Lumbar Posterior Decompression for the Acquisition of Better Surgical Results

Abstract

  The primary therapy for lumbar spinal canal stenosis (LSS) is conservative treatment. Although severe symptoms of LSS are dramatically improved by surgery some results are unsatisfactory (failed back surgery syndrome). Surgical indications and procedures and the response to postoperative residual symptoms are three issues that must be considered to obtain good results after LSS treatment.
  According to earlier studies the long-term surgical results were unexpectedly unsatisfactory and contrary to expectations, conservative treatment could prevent symptom exacerbation. The decision to perform surgery must not be based on radiological findings alone because there is no correlation between the radiologically defined stenosis- and the symptoms grade.
  The main goal of the surgical treatment of LSS is decompression of neural structures. Not only the spinal canal but also the nerve roots should be decompressed appropriately. At surgery, posterior elements such as the paraspinal muscles and facet joints should be preserved as much as possible. As a less invasive surgical option we recommend bilateral decompression using the spinous-process splitting approach and bilateral decompression via hemilaminectomy. Fusion surgery may be an alternative approach although its efficacy remains to be determined.
  Postoperative residual symptoms should not be readily accepted as a sequel of surgery, rather, a merger of peripheral neuropathy should be considered. Superior cluneal nerve neuropathy produces low back pain and tarsal tunnel syndrome results in numbness and pain of the soles of the feet. In some patients it is difficult to distinguish between S1 symptom due to lumbar disease and piriformis syndrome. It is also difficult to distinguish between L5 symptoms due to lumbar disease and peroneal nerve neuropathy. These diseases can be addressed by observation therapy and surgery without lumbar re-operation. We found that these peripheral nerve neuropathies affected lumbar surgery outcomes and that in patients subsequently treated by observation therapy and surgery the JOA scores improved by 3.8 points.
  Spinal surgeons must respond appropriately to different situations encountered in the course of long-term postoperative observation.