12RahmanAbdul_Treatment


 

 

 

 

 
200          Rahman, Iacob          Treatment of lumbar spinal stenosis (LSS) and outcome 

 

 

 

 

 

 

 

Treatment of lumbar spinal stenosis (LSS) and outcome 

Hawis Abdul Salam Abdul Rahman1, Gabriel Iacob2 

1Siria, 2Neurosurgery Clinic Bucharest Romania 

“Outcome may be improved by more careful selection of patients and by performance of an 

adequate surgical decompression” Deen G. et al. - Mayo Clin Proc 1995, 70, 33-36 

 
The natural history of lumbar spinal 

stenosis is critical to treatment decisions, since 

it is unlikely that symptoms will worsen or that 

neurologic function will deteriorate rapidly, 

prophylactic treatment is not warranted; also 

there are no specific recommandations: see 

randomized prospective controlled trials of 

surgical vs nonsurgical treatment (1-18). 

Because spontaneous improvement is 

uncommon, watchful waiting is an 

unsatisfactory strategy for patients with 

intolerable symptoms, surgical attitude lukes 

like natural to alleviate pains, to improve 

fonctional capacity, to  obtain symptoms 

resolution (1)(2)(4)(7)(8)(11-13)(17)(18). 

The clinical coursevaries considerably: in 

most patients, is chronic, benign, stagnating – 

see also EMG changes (16), partially 

controllable by conservative treatment or is 

expected to progress slowly, with neurogenic 

claudication or although rare, with a cauda 

equine syndrome – with sensory and motor 

deficit, saddle anesthesia, bowel and bladder 

dysfunction, imposing a causal treatment of 

spinal canal stenosis (10)(14-16)(20). If disk 

prolapse tends to regress spontaneously, the 

causative degenerative changes associated 

with spinal stenosis will progress slowly 

(15)(21-23). In most patients (60% to 70%), 

the pain seems to stagnate in the medium term 

(5)(6); of the natural course of 31 patients with 

LSS over 49 months reports: unchanged 

symptoms in 70%, improvement, even 

walking capacity in 15%, worsening in 15%(5). 

In patients with pronounced symptoms, a 

high degree of stenosis and spondylolisthesis, 

a progressive disease course may be assumed 

and surgery is consistent with clinical 

experience, showing several advantages in 

terms of disability, leg pain, backache, for 

symptoms recurrencies at least in the short 

term, most surgically treated patients would 

again choose surgery and quality of life at 3-6 

months, remained for up to 2-4 years (1-

3)(6)(7)(11-13)(17-23). There are also unclear 

aspects too: why there is no no difference in 

the outcomes of patients who underwent 

surgery earlier vs later in the disease; several 

outcome parameters are unknown: the 

duration of follow-up, the outcome measures, 

level of pain, use of analgesics, walking 

capacity, fluctuating evolution, medical and 

surgical treatments frequently interference, 

time for surgery (2-8)(10-14) (16-23). 

Also nonsurgical management is effective: 

up to one third of patients treated surgically 



 

 

 

 

 
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responded to non-surgical treatment: 70% 

satisfactory at 6 months, 57% satisfactory at 4 

yrs; it’s generating a slight to moderate 

improvement for a time, it is advisable initial 

for most patients (1)(7)(8)(10). A recent 

publication in the New England Journal of 

Medicine (2), the Spine Patient Outcomes 

Research, 13h Trial (SPORT) from the US, 

supported these results in a larger group of 289 

patients, in a randomized cohort and 365 

patients in an observational cohort. Surgery 

resulted in faster and significantly better 

alleviation of complaints than conservative 

treatment. Interestingly, patients who did not 

have surgery also experienced a reduction in 

symptoms, albeit at a slower rate. However, 

this study showed that surgery is superior to 

conservative treatment in the longer term, 

decompression should be advocated whenever 

history, symptoms, findings and imaging 

clearly indicate its use in patients with LSS 

refractory to conservative treatment for at least 

3 months, the patient should be informed 

about results. Similar results has also 

Malmivaara (1), but no current 

recommendations. 

