Lumbar Spinal Stenosis in Elderly Patients HULAGU KAPTAN,a OMUR KASIMCAN,a KUTAY CAKIROGLU,b MUSTAFA NECMI ILHAN,c AND CELAL KILICd a Department
of Neurosurgery, Ulus Hospital, 06700 Ankara, Turkey
b Department
of Neurosurgery, Gazi Hospital, 06700 Ankara, Turkey
c Department
of Public Health, Gazi University School of Medicine, 06700 Ankara, Turkey
d Department
of Neurosurgery, Ankara Education and Research Hospital, 06700 Ankara, Turkey
ABSTRACT: Over a 3-year period in our clinic, surgeons operated on 32 persons over 65 years old with lumbar spinal stenosis. This article presents the retrospective analysis of the clinical, radiological, and shortterm surgical outcomes. The stenosis seen most commonly among the elderly develops focally at the intervertebral junctions as a result of a complex process of disc degeneration, facet arthropathy, ligamentum flavum hypertrophy, spondylosis, and sometimes spondylolisthesis. All patients underwent a midline decompressive laminectomy with foraminotomies at the affected levels, and discectomy was performed in persons with lumbar disc hernia. Average age was 71.15 ± 5.09 (65–80); 50% (16) were women, and 50% (16) were men. The most frequent symptoms were pain (96.9%) and neurological claudication (90.6%). The average preoperative duration of the symptoms was 139.87 ± 115.03 weeks. The most frequent neurological symptoms were reflex disturbances (62.5%), Las`eques’s sign (SLR) (+)(53%), and motor deficit (50%). The anteroposterior diameter of the spinal canal was less than 11.5 mm in 71.9% of the cases. In 62.5% of the patients, partial recovery was observed in the short term; 68.8% of the patients underwent laminectomy. Of those, 87.5% had total and 12.5% had partial laminectomies. In addition to laminectomy, discectomy was performed in 31.3% of the patients. Total laminectomy was more likely to be performed on patients older than 65 years, because the anteroposterior diameter was more likely to be below 11.5 mm in this cohort of patients. In lumbar stenosis, surgical treatment—decompression—is an effective method. Surgery has been demonstrated to be effective even in patients over the age of 75 years. KEYWORDS: lumbar spinal stenosis; elderly; laminectomy; discectomy; decompression Address for correspondence: Hulagu Kaptan, Department of Neurosurgery, Ulus Hospital, 06700 Ulus, Ankara, Turkey. Voice: +90-505-398-87-02; fax: +90-312-232-44-64.
[email protected] C 2007 New York Academy of Sciences. Ann. N.Y. Acad. Sci. 1100: 173–178 (2007). doi: 10.1196/annals.1395.015 173
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INTRODUCTION Stenosis develops focally at the intervertebral junctions as a result of a complex process of disc degeneration, facet arthropathy, ligamentum flavum hypertrophy, spondylosis, and sometimes spondylolisthesis.1 Patients report a history of long-term back pain. The main symptoms are lumbar and sciatic pain, neurological deficits, and claudicatio intermittens spinalis.2–4 Upon neurological examination, Las`eques’s sign (SLR) was negative in 65% of the presentations. SLR is frequently observed in lumbar disc degeneration and in spinal stenosis accompanied by lumbar disc degeneration.1,5 Stenosis was typically observed at the L4-5 level; in 22% of all cases, it could be observed at multiple levels.2,4 If the anteroposterior diameter of the spinal canal is observed to be less than 11.5 mm in CT scan, stenosis should be considered. The basic goal of the operation is a satisfactory and total decompression.2,3 In lumbar stenosis, surgical treatment — decompression—has been demonstrated to be an effective treatment method even in patients over the age of 75 years. When performing this operation, it is important to protect the stability of the spinal zone.3,6
METHODS Diagnoses were made on the basis of patients’ histories and their clinical and radiological examinations. All patients underwent midline decompressive laminectomies with foraminotomies at the affected levels. In lumbar disc hernia cases, discectomy was also performed. Short-term results were categorized as worse, unchanged, improved, or completely resolved following surgery.
RESULTS AND DISCUSSION Average age was 71.15 ± 5.09 (65–80 years); 50% (16) were women, and 50% (16) were men. The most frequent symptoms for those above 65 years were pain (96.9%) and neurological claudication (90.6%). The average preoperative duration of symptoms was 139.87 ± 115.03 weeks. The most frequent neurological symptoms were reflex disturbances (62.5%), SLR (+) (53%), and motor deficit (50%). The anteroposterior diameter of the spinal canal was less than 11.5 mm in 71.9% of the cases. Partial recovery was observed over the short term in 62.5% of the cases. Laminectomy was performed on 68.8% of the patients; and, of those, 87.5% received total and 12.5% received partial laminectomies. Discectomy was performed in addition to laminectomy in 31.3% of the patients. The location of the stenosis in these patients was as follows: L2-3, 5 cases (15.6%); L3-4, 17 cases (53.1%); L4-5, 23 cases (71.8%); and L5-S1, 7 cases (21.8%). Stenosis occurred at two levels in 10
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TABLE 1. Characteristics of lumbar spinal stenosis in older patientsa
Sex
N
Percent
Male Female Symptoms Pain Neurological claudication Motor Sensory Neurological symptoms Reflex disturbances Las`eques’s sign Motor deficit Sensory deficit Normal Anteroposterior spinal canal diameter < 11.5 mm 11.5 mm and above Surgical approach Total laminectomy Partial laminectomy Additional discectomy Short-term outcome Unchanged Partial recovery Total recovery
16 16
50 50
31 29 1 2
96.9 90.6 3.1 6.3
20 17 16 13 3
62.5 53.0 50.0 40.6 9.4
23 9
71.9 28.1
28 4 10
87.5 12.5 31.3
12 20 0
37.5 62.5 0
a Preoperative
duration of symptoms of 139.88 ± 115.03 months.
