Functional Outcome of Surgical Treatment for Lumbar Spinal Stenosis

Measured with Oswestry Disability Index

I Made Tusan Sidharta* Dr.dr. I Ketut Suyasa, SpB.,SpOT (K)**

*Resident of Orthopedic and Traumatology Department, Sanglah General Hospital,

Udayana University, Bali
** Staff of Orthopedic and Traumatology Department, Sanglah General Hospital,
Udayana University Bali

Correspondence to : I Made Tusan Sidharta, Orthopedic and Traumatology Department, Sanglah

General Hospital,Udayana University, Bali. (0361) 257427. Tusanmade03@gmail.com.

Abstract
Introduction
Stenosis is the commonest problem of lumbar spine in people over the age 65 years. The initial
treatment should be conservative. Surgery is required after the failure of conservative care. Our
study refers to patients with degenerative spinal stenosis. The patients were treated by
decompression posterior stabilisation fusion. We analyzed the outcome in terms of functional
recovery.

Material and Method

Between 2012 and 2016, 33 patients suffering from lumbar spinal stenosis underwent posterior
decompression Posterior Stabilisation at Sanglah Hospital. Postoperatively, all patients
underwent clinical monitoring by the Oswestry disability index (ODI) on monthly basis. The
differences observed (before the operation, 3, and 6 month after the operation) were evaluated
by Wilcoxon Non Parametric test.

Result
Postoperative ODI improved significantly. Preoperatively, 14/33 patients were moderate
disability. Three months after the surgery, 12/33 patients cope with most of living activities.
Six months after the surgery, there were 23 of 33 patients in this group.

Discussion
Functional outcome of the patient treated with surgery improved significantly as measured with
ODI after 3 and 6 months. this resulted was supported by another research that conclude surgery
improved all the patient-reported outcome measures.

Conclusion
In conclusion we found that wide posterior decompression, Posterior Stabilisation
Posterolateral fusion, improved all the patient-reported outcome measures with ODI score.

Keywords
Lumbar Spinal Canal Stenosis, Decompression Posterior Stabilisation Posterolateral Fusion,
Oswestry Disability Index
Introduction

Stenosis is the commonest problem of the lumbar spine in people over the age of 65 years and

surgery is required with increasing frequency. Spinal stenosis has been defined as a narrowing

of the vertebral canal and/or the foramen, to a degree that gives rise to compression of

lumbosacral nerve roots or the cauda equine.1 This narrowing derives from facet or ligamentum

flavum hypertrophy, extruded disc, spondylolisthesis or any combination of the above. It may

form part of a generalized degenerative process at several spinal levels or may be more

localized.1,2

The etiological classification of lumbar spinal stenosis, distinguishes between

congenital or developmental and acquired or degenerative stenosis. Spinal stenosis may cause

chronic pain and difficulty in walking.1 The diagnosis depends on various factors, including

the presenting history, physical findings and imaging modalities. Magnetic resonance imaging

(MRI) has been proven to be the mainstay of investigation.3 The initial treatment should be

conservative. The natural long-term outcome of conservative treatment, however, is often

unsatisfactory. In a study of conservatively managed patients followed for four years, Johnsson,

Rosen and Uden noted that 77% had persistent claudication, 85% were unchanged or had

deteriorated, and 63% had continual. Surgery is required after the failure of conservative care.

The procedure aims to decompress the spinal canal and the foramen while minimising the risk

of secondary instability.2,3

Although there is a lot of interest in this topic, there has been a lack of randomized

studies on effectiveness of the surgical treatment.1

Our study refers to patients with degenerative spinal stenosis. The patients were treated

by decompression posterior stabilization fusion with bone graft. We analyzed the outcome in

terms of functional recovery and also the extent to which the results of surgery were long-

lasting.
Material and Method

Between 2012 and 2016, 33 patients suffering from lumbar spinal stenosis in Sanglah General

Hospital underwent posterior decompression Stabilisation fusion using transpedicular systems

at Sanglah Hospital.

