Retrospective and Prospective Study to Analyse Outcome of Surgical Management of Patients Treated for Multisegmental Lumbar Canal Stenosis

Aditya, Thakur (2020) Retrospective and Prospective Study to Analyse Outcome of Surgical Management of Patients Treated for Multisegmental Lumbar Canal Stenosis. Masters thesis, Madras Medical College, Chennai.


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INTRODUCTION: Low Back Pain is one the most leading cause of disability adjusted life years (DALYs) globally just after Ischemic heart disease, cerebrovascular disease and lower respiratory infection. Numerous studies are being done to evaluate the aetiology and management of these malady. Lumbar canal stenosis describes a condition in which there is diminished space available for the neural and Vascular elements in the lumbar Spine secondary to degenerative changes in the spinal canal. When symptomatic, this cause a variable clinical syndrome of gluteal and /or lower extremity pain and /or which may occur with or without back pain. Symptomatic Lumbar spinal stenosis has certain characteristic provocative and palliative features. Provocative feature include upright exercise such as walking or positionally- induced neurogenic claudication. Palliative features commonly include symptomatic relief with forward flexion, sitting and/or recumbency. Our study was as an effort to address the management of these epidemic. AIM OF THE STUDY: This is Retrospective and prospective study to analyse the surgical management of patients with multi-segmental lumbar canal stenosis. 1. To analyse surgical intervention in the management of multi-segmental lumbar canal stenosis. 2. To assess the neurological and functional outcome of surgical procedure done. MATERIALS AND METHODS: STUDY DESIGN: Retrospective and Prospective analytical study. Patients satisfying inclusion criteria were included in the study after obtaining written informed consent. 25 patients with multisegmental lumbar canal stenosis were recruited and under went surgical intervention. INCLUSION CRITERIA: Adult patient with back pain, sciatica, neurogenic claudication. Radiograph of lumbo-sacral spine with instability/deformity. MRI finding suggestive of lumbar canal stenosis, absolute stenosis (mid sagittal diameter of the canal < 10cm), Relative stenosis (mid sagittal diameter of the canal 10mm - 13mm). Multiple level canal stenosis (two or more level). EXCLUSION CRITERIA: Congenital lumbar canal stenosis. MRI suggestive of Lumbar Canal stenosis but patient symtomatically normal. Preoperative evaluation: Patient history and neurological examination.Preoperative clinical evaluation of the patients was made by Modified Japanese Orthopaedic Association (JOA) score Visual analogue score for back pain and neurogenic Claudication (VAS).Radiography of the lumbosacral spine: Standard Anteroposterior View, Lateral View, Dynamic Flexion-extension lateral view, MRI of lumbosacral spine. SURGICAL TECHNIQUE: For all the procedure, patient under Endotracheal tube General Anaesthesia with knee chest position in Hall’s Frame. Thorough standard Posterior Midline Approach.Patients were randomly distributed among two expert surgical team, in which one team exclusively did IBF and other did exclusively PLF 12 patients in Group A had decompression with anterior interbody fusion (IBF) and --- patients in Group B had Decompression with Posterolateral fusion (PLF). Pre-op protocol were same for all the patients including Pre-op Neurology charting, Modified JOA score, VAS. Both the group were followed up similarly. RESULTS: In our study population the Pre op modified JOA score was 8.76 it improved to in the last follow up. Demographically Male gender group had mean Pre op modified JOA of 9.71 with mean improvement of 13.64 in the last follow. Male group had the mean recovery rate of 75.64%. In female group had mean preop modified JOA of 7.54 with mean improvement of 13.27 in the last follow up. Recovery rate observed in female group was 76.25%. In the group with Decompression Posterior stabilization with Anterior Reconstruction with fusion prep JOA was 14.75 in 12 months follow up the where as it was 13.46 in the group with Decompression with Posterolateral fusion.In our series of 25 patients mean Pre-op VAS was 7.4 and it reduced to mean post op VAS of 1.06. Demographically Male group had Pre-op VAS of 7.2 and it reduced to 0.85 in the last follow up. In female group Pre-op VAS was 7.54 and it reduced to 1.27 in the last follow up.In group with Decompression with instrumented interbody fusion Pre-op VAS was 8.0, which reduced to mean of 0.58 in the last follow up. In the group with Decompression with posterolateral fusion Pre-op VAS was 7.53 which was reduced to mean of 1.38 in the last followup. In 2wks, 1 month and 3 months follow up post operatively patients with instrumented interbody fusion had lower score when compared to patients with only posterolateral fusion. DISCUSSION: Ganz [et. al.] (1990) in their series of 33 patients 86% show good outcome. Nath [et. al.] (2012) reported 64% patients with excellent and 28% showed good outcome at one year follow up in series of 32 patient. In our series, at one year of follow up (Modified JOA score) In Group A (IBF) 66.6 % had excellent outcome while in group B 76.92% patients had excellent outcome. In sum, 72% (n=18) had “excellent” clinical outcome and 28% responded with “good” clinical outcome. Which is statistically significant as measured by paired T Test with P value < 0.05. Group A (IBF) had earlier functional recovery when compare to Group B alone which was evident by VAS at 2wks, 1 month and 3rd month and Modified JOA score. At One year follow up all had similar VAS and Modified JOA, these comparable results were supported by statistical test in form of ANOVA one way test which was insignificant statistically. CONCLUSION: Surgical management of multisegmental lumbar canal stenosis yields better result than conservative management. Adequate Decompression laminectomy with instrumental stabilisation of the effected segment is a key to pain relief.Decompression with extended posterolateral fusion with anterior reconstruction with cage heals early with improved functional outcome and it helps in early mobilisation.

Item Type: Thesis (Masters)
Additional Information: 221712001
Uncontrolled Keywords: Lumbar canal stenosis, Multisegmental Lumbar canal stensosis, Surgical intervention, Decompression surgery, Modified JOA, VAS, PLIF, PLF.
Subjects: MEDICAL > Orthopaedics
Depositing User: Subramani R
Date Deposited: 13 Feb 2021 11:50
Last Modified: 13 Feb 2021 11:50

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