今日の臨床サポート

腰部脊柱管狭窄症

著者: 橋爪洋1) 和歌山県立医科大学 保健看護学部病態学・医学部整形外科学講座 兼務

著者: 吉田宗人2) 社会医療法人スミヤ 角谷整形外科病院院長・和歌山県立医科大学名誉教授

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2021/09/22
参考ガイドライン:
  1. 日本整形外科学会:腰部脊柱管狭窄症診療ガイドライン 2021(改訂第2版)
患者向け説明資料

概要・推奨   

  1. MRIは腰部脊柱管狭窄症の画像診断に適した非侵襲的な検査であるしかし、最も大切なのは臨床症状や身体所見であり、画像所見は補助診断に過ぎないことを理解する
  1. 馬尾型もしくは混合型の患者には、リマプロスト投与が推奨される推奨度2RsJ)。
  1. 神経根型もしくは腰痛を有する患者には、非ステロイド性抗炎症薬(NSAIDs投与が推奨される。ただし、腎機能障害、消化器障害などへの配慮が必要であり、短期間の使用が望ましい(推奨度2、RJ)。
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要と
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となり
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
橋爪洋 : 特に申告事項無し[2021年]
吉田宗人 : 未申告[2021年]
監修:酒井昭典 : 講演料(旭化成ファーマ(株),第一三共(株),中外製薬(株)),奨学(奨励)寄付など(旭化成ファーマ(株),第一三共(株),中外製薬(株))[2021年]

改訂のポイント:
  1. 2021年に腰部脊柱管狭窄症ガイドラインが改訂されたため、その情報を反映させた。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 腰椎部において椎骨、椎間板、靭帯(後縦靭帯、黄色靭帯)で構成される脊柱管内には、硬膜で覆われた脊髄神経(腰髄神経・仙髄神経)の束が通過しており、各椎弓根の高さで分岐した脊髄神経は椎間孔を通って脊柱外部に出て行く。
 
腰椎部の解剖

a:脊椎と脊髄・脊髄神経の位置関係
b:L4/5椎間板が脊柱管内で突出した場合、L4神経ではなくL5神経が障害される
c:腰椎横断面とMR像(L1椎体高位)

 
  1. 腰部脊柱管狭窄症は神経の通路である脊柱管や椎間孔が狭小化することで、特有の症状(立位の継続や歩行により出現あるいは増悪する殿部下肢の疼痛や痺れ、会陰部症状)を呈する症候群である[1]
  1. 多くは腰椎の椎間板と椎間関節の変性を基盤として発生し、黄色靭帯の変性肥厚を伴う。
 
腰部脊柱管狭窄の模式図

a:正常な腰部脊柱管
b:腰部脊柱管狭窄

出典

 
  1. 50歳代以後に発生し、加齢と共に有病者の割合は増加する[2]
 
腰部脊柱管狭窄症の性別・年代別分布

和歌山県の住民コホート1009名を対象に行われた横断研究結果である。横軸は年代、縦軸は検診参加者における有病者の割合を示す。(下記文献を改変)

出典

img1:  Prevalence of symptomatic lumbar spinal stenosis and its association with physical performance in a population-based cohort in Japan: the Wakayama Spine Study.
 
 Osteoarthritis Cartilage. 2012 Oct;20(10・・・
 
  1. 外来受診する60歳以上の患者の中で殿部下肢痛の最も多い原因である[3]
問診・診察のポイント  
問診:
  1. 発症時期を確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Y Ishimoto, N Yoshimura, S Muraki, H Yamada, K Nagata, H Hashizume, N Takiguchi, A Minamide, H Oka, H Kawaguchi, K Nakamura, T Akune, M Yoshida
雑誌名: Osteoarthritis Cartilage. 2012 Oct;20(10):1103-8. doi: 10.1016/j.joca.2012.06.018. Epub 2012 Jul 10.
Abstract/Text OBJECTIVE: The purpose of this study was to investigate the prevalence of symptomatic lumbar spinal stenosis (LSS) and to clarify the association between symptomatic LSS and physical performance using magnetic resonance imaging (MRI) in a population-based cohort.
DESIGN: This cross-sectional study was performed as a part of the research on osteoarthritis/osteoporosis against disability (ROAD) in Japan and 1,009 subjects (335 men, 674 women, mean age 66.3 years, age range 21-97 years) were analyzed. An experienced orthopedic surgeon obtained the medical history and performed the physical testing for all participants. Symptomatic LSS diagnostic criteria required the presence of both symptoms and radiographic LSS findings. A 6-m walking time, chair standing time, and one-leg standing time were obtained from all participants.
RESULTS: The prevalence of symptomatic LSS was 9.3% (95% confidence interval [CI]: 7.7-11.3) overall, 10.1% (CI: 7.4-13.8) in men and 8.9% (CI: 7.0-11.3) in women. There was a difference in the prevalence with increasing age by gender. The LSS prevalence showed little difference with age greater than 70 years for men, but the LSS prevalence for women was higher with increasing age. Among physical performance measures, 6-m walking time at a maximal pace was significantly associated with symptomatic LSS (P = 0.03).
CONCLUSION: The prevalence of symptomatic LSS was approximately 10% in a cohort resembling the general Japanese population. A 6-m walking time at a maximal pace was a more sensitive index than walking at a usual pace in assessing decreased physical performance associated with symptomatic LSS.

Copyright © 2012 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.
PMID 22796511  Osteoarthritis Cartilage. 2012 Oct;20(10):1103-8. doi: ・・・
著者: Shin-ichi Konno, Shin-ichi Kikuchi, Yasuhisa Tanaka, Ken Yamazaki, You-ichi Shimada, Hiroshi Takei, Toru Yokoyama, Masahiro Okada, Shou-ichi Kokubun
雑誌名: BMC Musculoskelet Disord. 2007 Oct 30;8:102. doi: 10.1186/1471-2474-8-102. Epub 2007 Oct 30.
Abstract/Text BACKGROUND: There is no validated gold-standard diagnostic support tool for LSS, and therefore an accurate diagnosis depends on clinical assessment. Assessment of the diagnostic value of the history of the patient requires an evaluation of the differences and overlap of symptoms of the radicular and cauda equina types; however, no tool is available for evaluation of the LSS category. We attempted to develop a self-administered, self-reported history questionnaire as a diagnostic support tool for LSS using a clinical epidemiological approach. The aim of the present study was to use this tool to assess the diagnostic value of the history of the patient for categorization of LSS.
METHODS: The initial derivation study included 137 patients with LSS and 97 with lumbar disc herniation who successfully recovered following surgical treatment. The LSS patients were categorized into radicular and cauda equina types based on history, physical examinations, and MRI. Predictive factors for overlapping symptoms between the two types and for cauda equina symptoms in LSS were derived by univariate analysis. A self-administered, self-reported history questionnaire (SSHQ) was developed based on these findings. A prospective derivation study was then performed in a series of 115 patients with LSS who completed the SSHQ before surgery. All these patients recovered following surgical treatment. The sensitivity of the SSHQ was calculated and clinical prediction rules for LSS were developed. A validation study was subsequently performed on 250 outpatients who complained of lower back pain with or without leg symptoms. The sensitivity and specificity of the SSHQ were calculated, and the test-retest reliability over two weeks was investigated in 217 patients whose symptoms remained unchanged.
RESULTS: The key predictive factors for overlapping symptoms between the two categories of LSS were age > 50, lower-extremity pain or numbness, increased pain when walking, increased pain when standing, and relief of symptoms on bending forward (odds ratio > or = 2, p < 0.05). The key predictive factors for cauda equina type symptoms were numbness around the buttocks, walking almost causes urination, a burning sensation around the buttocks, numbness in the soles of both feet, numbness in both legs, and numbness without pain (odds ratio > or = 2, p < 0.05). The sensitivity and specificity of the SSHQ were 84% and 78%, respectively, in the validation data set. The area under the receiver operating characteristic curve was 0.797 in the derivation set and 0.782 in the validation data set. In the test-retest analysis, the intraclass correlation coefficient for the first and second tests was 85%.
CONCLUSION: A new self-administered, self-reported history questionnaire was developed successfully as a diagnostic support tool for LSS.

