Spinal Stenosis

Latest SPORT Data Supports Back Surgery for Degenerative Spondylolisthesis

cmaynard — Thu, 11 Jun 2009 12:36:10 -0700

June 11, 2009
by: Sylvia Marten

Spine-Health has blogged in the past about the Spine Patient Outcomes Research Trial (SPORT), including one study concluding that [url:6608,type=|node|,content=|back surgery was better for patients with degenerative spondylolisthesis|].

Well, SPORT just recently released the latest data on this study. Its verdict? The newest data supported this earlier conclusion, finding that back pain relief was more prevalent four years later for those patients who voluntarily had lumbar laminectomy surgery as opposed to those who voluntarily passed on this surgery.

Here’s a quick summary of these latest SPORT findings:

Identical Approach, Longer-Elapsed Time Frame, More Crossover, Similar Results.

To recap, there were two cohorts in this study: 304 patients in a randomized cohort (meaning that they were randomly chosen either to have or not have laminectomy surgery to treat their [url:6000,type=|node|,content=|spondylolisthesis|] and [url:152,type=|term|,content=|spinal stenosis|]) and 303 patients in an observational cohort (meaning that these patients voluntarily chose to have or not have this surgery).

It should be known that 66 percent of those patients who were randomly chosen to have surgery did so within four years and that 97 percent of those patients who chose surgery also had a laminectomy in that time period.

More telling were the latest findings that 54 percent of those people who were randomized not to have surgery ended up having surgery within four years and that 33 percent of those who voluntarily passed on surgery eventually had it. For more than a half and approximately a third of these specific patients, not having surgery apparently wasn’t as beneficial in terms of providing back pain relief.

Adding more intrigue to this study were the responses of those patients who voluntarily had surgery for their back pain. This group of patients reported improvements of 15.3 points for bodily pain and 18.9 points for physical function, and decreases of 14.3 points on the Oswestry Disability Index, signifying that gains experienced two years after back surgery were still maintained four years later.

At the end of the day, these latest findings confirm how laminectomy surgery may have wonderful results for people dealing with spondylolisthesis. Still, one must not rush to assume that surgery is always better than not having surgery when addressing spondylolisthesis associated with spinal stenosis. It should be noted that non-surgical treatments may adequately alleviate back pain for others, as very well may have been the case for the 70 percent of the observational patients who initially passed on and still did not have surgery four years later.

As each patient’s case is unique in itself, it ultimately comes down to the patient and his or her doctor examining their options and making a decision that they are most comfortable with and feel is the best course of action at the time.

Source: The Journal of Bone and Joint Surgery

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[url:18465,type=|node|]

Who is a Good Candidate for the X-STOP Procedure for Lumbar Spinal Stenosis? One Spine Surgeon’s Opinion.

Ben Parr — Thu, 29 Jan 2009 08:20:51 -0800

By [url:9659,type=|node|,content=|Rafael Levin, M.D.|]
January 29th, 2009

In my practice, I frequently get asked about when the [url:1618,type=|node|,content=|X-STOP procedure|] for treatment of lumbar spinal stenosis should be considered as a treatment option.

Based on the mechanism by which the X-stop device operates, and based on my personal surgical experience, in my opinion the highest predictability for clinical success using the X-stop device exists in patients who fit the following criteria:

Complain primarily of lower extremity neurogenic claudication symptoms (e.g. leg pain, heaviness, fatigue, tingling) rather than back pain alone.
Have symptoms that are generally brought on by back extension (bending backward), prolonged standing and walking.
Get significant reproducible relief of their leg pain (and or numbness, heaviness and tingling sensation) with rest while sitting, and with forward bending (such as when leaning forward against a shopping cart or walker.)
Have significant stenosis on imaging studies (MRI and CT scans) classified as mild to moderate, moderate, or even moderate to severe in some cases, but generally not so advanced to be classified as severe stenosis.
Have stenosis primarily due to soft tissue compression resulting from disc bulging and/or excess ligament, rather than primarily bony stenosis (resulting from bone spurs and enlarged facet joints).
Have some mobility within the stenotic motion segment (i.e., do not have a completely collapsed disc space or functionally fused facet joint).
Do not have hyper-mobility or frank instability within the stenotic motion segment. These patients may require a stabilization procedure such as fusion in addition to a decompression (lumbar laminectomy).
Have a single level, or at the most two levels, of [url:152,type=|term|,content=|spinal stenosis|].
Do not have clinically significant stenosis at the L5-S1 level, the bottom segment of the lumbar spine. This is the lowest spinal motion segment and, due to anatomical constraints, this level cannot be treated using the X-stop device.
Do not have advanced loss of bone (advanced osteoporosis).

With any surgery, the goal is to make sure that the procedure will be effective in treating the individual patient’s symptoms and clinical presentation. While all of the above have not been conclusively demonstrated in medical studies, this is what I have found to be most effective in treating patients with the X-STOP.

[url:9659,type=|node|,content=|Dr. Rafael Levin|] is a board certified Adult and Pediatric Spine Surgeon. He received his MD in 1998 from John Hopkins University, School of Medicine in Baltimore, Maryland. Dr. Levin has researched and published numerous works, including “Treating the Patient with Metastatic Spine Disease,” and “The Definitive Guide to Medical School Admission.”

