Lumbar Posterior Decompression for the Acquisition of Better Surgical Results Kyongsong Kim, M.D. 1, Toyohiko Isu, M.D. 2, R

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1 Lumbar Posterior Decompression for the Acquisition of Better Surgical Results Kyongsong Kim, M.D. 1, Toyohiko Isu, M.D. 2, Rinko Kokubo, M.D. 1, Daijiro Morimoto, M.D. 4, Naotaka Iwamoto, M.D. 2, Yasuhiro Chiba, M.D. 2, Atsushi Sugawara, M.D. 3, Shiro Kobayashi, M.D. 1, and Akio Morita, M.D. 4 1 Department of Neurosurgery, Chiba Hokuso Hospital, Nippon Medical School, 2 Department of Neurosurgery, Kushiro Rosai Hospital, 3 Department of Neurosurgery, Iwate Medical University, 4 Department of Neurosurgery, Nippon Medical School The primary therapy for lumbar spinal canal stenosis LSS is conservative treatment. Although severe symptoms of LSS are dramatically improved by surgery some results are unsatisfactory failed back surgery syndrome. Surgical indications and procedures and the response to postoperative residual symptoms are three issues that must be considered to obtain good results after LSS treatment. According to earlier studies the long term surgical results were unexpectedly unsatisfactory and contrary to expectations, conservative treatment could prevent symptom exacerbation. The decision to perform surgery must not be based on radiological findings alone because there is no correlation between the radiologically defined stenosis and the symptoms grade. The main goal of the surgical treatment of LSS is decompression of neural structures. Not only the spinal canal but also the nerve roots should be decompressed appropriately. At surgery, posterior elements such as the paraspinal muscles and facet joints should be preserved as much as possible. As a less invasive surgical option we recommend bilateral decompression using the spinous process splitting approach and bilateral decompression via hemilaminectomy. Fusion surgery may be an alternative approach although its efficacy remains to be determined. Postoperative residual symptoms should not be readily accepted as a sequel of surgery, rather, a merger of peripheral neuropathy should be considered. Superior cluneal nerve neuropathy produces low back pain and tarsal tunnel syndrome results in numbness and pain of the soles of the feet. In some patients it is difficult to distinguish between S1 symptom due to lumbar disease and piriformis syndrome. It is also difficult to distinguish between L5 symptoms due to lumbar disease and peroneal nerve neuropathy. These diseases can be addressed by observation therapy and surgery without lumbar re operation. We found that these peripheral nerve neuropathies affected lumbar surgery outcomes and that in patients subsequently treated by observation therapy and surgery the JOA scores improved by 3.8 points. Spinal surgeons must respond appropriately to different situations encountered in the course of long term postoperative observation. Received October 31, 2013 accepted November 11, 2013 Key words lumbar spinal canal stenosis, natural history, peripheral nerve entrapment neuropathy, posterior decompression, surgical result Jpn J Neurosurg Tokyo , Address reprint requests to Kyongsong Kim, M.D., Department of Neurosurgery, Chiba Hokuso Hospital, Nippon Medical School, 1715 Kamagari, Inzai shi, Chiba , Japan

2 lumbar spinal canal stenosis LSS LSS LSS LSS LSS LSS Lohman 13 CT LSS LSS Tadokoro 23 2 LSS LSS 2 randomized prospective study LSS LSS LSS LSS Fig / Jpn J Neurosurg VOL. 23 NO

canal stenosis before A, B and after surgery C, D.

3 creatine phosphokinase CPK B C C C C 6 19 LSS 11

2 The schematics of the histological changes in

3 Fig. 2 2 A B Fig. 1 Schematics and MRI axial T2WI of lumbar spinal canal stenosis before A, B and after surgery C, D. C D 10 A / B A / C / Fig. 3 creatine phosphokinase CPK B C C C C 6 19 LSS mm A B C Fig. 2 The schematics of the histological changes in lumbar posterior approaches to the spinal canal A Complete removal of spinous process. B Unilateral paraspinal dissection from the spinous process with cutting of the spinous process. C Bilateral decompression via hemilaminectomy

A B C Fig. 3 The schematics of the 3 different posterior approaches to the spinal canal A Unilateral paraspinal dissection from the spinous process with cutting of the spinous process.

4 A B C Fig. 3 The schematics of the 3 different posterior approaches to the spinal canal A Unilateral paraspinal dissection from the spinous process with cutting of the spinous process. B Modified bilateral decompression via hemilaminectomy. C Bilateral decompression via spinous process splitting. A B Fig. 4 The Schematics of the lateral recess opening For the nerve root decompression, it confirms the pedicle and opens the lateral recess. º SONOPET º 12 Fig LSS LSS AANS 2005 option 21 NASS 2007 grade B Jpn J Neurosurg VOL. 23 NO

5 A B C D E F G H Fig. 5 Lumbar CT of the lumbar spinal canal stenosis before A D and after E H posterior decompression L3 4 to L4 5. The lateral recess is opened at the pedicle level arrows. LSS LSS * LSS LSS LSS W W 8 Tinel L5 S1 L5 L5 9 Fig