PMID 17967201  BMC Musculoskelet Disord. 2007 Oct 30;8:102. doi: 10.11・・・
著者: Shinichi Konno, Yasuaki Hayashino, Shunichi Fukuhara, Shinichi Kikuchi, Kiyoshi Kaneda, Atsushi Seichi, Kazuhiro Chiba, Kazuhiko Satomi, Kensei Nagata, Shinya Kawai
雑誌名: Eur Spine J. 2007 Nov;16(11):1951-7. doi: 10.1007/s00586-007-0402-2. Epub 2007 Jun 5.
Abstract/Text No clinical diagnostic support tool can help identify patients with LSS. Simple diagnostic tool may improve the accuracy of the diagnosis of LSS. The aim of this study was to develop a simple clinical diagnostic tool that may help physicians to diagnose LSS in patients with lower leg symptoms. Patients with pain or numbness of the lower legs were prospectively enrolled. The diagnosis of LSS by experienced orthopedic specialists was the outcome measure. Multivariable logistic regression analysis identified factors that predicted LSS; a simple clinical prediction rule was developed by assigning a risk score to each item based on the estimated beta-coefficients. From December 2002 to December 2004, 104 orthopedic physicians from 22 clinics and 50 hospitals evaluated 468 patients. Two items of physical examination, three items of patients' symptom, and five items of physical examination were included in the final scoring system as a result of multiple logistic regression analysis. The sum of the risk scores for each patient ranged from -2 to 16. The Hosmer-Lemeshow statistic was 11.30 (P = 0.1851); the area under the ROC curve was 0.918. The clinical diagnostic support tool had a sensitivity of 92.8% and a specificity of 72.0%. The prevalence of LSS was 6.3% in the bottom quartile of the risk score (-2 to 5) and 99.0% in the top quartile (12 to 16). We developed a simple clinical diagnostic support tool to identify patients with LSS. Further studies are needed to validate this tool in primary care settings.

PMID 17549525  Eur Spine J. 2007 Nov;16(11):1951-7. doi: 10.1007/s0058・・・
著者: R J Bischoff, R P Rodriguez, K Gupta, A Righi, J E Dalton, T S Whitecloud
雑誌名: J Spinal Disord. 1993 Aug;6(4):289-95.
Abstract/Text The sensitivity, specificity, and accuracy of computed tomography (CT)-myelography, magnetic resonance imaging (MRI), and myelography in making the diagnosis of herniated nucleus pulposus (HNP) and spinal stenosis were compared in a retrospective study involving 59 surgical procedures in 57 patients who had all three tests performed preoperatively. One hundred nineteen levels were surgically explored for evidence of HNP and spinal stenosis. The results of each test were correlated with what was found at each surgical level explored. Overall, myelo-CT was the most accurate test for diagnosing HNP (76.4%) as well as the most sensitive (77.8%), whereas myelography was the most specific (89.2%). In making the diagnosis of spinal stenosis, myelo-CT and MRI were equally accurate (85.3%) and sensitive (87.2%), whereas myelography was the most specific (88.9%). In a special subset of patients who had revision surgery, the accuracy rate in diagnosing spinal stenosis or HNP was highest with MRI (84.9%), as was the sensitivity (69.2%) and specificity (95%). According to the results obtained from this series of patients, myelo-CT seems to be the most sensitive and accurate test in diagnosing HNP and spinal stenosis, whereas myelography is the most specific, although no statistical significance was noted in this study. However, because MRI did compare favorably with myelo-CT in most instances, particularly in revision surgery; it may be the procedure of choice due to its noninvasiveness and relative lack of side effects.

PMID 8219542  J Spinal Disord. 1993 Aug;6(4):289-95.
著者: L S Jia, Z R Shi
雑誌名: Chin Med J (Engl). 1991 Apr;104(4):303-6.
Abstract/Text We studied the diagnostic accuracy of magnetic resonance imaging (MRI) and the possibility of its substitution for myelography in 78 patients with lumbar canal stenosis and/or disc herniation, who had myelography and MRI examination. The diagnostic results of the two methods were compared respectively with those of operation, showing no statistical significance (coincidence rate 88.5% vs 92.3%, P greater than 0.05). We conclude that MRI could clearly reveal the pathological changes and anatomical relations of lumbar structures without invasive and radioactive damages, and that with the improvement of operative technique, better understanding of images, and reduction of cost, MRI is likely to replace myelography in the future.

PMID 2065548  Chin Med J (Engl). 1991 Apr;104(4):303-6.
著者: D L Kent, D R Haynor, E B Larson, R A Deyo
雑誌名: AJR Am J Roentgenol. 1992 May;158(5):1135-44. doi: 10.2214/ajr.158.5.1533084.
Abstract/Text We undertook a literature synthesis of CT, MR, and myelographic studies to evaluate what is known about the diagnostic accuracy of these imaging tests for the diagnosis of lumbar spinal stenosis in adults without prior surgery. From 116 possibly relevant studies, we reviewed 14 articles that included cases of spinal stenosis with a reference standard other than the imaging tests of interest. Of the studies we reviewed, two involved only MR, nine only CT, and three used both; six studies included myelography. Rating categories of A, B, C, or D were assigned for the quality of research methods used to estimate diagnostic accuracy. All studies received either a C or D rating. Common methodologic problems were failure to assemble a representative cohort for study, small sample size, and failure to maintain independence between image readings and reference standards. Sensitivity ranged from 0.81 to 0.97 for MR, from 0.70 to 1.0 for CT, and from 0.67 to 0.78 myelography. Studies varied greatly in case selection, definition of test and disease categories, and geographic locale, so no pooled estimates could be derived. In asymptomatic patients, abnormal findings appeared on CT or MR in 4-28% of cases and were more common in the elderly. Published studies of the value of CT and MR for the diagnosis of lumbar stenosis lack methodologic rigor and do not permit strong conclusions about the relative diagnostic accuracies of these procedures. For the present, the choice between MR or CT depends on issues such as costs, reimbursements, access to equipment, skill of radiologists, and patient safety. Better studies will be needed to document claims for improvements in imaging accuracy as MR technologies evolve. These studies should emphasize larger sample sizes, more attention to research designs that avoid methodologic biases, and the contribution of imaging diagnoses to ultimate clinical outcome.

PMID 1533084  AJR Am J Roentgenol. 1992 May;158(5):1135-44. doi: 10.2・・・
著者: B Schnebel, S Kingston, R Watkins, W Dillin
雑誌名: Spine (Phila Pa 1976). 1989 Mar;14(3):332-7.
Abstract/Text Retrospectively, the MR (magnetic resonance) and contrast CT (computed tomography examinations of 41 patients (123 segments) were objectively scored to evaluate spinal stenosis and disc degeneration. Five categories to evaluate stenosis included the facet joint, foramina, central canal, disc on sagittal section, and disc on axial section. In addition, the ability to demonstrate spondylolysis was compared. The examinations were interpreted by a single observer blinded to the results. Comparisons show 96.6% agreement between MR and contrast CT in the diagnosis of spinal stenosis. Magnetic resonance showed disc degeneration in 74 of 123 segments, while CT showed disc degeneration disease in 27 of 123 segments. Spondylolysis was recognized at three segments on both MR and CT. In conclusion, MR and contrast CT are comparable in their abilities to demonstrate spinal stenosis, and MR is more sensitive in demonstrating disc degeneration.

PMID 2711248  Spine (Phila Pa 1976). 1989 Mar;14(3):332-7.
著者: G R Bell, R H Rothman, R E Booth, J M Cuckler, S Garfin, H Herkowitz, F A Simeone, C Dolinskas, S S Han
雑誌名: Spine (Phila Pa 1976). 1984 Sep;9(6):552-6.
Abstract/Text One hundred twenty-two patients with surgically confirmed pathology consisting of either herniated lumbar disc, spinal stenosis, or both were included in this investigation. For each of these patients, preoperative metrizamide myelography and computerized tomography were performed. Each myelogram and CT scan was read blindly so that the neuroradiologist interpreting the study had no knowledge of the patient's surgical pathology, clinical examination, nor any knowledge of the interpretation of the other preoperative test. A painstaking attempt was made to describe precisely both the exact nature of the preoperative myelogram and CT scan interpretations. The correlations between the preoperative interpretation of each test and the observed surgical findings then were analyzed statistically. Based upon this analysis, myelography was found to be more accurate than computed tomography in the diagnosis of herniated lumbar disc (83% vs. 72%). In the diagnosis of spinal stenosis, myelography was slightly more accurate than computed tomography (93% vs. 89%). Based upon the results of this study, the authors conclude that metrizamide myelography is more accurate than computed tomography in the diagnosis of both herniated lumbar disc and spinal stenosis and remains the diagnostic study of choice for these conditions. Furthermore, metrizamide myelography gives the added advantage of visualizing the thoracolumbar junction and, thus, affords the opportunity to diagnose occult spinal tumors.