The conservative treatment are based on 

observations, clinical judgments; should be 

applied in a stepwise pathway that progresses 

from least invasive treatments: activity 

restrictions, physical therapy, analgesics, 

antiinflammatory medications, lumbo-sacral 

orthoses, to most invasive epidural or 

intratecal injection with corticoid products, 

calcitonin, peripheral vasodilators medication 

with a success rate of 50-65% of cases, 

Prostaglandin E (3)(6)(7)(10-12)(17)(23-

30)(32). There are also reports, but not high-

quality trials, reporting no substantial change 

over the course of 1 year to majority of 

symptomatic patients with lumbar spinal 

stenosis whose are managed non operatively 

(5)(7)(13)(19)(22)(23). Decompression is 

more effective than other alternative ? (8)(21) 

The conservative treatment indications are 

(16): as initial treatment for radiculopathies 

cases, without significant deficits, reducing 

pain, augmenting walking distance; a 

therapeutic option to those patients who 

cannot be operated.  

Several alternatives are deployed as a 

multimodal therapeutic concept: 

- physical therapy(16)(19)(20)(23)(27) gives 

symptomatic relief of root or low back pain 

with the goals of improving strength, 

endurance and flexibility, significant benefit 

concerning: standing time, pain score, Roland 

disability score, walking distance; maintaining 

a better posterior pelvic tilt. Using a 

customized program several therapeutic 

alternatives could be used: 

� active exercises in the form of 
stretching to increase lumbo-pelvic 

muscular stabilization, distraction, 

manipulation and neural 

mobilization, encouraging lumbar 

flexion and flattening of the lumbar 

lordotic curve; also exercises 

performed during lumbar flexion, 

such as bicycling are better tolerated 

than walking, avoid hyperextension 

and side bending  

� massage, ultrasound, TENS, braces, 
supports, lumbar corsets - for a 

limited number of hours per day, to 

avoid atrophy of paraspinal muscles, 



 

 

 

 

 
202          Rahman, Iacob          Treatment of lumbar spinal stenosis (LSS) and outcome 

 

 

 

 

 

 

 

in patients with symptomatic spinal 

stenosis with pain, maintaining a 

posture of slight lumbar flexion; 

although there are no trial data to 

guide this decision; treadmill and 

ergometer training acupuncture; 

biofeedback; hot or cold packs; 

traction or chiropractic 

manipulation. These therapies (14) 

have not been compared in any 

randomized controlled trial and there 

is considerable variability among 

practitioners in their use. 

- for pain: medication such as acetaminophen, 

non-steroidal anti-inflammatory drugs 

(NSAIDs), Anti-cox 2–debatable efficacy, used 

for short time (2)(4)(13)(23)(27-30), tolerance 

mediocre, although there is no clear rationale, 

but are strongly contraindicated in patients 

with a history of congestive heart failure, 

peptic ulcer or kidney disease; muscle 

relaxants – used when pain is not controlled by 

antalgic drugs, NSAIDs, but no proofs; also 

mild narcotic analgesics. 

- lumbar epidural corticosteroid injections 

(24)(25-28) are justified to control severe roots 

symptoms on the assumption that symptoms 

may result from inflammation at the interface 

between the nerve root and the compressing 

tissues. Data on the efficacy of epidural 

injections are sparse and mixed; on low time, 

especially in older patients is a lack of 

consistent evidence of efficacy (24). In patients 

with predisposing conditions, such as diabetic 

patients and in repeated infiltrations, 

infections are possible, which may have severe 

consequences (31). No efficacy or even 

negative results with foraminal or even 

intrathecal, made blind or under fluoroscopic 

control (28) 

-relational causes treatement: anxiolytic, 

antidepressive, relaxation, education (reassure 

the patient, explain) 

- long-term opioid therapy (28) should be 

considered for older patients with 

unsatisfactory response to other medical 

therapies and who are not surgical candidates 

with the following caveats: assess for pain 

control and functional improvement in 

walking, standing, self-care activities, may 

generate complications: constipation and in 

the older patient may adversely affect 

cognition. 