Clinical evaluation

The patients underwent a thorough preoperative clinical (including neurological) and

radiographic examination. Patients had suffered from spinal stenosis with serious symptoms of

back pain and/or sciatica for periods ranging from 6 months up to many years. The preoperative

clinical test also included completing the Oswestry disability index. All patients had to

complete the above-mentioned test on admission to the department, under the supervision of

an assistant not associated with the study.

Inclusion Criteria.4

 Patients with symptoms related to lumbar spinal stenosis together with radiological

signs of stenosis that have completed at least 6 months of unsuccessful conservative

management.

 Patients that have documented clinical outcome data (Oswestry Disability Index)

prior to the surgery and at the 3rd and 6th month of the surgery.

Exclusion Criteria

 Patients with significant radiological instability as proved by dynamic X-rays

 Patients with significant bulging or herniated disc, spondylolysis, spondylolisthesis,

polyneuropathy and vascular insufficiency in the lower extremity

 Patients with a history of a previous lumbar surgical intervention

Radiological Evaluation

The preoperative radiographic examination included plain radiographs. All patients underwent

either an MRI or a myelography. In patients suspected of having dynamic stenosis or a

substantial degree of concurrent scoliosis, myelography and myelo-CT were chosen. The

number of levels to be decompressed was decided preoperatively according to the findings

from MRI or myelo-CT.1 For radiological evaluation, T2-weighted axial MR sections were

used to assess the lumbar canal diameter. Anterior-posterior canal diameter between 13 – 10

mm was recorded as mild stenosis and 10 – 7 mm as moderate stenosis. Values smaller than 7

mm were considered as severe stenosis.4

Surgical Technique

Midline skin incision was made over the relevant segment which was determined by

fluoroscopy. A subperiosteal dissection of the paravertebral musculature from the spinous

process and lamina was achieved by blunt dissection and monopolar cautery. Meticulous

hemostasis was achieved with bipolar coagulation. Lateral extend of the dissection included

only the lamina of the relevant segment. Facet articulations were left untouched.4 The surgical

technique started with pedicular screw fixation at levels to be decompressed. Next, wide

decompression was done through a laminectomy, including the spinous process and the

ligamentum flavum, from the outer edge of one lateral recess to the outer edge of the

corresponding one. Decompression took place at those levels where the posterior segments

placed significant pressure on the spinal cord, the cauda equina, or the exiting nerve roots, as

confirmed by the radiological examinations and the patient’s symptoms. This technique

facilitated direct access to the meningeal sac, the roots that exit from it and the region where

the roots enter the intervertebral foramen. In cases where there was pressure on the root in the

lateral recess or the intervertebral foramen, a wide decompression was performed in those two

structures.1
 The operation was completed through the placement of autogenous and synthetic

allografts between the exposed facets and transverse processes of decompressed vertebrae, in

order to achieve posterolateral fusion. The patients were fully activated on the second

postoperative day, with drainage removal. No protective body cast was used.1

Follow Up

Postoperatively, all patients underwent clinical monitoring by completing the Oswestry

disability index on a monthly basis. The forms were completed by the patients themselves.1

Oswestry Disability Index is a simple, condition specific, multidimensional tool with the

advantage of easy patient comprehension and compliance. Patients were asked to fill the

questionnaire the day before their surgery and at 3rd and 6th months. They were not aware of

the scoring of the questionnaire, nor did they see their previous scores on follow-up. The mean

ODI scores at each time period as well as the change in ODI scores were calculated.1,4

Postoperative radiographic documentation included anteroposterior, lateral and flexion-

extension plain films. With these views, stability of the fixed levels, fusion, and condition of

the adjacent levels were evaluated

Statistics

The differences that were observed diachronically (before the operation and 3, and 6 month

after the operation) were evaluated by Wilcoxon Non Parametric test, where the significance

was determined as p < 0.05. Results of Oswestry index sections. The scale is graded 0–5, with