PMID 6495025  Spine (Phila Pa 1976). 1984 Sep;9(6):552-6.
著者: Mutlu Cihangiroglu, Hanifi Yildirim, Zulkif Bozgeyik, Utku Senol, Huseyin Ozdemir, Cahide Topsakal, Saim Yilmaz
雑誌名: Eur J Radiol. 2004 Sep;51(3):202-8. doi: 10.1016/j.ejrad.2003.08.004.
Abstract/Text OBJECT: aim of this study was to analyse the observer variability in the diagnosis and definition of disc pathologies with low and high-field strength MR scanners.
MATERIAL AND METHODS: 95 patients with low back pain or radicular pain who were referred from two different centers were included in the study. Fifty-seven patients were scanned with 0.3 T MR (group 1) and 38 patients with 1.5 T (group 2). The intraobserver and interobserver reliability were assessed with the cappa coefficient which was characterised as follows: values less than 0.0 = 'poor' agreement, values 0.01-0.2 = 'slight' agreement beyond chance, 0.21-0.4 = 'fair' agreement, 0.41-0.60 = 'moderate' agreement, 0.61-0.80 = 'substantial' agreement and 0.81-1.00 = 'almost perfect' agreement.
RESULTS: intraobserver agreement in group 1 and group 2 for both readers was 'almost perfect' in differentiating normal and pathological discs; 'substantial-almost perfect' in defining the disc pathologies, 'moderate-substantial' in root compression, and 'moderate-substantial' in spinal stenosis. Interobserver agreement was 'almost perfect' in differentiating normal and pathological discs, 'substantial' in defining disc pathologies, 'moderate' in root compression and 'moderate' in spinal stenosis in the group 1, whereas in group 2, it was 'almost perfect' in differentiating normal and pathological discs, 'almost perfect' in defining disc pathologies, 'slight-substantial' in root compression and 'moderate' in spinal stenosis.
CONCLUSION: in the diagnosis of root compression and spinal stenosis, the intra and interobserver agreements were relatively poor with both high and low-strength field MRIs, indicating a need for more objective criteria. In differentiating normal and pathologic appearance of disc, the interobserver agreement was considerably better with high-field compared to low-field strength MRI. In cases where this definition is important, high-field strength scanners should be preferred.

PMID 15294326  Eur J Radiol. 2004 Sep;51(3):202-8. doi: 10.1016/j.ejra・・・
著者: L G Jenis, H S An
雑誌名: Spine (Phila Pa 1976). 2000 Feb 1;25(3):389-94.
Abstract/Text Lumbar foraminal stenosis is an important pathologic entity to identify in the patient being treated for radicular symptoms. This update reviews the anatomy, clinical presentation, neuroradiographic evaluation, and treatment of pathology located in the intervertebral foramen. Patients with significant leg pain refractory to conservative treatment and concordance between the demonstrated area of stenosis and radicular symptoms and signs are candidates for the decompressive procedures discussed. The role of arthrodesis and spinal instrumentation in the management of foraminal stenosis also is addressed.

PMID 10703115  Spine (Phila Pa 1976). 2000 Feb 1;25(3):389-94.
著者: I Macnab
雑誌名: J Bone Joint Surg Am. 1971 Jul;53(5):891-903.
Abstract/Text
PMID 4326746  J Bone Joint Surg Am. 1971 Jul;53(5):891-903.
著者: C V Burton, W H Kirkaldy-Willis, K Yong-Hing, K B Heithoff
雑誌名: Clin Orthop Relat Res. 1981 Jun;(157):191-9.
Abstract/Text An interinstitutional study on the failed back surgery syndrome (FBSS) has determined that failure to recognize or adequately treat lateral stenosis of the lumbar spine with resultant nerve irritation and/or compression comprised the primary etiology in 57% to 58% of patients. Other common causes were recurrent or persistent disk herniation and lumbosacral adhesive arachnoiditis. The diagnosis of stenosis was made either by high-resolution CT scan of the lumbar spine or by directly testing lateral canal and for animal patency at the time of surgery. It is now appreciated that the process of degenerative disk disease, particularly when enhanced by diskectomy, results in progressive loss of intervertebral disk volume and predisposes to future ipsilateral or contralateral lateral spinal stenosis. Degenerative disk disease is ultimately a bilateral process and therefore surgical exposure should be bilateral. The direct and indirect costs of FBSS to patients and to society as well as the toll in human suffering are very high. This is particularly a matter of concern when it is realized that for many FBSS patients, surgery could have been avoided in the first place by preventive care or by innovative conservative treatment. When surgery is indicated, adequate diagnostic tests and the execution of appropriate procedures based upon this information should largely prevent the failed back surgery syndrome.

PMID 7249453  Clin Orthop Relat Res. 1981 Jun;(157):191-9.
著者: J Kunogi, M Hasue
雑誌名: Spine (Phila Pa 1976). 1991 Nov;16(11):1312-20.
Abstract/Text The clinical, radiologic, and operative findings, and clinical results in 26 cases of foraminal nerve root involvement, each treated by variable operative procedures for an existing pathologic condition, were studied. These 26 cases consisted of 8 intraforaminal or extraforaminal lumbar disc herniations and 18 foraminal nerve root entrapments. The cases with an extreme lateral lumbar disc herniation underwent lateral fenestration or osteoplastic hemilaminectomy without concomitant spinal fusion, and showed excellent operative results. A sufficient selective decompression was achieved with a good clinical result in the cases of lumbar spondylosis without preoperative spinal instability, by lateral fenestration or osteoplastic hemilaminectomy. This result suggests that the selective decompression procedure is recommended for cases with reliable preoperative diagnoses. When an intraspinal lesion makes it difficult to diagnose coexisting foraminal nerve root involvement, decompression of the nerve root canal, approaching from medial to lateral, is recommended. The fusion operation should be performed in cases undergoing even a unilateral total facetectomy, regardless of the patient's old age. A correct preoperative diagnosis is crucial in order to obtain satisfactory operative results.

PMID 1750006  Spine (Phila Pa 1976). 1991 Nov;16(11):1312-20.
著者: Hiroshi Yamada, Munehito Yoshida, Hiroshi Hashizume, Akihito Minamide, Yukihiro Nakagawa, Masaki Kawai, Hiroshi Iwasaki, Syunji Tsutsui
雑誌名: J Spinal Disord Tech. 2012 Jul;25(5):268-76. doi: 10.1097/BSD.0b013e3182206dd3.
Abstract/Text STUDY DESIGN: A retrospective case study of the spinal microendoscopic surgery for the treatment of extraforaminal stenosis at the lumbosacral junction.
OBJECTIVE: To evaluate the efficacy of a minimally invasive technique using spinal microendoscope and to examine the 2-year surgical outcome for this disease.
SUMMARY OF BACKGROUND DATA: The paraspinal approach has been the gold standard to expose the extraforaminal space. Although it seems to be ideal, the constricted surgical field of view may compromise the surgeon's ability and increase the risk of complications. This technique can be improved further.
METHODS: A total of 32 patients, who completed a minimum follow-up of 2 years after the surgery, were included in this study. The study group consisted of 16 men and 16 women with an average age at surgery of 64 years and a mean follow-up of 37.4 months. Clinical results were evaluated according to the Japanese Orthopaedic Association (JOA) scoring system, visual analog scale, and the North American Spine Society Low Back Outcome Instrument.
RESULTS: Two of these patients required revision surgery to correct insufficient decompression in the foramen. In the 30 other patients, the mean JOA score was 15.1 points before surgery and 23.1 points at the final follow-up. The mean recovery rate was 60.1%. The JOA scores improved significantly after surgery and the satisfactory results were maintained until the final follow-up. The visual analog scale scores for low-back pain, leg pain, and numbness also significantly improved. Twenty-eight of 32 patients (87.6%) were satisfied with this procedure.
CONCLUSIONS: The spinal microendoscopic surgery demonstrated efficacy for treating extraforaminal stenosis at the lumbosacral junction where the lesion is difficult to be exposed. Quick and easy access along with minimal damage to the back muscles and bony structures could be accomplished using the property of its oblique view and angled surgical equipments. This procedure has produced long-lasting favorable outcomes and high patient satisfaction. Novel minimally invasive surgery may replace conventional open methods.

