Lumbar spinal stenosis: who should be fused? An updated review

Farzad Omidi-Kashani, Ebrahim Ghayem Hasankhani, Amir Ashjazadeh, Farzad Omidi-Kashani, Ebrahim Ghayem Hasankhani, Amir Ashjazadeh

Abstract

Lumbar spinal stenosis (LSS) is mostly caused by osteoarthritis (spondylosis). Clinically, the symptoms of patients with LSS can be categorized into two groups; regional (low back pain, stiffness, and so on) or radicular (spinal stenosis mainly presenting as neurogenic claudication). Both of these symptoms usually improve with appropriate conservative treatment, but in refractory cases, surgical intervention is occasionally indicated. In the patients who primarily complain of radiculopathy with an underlying biomechanically stable spine, a decompression surgery alone using a less invasive technique may be sufficient. Preoperatively, with the presence of indicators such as failed back surgery syndrome (revision surgery), degenerative instability, considerable essential deformity, symptomatic spondylolysis, refractory degenerative disc disease, and adjacent segment disease, lumbar fusion is probably recommended. Intraoperatively, in cases with extensive decompression associated with a wide disc space or insufficient bone stock, fusion is preferred. Instrumentation improves the fusion rate, but it is not necessarily associated with improved recovery rate and better functional outcome.

Keywords: Instrumentation; Lumbar vertebrae; Spinal fusion; Spinal stenosis.

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1
Fig. 1
A 52-year-old female was treated with decompression and instrumentation 1 year ago. She presented with flat back syndrome, refractory low back pain, and walking disability. During revision surgery, no evidence of fusion was observed, the instrument was removed, and lumbar lordosis was re-created.
Fig. 2
Fig. 2
An 87-year-old male patient presented with annoying claudication and low back pain. In preoperative imaging studies, degenerative scoliosis associated with significant stenosis was observed. He was scheduled for neural decompression, deformity correction, and instrumented posterolateral fusion.
Fig. 3
Fig. 3
A 36-year-old man presented with L5-S1 isthmic spondylolisthesis. He was treated with laminectomy, slip reduction, and instrumented posterolateral fusion.
Fig. 4
Fig. 4
A 32-year-old woman presented with refractory L4 spondylolysis, L4-L5 degenerative disc disease, and L4 radiculopathy. She was treated with decompression, and in situ instrumented fusion.
Fig. 5
Fig. 5
A 42-year-old man presented with chronic refractory low back pain, and a degenerative disc disease in the L4-L5 space. His pain was almost completely eliminated after a trial of local anesthetic injection during discography. He ultimately underwent instrumented transforaminal lumbar interbody fusion. During the latest follow-up visit at 32 months post-operatively, he was completely pain free and could work like an otherwise healthy man.
Fig. 6
Fig. 6
A 56-year-old female patient presented with L4-L5 stenosis and spondylolisthesis associated with a relatively spontaneous fusion of L5-S1. The instability may be de novo or secondary to the relatively stabilized L5-S1 segment (arrow). She was treated with decompression and instrumented posterolateral spondylodesis.
Fig. 7
Fig. 7
A 35-year-old man presented with L5-S1 isthmic spondylolisthesis (grade II), severe low back pain, and right leg pain since six months. He was treated with slip reduction, TLIF cage, and instrumented posterolateral fusion. Right image shows the intraoperative fluoroscopic lateral view of the lumbosacral area. TLIF, transforaminal lumbar interbody fusion.
Fig. 8
Fig. 8
A 54-year-old woman presented with clinically debilitating L4-L5 spondylolisthesis. For surgical treatment, vertebral reduction, instrumented posterolateral fusion, and posterior lumbar intervertebral fusion were performed.

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