-calcitonin could be tried in patients with 

lumbar spinal stenosis administered by nasal 

spray to improve pain and walking tolerance, 

usually apparent within 4 to 6 weeks, despite 

double blind, randomized, placebo-controlled 

trial (29)(30). The calcitonin’s mechanism of 

action is unknown: nonspecifically by raising 

the level of endogenous opioids - beta 

endorphins or by enhancing circulation to an 

ischemic cauda equine (22). 

- prostaglandin E was credited by Yoshihara 

(32) useful in LSS treatment, based on same 

raising the endogenous opioids level. 

The conservative treatment conclusions:  

- conservative treatment is a therapeutic 

option for LSS without major risks - see 

NSAIDs complications 

- it’s acceptable for the patient 

- several options could be used to those 

patients who cannot be operated 

- it must be applied as the first treatment 

The surgical treatment is not only a 

solution for resistant symptoms in patients 



 

 

 

 

 
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with LSS, but even useful: in cases of consistent 

clinical and radiological findings after 

adequate conservative therapeutic measures 

have failed for a time at least three months, to 

patients with realistic expectations; certified 

although by few evidence-based insights into 

the treatment options (1)(2)(4)(6-

8)(12)(17)(19)(23)(33-41). 

Surgical treatment in LSS means 

(33)(34)(38)(40-55): 

-a functional surgery – never operate pictures 

with the aim to alleviate symptoms, to 

normalize daily life activities, improving 

functional capacity, achieving a good quality 

of life 

-difficult surgery – most aged patients, with 

chronic illness; there are still 20% 

unsatisfactory results 

-experience - surgical treatment should be 

applied to each patient, with a perfect 

correspondence between neuro-radiological 

and clinical findings  

There are several points to consider into the 

preoperative planning (33)(50)(51)(56): 

� medical status & physiologic age of 
the patient 

� clinical and morphologic aspects, 
associated pathology – it’s rational to 

consider a disturbed balance between 

the capacity of the spinal canal and its 

contents at the time of presentation 

must be responsible for the insidious 

onset of neurogenic claudication; also 

is usually symptomatic at a particular 

side & motion segment/s rather than 

affecting bilateral multiple 

radiological involved  levels; careful 

evaluation of all available data proved 

that the number of nerve roots 

requiring decompression is often less  

than what appears in radiological 

studies alone 

� the timing for surgery has not been 
clearly decided. Data comparing the 

outcomes of patients who underwent 

surgery earlier vs later in the disease 

suggest no difference in outcome 

� is there deformity/instability too ?, the 
suggested decompression technique 

alone may lead to segmental 

instability ? 

� a fusion technique should be 
performed to all cases ? – see loss of 

mobility of the operated segment, 

possible adjacent segment 

decompensation or unless instability 

is present pre-op; for older patients 

ability to fuse may be compromised, 

also fixation may not be adequate 

� the proposed surgical procedure 
should be correlated with long-term 

results relating especially to modern 

techniques, which are still often 

lacking 

� should this operation to be the “last 
surgery”? 

� it’s also art of surgery– adequacy for 
enlarged lumbar spinal canal - it’s a 

balance between doing too much and 

not doing enough: suppressing the 

conflict between the lumbar spinal 

canal with disco-ligamentous 

structures and the content 

represented by the dural sac and 

radicular nerves, decompressing the 

neural foramina, eliminating pressure 



 

 

 

 

 
204          Rahman, Iacob          Treatment of lumbar spinal stenosis (LSS) and outcome 

 

 

 

 

 

 

 

on the spinal nerve roots, without 

generating spinal instability, never 

prophylactic 

In the absence of randomized prospective 

controlled trials of surgical vs nonsurgical 

treatment several ideas should be underlined 

(1)(2)(4)(11)(12)(16)(19)(20)(23)(33)(34)(39)

(41) (50)(54)(56): 