PMID 21811183  J Spinal Disord Tech. 2012 Jul;25(5):268-76. doi: 10.10・・・
著者: T Amundsen, H Weber, H J Nordal, B Magnaes, M Abdelnoor, F Lilleâs
雑誌名: Spine (Phila Pa 1976). 2000 Jun 1;25(11):1424-35; discussion 1435-6.
Abstract/Text STUDY DESIGN: A cohort of 100 patients with symptomatic lumbar spinal stenosis, characterized in a previous article, were given surgical or conservative treatment and followed for 10 years.
OBJECTIVES: To identify the short- and long-term results after surgical and conservative treatment, and to determine whether clinical or radiologic predictors for the treatment result can be defined.
SUMMARY OF BACKGROUND DATA: Surgical decompression has been considered the rational treatment. However, clinical experience indicates that many patients do well with conservative treatment.
METHODS: In this study, 19 patients with severe symptoms were selected for surgical treatment and 50 patients with moderate symptoms for conservative treatment, whereas 31 patients were randomized between the conservative (n = 18) and surgical (n = 13) treatment groups. Pain was decisive for the choice of treatment group. All patients were observed for 10 years by clinical evaluation and questionnaires. The results, evaluated by patient and physician, were rated as excellent, fair, unchanged, or worse.
RESULTS: After a period of 3 months, relief of pain had occurred in most patients. Some had relief earlier, whereas for others it took 1 year. After a period of 4 years, excellent or fair results were found in half of the patients selected for conservative treatment, and in four fifths of the patients selected for surgery. Patients with an unsatisfactory result from conservative treatment were offered delayed surgery after 3 to 27 months (median, 3.5 months). The treatment result of delayed surgery was essentially similar to that of the initial group. The treatment result for the patients randomized for surgical treatment was considerably better than for the patients randomized for conservative treatment. Clinically significant deterioration of symptoms during the final 6 years of the follow-up period was not observed. Patients with multilevel afflictions, surgically treated or not, did not have a poorer outcome than those with single-level afflictions. Clinical or radiologic predictors for the final outcome were not found. There were no dropouts, except for 14 deaths.
CONCLUSIONS: The outcome was most favorable for surgical treatment. However, an initial conservative approach seems advisable for many patients because those with an unsatisfactory result can be treated surgically later with a good outcome.

PMID 10828926  Spine (Phila Pa 1976). 2000 Jun 1;25(11):1424-35; discu・・・
著者: Andrew J Haig, Henry C Tong, Karen S J Yamakawa, Christopher Parres, Douglas J Quint, Anthony Chiodo, Jennifer A Miner, Vaishali C Phalke, Julian T Hoff, Michael E Geisser
雑誌名: Spine (Phila Pa 1976). 2006 Dec 1;31(25):2950-7. doi: 10.1097/01.brs.0000247791.97032.1e.
Abstract/Text STUDY DESIGN: Longitudinal masked, double-controlled cohort study.
OBJECTIVES: To determine prognosis and predictors of function and pain in persons with spinal stenosis.
SUMMARY OF BACKGROUND DATA: The clinical syndrome of spinal stenosis is common and disabling, but not clearly related to anatomic measures. Prognosis not well studied.
METHODS: Persons 55 to 80 years of age with and without stenosis on preliminary review of magnetic resonance imaging (MRI), and asymptomatic volunteers underwent screening, questionnaires, physical examination, ambulation testing, masked electromyogram (EMG), and masked MRI scans; these were repeated at >18 months.
RESULTS: Twenty-three asymptomatic, 28 back pain, and 32 clinically diagnosed stenosis subjects underwent follow-up. Although initial and follow-up diagnosis tended to agree (kappa = 0.394, P < 001), there were substantial shifts between the three groups. Among persons with clinically diagnosed stenosis, every measure trended for improvement, including significant changes in pain, ambulation, and EMG. Ambulation velocity and Pain Disability Index at follow-up were predicted by initial disability measures. Pain was predicted by initial sleep difficulty but not initial pain. EMG and MRI did not predict function or pain.
CONCLUSION: Clinically recognized spinal stenosis is fluctuating and largely improving, and in continuum with back pain and no symptoms. Since anatomic and neurologic deficits do not predict future function, they should not be weighed heavily in surgical risk-benefit discussions.

PMID 17139226  Spine (Phila Pa 1976). 2006 Dec 1;31(25):2950-7. doi: 1・・・
著者: O Airaksinen, A Herno, V Turunen, T Saari, O Suomlainen
雑誌名: Spine (Phila Pa 1976). 1997 Oct 1;22(19):2278-82.
Abstract/Text STUDY DESIGN: A retrospective, follow-up study.
OBJECTIVES: To investigate the overall outcome of surgery for lumbar spinal stenosis and to investigate the preoperative factors affecting outcome.
SUMMARY OF BACKGROUND DATA: The success rates of surgical intervention for lumbar spinal stenosis vary, and few preoperative factors have been found to be significantly correlated to surgical outcome.
METHODS: A total of 438 patients (183 women, 255 men) who underwent decompressive surgery for lumbar spinal stenosis were re-examined and evaluated for outcome 4.3 years after surgery. Outcome was based on subjective disability, which was assessed using the Oswestry low back pain questionnaire. The preoperative data (clinical documentation, length of laminectomy, and radiographs) were collected from patient records that had been stored in the hospital. Preoperative factors affecting outcome were reported.
RESULTS: The mean value of the Oswestry disability score of these 438 patients was 34 +/- 18 (women, 36.3 +/- 17; men, 32.3 +/- 18; P < 0.05). Age did not influence general outcome. The proportion of good to excellent outcomes of all 438 patients was 62% (women, 57%; men, 65%). Diabetes, hip joint arthrosis, and preoperative fracture of the lumbar spine seemed to be associated with poor outcome. The ability to work before or after surgery and a history of no prior back surgery were predictive of good outcome.
CONCLUSION: The results suggest that clear myelographic stenosis and no prior surgical intervention, no comorbidity of diabetes, no hip joint arthrosis, and no preoperative fracture of the lumbar spine are factors associated with a good outcome in surgical management of lumbar spinal stenosis.

PMID 9346149  Spine (Phila Pa 1976). 1997 Oct 1;22(19):2278-82.
著者: Steven J Atlas, Robert B Keller, Yen A Wu, Richard A Deyo, Daniel E Singer
雑誌名: Spine (Phila Pa 1976). 2005 Apr 15;30(8):936-43.
Abstract/Text STUDY DESIGN: A prospective observational cohort study.
OBJECTIVE: To assess long-term outcomes of patients with lumbar spinal stenosis treated surgically or nonsurgically.
SUMMARY OF BACKGROUND DATA: The relative benefit of various treatments for lumbar spinal stenosis is uncertain. Surgical treatment has been associated with short-term improvement, but recurrence of symptoms has been documented. Few studies have compared long-term outcomes of surgical and nonsurgical treatments.
METHODS: Patients recruited from the practices of orthopaedic surgeons, neurosurgeons, and occupational medicine physicians throughout Maine had baseline interviews with follow-up questionnaires mailed at regular intervals over 10 years. Clinical data were obtained at baseline from a physician questionnaire. Most patients initially undergoing surgery had a laminectomy without fusion performed. Outcomes including patient-reported symptoms of leg and back pain, functional status, and satisfaction were assessed at 8- to 10-year follow-up. Primary analyses were based on initial treatment received with secondary analyses examining actual treatment received by 10 years.
RESULTS: Of 148 eligible consenting patients initially enrolled, 105 were alive after 10 years (67.7% survival rate). Among surviving patients, long-term follow-up between 8 and 10 years was available for 97 of 123 (79%) patients (including 11 patients who died before the 10-year follow-up but completed a 8 or 9 year survey); 56 of 63 (89%) initially treated surgically and 41 of 60 (68%) initially treated nonsurgically. Patients undergoing surgery had worse baseline symptoms and functional status than those initially treated nonsurgically. Outcomes at 1 and 4 years favored initial surgical treatment. After 8 to 10 years, a similar percentage of surgical and nonsurgical patients reported that their low back pain was improved(53% vs. 50%, P = 0.8), their predominant symptom (either back or leg pain) was improved (54% vs. 42%, P = 0.3), and they were satisfied with their current status (55% vs. 49%, P = 0.5). These treatment group findings persisted after adjustment for other determinants of outcome in multivariate models. However, patients initially treated surgically reported less severe leg pain symptoms and greater improvement in back-specific functional status after 8 to 10 years than nonsurgically treated patients. By 10 years, 23% of surgical patients had undergone at least one additional lumbar spine operation, and 39% of nonsurgical patients had at least one lumbar spine operation. Patients undergoing subsequent surgical procedures had worse outcomes than those continuing with their initial treatment. Outcomes according to actual treatment received at 10 years did not differ because individuals undergoing additional surgical procedures had worse outcomes than those continuing with their initial treatment.
CONCLUSIONS: Among patients with lumbar spinal stenosis completing 8- to 10-year follow-up, low back pain relief, predominant symptom improvement, and satisfaction with the current state were similar in patients initially treated surgically or nonsurgically. However, leg pain relief and greater back-related functional status continued to favor those initially receiving surgical treatment. These results support a shared decision-making approach among physicians and patients when considering treatment options for lumbar spinal stenosis.

