Further research into the clinical value of this independent red flag or its added value in combination with other red flags is recommended

Objective: To present early results of a new technique of dynamic stabilisation of the lumbo-sacral spine. Design: Prospective study. Subjects: Between September 2000 and December 2001, 43 patients underwent posterior spinal stabilisation using the Dynamic Neutralisation System (DYNESYS) (Sulzer Medica). Outcome Measures: Oswestry Disability indices, complications, visual analogue pain scores, patient satisfaction. Results: The perceived indications were isolated degenerative disc disease (26), spondylolisthesis (8), degenerate adult scoliosis (4), failed Graf stabilisation (1), lumbar canal stenosis (3) and traumatic compression fracture (1). Fixation was at one level in 14, two levels in 23, and three or four levels in 6 patients. Thirty-seven had Dyne-sys fixation alone and six had additional procedures at the same operation. Complications included facet fracture (1), broken pedicle screw (1), apparent screw loosening (1) and discitis (1). At average follow-up of eight months (range 2–14 months), the average Oswestry disability score had fallen from 52 to 32 and the visual analogue pain score from 7.5 to 1.7. 65% of patients were pleased or better with their result. Conclusions: The Dynesys system seems to be a safe alternative to conventional operative treatment for degenerative disorders of the lumbar spine without the need for rigid fusion. The anatomic re-stabilisation may allow the spinal segment to recover. The early results are encouraging. It is hoped that longer term follow-up will clarify the groups of patients who will benefit most from this procedure

Purpose: There are a wide variety of operative procedures for lumbar spinal canal stenosis. Bilateral fenestration, preserving the continuity of the lamina and spinous processes, has widely been employed in our department and its affiliated hospitals. The following questions are raised: Are decompressive effects of fenestration and spinal stability maintained without spinal fusion or instrumentation? In order to answer the questions, we compared the rates of revision after fenestration with those after laminectomy alone and decompressive surgery with spinal fusion. Materials and methods: The registry of spinal surgeries of our university and affiliated hospitals from 1988 to 1997 was consulted. During the first 5-years period 1159 patients underwent decompressive surgery. 908 of them had spondylosis and 251 had degenerative spondylolisthesis (DO) as a contributing factors of neural compression. Fenestration was done in 740 (81%) of patients with spondylosis and in 176 (70%) of patients with DO. Results: Regarding the whole series 31 out of 1159 patients had a revision. The revision rate was 2.7%. 15 out of 908 patients (1.7%) with spondylosis and 16 out of 251 patients (6.4%) with DO underwent revisions. 11 out of 740 (1.5%) with spondylosis and 11 out of 176 (6.3%) with DO underwent revisions after fenestration. No significant differences were found among the revision rate of fenestration, laminectomy and decompressive surgery with spinal fusion. Conclusion: The decompressive effect of fenestration was maintained long enough, even for degenerative spondylolisthesis. As a first operation spinal fusion is not necessarily indicated for lumbar canal stenosis