-stenotic symptoms improved significantly 

more often in surgically treated patients; there 

is an advantage at least in the short term than 

in conservatively treated patients 

-most surgically treated patients would again 

choose surgery; no difference in outcomes of 

patients who underwent surgery earlier vs later 

in the disease; but over 10 years outcome was 

most favorable with surgery 

-however, up to one third of patients treated 

non surgically also do well and an initial non-

surgical approach was advisable for most 

patients 

The aims of surgical techniques 

(50)(51)(53)(54) in degenerative lumbar 

spinal stenosis should be critical evaluated 

since the aims of the procedure are clearly 

explained in the written consent, especially to 

old-aged patients:  

� to restore functional capacity acting 
on neuro-vascular compression, with 

no or limiting complaints: neurogenic 

claudication + mono or multi roots 

resting or in efforts pain; subjective 

neurologic signs + neurologic deficit 

during walking, to improve leg and 

low back symptoms, to increase the 

pain - free walking distance 

� to achieve a good quality of life using a 
technique for “maximum effect with 

minimum trauma”: minimize tissue 

disruption, decompress the lumbar 

channel and the roots, avoid to 

destabilize, no stabilization, no 

instrumentation, minimize time of 

surgery and length of hospital stay, 

minimize post operative morbidity, 

avoiding complications, to permit a 

rapid patient mobilization, almost 

addressability is for old, fragile 

patients think to an unique surgical 

procedure 

It’s better to inform the patient, that 

surgical treatment has no action on 

(33)(51)(54): 

-  focal or diffuse low back pain and/or 
stiffness 

- “degenerative” illness 
- no patient will be completely free of 

complaints  

- no patient will have a new lumbar 
spine after the operation 

Surgical indications are depending on case 

to case evaluation (37)(38-41)(50):  

-general indications related to age - 

without a priori contraindications, co-

morbidities, surgeon experience which 

predicts failure of conservative therapy or 

patients intolerant to conservative therapy, 

younger age and somatic co-morbidity were 

independently associated with life 

dissatisfaction  

-specific indications related to: degree of 

stenosis, MRI findings, with evidence of good 

correlation between severity of symptoms, 

radiological concordance and surgical 

outcome and poor correlation between degree 

of stenosis with degree of symptoms; degree of 



 

 

 

 

 
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disability (ODI, Pain Analog Scales, walking 

distance, daily life activities), degree of 

instability and associated neurological deficit, 

surgical option and the timing for surgery 

individualized on patient request. 

Establishing indications, there are several 

situations (50)(54): 

� Incidental finding of LSS and those 
with no limitation of life style; not 

bothered by symptoms (mild): 

- explanation of findings, reassurance 
and “watchful waiting” 

- treat any co-morbidities or other 
conditions contributing to symptoms 

of stenosis  

- treat low back pain with NSAID’s 
(selective cox2 inhibitors) 

� Symptomatic LSS: patients with cauda 
equine syndrome (52) should be 

operated on emergency – rare cases 

� Symptomatic LSS with persistent or 
worsening symptoms of neurogenic 

claudication and/or radiculopathy 

(reduced walking distance but can 

manage daily activities with 

medication) despite conservative 

therapy for at least 3 months, with 

minimal co-morbidities, 

radiologically demonstrated severe 

stenosis - the best patients to benefit 

from surgery. Also in cases with 

recurrent symptoms (56) proofed 

clinically and radiologically of: 

residual stenosis at operative site due 

to inadequate first surgery, stenosis at 

adjacent levels to surgical site, new 

herniated disc, epidural and 

arachnoidal adhesions, instability 

and/or spondylolisthesis following 

first surgery, in the absence of 

demonstrated stenosis, further 

investigations are warranted: contrast 

studies, EMG and NCS. For 

symptomatic LSS evidence in the 

literature is poor for correlating 

degree of stenosis with degree of 

symptoms, but there is a good 

correlation between severity of 

symptoms and surgical outcome (34). 

Because the timing for surgery has not 

been clearly decided (50), option for 

early surgical management is based, 

in selected patients, on surgeon 

experience who predicts failure of 

conservative therapy, to those 

patients failing or intolerant to 

conservative therapy or patients with 

associated instability and 

neurological deficit. 