PMID 15834339  Spine (Phila Pa 1976). 2005 Apr 15;30(8):936-43.
著者: M Cornefjord, G Byröd, H Brisby, B Rydevik
雑誌名: Eur Spine J. 2000 Dec;9(6):563-70.
Abstract/Text Limited data are available about the long-term outcome of surgical treatment for lumbar spinal stenosis, and there is a wide variation in reported success rates. There is also a controversy regarding differences in long-term outcome between patients undergoing decompressive surgery alone and those undergoing both decompression and fusion. The aim of this study was to evaluate the long-term clinical outcome and possible complications of decompressive surgery, with special reference to possible differences between patients undergoing fusion, with or without instrumentation, and those undergoing decompression alone. All 124 patients undergoing first-time surgery for lumbar spinal stenosis between 1982 and 1991 at our department were included, and their medical records were reviewed retrospectively. Ninety-six of the patients were available for follow-up and were re-examined by an independent investigator and assessed with a questionnaire after a mean follow-up period of 7.1 (range 4.0-12.2) years. Sixty-five percent of all the patients at the follow-up were subjectively satisfied. Eighty-eight percent of the patients reported constant or daily leg pain preoperatively compared to 43% at follow-up. Constant or daily low back pain was reported by 83% of the patients preoperatively compared to 45% at follow-up. Improvement in walking capacity was found in most patients, and only 4% of the patients who had a preoperatively documented maximum walking distance reported a decreased walking capacity. Twenty-four (25%) of all patients used analgesics daily at the time of follow-up, 34 patients (35%) occasionally and 38 patients (40%) never. The patients with fusions, instrumented or non-instrumented, did not differ significantly from the unfused patients regarding any of the above-mentioned parameters. The results of the study showed that most patients demonstrated a considerable improvement in walking capacity at follow-up. This improvement was significant (P < 0.001) and of clinical importance. A significant improvement regarding both low back pain and leg pain was found postoperatively compared to preoperatively (P < 0.001). There were no statistical differences, judged by all the evaluated parameters, regarding the clinical outcome between patients who were fused and those who were not. Neither were any significant differences found between instrumented fusions compared to uninstrumented fusions. In accordance with most other long-term follow-up studies, about two-thirds (65%) of the patients claimed a satisfactory result at follow-up.

PMID 11189928  Eur Spine J. 2000 Dec;9(6):563-70.
著者: H Hurri, P Slätis, J Soini, K Tallroth, H Alaranta, T Laine, M Heliövaara
雑誌名: J Spinal Disord. 1998 Apr;11(2):110-5.
Abstract/Text The present study focuses on the long-term prognosis of radiographically verified stenosis of the lower lumbar spine. The purpose here was to describe the outcome 12 years after radiographic diagnosis of spinal stenosis and to identify factors predicting disability after operative or conservative treatment. Data were compiled on 75 patients (43 men and 32 women) with changes in functional myelography diagnostic for spinal stenosis. Their mean age at the interview 12 years later was 61 years. The sagittal diameter of the dural sac was measured from baseline myelographs at all intervertebral levels and was corrected for magnification. In the interview, subjective outcome assessment was obtained with a structured questionnaire, and the low-back disorder was scored using the Oswestry disability index. The sagittal diameter of the dural sac was severely stenotic (<7.0 mm) in 32 patients (26 operated), and moderately stenotic (7.0-10.5 mm) in 43 patients (31 operated). The severity of the stenosis significantly predicted disability, even when the effects of age, sex, therapy regimen, and body mass index were adjusted for. For moderate and severe stenosis, the adjusted mean Oswestry indices were 28.4 and 39.1, respectively (p = 0.01). Therapy as such (operative versus nonoperative) did not significantly correlate with later disability. The radiographic severity of lumbar spinal stenosis predicts disability independently of therapy regimen. Randomized clinical trials are needed to establish the indications for surgical and conservative treatment. Radiographic severity of the stenosis should be considered as an effect-modifying or confounding factor in clinical trials and other studies focusing on the outcome of lumbar spinal stenosis.

PMID 9588466  J Spinal Disord. 1998 Apr;11(2):110-5.
著者: M J Javid, E J Hadar
雑誌名: J Neurosurg. 1998 Jul;89(1):1-7. doi: 10.3171/jns.1998.89.1.0001.
Abstract/Text OBJECT: Decompressive laminectomy for stenosis is the most common operation performed in the lumbar spine in older patients. This prospective study was designed to evaluate long-term results in patients with symptomatic lumbar stenosis.
METHODS: Between January 1984 and January 1995, 170 patients underwent surgery for lumbar stenosis (86 patients), lumbar stenosis and herniated disc (61 patients), or lateral recess stenosis (23 patients). The male/female ratio for each group was 43:43, 39:22, and 14:9, respectively. The average age for all groups was 61.4 years. For patients with lumbar stenosis, the success rate was 88.1 % at 6 weeks and 86.7% at 6 months. For patients with lumbar stenosis and herniated disc, the success rate was 80% at 6 weeks and 77.6% at 6 months, with no statistically significant difference between the two groups. For patients with lateral recess stenosis, the success rate was 58.7% at 6 weeks and 63.6% at 6 months; however, the sample was not large enough to be statistically significant. One year after surgery a questionnaire was sent to all patients; 163 (95.9%) responded. The success rate in patients with stenosis had declined to 69.6%, which was significant (p = 0.012); the rate for patients with stenosis and herniated disc was 77.2%; and that for lateral recess stenosis was 65.2%. Another follow-up questionnaire was sent to patients 1 to 11 years after surgery (average 5.1 years); 146 patients (85.9%) responded, 10 (5.9%) were deceased, and 14 (8.2%) were lost to follow-up review. At 1 to 11 years the success rate was 70.8% for patients with stenosis, 66.6% for those with stenosis and herniated disc, and 63.6% for those with lateral recess stenosis. Eleven patients who underwent reoperation were included in the group of patients whose surgeries proved unsuccessful, regardless of their ultimate outcome. There was no statistically significant difference in outcome between 1 year and 1 to 11 years with respect to stenosis, stenosis with herniated disc, and lateral recess stenosis.
CONCLUSIONS: In conclusion, long-term improvement after laminectomy was maintained in two-thirds of these patients.

PMID 9647165  J Neurosurg. 1998 Jul;89(1):1-7. doi: 10.3171/jns.1998.・・・
著者: B M Jolles, F Porchet, N Theumann
雑誌名: J Bone Joint Surg Br. 2001 Sep;83(7):949-53.
Abstract/Text We carried out a retrospective review of 155 patients with lumbar spinal stenosis who had been treated surgically and followed up regularly: 77 were evaluated at a mean of 6.5 years (5 to 8) after surgery by two independent observers. The outcome was assessed using the scoring system of Roland and Morris, and the rating system of Prolo, Oklund and Butcher. Instability was determined according to the criteria described by White and Panjabi. A significant decrease in low back pain and disability was seen. An excellent or good outcome was noted in 79% of patients; 9% showed secondary radiological instability. Surgical decompression is a safe and efficient procedure. In the absence of preoperative radiological evidence of instability, fusion is not required.

