Minim Invasive Neurosurg 2007; 50(1): 18-22
DOI: 10.1055/s-2006-947996
Original Article

© Georg Thieme Verlag KG Stuttgart · New York

Minimally Invasive Decompression for Lumbar Spinal Canal Stenosis in Younger Age Patients Could Lead to Higher Stresses in the Remaining Neural Arch - A Finite Element Investigation

A. Ivanov 1 , A. Faizan 1 , K. Sairyo 1 , N. Ebraheim 1 , A. Biyani 1 , V. K. Goel 1
  • 1Engineering Center for Orthopaedic Research Excellence (E-CORE), Departments of Orthopaedic Surgery and Bioengineering, Colleges of Medicine and Engineering, University of Toledo, Toledo, Ohio, USA
Further Information

Publication History

Publication Date:
04 June 2007 (online)


Background and Purpose: A young patient group with the symptoms of acquired spinal stenosis has been identified recently in the literature. The patients between 25-50 years of age were found to have signs of lumbar spinal stenosis because of degenerative spinal changes. Some of them were operated on using the same limited decompression approaches as the older patients. However, this group differs from the geriatric population due to the scarcity of remodeling degenerative signs at the spine. Therefore, the possible ligamentous laxity, facet joint degeneration or only the removal of some spinal structures could lead to the increased stresses in the remaining spinal arch and could have an unfavorable course of events after the procedure. A biomechanical study has been done using an experimentally validated finite element model (FEM) of the intact L3-S1 lumbar spine to elucidate the influence of the limited decompression on range of motion (ROM) and stress distribution on the neural arch in this patient group.

Methods: We simulated unilateral laminotomy L4 and medial facetectomy L4-5, medial facetectomy L4-5 and lateral fenestration of L5 pars interarticularis, combined transarticular lateral and medial approach with partial facetectomy L4-5, “port-hole” decompression at the L4 level, and hemilaminectomy L4 with medial facetectomy L4-5. The ROM and maximum von Mises stresses were analyzed in flexion, extension, lateral bending, and axial rotation in response to a 10.6 Nm moment with 400 N axial compression. The data were compared with the intact spine and hemilaminectomy L4 with medial facetectomy L4-5 models.

Results and Conclusion: The investigation revealed almost the same ROM after simulation but a considerable increase in stresses at both the pars interarticularis and the inferior facet after limited decompressions, especially in extension and rotation to the contralateral side. Stresses at the contralateral L4 pedicle were highest after L4 hemilaminectomy and medial facetectomy L4-5. Due to the observed increases in stresses, the surgeon should be aware of the possibilities of stress-fractures in this patient group.