6 B D A C E Fig. 6 Lumbar MRI T2WI A sagittal, B axial L3 4, C axial L4 5 and CT myelography D axial L4 5 show moderate spinal canal stenosis at the L3 4 and L4 5 levels. His lower limb pain disappeared following left L5 root block, although left L5 root radiculography E reveals no entrapment on the neuroforamen. B D F A C E G Fig. 7 Lumbar MRI T2WI A sagittal, B axial L3 4, C axial L4 5 and axial CT D L3 4, E L4 5 demonstrate spinal canal stenosis at the L3 4 and L4 5 levels and spondylolisthesis at L4 5. Her lower limb pain and numbness partially remained, although post operative lumbar axial CTs F L3 4, G L4 5 show appropriate decompression. Her symptoms improved following treatment for piriformis syndrome. Jpn J Neurosurg VOL. 23 NO

7 Fig Tinel / 7 15 LSS 35 W W W W JOA 3.8 W W W LSS W 1 Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE Long term outcomes of surgical and nonsurgical management of lumbar spinal stenosis 8 to 10 year results from the maine lumbar spine study. Spine Phila Pa , Chang Y, Singer DE, Wu YA, Keller RB, Atlas SJ The effect of surgical and nonsurgical treatment on longitudinal outcomes of lumbar spinal stenosis over 10 years. J Am Geriatr Soc , Filler AG, Haynes J, Jordan SE, Prager J, Villablanca JP, Farahani K, McBride DQ, Tsuruda JS, Morisoli B, Batzdorf U, Johnson JP Sciatica of nondisc origin and piriformis syndrome diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment. J Neurosurgery Spine , Jönsson B, Annerz M, Sjöberg C, Strömqvist B A prospective and consecutive study of surgically treated lumbar spinal stenosis. Part Five year follow up by an independent observer. Spine Phila Pa , Kim K, Isu T, Chiba Y, Morimoto D, Ohtsubo S, Kusano M, Kobayashi S, Morita A The usefulness of ICG video angiography in the surgical treatment of superior cluneal nerve entrapment neuropathy technical note. J Neurosurg Spine in press Kim K, Isu T, Sugawara A, Matsumoto R, Isobe M Comparison of the effect of 3 different approaches to the lumbar spinal canal on postoperative paraspinal muscle damage. Surg Neurol , Kim K, Isu T, Matsumoto R, Isobe M, Kogure K Surgical pitfalls of an ultrasonic bone curette SONOPET in spinal surgery. Neurosurgery 59 4 Suppl 2 ONS , Lohman CM, Tallroth K, Kettunen JA, Lindgren KA Comparison of radiologic signs and clinical symptoms of spinal stenosis. Spine Phila Pa , Malmivaara A, Slätis P, Heliövaara M, Sainio P, Kinnunen H, Kankare J, Dalin Hirvonen N, Seitsalo S, Herno A, Kortekangas P, Niinimäki T, Rönty H, Tallroth K, Turunen V, Knekt P, Härkänen T, Hurri H Finnish Lumbar Spinal Research Group Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Spine Phila Pa , Morimoto D, Isu T, Kim K, Imai T, Yamazaki K, Matsumoto R, Isobe M Surgical treatment of superior cluneal nerve entrapment neuropathy. J Neurosurg Spine , Morimoto D, Isu T, Kim K, Sugawara A, Matsumoto R, Isobe M Microsurgical medial fenestration with an ultrasonic bone curette for lumbar foraminal stenosis. J Nippon

8 Med Sch , North American Spine Society Diagnosis and treatment of degenerative lumbar spinal stenosis Internet. Burr Ridge, North American Spine Society, 2007 Jan cited 2010 Oct 14. Available from http: Documents NASSCG_Stenosis pdf 19 Oertel MF, Ryang YM, Korinth MC, Gilsbach JM, Rohde V Long term results of microsurgical treatment of lumbar spinal stenosis by unilateral laminotomy for bilateral decompression. Neurosurgery , Pearson A, Blood E, Lurie J, Abdu W, Sengupta D, Frymoyer JW, Weinstein J Predominant leg pain is associated with better surgical outcomes in degenerative spondylolisthesis and spinal stenosis results from the Spine Patient Outcomes Research Trial SPORT. Spine Phila Pa , Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC 3rd, Wang J, Walters BC, Hadley MN American Association of Neurological Surgeons Congress of Neurological Surgeons Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 10 fusion following decompression in patients with stenosis without spondylolisthesis. J Neurosurg Spine , Tadokoro K, Miyamoto H, Sumi M, Shimomura T The prognosis of conservative treatments for lumbar spinal stenosis analysis of patients over 70 years of age. Spine Phila Pa , Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Blood E, Hanscom B, Herkowitz H, Cammisa F, Albert T, Boden SD, Hilibrand A, Goldberg H, Berven S, An H SPORT Investigators Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med , W Jpn J Neurosurg VOL. 23 NO

8 The Bulletin of Meiji University of Integrative Medicine API II 61 ASO X 11 7 X-4 6 X m 5 X-2 4 X 3 9 X 11 7 API 0.84 ASO X 1 1 MR-angio

8 The Bulletin of Meiji University of Integrative Medicine API II 61 ASO X 11 7 X-4 6 X m 5 X-2 4 X 3 9 X 11 7 API 0.84 ASO X 1 1 MR-angio 7-14 2010 1 1 1 2 1 1 1 2 Fontaine II ASO61 3 API ASO ASO ASO API API KKKKKKKKKK ASO Fontaine II API Received April 14, 2009; Accepted July 16, 2009 I arteriosclerosis obliterans: ASO ASO 50 70 1,2 Fontaine