PMID 11603533  J Bone Joint Surg Br. 2001 Sep;83(7):949-53.
著者: B Jönsson, M Annertz, C Sjöberg, B Strömqvist
雑誌名: Spine (Phila Pa 1976). 1997 Dec 15;22(24):2938-44.
Abstract/Text STUDY DESIGN: A prospective and consecutive study of surgical results obtained during serial follow-up investigations in patients who underwent surgery for central lumbar spinal stenosis.
OBJECTIVES: To evaluate the result after surgical decompression for lumbar spinal stenosis, at regular intervals after surgery, and to correlate these results with values for preoperative parameters; special interest was focused on the results in relation to the degree of constriction of the spinal canal.
SUMMARY OF BACKGROUND DATA: The outcome after surgery for spinal stenosis is debatable; long-term follow-up investigations have indicated deterioration with passing time. Results of studies in nonsurgical patients have demonstrated that the symptoms do not progress with time. Results of a meta-analysis of the literature on surgical results have demonstrated a wide variation of outcomes.
MATERIAL AND METHODS: In a prospective study, 105 consecutive patients who underwent surgical decompression (laminectomy with facet-preserving technique, but no fusion) were evaluated at follow-up examinations 4 months and 1, 2, and 5 years after surgery. At the follow-up examinations, the patient's opinion on the surgical result was registered, using a four-grade scale. The occurrence of pain at rest and at night was registered, as well as the patient's walking ability. Statistical analysis was performed, relating the surgical results to patient age, gender, preoperative duration of symptoms and radiographically observed constriction as described in Part I of this study. The radiologist was blinded to patient outcome. Logistic regression analysis was performed.
RESULTS: During the follow-up period, 19 patients underwent reoperation, consisting of fusion to treat lumbar pain (n = 4), repeat decompression because of progressive stenosis (n = 13), and repairs in response to surgical complications (n = 2). Follow-up results: The result, related to the recurrence of leg symptoms, deteriorated with passing time. Excellent results were reported by 63% to 67% at 4-month and 2-year follow-ups compared with 52% at the 5-year follow-up. There was a correlation between the constriction of the spinal canal and the outcome at all intervals. Patients with an anteroposterior diameter of 6 mm or less at the narrowest site had significantly better results. The logistic regression analysis demonstrated a significant correlation between a severe reduction of the anteroposterior diameter and excellent results and a tendency toward better results in patients with a shorter preoperative duration of symptoms. Improvement of walking ability was also associated with a pronounced constriction of the spinal canal.
CONCLUSION: The results after surgical decompression in patients with central spinal stenosis deteriorated with time. There was a significant correlation between good result and pronounced constriction of the spinal canal. Patients with a preoperative duration of symptoms of less than 4 years and patients with no preoperative back pain tended to have better surgical outcomes. The reoperation rate was 18% within 5 years. When surgery for spinal stenosis is contemplated, these prognostic factors should be taken into consideration: The "ideal patient" has a pronounced constriction of the spinal canal, insignificant lower back pain, no concomitant disease affecting walking ability, and a symptom duration of less than 4 years.

PMID 9431630  Spine (Phila Pa 1976). 1997 Dec 15;22(24):2938-44.
著者: J N Katz, S J Lipson, L C Chang, S A Levine, A H Fossel, M H Liang
雑誌名: Spine (Phila Pa 1976). 1996 Jan 1;21(1):92-8.
Abstract/Text STUDY DESIGN: Retrospective review and prospective follow-up of 88 patients who had decompressive laminectomy with or without fusion from 1983 to 1986.
OBJECTIVE: To determine the 7- to 10-year outcome of surgery for degenerative lumbar spinal stenosis.
SUMMARY OF BACKGROUND DATA: There is limited information on the impact of surgery for lumbar spinal stenosis on symptoms, walking ability, and satisfaction, as well as reoperation.
METHODS: Patients completed standardized questionnaires in 1993 that included items about reoperations, back pain, leg pain, walking capacity, and satisfaction with surgery. Associations between preoperative demographic and clinical variables and outcomes 7 to 10 years after surgery were evaluated in univariate and multivariate analyses.
RESULTS: Average preoperative age was 69 years and eight patients received fusion. Of 88 patients in the original cohort, 20 (23%) were deceased and 20 (23%) had undergone reoperation by 7- to 10-year follow-up. Fifty-five patients answered questionnaires. Average duration of follow-up was 8.1 years. Thirty-three percent of the respondents had severe back pain at follow-up, 53% were unable to walk two blocks, and 75% were satisfied with the results of surgery. The severity of current spine-related symptoms was a stronger correlate of physical functional status at the time of follow-up than age or nonspinal comorbid conditions.
CONCLUSIONS: Seven to 10 years after decompressive surgery for spinal stenosis, 23% of patients had undergone reoperation and 33% of respondents had severe back pain. Despite a high prevalence of nonspinal problems in this elderly cohort, spinal symptoms were the most important correlate of reduced functional status.

PMID 9122770  Spine (Phila Pa 1976). 1996 Jan 1;21(1):92-8.
著者: O Nakai, A Ookawa, I Yamaura
雑誌名: J Bone Joint Surg Am. 1991 Sep;73(8):1184-91.
Abstract/Text Thirty-four patients who had central stenosis of the lumbar spine were treated with wide fenestration, a procedure in which only the medial parts of the inferior facets and the adjoining ligamentum flavum were removed. The patients were followed for an average of five and one-half years (range, four and one-half years to seven years and ten months). Wide fenestration successfully relieved the symptoms. The new bone that was laid down in the operatively treated segments did not reproduce the symptoms of spinal stenosis; instead, it appeared to stabilize those segments.

PMID 1890119  J Bone Joint Surg Am. 1991 Sep;73(8):1184-91.
著者: G F Tuite, J D Stern, S E Doran, S M Papadopoulos, J E McGillicuddy, D I Oyedijo, S V Grube, C Lundquist, H S Gilmer, M A Schork
雑誌名: J Neurosurg. 1994 Nov;81(5):699-706. doi: 10.3171/jns.1994.81.5.0699.
Abstract/Text All patients who underwent decompressive lumbar laminectomy in the Washtenaw County, Michigan metropolitan area during a 7-year period were studied for the purpose of defining long-term outcome, clinical correlations, and the need for subsequent fusion. Outcome was determined by questionnaire and physical examination from a cohort of 119 patients with an average follow-up evaluation interval of 4.6 years. Patients graded their outcome as much improved (37%), somewhat improved (29%), unchanged (17%), somewhat worse (5%), and much worse (12%) compared to their condition before surgery. Poor outcome correlated with the need for additional surgery, but there were few additional significant correlations. No patient had a lumbar fusion during the study interval. The outcome after laminectomy was found to be less favorable than previously reported, based on a patient questionnaire administered to an unbiased patient population. Further randomized, controlled trials are therefore necessary to determine the efficacy of lumbar fusion as an adjunct to decompressive lumbar laminectomy.

PMID 7755690  J Neurosurg. 1994 Nov;81(5):699-706. doi: 10.3171/jns.1・・・
著者: Leslie C L Ng, Suhayl Tafazal, Philip Sell
雑誌名: Eur Spine J. 2007 Feb;16(2):199-206. doi: 10.1007/s00586-006-0078-z. Epub 2006 Feb 22.
Abstract/Text The effect of the duration of symptoms on the outcome of lumbar decompression surgery is not known. The aim of our study was to determine the predictors of functional outcome of lumbar decompression surgery for degenerative spinal stenosis with particular emphasis on the duration of symptoms. In this prospective cohort study, we recruited 100 patients with a full data set available at 1-year and 85% at 2-year follow-ups: 49 females and 51 males with an average age of 62 (range 52-82). The pre- and post-operative outcome measures were Oswestry disability index (ODI), low back outcome score (LBOS), pain visual analogue score (VAS), modified somatic perception (MSP) and modified Zung depression (MZD) score. Dural tear occurred in 14%, and there was one post-operative extra-dural heamatoma. Overall, the ODI improved from a pre-operative of 56 (+/-13) to a 1-year ODI of 40 (+/-22) and at 2-year ODI of 40 (+/-21). The VAS improved from an average of 8 to 5.2 at 1 year and 4.9 at 2 years. There was a statistical significant association between symptom duration and the change in ODI (P=0.007 at 1-year follow-up, P=0.001 at 2-year follow-up), LBOS (P=0.001 at 1-year follow-up, P<0.001 at 2-year follow-up) and VAS (P=0.003 at 1-year follow-up, P=0.001 at 2-year follow-up). Subgroup analyses showed that patients with symptom duration of less than 33 months had a more favourable result. In addition, the patients who rated the operation as excellent had a statistically significantly shorter duration of symptoms. We have not found a predictive value for age at operation, MSP or MZD. The number of levels of decompression and the different types of decompression surgery did not influence the surgical results. Our study indicates that the symptom duration of more than 33 months has a less favourable functional outcome.