Additional Reading:

[url:1618,type=|node|]

Playing Golf After Spinal Stenosis Surgery

Ben Parr — Thu, 15 Jan 2009 07:51:50 -0800
By Stephanie Burke
January 15th, 2009

Lumbar spinal stenosis is a relatively common problem among people in the over 65 age group, and a very common reason for surgery.

For active senior citizens, leg pain and other symptoms from lumbar spinal stenosis can affect their ability to enjoy and participate in activities such as golf. With time they may find that they can no longer walk 18 holes and eventually cannot even get around for 9 holes. Using a cart may become the only way they can golf. Rarely, the [url:998,type=|node|,content=|sciatic pain|] may be constant enough that golfing even with a cart is not feasible.

For patients who undergo [url:8876,type=|node|,content=|spinal stenosis surgery|], many will ask if they will be able to resume golfing. The answer for many is yes, but there are a number of considerations to keep in mind.

Here is the advice that [url:8967,type=|node|,content=|Stephen Hochschuler, MD|], orthopedic spine surgeon at Texas Back Institute gives his patients who are having surgery for spinal stenosis:

"First, recognize that golfing is not really the best thing for your low back. The golf swing imparts a tremendous amount of stress to the lumbar spine. If you are going to return to golf, be willing to accept that there is some risk of injury to the low back.
When you hit the ball, hit it with about 50 to 75% of the force you would normally use.
Use a back support. This has several benefits: it is a good reminder that you have a back problem; it will keep your lower back warm, which helps keep the muscles and soft tissues loose; and it limits the motion of your low back a little. You can tighten it when you address the ball, and loosen it when you are not playing.
If you can take ibuprofen, take it (e.g. Advil) about half hour before playing.
Be sure to warm up carefully and thoroughly with gentle stretching.
If at all possible, consider switching your swing to the 'natural golf' method, as this will reduce stress on your low back”

Finally, most doctors stress that if your leg pain or other symptoms flare up, take a break from golf for at least a few weeks and return to gentle strengthening and stretching exercises.

The specific patient’s overall health and the type of [url:1053,type=|node|,content=|stenosis surgery|] being performed will also dictate to some extent if and when an individual can return to golf, so it is important to discuss your individual situation with your doctor.

By: Stephanie Burke

Additional Reading:

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Surgery for Lumbar Spinal Stenosis Provides More Pain Relief than Nonsurgical Treatment

Stephanie — Tue, 01 Apr 2008 07:45:33 -0700

April 1, 2007
by: Sylvia Marten

Surgery is more effective than nonsurgical treatment in providing pain relief for patients with [url:708,type=|node|,content=|lumbar spinal stenosis|], new study results find.

At all update points, both the study participants who had surgery and who had non-surgical treatments showed improvement: however, the participants who had a [url:6023,type=|node|,content=|laminectomy|] showed greater improvement in their pain levels and ability to function, while those who had non-surgical [url:1053,type=|node|,content=|stenosis treatments|] showed only a moderate improvement. The improvements were maintained at 2 years of followup.

These above results stem from the Spine Patient Outcomes Research Trial (SPORT), a large 7-year trial undertaken at 13 prominent spine centers and sponsored by the National Institutes of Health. The study included 654 patients with lumbar spinal stenosis (without associated degenerative spondylolisthesis).

Study participants who had the [url:18464,type=|node|,content=|spinal stenosis surgery|] had standard posterior decompressive [url:6023,type=|node|,content=|laminectomy|], and those who had non-surgical care had one or a combination of at least active physical therapy (such as stretching, exercise), education for home exercise and ergonomics, and possibly nonsteroidal anti-inflammatory drugs.

Source: New England Journal of Medicine. 2008;358:794-810.

Read More:

[url:152,type=|term|,content=|Spinal Stenosis Health Center|]

Laser Disc Decompression for Spinal Stenosis: Does it Work?

Mon, 30 Jul 2007 15:46:34 -0700

July 30, 2007
by: Peter

[url:5998,type=|node|,content=||]
[url:5998,type=|node|,content=||] [url:5998,type=|node|,content=|See the Spinal Stenosis
Interactive Video|]

As a practicing spine surgeon, I am often asked by patients if their [url:1580,type=|node|,content=|disc decompression surgery|] can be done with a laser. There is a perception by the general population that lasers are a modern, almost futuristic, up and coming technology. The reality is that lasers have been around for a long time and are almost completely useless when it comes to spine surgery.

[url:17599,type=|node|,content=|A laser|] is a focused beam of light that can be used for cutting soft tissue. In eye surgery, they are definitely useful and have changed corrective eye procedures drastically. In the spine, electrocautery is much more practical for cutting soft tissue. Lasers can cut disc tissue, but it is far easier and more reliable to mechanically grab the disc fragment and remove it from compressing the nerve. Also, since discs lie right next to the nerve root, one risks the chance of damaging the nerve root with the laser. Lasers cannot cut bone so they cannot be used to decompress patients with [url:152,type=|term|,content=|spinal stenosis|].