� Symptomatic LSS in patients with co-
morbidities that increase surgical risk 

(46) 

- severe medical conditions (severe 
pulmonary disease or unstable 

cardiac status) 

- morbid obesity, diabetic 
- severe osteoporosis 
- extremely advanced age: treat with 

conservative measures, use adaptive 

techniques for restoring mobility, 

utilize rehabilitation services  

Such patients should be treated with 

conservative measures, adaptive 

techniques for restoring mobility, 

utilize rehabilitation services 



 

 

 

 

 
206          Rahman, Iacob          Treatment of lumbar spinal stenosis (LSS) and outcome 

 

 

 

 

 

 

 

� Patients with LSS candidates for 
instrumentation and fusion 

(35)(36)(48): pre-existing 

spondylolisthesis, instability; if 

proposed operation may compromise 

spinal integrity (about 5% 

laminectomies - in most series ended 

up requiring stabilization) a consent 

should be obtained. 

LSS surgical tactic strategy should respond 

to 5 problems (33)(43)(45)(48-51): 

1. should we decompress ? 

Yes, in a majority of cases  

No in cases with instability; hypermobility 

may accentuate compression – it’s better to 

stabilise without decompression 

2. what kind of surgery should be done ? 

Micro or Macro ?  

It’s better to choose the best operative 

technique, avoid reintervention, never 

preventive. The operative technique should 

minimize tissue disruption (smaller incisions, 

less tissue trauma), minimal blood loss, 

minimize time of surgery, length of hospital 

stay, post operative morbidity, with earlier 

return to activities and work; easier operative 

approach in obese patients. It should be used 

local or regional anesthesia combined with 

conscious sedation, less postoperative pain 

medication is required.  

What to do in the meantime - requirements: 

continue with current best practice - surgical 

expertise and experience for patient selection 

& for surgical skills, inform patients of surgical 

choices and availability of resources and 

facilities in institution - informed consent  

3. which roots should be decompressed ? 

Electrophysiological testing correlated to 

through neurological examination is more 

accurate than radiological evaluation alone in 

choosing the roots to be decompressed. In 

practice we deal with several situations:  

-central lumbar canal stenosis even with 

unilateral radiculopathy, during walking or 

effort – 

decompress all roots 

-lateral recess stenosis bilateral with unilateral 

radiculopathy, at one level - decompress both 

roots 

-lateral recess stenosis multilevel, with 

unilateral radiculopathy – radical fenestration 

and foraminotomy technique, decompressing 

only the symptomatic side & level 

-foraminal stenosis - decompress affected root 

4. stabilisation is needed ? There are several 

aims to respect: 

-treat a dynamic component- patients with 

severe symptoms and radiographic evidence of 

excessive motion, greater than 4 mm 

translation or 10o of rotation, who fail to 

respond to a trial of nonsurgical treatment 

- prevent a postoperatory instability 

Stabilization is needed for: confirmed 

preoperative instability, extent of bone 

resection, articular processes orientation, 

spinal static condition 

5. what type of stabilisation should be used? 

- preoperatory instability, see also articular 

processes orientation - spinal static 

- the extent of bone resection 

Caveats: No systematic stabilization ! 

Stabilization should be limited ! 

No stabilization for lumbar associated 

pains ! 



 

 

 

 

 
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-Fusion should be made to obtain a 

stabilization after arthrectomy, to correct a 

deformity, to avoid a hyper-mobility, 

maintaining lordosis and foraminal size 

-Arthrodesis &instrumentation 

- open - rigid stabilization systems with 

pedicle screw fixation 

- percutaneous 

- motion preservation: dynamic 

stabilization systems 

- facet arthroplasty 

 - TFAS® Total Facet Arthroplasty System 

- Lumbar interspinous implants: 

       - Colfex, Wallis, Diam, X-Stop 

Surgical Interventions for LSS 

A variety of surgical techniques can be 

used depending on patient selection (informed 

written choice and consent) surgical skills, 

surgeon expertise and experience, but also 

availability of resources and facilities in each 

institution (50)( 54)(55)( 57)(58)(60-133) 

A. For lumbar spinal stenosis  
1. “the gold standard technique” – 

microsurgery using microscope and micro 

instruments to realize microsurgical 

decompression without instrumented fusion 

and with segmental stabilization. 