PMID 16496190  Eur Spine J. 2007 Feb;16(2):199-206. doi: 10.1007/s0058・・・
著者: Nobuhiro Hara, Hiroyuki Oka, Takashi Yamazaki, Katsushi Takeshita, Motoaki Murakami, Kazuto Hoshi, Sei Terayama, Atsushi Seichi, Kozo Nakamura, Hiroshi Kawaguchi, Ko Matsudaira
雑誌名: Eur Spine J. 2010 Nov;19(11):1849-54. doi: 10.1007/s00586-010-1374-1. Epub 2010 Mar 23.
Abstract/Text Leg pain/numbness and gait disturbance, two major symptoms in the lower extremities of lumbar spinal stenosis (LSS), are generally expected to be alleviated by decompression surgery. However, the paucity of information available to patients before surgery about specific predictors has resulted in some of them being dissatisfied with the surgical outcome when the major symptoms remain after the procedure. This prospective, observational study sought to identify the predictors of the outcome of a decompression surgery: modified fenestration with restorative spinoplasty. Of 109 consecutive LSS patients who underwent the decompression surgery, 89 (56 males and 33 females) completed the 2 year follow-up. Both leg pain/numbness and gait disturbance determined by the Japanese Orthopedic Association scoring system were significantly improved at 2 years after surgery compared to those preoperative, regardless of potential predictors including gender, preoperative presence of resting numbness in the leg, drop foot, cauda equina syndrome, degenerative spinal deformity or myelographic filling defect, or the number of decompressed levels. However, 27 (30.3%) and 13 (14.6%) patients showed residual leg pain/numbness and gait disturbance, respectively. Among the variables examined, the preoperative resting numbness was associated with residual leg pain/numbness and gait disturbance, and the preoperative drop foot was associated with residual gait disturbance, which was confirmed by logistic regression analysis after adjustment for age and gender. This is the first study to identify specific predictors for these two remaining major symptoms of LSS after decompression surgery, and consideration could be given to including this in the informed consent.

PMID 20309711  Eur Spine J. 2010 Nov;19(11):1849-54. doi: 10.1007/s005・・・
著者: Leslie Ng, Neeraj Chaudhary, Philip Sell
雑誌名: Spine (Phila Pa 1976). 2005 Apr 15;30(8):857-62.
Abstract/Text STUDY DESIGN: A randomized, double-blind controlled trial.
OBJECTIVES: To determine the treatment effect of corticosteroids in periradicular infiltration for chronic radicular pain. We also examined prognostic factors in relation to the outcome of the procedure.
SUMMARY OF BACKGROUND DATA: Various studies have examined the therapeutic value of periradicular infiltration using treatment agents consisting of local anesthetic and corticosteroids for radicular pain, secondary to lumbar disc herniation and spinal stenosis. There is currently no randomized trial to determine the efficacy of a single injection of corticosteroids for chronic radicular pain.
METHODS: Eligible patients with radicular pain who had unilateral symptoms who failed conservative management were randomized for a single injection with bupivacaine and methylprednisolone or bupivacaine only. Outcome measures included the Oswestry Disability Index, visual analogue score for back pain and leg pain, claudication walking distance, and the patient's subjective level of satisfaction of the outcome.
RESULTS: We recruited 43 patients in the bupivacaine and methylprednisolone group and 43 patients in the bupivacaine only group. The follow-up rate is 100%. Five patients had early termination of the trial for discectomy and further root block. There is no statistically significant difference in the outcome measures between the groups at 3 months (change of the Oswestry Disability Index [P = 0.68], change in visual analogue score [back pain, P = 0.68; leg pain, P = 0.94], change in walking distance [P = 0.7]). Duration of symptoms has a statistically significant negative association with the change in Oswestry Disability Index (P = 0.03).
CONCLUSION: Clinical improvement occurred in both groups of patients. Corticosteroids did not provide additional benefit.

PMID 15834326  Spine (Phila Pa 1976). 2005 Apr 15;30(8):857-62.
著者: Ko Matsudaira, Atsushi Seichi, Junichi Kunogi, Takashi Yamazaki, Atsuki Kobayashi, Yorito Anamizu, Junji Kishimoto, Kazuto Hoshi, Katsushi Takeshita, Kozo Nakamura
雑誌名: Spine (Phila Pa 1976). 2009 Jan 15;34(2):115-20. doi: 10.1097/BRS.0b013e31818f924d.
Abstract/Text STUDY DESIGN: Randomized controlled trial.
OBJECTIVE: To examine the effect of limaprost, an oral prostaglandin (PG) E1 derivative, on health-related quality of life (HRQOL) in patients with symptomatic lumbar spinal stenosis (LSS), compared to etodolac, a NSAID.
SUMMARY OF BACKGROUND DATA: Limaprost, an oral PGE1 derivative, was developed in Japan to treat numerous ischemic symptoms of thromboangiitis obliterans (TAO) and LSS. Previous studies have demonstrated the effectiveness of limaprost in the symptoms in patients with LSS. However, the evidence for effect on patient-reported outcomes, such as patient's HRQOL or satisfaction, is limited.
METHODS: This study was conducted at 4 study sites in Japan. Briefly, inclusion criteria were: age between 50 and 85 years; presence of both neurogenic intermittent claudication (NIC) and cauda equina symptoms (at least presence of bilateral numbness in the lower limbs); and MRI-confirmed central stenosis with acquired degenerative LSS. Limaprost (15 microg/d) or etodolac (400 mg/d) was administered for 8 weeks. The primary outcome was Short Form (SF)-36, and the secondary outcomes were the verbal rating scale of low back pain and leg numbness, walking distance, subjective improvement, and satisfaction.
RESULTS: A total of 79 participants were randomized (limaprost:etodolac = 39:40). Thirteen participants withdrew from the study (limaprost:etodolac = 5:8) and 66 completed the study (limaprost:etodolac = 34:32). Comparisons showed that limaprost resulted in significantly greater improvements in the SF-36 subscales of physical functioning, role physical, bodily pain, vitality, and mental health. Limaprost was also significantly better than etodolac for leg numbness, NIC distance, and subjective improvement and satisfaction. In the subgroup analysis stratified by symptom severity, limaprost seemed more effective for milder symptoms. No serious adverse effects were reported in either treatment group.
CONCLUSION: In this study, limaprost was found to be efficacious on most outcome measures, such as HRQOL, symptoms and subjective satisfaction, in LSS patents with cauda equina symptoms.

PMID 19112336  Spine (Phila Pa 1976). 2009 Jan 15;34(2):115-20. doi: 1・・・
著者: Akira Onda, Shin-Ichi Kikuchi, Shoji Yabuki, Koji Otani, Takuya Nikaido, Kazuyuki Watanabe, Shin-Ichi Konno
雑誌名: Eur Spine J. 2013 Apr;22(4):794-801. doi: 10.1007/s00586-012-2551-1. Epub 2012 Oct 23.
Abstract/Text PURPOSE: Limaprost, a prostaglandin E1 analog, has vasodilatory properties and increases blood flow of the nerve root. However, it has not been clarified whether limaprost affects pain sensation associated with radiculopathy due to lumbar spinal stenosis (LSS). The aim of this study was to compare the efficacy of oral limaprost with nonsteroidal anti-inflammatory drugs (NSAIDs) for radiculopathy.
METHODS: We performed a multicenter prospective randomized trial. Patients with LSS who had radicular-type neurologic intermittent claudication assessed based on a self-reported diagnostic support tool were randomized into three treatment groups. Limaprost, NSAIDs, or limaprost plus NSAIDs were administered orally for 6 weeks. Leg pain, low back pain (LBP) and the associated symptoms were assessed by a numerical rating scale (NRS) both at rest and on movement as well as the Roland-Morris Disability Questionnaire (RDQ) and Short Form (SF)-36.
RESULTS: Sixty-one patients were enrolled in the study. Each treatment finally reduced radicular pain, and the improvement was prominent in a combination treatment. There were no significant differences in radicular pain among three groups at final follow-up. LBP was not influenced by limaprost, and a significant reduction of LBP and RDQ was confirmed in a combination treatment compared with limaprost. Physical function of the SF-36 subscales after a combination treatment showed a marked alleviation compared with NSAIDs.
CONCLUSIONS: These obtained findings suggest that the effects of limaprost seem to be limited to radicular pain, not for LBP. Overall, a combination treatment might be more effective in the management of radiculopathy induced by LSS than monotherapy with either agent.

