Download PDF
Die Wirbelsäule 2017; 01(02): 95-100
DOI: 10.1055/s-0043-105801
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Lumbale Dekompression – Timing, Techniken, Ergebnisse

Lumbar decompression – timing, techniques, results
Florian Ringel
Neurochirurgische Klinik und Poliklinik, Universitätsmedizin Mainz
,
Naureen Keric
› Author Affiliations
Further Information

Publication History

Publication Date:
03 May 2017 (online)

    Permissions and Reprints

Zusammenfassung

Hintergrund Eine symptomatische degenerative lumbale Spinalkanalstenose tritt bei zunehmenden Durchschnittsalter der Gesamtbevölkerung mit einer steigenden Häufigkeit auf. Bei Versagen einer konservativen Therapie stellt sich die Frage der idealen operativen Versorgung und des Timings.

Methoden Es wurde eine selektive Literaturrecherche durchgeführt.

Ergebnisse Verschiedene direkte und indirekte Dekompressionstechniken stehen zur Verfügung. Als Goldstandard wird weiterhin oftmals die Facettengelenks-schonende Lamiektomie bezeichnet. Allerdings sind weniger invasive Techniken – uni- oder bilaterale Laminotomien, Dornfortsatzspaltungen – heute häufig verwendet und liefern die gleichen Ergebnisse in Hinblick auf die Stenosesymptomatik wie Laminektomien. Weniger invasive Verfahren haben jedoch den Vorteil geringerer sekundärer Instabilitäten. Eine indirekte Dekompressionstechnik sind interspinöse Spreizer. Auch diese Technik kann die gleichen Ergebnisse wie eine knöcherne Dekompression erreichen, ist allerdings mit einer signifikant höheren Reoperationsrate assoziiert.

Schlussfolgerung Die unterschiedlichen Operationsverfahren zeigen eine gute Wirksamkeit zur Behandlung der lumbalen Spinalkanalstenose, weniger invasive Verfahren sollten der klassischen Laminektomie vorgezogen werden.

Abstract

Background With increasing mean age of our population the incidence of symptomatic degenerative lumbar stenosis increases. After failure of conservative therapy surgery is indicated and the question of timing and ideal technique arises.

Methods A selective literature search was performed.

Results Different direct and indirect techniques for decompression are available. Facet-sparing laminectomy is often referred to as gold standard of lumbar decompression. However, less invasive methods as uni- or bilateral laminotomies or spinous process split are commonly used. The results concerning disability of the patient are as good as after laminectomy associated with the advantage of less secondary instabilities. Interspinous devices are an option for indirect decompression of the spinal canal. With respect to disability the result are non-inferior to bony decompression but associated with an increased reoperation rate.

Conclusion Available surgical techniques do show good efficacy to treat lumbar spinal stenosis. Less-invasive techniques should be the techniques of choice.

Schlüsselwörter

lumbale Spinalkanalstenose - Dekompressionstechniken - Laminektomie - Laminotomie

Keywords

lumbar stenosis - decompression techniques - timing - laminotomy - laminectomy - facet-sparing laminectomy - undercutting
 