cases (31.2%), at three levels in 3 cases (9.3%), at four levels in 1 case (3.1%), and at multiple levels in 14 cases (43.6%) (TABLE 1). Total laminectomy was performed in 93.4% of the cases in which the anteroposterior diameter of the spinal canal was less than 11.5 mm. A partial recovery was achieved in 65.6% of these patients. A partial laminectomy was performed in 94.7% of the cases in which the anteroposterior diameter was greater than 11.5 mm; a partial recovery was achieved in 73.7% of these patients. Among those patients older than 65 years, 71.9% presented with an anteroposterior spinal canal diameter of less than 11.5 mm, and total laminectomy was performed in 87.5% of these cases. In those patients whose spinal canals are found to have an anteroposterior diameter of less than 11.5 mm, lumbar spinal stenosis is obvious, and total laminectomy is performed more frequently. The incidence of partial recovery in these cases is less frequent compared with the other presentations. SLR was positive in 53% of the patients in our study. Positive SLR has been reported in the literature at a rate of about 34% among patients with lower back pain, and it also been reported in young patients. The average rate of SLR-positive findings among lumbar spinal stenosis patients is 35–40%.7 The
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reason for our more-frequent finding of SLR-positive cases may be that SLR is closely associated with lumbar disc hernia, and our study included a high incidence of disc hernia cases. The current widespread use of MRI also enables us to diagnose lumbar disc hernia more easily, compared with earlier studies in the literature.3–5,7,8 Neurological claudication is an indication of potential lumbar spinal stenosis, and it occurs frequently (90.6% and 92.5%) among our patients with lumbar spinal stenosis. In the literature, the incidence among patients with this presentation ranges between 65% and 91%.3 Because these patients have difficulty walking, decreased quality of life quality is a principal reason for surgery. If quality of life cannot be restored through the use of more conservative methods, the patient becomes a candidate for surgical intervention,1 an approach that is supported by the literature.7 Reflex disturbances have been observed in 62.5% of presenting cases. Reflex disturbances are related to age, as they are seen frequently the elderly population.7 Stenosis was most commonly seen at the L4-5 level in our group (71.8%). According to the literature, stenosis is most commonly seen at the L3-4 level in patients above 70 years old.7 In our study, multiple laminectomy was determined to be necessary in 43.6% of the patients. In the literature, single- and multiple-level laminectomy rates are quite similar.7 Therefore, our single- and multiple-level laminectomy rates are in accordance with the literature. Of our laminectomy patients, 71.9% had an anteroposterior spinal canal diameter of less than 11.5 mm. Among the elderly, spinal stenosis is more obvious, as is reported in the literature.7 When the stenosis is more obvious, surgery is performed sooner, and postoperative results are more positive.9 In our study, however, more patients were found to have anteroposterior spinal canal diameters of less than 11.5 mm in the older age group, so more total laminectomies were performed. In research carried out by Gelalis et al.,10 the surgical results for spinal decompression in patients with a mean age of 59.9 years were evaluated: 46% were rated as having an excellent outcome and 26% were rated as having a good outcome. In a study by Ivanov et al., 71.4% of decompression surgery patients reported feeling much better postoperatively.8 In our study, short-term partial recovery was observed in 71.6% of the cases. Sanderson and Wood emphasized that the results were excellent in 64% of patients after decompression surgery among patients older than 65 years and further reported no difference between old and young patients with regard to the long-term results of decompressive surgery.11 Silvers et al. and Trouillier et al. state that limited decompression is a better method of treatment for spinal stenosis than extensive decompression than fusion.12,13 Fusion is rarely necessary after decompressive laminectomy; it should be avoided if instability does not occur. Fusion was not performed on any of the patients in our study. In spite of these reports, Kabre et al.
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recently recommended extensive laminectomy, providing vertebral stability is protected.14 The health problems of the elderly have increased along with the increase in population of older persons. It is believed that in spondyloarthrosis, which is one of the foremost problems of older age groups, comparing various lumbar spinal stenosis treatment approaches represents a valuable contribution to the literature. It is believed that total laminectomy is more suitable for those in the oldest age group, and is thus more commonly performed in the cases. In patients who received only laminectomy, the anteroposterior spinal canal diameter was less than 11.5 mm. Surgery is directed at nerve root decompression and on maintaining a stable and balanced spine. It has been demonstrated that surgery has been advantageous even in patients above the age of 75 years.
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11. SANDERSON, P.L. & P.L. WOOD. 1994. Surgery for lumbar spinal stenosis in old people. J. Bone. Joint. Surg. Br. 76: 335–336. 12. SILVERS, H.R., P.J. LEWIS & H.L. ASCH. 1993. Decompressive lumbar laminectomy for spinal stenosis. J. Neurosurg. 78: 695–701 13. TROUILLIER, H., C. BIRKENMAIER, J. KLUZIK, et al. 2004. Operative treatment for degenerative lumbar spinal canal stenosis. Acta. Orthop. Belg. 70: 337–343. 14. KABRE, A., M.C. BA, R. CISSE, et al. 2003. Lumbar canal stenosis in Ouagadougou: aetiological, clinical aspects and prognosis regarding 80 cases. Dakar Med. 48: 138–141.