PMID 23090093  Eur Spine J. 2013 Apr;22(4):794-801. doi: 10.1007/s0058・・・
著者: Julie M Whitman, Timothy W Flynn, John D Childs, Robert S Wainner, Howard E Gill, Michael G Ryder, Matthew B Garber, Andrew C Bennett, Julie M Fritz
雑誌名: Spine (Phila Pa 1976). 2006 Oct 15;31(22):2541-9. doi: 10.1097/01.brs.0000241136.98159.8c.
Abstract/Text STUDY DESIGN: Multicenter randomized, controlled trial.
OBJECTIVE: To compare two physical therapy programs for patients with lumbar spinal stenosis.
SUMMARY OF BACKGROUND DATA: Scant evidence exists regarding effectiveness of nonsurgical management programs for lumbar spinal stenosis.
METHODS: Fifty-eight patients with lumbar spinal stenosis were randomized to one of two 6-week physical therapy programs. One program included manual physical therapy, body weight supported treadmill walking, and exercise (Manual Physical Therapy, Exercise, and Walking Group), while the other included lumbar flexion exercises, a treadmill walking program, and subtherapeutic ultrasound (Flexion Exercise and Walking Group). Perceived recovery was assessed with a global rating of change scale. Secondary outcomes included: Oswestry, a numerical pain rating scale, a measure of satisfaction, and a treadmill test. Testing occurred at baseline, 6 weeks, and 1 year. Perceived recovery, pain, and other healthcare resources used were collected with a long-term follow-up questionnaire.
RESULTS: A greater proportion of patients in the manual physical therapy, exercise, and walking group reported recovery at 6 weeks compared with the flexion exercise and walking group (P = 0.0015), with a number needed to treat for perceived recovery of 2.6 (confidence interval, 1.8-7.8). At 1 year, 62% and 41% of the manual therapy, exercise, and walking group and the flexion exercise and walking group, respectively, still met the threshold for recovery. Improvements in disability, satisfaction, and treadmill walking tests favored the manual physical therapy, exercise, and walking group at all follow-up points.
CONCLUSIONS: Patients with lumbar spinal stenosis can benefit from physical therapy. Additional gains may be realized with the inclusion of manual physical therapy interventions, exercise, and a progressive body-weight supported treadmill walking program.

PMID 17047542  Spine (Phila Pa 1976). 2006 Oct 15;31(22):2541-9. doi: ・・・
著者: Aravind Athiviraham, David Yen
雑誌名: Clin Orthop Relat Res. 2007 May;458:90-3. doi: 10.1097/BLO.0b013e31803799a9.
Abstract/Text For patients with clinical and radiographic lumbar spinal stenosis, is surgery or continued nonsurgical treatment a better option for improvements in baseline disability scores; and what proportion of patients treated surgically and nonsurgically get better, worse, or remain the same with time? We prospectively evaluated 125 consecutive patients for this non-randomized cohort study. Of the patients choosing surgery, 54 underwent decompression only and 42 had decompression and fusion for preexisting spondylolisthesis; twenty-nine patients declined surgery. At 2 years followup, the average improvements in Roland-Morris questionnaire score in the decompression only, decompression with fusion, and nonsurgical groups were 6.9, 6.1, and 1.2, respectively. The percentages of patients who were better, worse, or the same were similar for those who had decompression only (63.3%, 4.1%, and 32.7%, respectively) and decompression with fusion (61.5%, 2.6%, and 35.9%, respectively) but different from those treated without surgery (25.0%, 12.5%, and 62.5%, respectively). We observed no occurrences of cauda equina syndrome or severe neurologic dysfunction in any of the groups after 2 years. A majority of patients declining surgery had persistent symptoms. The majority of patients who choose surgery will be improved but will have residual symptoms and therefore should be counseled about realistic expectations.

PMID 17308483  Clin Orthop Relat Res. 2007 May;458:90-3. doi: 10.1097/・・・
著者: Antti Malmivaara, Pär Slätis, Markku Heliövaara, Päivi Sainio, Heikki Kinnunen, Jyrki Kankare, Nina Dalin-Hirvonen, Seppo Seitsalo, Arto Herno, Pirkko Kortekangas, Timo Niinimäki, Hannu Rönty, Kaj Tallroth, Veli Turunen, Paul Knekt, Tommi Härkänen, Heikki Hurri, Finnish Lumbar Spinal Research Group
雑誌名: Spine (Phila Pa 1976). 2007 Jan 1;32(1):1-8. doi: 10.1097/01.brs.0000251014.81875.6d.
Abstract/Text STUDY DESIGN: A randomized controlled trial.
OBJECTIVES: To assess the effectiveness of decompressive surgery as compared with nonoperative measures in the treatment of patients with lumbar spinal stenosis.
SUMMARY OF BACKGROUND DATA: No previous randomized trial has assessed the effectiveness of surgery in comparison with conservative treatment for spinal stenosis.
METHODS: Four university hospitals agreed on the classification of the disease, inclusion and exclusion criteria, radiographic routines, surgical principles, nonoperative treatment options, and follow-up protocols. A total of 94 patients were randomized into a surgical or nonoperative treatment group: 50 and 44 patients, respectively. Surgery comprised undercutting laminectomy of the stenotic segments in 10 patients augmented with transpedicular fusion. The primary outcome was based on assessment of functional disability using the Oswestry Disability Index (scale, 0-100). Data on the intensity of leg and back pain (scales, 0-10), as well as self-reported and measured walking ability were compiled at randomization and at follow-up examinations at 6, 12, and 24 months.
RESULTS: Both treatment groups showed improvement during follow-up. At 1 year, the mean difference in favor of surgery was 11.3 in disability (95% confidence interval [CI], 4.3-18.4), 1.7 in leg pain (95% CI, 0.4-3.0), and 2.3(95% CI, 1.1-3.6) in back pain. At the 2-year follow-up, the mean differences were slightly less: 7.8 in disability (95% CI, 0.8-14.9) 1.5 in leg pain (95% CI, 0.3-2.8), and 2.1 in back pain (95% CI, 1.0-3.3). Walking ability, either reported or measured, did not differ between the two treatment groups.
CONCLUSIONS: Although patients improved over the 2-year follow-up regardless of initial treatment, those undergoing decompressive surgery reported greater improvement regarding leg pain, back pain, and overall disability. The relative benefit of initial surgical treatment diminished over time, but outcomes of surgery remained favorable at 2 years. Longer follow-up is needed to determine if these differences persist.

PMID 17202885  Spine (Phila Pa 1976). 2007 Jan 1;32(1):1-8. doi: 10.10・・・
著者: James N Weinstein, Tor D Tosteson, Jon D Lurie, Anna N A Tosteson, Emily Blood, Brett Hanscom, Harry Herkowitz, Frank Cammisa, Todd Albert, Scott D Boden, Alan Hilibrand, Harley Goldberg, Sigurd Berven, Howard An, SPORT Investigators
雑誌名: N Engl J Med. 2008 Feb 21;358(8):794-810. doi: 10.1056/NEJMoa0707136.
Abstract/Text BACKGROUND: Surgery for spinal stenosis is widely performed, but its effectiveness as compared with nonsurgical treatment has not been shown in controlled trials.
METHODS: Surgical candidates with a history of at least 12 weeks of symptoms and spinal stenosis without spondylolisthesis (as confirmed on imaging) were enrolled in either a randomized cohort or an observational cohort at 13 U.S. spine clinics. Treatment was decompressive surgery or usual nonsurgical care. The primary outcomes were measures of bodily pain and physical function on the Medical Outcomes Study 36-item Short-Form General Health Survey (SF-36) and the modified Oswestry Disability Index at 6 weeks, 3 months, 6 months, and 1 and 2 years.
RESULTS: A total of 289 patients were enrolled in the randomized cohort, and 365 patients were enrolled in the observational cohort. At 2 years, 67% of patients who were randomly assigned to surgery had undergone surgery, whereas 43% of those who were randomly assigned to receive nonsurgical care had also undergone surgery. Despite the high level of nonadherence, the intention-to-treat analysis of the randomized cohort showed a significant treatment effect favoring surgery on the SF-36 scale for bodily pain, with a mean difference in change from baseline of 7.8 (95% confidence interval, 1.5 to 14.1); however, there was no significant difference in scores on physical function or on the Oswestry Disability Index. The as-treated analysis, which combined both cohorts and was adjusted for potential confounders, showed a significant advantage for surgery by 3 months for all primary outcomes; these changes remained significant at 2 years.
CONCLUSIONS: In the combined as-treated analysis, patients who underwent surgery showed significantly more improvement in all primary outcomes than did patients who were treated nonsurgically. (ClinicalTrials.gov number, NCT00000411 [ClinicalTrials.gov].).

Copyright 2008 Massachusetts Medical Society.
PMID 18287602  N Engl J Med. 2008 Feb 21;358(8):794-810. doi: 10.1056/・・・

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