5 meaning maximum disability and 0 meaning minimum disability.5

Preop 3 month Post 6 month Post

Op Op

Pain 3.75 1.72 0.72

Personal Care 3.056 1.8 0.90

 Lifting 4.22 2.4 1.33

Walking 3.14 1.94 1.03

Sitting 3.3 1.7 0.75

Standing 3.7 2.11 0.93

Sleeping 1.97 1.02 0.69

Sex life 3.33 2.19 1.48

Social Life 3.05 1.69 0.96

Traveling 3.56 1.61 0.96

Table 1. Mean Oswestry Disability Index Score preoperatively, 3 month and 6 month
postoperatively.

Result

We review 33 patients suffering from lumbar spinal stenosis between 2012 and 2016 whom

underwent posterior decompression stabilization posterolateral fusion at Sanglah Hospital. We

evaluate ODI score preoperatively, 3 month and 6 month after the surgery. ODI score consist

of 10 sections called pain, personal care, lifting, walking, sitting, standing, sleeping, sex life,

social life and traveling. Each section scale is grade 0-5, with 5 meaning maximum disability

and 0 meaning minimum disability.5 The score for each sections were tabulated and calculated

for descriptive and normality test with saphiro wilk. The scores of all parameter was not

normally distribute, and still not normally distributed after data transformation process .

We performed Wilcoxon test for comparative hypothesis test of numeric variable 2

related data with not normally distributed. Postoperative Oswestry Disability index improved

significantly (P<0.05). Preoperatively, 14/33 patients were in moderate disability, they

experiences more pain and difficulty with sitting, lifting and standing. Travel and social life

are more difficult and they may be disabled from work. No patient can cope with most living
activities and there were 3/33 patients either bed-bound or exaggerating their symptom. Three

months after the surgery, 12/33 patients start to cope with most of living activities, nine patients

still experiences more pain and difficulty with sitting, lifting and standing but no patient was

bed bound. This result was statistically significant (P 0.00). Six months after the surgery, the

patient whom can cope with most living activities increase significantly, there were 23 of 33

patients in this group, 4 patients still experiences pain and difficulty with sitting, lifting and

standing, and also 5 and 1 patient still have pain as the main problem and back pain impinges

on all aspect of the patient’s life correspondingly (P 0.00).

Discussion

Functional outcome of the patient with lumbar spinal canal stenosis treated with decompression

stabilization fusion surgery improved significantly as measured with Oswestry Disability Index

after 3 and 6 months of observation. Oswestry disability index (also known as the Oswestry

Low Back Pain Disability Questionnaire) is a tool to measure patient’s permanent functional

disability, consist of 10 sections. For each section the total possible score is 5; if the first

statement is marked the section score 0; if the last statement is marked, score 5. If all 10 sections

are completed, the total score divide by maximum possible score (50) times 100%. The

interpretation of the score was, 0-20% minimal disability, 21-40% moderate disability, 41-60%

severe disability, 61-80% Crippled and 81-100% the patients are either bed – bound or

exaggerating their symptoms.5 Preoperatively 14 patients were in moderate disability, no

patient has minimal disability with 3 patients were bed bound. Three month after the surgery,

12 patients were minimal disability, 9 patients moderate disability and no patient bed bound.

After 6 months observation, we found that 23 patients have minimal disability, 4 patients

moderate, 5 severe and 1 crippled. We performed Wilcoxon test for comparative hypothesis

test and the result is significant.