  • Literatur

  • 1 Kalff R, Ewald C, Waschke A. et al. Degenerative lumbar spinal stenosis in older people: current treatment options. Dtsch Arztebl Int 2013; 110: 613-623
    PubMedGoogle Scholar
  • 2 Radcliff KE, Rihn J, Hilibrand A. et al. Does the duration of symptoms in patients with spinal stenosis and degenerative spondylolisthesis affect outcomes?: analysis of the Spine Outcomes Research Trial. Spine (Phila Pa 1976) 2011; 36: 2197-2210
    CrossrefPubMedGoogle Scholar
  • 3 Zweig T, Enke J, Mannion AF. et al. Is the duration of pre-operative conservative treatment associated with the clinical outcome following surgical decompression for lumbar spinal stenosis? A study based on the Spine Tango Registry. Eur Spine J 2017; 26: 488-500
    CrossrefPubMedGoogle Scholar
  • 4 Detwiler PW, Spetzler CB, Taylor SB. et al. Biomechanical comparison of facet-sparing laminectomy and Christmas tree laminectomy. J Neurosurg 2003; 99: 214-220
    Google Scholar
  • 5 Spetzger U, Bertalanffy H, Naujokat C. et al. Unilateral laminotomy for bilateral decompression of lumbar spinal stenosis. Part I: Anatomical and surgical considerations. Acta Neurochir (Wien) 1997; 139: 392-396
    CrossrefPubMedGoogle Scholar
  • 6 Spetzger U, Bertalanffy H, Reinges MH. et al. Unilateral laminotomy for bilateral decompression of lumbar spinal stenosis. Part II: Clinical experiences. Acta Neurochir (Wien) 1997; 139: 397-403
    CrossrefPubMedGoogle Scholar
  • 7 Overdevest G, Vleggeert-Lankamp C, Jacobs W. et al. Effectiveness of posterior decompression techniques compared with conventional laminectomy for lumbar stenosis. Eur Spine J 2015; 24: 2244-2263
    CrossrefPubMedGoogle Scholar
  • 8 Nerland US, Jakola AS, Solheim O. et al. Minimally invasive decompression versus open laminectomy for central stenosis of the lumbar spine: pragmatic comparative effectiveness study. BMJ 2015; DOI: 10.1136/bmj.h1603.
    CrossrefPubMedGoogle Scholar
  • 9 Hermansen E, Romild UK, Austevoll IM. et al. Does surgical technique influence clinical outcome after lumbar spinal stenosis decompression? A comparative effectiveness study from the Norwegian Registry for Spine Surgery. Eur Spine J 2017; 26: 420-427
    CrossrefPubMedGoogle Scholar
  • 10 Alimi M, Hofstetter CP, Torres-Campa JM. et al. Unilateral tubular approach for bilateral laminotomy: effect on ipsilateral and contralateral buttock and leg pain. Eur Spine J 2017; 26: 389-396
    CrossrefPubMedGoogle Scholar
  • 11 Komp M, Hahn P, Oezdemir S. et al. Bilateral spinal decompression of lumbar central stenosis with the full-endoscopic interlaminar versus microsurgical laminotomy technique: a prospective, randomized, controlled study. Pain Physician 2015; 18: 61-70
    CrossrefPubMedGoogle Scholar
  • 12 Moojen WA, Arts MP, Jacobs WC. et al. Interspinous process device versus standard conventional surgical decompression for lumbar spinal stenosis: randomized controlled trial. BMJ 2013; DOI: 10.1136/bmj.f6415.
    CrossrefPubMedGoogle Scholar
  • 13 Stromqvist BH, Berg S, Gerdhem P. et al. X-stop versus decompressive surgery for lumbar neurogenic intermittent claudication: randomized controlled trial with 2-year follow-up. Spine (Phila Pa 1976) 2013; 38: 1436-1442
    CrossrefPubMedGoogle Scholar
  • 14 Machado GC, Ferreira PH, Harris IA. et al. Effectiveness of surgery for lumbar spinal stenosis: a systematic review and meta-analysis. PloS One 2015; DOI: 10.1371/journal.pone.0122800.
    CrossrefPubMedGoogle Scholar
  • 15 Weinstein JN, Tosteson TD, Lurie JD. et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. The New England journal of medicine 2008; 358: 794-810
    CrossrefPubMedGoogle Scholar
  • 16 Weinstein JN, Tosteson TD, Lurie JD. et al. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976) 2010; 35: 1329-1338
    CrossrefPubMedGoogle Scholar
  • 17 Burgstaller JM, Held U, Brunner F. et al. The Impact of Obesity on the Outcome of Decompression Surgery in Degenerative Lumbar Spinal Canal Stenosis: Analysis of the Lumbar Spinal Outcome Study (LSOS): A Swiss Prospective Multicenter Cohort Study. Spine (Phila Pa 1976) 2016; 41: 82-89
    CrossrefPubMedGoogle Scholar
  • 18 Stromqvist B, Fritzell P, Hagg O. et al. Swespine: the Swedish spine register : the 2012 report. Eur Spine J 2013; 22: 953-974
    CrossrefPubMedGoogle Scholar
  • 19 Sigmundsson FG, Jonsson B, Stromqvist B. Determinants of patient satisfaction after surgery for central spinal stenosis without concomitant spondylolisthesis: a register study of 5100 patients. Eur Spine J 2017; 26: 473-480
    CrossrefPubMedGoogle Scholar