  • 1 Ciol MA, Deyo RA, Howell E, Kreif S. An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations.  J Am Geriatr Soc. 1996;  44 285-290
  • 2 Sarpenyer MA. Congenital stricture of the spinal canal.  J Bone Joint Surg. 1945;  27 70-79
  • 3 Verbiest H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal.  J Bone Joint Surg [Br]. 1954;  36 230-237
  • 4 Epstein JA, Malis LI. Compression of spinal cord and cauda equina in achondroplastic dwarfs.  Neurology. 1955;  5 875-581
  • 5 Papp T, Porter RW, Craig CE, Aspden RM, Campbell DM. Significant antenatal factors in the development of lumbar spinal stenosis.  Spine. 1997;  15 1805-1810
  • 6 Verbiest H. Neurogenic intermittent claudication. New York, Elsevier 1976
  • 7 Verbiest H. Sur certaines formes rares de compression de queue de cheval. In: Hommage a Clovis Vincent. Paris: Maline 1949: 161-174
  • 8 van Akkerveeken PF. A taxonomy of lumbar stenosis with emphasis on clinical applicability.  Eur Spine J. 1994;  3 130-136
  • 9 Giles GF. Mechanisms of neurovascular compression within the spinal and intervertebral canals.  J Manipulative Physiol Ther. 2000;  23 107-112
  • 10 Hiwatashi A, Danielson B, Moritani T, Bakos RS, Rodenhause TG, Pilcher WH, Westesson PL. Axial loading during MR imaging can influence treatment decision for symptomatic spinal stenosis.  AJNR Am J Neuroradiol. 2004;  25 170-174
  • 11 Hejazi N, Witzmann A, Hergan K, Hassler W. Combined transarticular lateral and medial approach with partial facetectomy for lumbar foraminal stenosis. Technical note.  J Neurosurg. 2002;  96 ((Suppl 1)) 118-121
  • 12 Ikuta K, Arima J, Tanaka T, Oga M, Nakano S, Sasaki K, Goshi K, Yo M, Fukagawa S. Short-term results of microendoscopic posterior decompression for lumbar spinal stenosis. Technical note.  J Neurosurg: Spine. 2005;  2 624-633
  • 13 Goel V, Grauer J, Patel T. et al . Effects of Charite artificial disc on the implanted and adjacent spinal segments mechanics using a hybrid testing protocol.  Spine. 2005;  30 2755-2764
  • 14 Sairyo K, Katoh S, Sasa T. et al . Athletes with unilateral spondylolysis are at risk of stress fracture at the contra-lateral pedicle and pars interarticularis: A clinical and biomechanical study.  Am J Sports Med. 2005;  33 583-590
  • 15 Sairyo K, Biyani A, Goel VK. et al . Pathomechanism of hypertrophy of ligamentum flavum: A multidisciplinary investigation by clinical, biomechanical, histological and biological assessment.  Spine. 2005;  30 2649-2656
  • 16 Sairyo K, Katoh S, Takata Y. et al . MRI signal changes of the pedicle as an indicator for early diagnosis of spondylolysis in children and adolescents. A clinical and biomechanical study.  Spine. 2006;  31 206-211
  • 17 Sairyo K, Goel VK, Masuda A. et al . Biomechanical rationale of endoscopic decompression for lumbar spondylolysis as an effective minimally invasive procedure - A study based on the finite element analysis.  Minim Invas Neurosurg. 2005;  48 119-122
  • 18 Kleeman TJ, Hiscoe AC, Berg EE. Patient outcomes after minimally destabilizing lumbar stenosis decompression: the “Port-Hole” technique.  Spine. 2000;  25 865-870
  • 19 Kunogi J, Hasue M. Diagnosis and operative treatment of intraforaminal and extraforaminal nerve root compression.  Spine. 1991;  16 1312-1320
  • 20 Grob D, Humke T, Dvorak J. Degenerative lumbar spinal stenosis. Decompression with and without arthrodesis.  J Bone Joint Surg [Am]. 1995;  77 1036-1041
  • 21 Herron LD, Newman MH. The failure of ethylene oxide gas-sterilized freeze-dried bone graft for thoracic and lumbar spinal fusion.  Spine. 1989;  14 496-500
  • 22 Wiltse LL, Kirkaldy-Willis WH, McIvor GW. The treatment of spinal stenosis.  Clin Orthop Relat Res. 1976;  11 83-91
  • 23 Deyo RA, Cherkin DC, Loeser JD, Bigos SJ, Ciol MA. Morbidity and mortality in association with operations on the lumbar spine. The influence of age, diagnosis, and procedure.  J Bone Joint Surg [Am]. 1992;  74 536-543
  • 24 Deyo RA, Ciol MA, Cherkin DC, Loesern JD, Bigos SJ. Lumbar spinal fusion: a cohort study of complication, reoperations, and resource use in the Medicare population.  Spine. 1993;  18 1463-1470
  • 25 Yuan HA, Garfin SR, Dickman CA, Mardjetko SM. A historical cohort study of pedicle screw fixation in thoracic, lumbar, and sacral spinal fusions.  Spine. 1994;  15 2279-2296
  • 26 Sheehan JP, Helm GA, Sheehan JM, Jane JA. Stress fracture of the pedicle after extensive decompression and contralateral posterior fusion for lumbar stenosis. Report of three cases.  Neurosurg Focus. 2002;  13 9
  • 27 Maurer SG, Wright KE, Bendo JA. Iatrogenic spondylolysis leading to contralateral pedicular stress fracture and unstable spondylolisthesis: a case report.  Spine. 2000;  25 895-898
  • 28 Rosen C, Rothman S, Zigler J, Capen D. Lumbar facet fracture as a possible source of pain after lumbar laminectomy.  Spine. 1991;  16 234-238
  • 29 Cyron BM, Hutton WC, Troup JD. Spondylolytic fractures.  J Bone Joint Surg [Br]. 1976;  58 462-466
  • 30 Cyron BM, Hutton WC. The fatigue strength of the lumbar neural arch in spondylolysis.  J Bone Joint Surg [Br]. 1978;  60 234-238
  • 31 Garber JE, Wright AM. Unilateral spondylolysis and contralateral pedicle fracture.  Spine. 1986;  11 63-66
  • 32 Aland C, Rineberg BA, Malberg M, Fried SH. Fracture of the pedicle of the fourth lumbar vertebra associated with contralateral spondylolysis. Report of a case.  J Bone Joint Surg [Am]. 1986;  68 1454-1455
  • 33 Stanley D, Smith TW. Contralateral pedicle stress fracture. An unusual complication of laminectomy.  Spine. 1990;  156 598-599
  • 34 Ooi Y, Suzuki Y, Sugawara S, Yamazaki N, Morisaki N. Acquired spondylolysis in child and young adult. Report of two case.  J Bone Joint Surg [Am]. 1968;  50 1649-1656
  • 35 Morita T, Ikata T, Katoh S, Miyake R. Lumbar spondylolysis in children and adolescents.  J Bone Joint Surg [Br]. 1995;  77 620-625
  • 36 Felon L, Faizan A, Goel VK, Sairyo K, Biyani A, Ebraheim N. , Effects of disc height decrease on the degenerated segment biomechanics. A finite element analysis: 52nd Annual Meeting of the Orthopaedic Research Society, Chicago, IL, 2006


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