 Paulsen RT et al (2016) performed retrospective study based on prospectively collected

data from 3.420 consecutive patients with clinical and magnetic resonance imaging confirmed

Lumbar Spinal Stenosis, patients were treated with posterior decompression surgery without

fusion, the outcome measures were Oswestry Disability Index (ODI), VAS, MCS (36-Short

Form Mental Component Summary), PCS (36-Short Form Physical Component Summary) and

Self-Reported Walking Distance. Of 3,420 cases enrolled, 2,591 (75%) had complete data after

a minimum interval of one year. The mean ODI scores were 39.8 and improved to 24. The

mean EQ-5D score was 0.40 and improved to 0.66. The mean VAS-leg improved from 54 to

36. The mean VAS-back improved from 46 to 34. The mean MCS improved from 28 to 36,

and, finally, the mean PCS improved from 40 to 45. All p-values were 0.0000. They conclude

that surgery improved all the patient-reported outcome measures and 82% of patients were

satisfied.6

Kaymaz et al (2011), performed study with Patients requiring surgery for severe,

symptomatic, lumbar spinal stenosis which evaluated retrospectively. Patients were treated

with single posterior decompression laminectomy. Oswestry disability index scores as well as

the complications attributable to surgery were recorded before, at the sixth month and at the

twelfth month of the surgery. Eighty patients were enrolled to the study. The mean age of the

population was 63,14. Neurogenic claudication was the most common finding (65%). Of the

patients, 67.5% had severe spinal stenosis. The mean ODI score at the baseline was relatively

high than in the literature and was measured as 74.30. At the end of the 6 months follow-up

period, all patients’ ODI scores significantly improved. Moreover, this improvement continued

till the end of the 12 month. They conclude that, in selected cases of symptomatic lumbar spinal

stenosis, single posterior decompression using laminectomy is safe and effective.4

Panagiotis et al (2009), performed study Between 1997 and 2003, 41 patients suffering
from degenerative lumbar spinal stenosis were included in a prospective clinical study. The

spinal stenosis was multilevel in all patients and in 13 of them there was degenerative scoliosis,

in 18 there was degenerative spondylolisthesis, and in 10 there was segmental instability. The

patients were assessed clinically with the Oswestry disability index (ODI) and visual analog

scale (VAS). Surgery included wide posterior decompression Stabilization and fusion and bone

graft. After a mean follow-up of 3.7 (1–6) years, the patients’ clinical improvement on the ODI

and VAS was statistically significant. Recurrent stenosis was not observed, and 39 of 41

patients were satisfied with the outcome. 3 patients with improvement initially had later surgery

because of instability. According to the above study, the surgery procedure gives good and

long lasting clinical result, when selection of patients is done carefully and when the spinal

levels that are to be decompressed are selected accurately.1

The indication for surgery is unacceptable pain or limitation of function. It is therefore

subjective, and varies according to patient expectations and lifestyle. There is no indication for

decompression in the patient with radiological stenosis, but with no symptoms of stenosis, or

with back pain only. The risk of not treating spinal stenosis is minimal, while that of operating

on an elderly patient with other health problems is unpredictable and sometimes substantial.

There are two components of an operation to be considered: decompression and fusion.

Obviously the primary aim of surgery is to create space for the neural elements by

decompression. In certain circumstances, fusion may also be considered, the main indication

being instability of the decompressed segment. The principle of decompression technique is

Decompress all stenosis areas and levels, paying specific attention to the foramen, which is the

commonest site of inadequate decompression. Wide laminectomy should be performed where

a stable spine is anticipated (narrowed disc with osteophytes) or where fusion will be

performed. Otherwise laminotomy should be performed. Preserve as much of the facet as

possible (at least 50%), to reduce the risk of iatrogenic instability. Discectomy should be
avoided as far as possible, and reserved for overt herniation. Decompression has been found to

provide long-term relief of stenosis symptoms in two out of three patients, although the results

decline with time. The biggest cause of dissatisfaction is persistent back pain, but there is no

evidence that fusion improves results in the absence of instability.7

Conclusion
In conclusion we found that wide posterior decompression stabilization posterolateral fusion,
improved all the patient-reported outcome measures with ODI score.

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