  • 20 Crawford 3rd CH, Glassman SD, Mummaneni PV. et al. Back pain improvement after decompression without fusion or stabilization in patients with lumbar spinal stenosis and clinically significant preoperative back pain. J Neurosurg Spine 2016; 25: 596-601
    CrossrefPubMedGoogle Scholar
  • 21 Kleinstuck FS, Grob D, Lattig F. et al. The influence of preoperative back pain on the outcome of lumbar decompression surgery. Spine (Phila Pa 1976) 2009; 34: 1198-1203
    CrossrefPubMedGoogle Scholar
  • 22 Pearson A, Blood E, Lurie J. et al. Predominant leg pain is associated with better surgical outcomes in degenerative spondylolisthesis and spinal stenosis: results from the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 2011; 36: 219-229
    CrossrefPubMedGoogle Scholar
  • 23 Moojen WA, Schenck CD, Nijeholt GJ. et al. Preoperative MR Imaging in Patients with Intermittent Neurogenic Claudication: Relevance for Diagnosis and Prognosis. Spine (Phila Pa 1976) 2015; DOI: 10.1097/BRS.0000000000001301.
    CrossrefPubMedGoogle Scholar
  • 24 Weber C, Giannadakis C, Rao V. et al. Is There an Association Between Radiological Severity of Lumbar Spinal Stenosis and Disability, Pain, or Surgical Outcome?: A Multicenter Observational Study. Spine (Phila Pa 1976) 2016; 41: E78-E83
    CrossrefPubMedGoogle Scholar
  • 25 Bayerl SH, Pohlmann F, Finger T. et al. The Sagittal Balance Does not Influence the 1 Year Clinical Outcome of Patients With Lumbar Spinal Stenosis Without Obvious Instability After Microsurgical Decompression. Spine (Phila Pa 1976) 2015; 40: 1014-1021
    CrossrefPubMedGoogle Scholar
  • 26 Dohzono S, Toyoda H, Matsumoto T. et al. The influence of preoperative spinal sagittal balance on clinical outcomes after microendoscopic laminotomy in patients with lumbar spinal canal stenosis. J Neurosurg Spine 2015; 23: 49-54
    CrossrefPubMedGoogle Scholar
  • 27 Pearson A, Blood E, Lurie J. et al. Degenerative spondylolisthesis versus spinal stenosis: does a slip matter? Comparison of baseline characteristics and outcomes (SPORT). Spine (Phila Pa 1976) 2010; 35: 298-305
    CrossrefPubMedGoogle Scholar
  • 28 Park DK, An HS, Lurie JD. et al. Does multilevel lumbar stenosis lead to poorer outcomes?: a subanalysis of the Spine Patient Outcomes Research Trial (SPORT) lumbar stenosis study. Spine (Phila Pa 1976) 2010; 35: 439-446
    CrossrefPubMedGoogle Scholar
  • 29 The Influence of Single-level Versus Multilevel Decompression on the Outcome in Multisegmental Lumbar Spinal Stenosis: Analysis of the Lumbar Spinal Outcome Study (LSOS) Data. Clin Spine Surg 2017; DOI: 10.1097/BSD.0000000000000469.
    CrossrefPubMedGoogle Scholar
  • 30 Giannadakis C, Nerland US, Solheim O. et al. Does Obesity Affect Outcomes After Decompressive Surgery for Lumbar Spinal Stenosis? A Multicenter, Observational, Registry-Based Study. World Neurosurg 2015; 84: 1227-1234
    CrossrefPubMedGoogle Scholar
  • 31 Gulati S, Nordseth T, Nerland US. et al. Does daily tobacco smoking affect outcomes after microdecompression for degenerative central lumbar spinal stenosis? – A multicenter observational registry-based study. Acta Neurochir (Wien) 2015; 157: 1157-1164
    CrossrefPubMedGoogle Scholar
  • 32 Sanden B, Forsth P, Michaelsson K. Smokers show less improvement than nonsmokers two years after surgery for lumbar spinal stenosis: a study of 4555 patients from the Swedish spine register. Spine (Phila Pa 1976) 2011; 36: 1059-1064
    CrossrefPubMedGoogle Scholar
  • 33 Ulrich NH, Kleinstuck F, Woernle CM. et al. Clinical outcome in lumbar decompression surgery for spinal canal stenosis in the aged population: a prospective Swiss multicenter cohort study. Spine (Phila Pa 1976) 2015; 40: 415-422
    CrossrefPubMedGoogle Scholar
  • 34 Desai A, Ball PA, Bekelis K. et al. SPORT: Does incidental durotomy affect longterm outcomes in cases of spinal stenosis?. Neurosurgery 2015; 76 (Suppl. 01) 57-63
    CrossrefPubMedGoogle Scholar
  • 35 Ulrich NH, Burgstaller JM, Brunner F. et al. The impact of incidental durotomy on the outcome of decompression surgery in degenerative lumbar spinal canal stenosis: analysis of the Lumbar Spinal Outcome Study (LSOS) data--a Swiss prospective multi-center cohort study. BMC Musculoskelet Disord 2016; 17: 170
    CrossrefPubMedGoogle Scholar
  • 36 Lurie JD, Tosteson TD, Tosteson A. et al. Long-term outcomes of lumbar spinal stenosis: eight-year results of the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 2015; 40: 63-76
    CrossrefPubMedGoogle Scholar
  • 37 Gerling MC, Leven D, Passias PG. et al. Risk Factors for Reoperation in Patients Treated Surgically for Lumbar Stenosis: A Subanalysis of the 8-year Data From the SPORT Trial. Spine (Phila Pa 1976) 2016; 41: 901-909
    CrossrefPubMedGoogle Scholar