It seems to me that the most practical use for lasers in spine surgery is for marketing. Like most businesses, spine surgery is very competitive, and having an edge in marketing can make a practice standout. I knew a spine surgeon who would tell his patients he could use a laser to do their surgery. He would cut the skin with a scalpel, then bring in a laser to cut the subcutaneous fat, then go back to electrocautery. However, since the laser was so slow, he would only use it for about thirty seconds before he went back to electrocautery. The laser performed no useful function during the surgery, but helped him for marketing purposes.

Spine-health.com has thousands of pages of information, all of which have been peer reviewed by a medical advisory board of prominent spine physicians. However, there is not one article on laser surgery as it is not an accepted spine procedure. At the major spine meetings and in the major spine journals there is a paucity of (if any) peer reviewed articles documenting any use of lasers in spine surgery.

So, if mainstream spine surgery is not interested in lasers, and lasers are primarily only useful as a good marketing tool, why do patients remain so interested in lasers? Perception plays a central role, and many patients perceive lasers to be a useful technology. Lasers are often perceived as an effective surgical approach for spine surgery because of two reasons: placebo response, and the tendency to always think the second opinion sounds more knowledgeable.

Placebo response: Patients with pain want to get better, and if they undergo an invasive procedure, they will try to get better if at all possible. The placebo response in patients with chronic pain can be as high as 70%, even if the procedure was a complete sham and did not address their spine pathology. However, in patients with true pathology the response doesn’t last very long. I recently operated on an elderly woman who had a degenerative spondylolisthesis and severe lumbar spinal stenosis. She had initially seen a local surgeon who had recommended a posterior decompression, instrumentation and fusion (which is what she needed for correction of her condition). She went to a center that claimed a laser surgery would suffice. After the laser surgery, she felt better for a couple of weeks, but then realized her pain was about the same. This is the placebo response. When I saw her and offered her the surgery she should have had in the first place, the reason the laser surgery had failed became apparent. I could see that none of the bone around the nerve roots had been removed, as would be expected since a laser surgery would have limited exposure and limited ability to deal with the anatomic problem causing the pain.

We did perform the surgery that was needed and she has subsequently done very well, as would be expected since this is a reliable surgery. The previous laser surgery had been touted as a minimally invasive surgery, which is its main benefit, but the drawback is that it does not address the pathology of lumbar spinal stenosis – the laser surgery does not remove the bone that is pressing against the nerve root and causing the pain. Unfortunately, since her laser surgery was not covered by insurance, the patient was out the cash.

Second opinion. The other factor that allows lasers to be marketed for spine surgery is that almost any second opinion for surgery has a tendency to sound smarter than the first opinion. The above patient had seen another surgeon prior to going to having laser surgery, and the first surgeon had recommended the appropriate surgery for her condition (decompression, instrumentation and fusion). The surgeon who wanted to use the laser, however, probably sounded smarter since he gave the second opinion. I have frequently heard that nobody should have a spine surgery unless they get a second opinion. The danger is that the next opinion a patient obtains may or may not be any smarter that the first opinion, and it may be based more on marketing than on any sound medical science. This is not to say that patients shouldn’t get second opinions – I am very much in favor of the patient having as much information as possible prior to deciding on surgery. Just be aware of the natural tendency for the second opinion to sound better.

Posted by: Peter Ullrich, MD

Back Surgery Best for Patients with Degenerative Spondylolisthesis

Wed, 06 Jun 2007 17:53:41 -0700

June 6, 2007
by: Sylvia Marten

Surgery Videos

The recently released results of the second SPORT study showed that patients who selected surgery to treat their [url:709,type=|node|,content=|lumbar degenerative spondylolisthesis|] had better outcomes when compared with those who selected nonsurgical treatment. The study included two groups of patients:

Randomized group – 304 patients
In the randomized group, 304 patients were randomly selected to receive either standard posterior decompressive [url:6023,type=|node|,content=|laminectomy|] (with or without a [url:1582,type=|node|,content=|spinal fusion|]) or nonsurgical care. Nonsurgical treatments included [url:171,type=|term|,content=|physical therapy|], epidural steroid injections, NSAIDS, and opioids. There was significant crossover from patients in the surgical and nonsurgical groups, with 64% of the surgical group having surgery and 49% of patients assigned to nonsurgical care also having surgery.

Because of the large percentage of patients who crossed over to from non-surgical treatment to surgical and vice-versa, the results of the study are really only meaningful by evaluating how the patients were actually treated, (vs. by their randomized groups).

Observational group – 303 patients
This group was allowed to choose whether to have surgery or receive nonsurgical treatment. 97% of patients who selected surgery went through with the operation, and 25% of the nonsurgical group ultimately chose surgical treatment.

The surgery for [url:6000,type=|node|,content=|spondylolisthesis|] included a decompressive laminectomy with or without an accompanying spinal fusion.

The large cross-over of patients and the favorable outcomes show what doctors and patients already know: those with pain fare best when their care was left to the individual discretion of patient and surgeon.

Primary source:

Surgery vs. Non-surgical Treatment for Lumbar Degenerative Spondylolisthesis