Microsurgical decompression of the spinal 

canal or “internal laminoplasty” 

(50)(51)(60)(61)(66)(71)(72)(75)(76)(78)(79)

(82)(129)(133) is defined as a mono or multi 

segmental, unilateral or bilateral internal 

enlargement of the central and/or lateral 

volume of the spinal canal, without 

performing a laminectomy. 

Surgical Principle 

The spinal canal is approached through a 

modified microsurgical inter-laminar route 

usually from the (most) symptomatic side. In 

cases with associated degenerative lumbar 

scoliosis, the approach from the convex side is 

preferred. The inter-laminar window is 

opened ipsilateral by resection of the 

hypertrophied yellow ligament. The insertions 

of the yellow ligament are resected by 

osteoclastic undercutting of the cranial and 

caudal lamina. Subarticular ipsilateral 

decompression is achieved by undercutting or 

partial resection of the medial parts of the 

superior facet of the infradiacent vertebra. 

Enlargement of the central parts of the spinal 

canal, controlateral decompression of the 

lateral recess is performed without the risk of 

destabilization of the motion segment by a 

limited and modified approach bringing in the 

working instruments through an “over-the 

top” approach which means undercutting of 

the laminae and resection of the ventral parts 

of the interspinous ligament. This approach 

was proposed by Poletti (73) and refined by 

McCulloch (75) for the treatment of lumbar 

disc herniations. 

Micro surgery for LSS has both technical as 

well as clinical advantages, but also 

limitations;  using para-spinal approach 

introduced by Wiltse in 1973 (63) are many 

advantages: 

Technical advantages: 

- permit bilateral decompression of the spinal 

canal through a unilateral approach, also the 

spinal nerves on both sides; from their dural 

sleeve exits to their entrance into the foramen 

- decreased trauma to paravertebral muscles 

on the ipsilateral side, preserving skin 

vascularisation which is dependent on two 

networks joigned at 30 mm from midline, no 



 

 

 

 

 
208          Rahman, Iacob          Treatment of lumbar spinal stenosis (LSS) and outcome 

 

 

 

 

 

 

 

trauma to paravertebral muscles on contro-

lateral side, preserve the posterior spinal 

elements: limiting the iatrogenic disruption of 

ligaments (supraspinous, interspinous), 

spinous processes, paraspinal muscles on the 

contro-lateral side as well as complete 

preservation of the laminae, the two thirds of 

the facet joint on the ipsilateral side and more 

than 75% of the facet joint of the contro-lateral 

side 

-avoids iatrogenic multifidus denervation, 

devascularization, atrophy - if approach are 

median, diminishing low back pain about to 

this muscle which is a key position 

-allows decompression, pedicle fixation under 

visual control (no need fluoro), TLIF, ELIF, 

PLF 

-offer direct access to  articular process, entry 

point of pedicle fixation, transverse process 

and sacral alar 

- decreased operative blood loss even in multi 

segmental approaches 

Clinical advantages result from the technical 

advantages: 

-decrease postoperative pain & infection rate, 

minimize rates of developing de novo 

postoperative changes in spinal alignment - 

segmental motion is similar to the intact spine,  

avoiding iatrogenic « instability » 

-decrease hospital stay & duration for 

rehabilitation, increase patient satisfaction and 

confort, quicker return to normal activities  

-early mobilization by decreased trauma to 

paravertebral muscles; important argue to 

decrease postoperative complications: such as 

deep venous thrombosis, urinary tract 

infection or pneumonia due to prolonged 

immobilization; especially in aged patients >70 

years,  without stability operation indication 

- reduce surgical morbidity in a frequently 

high-risk patient group. 

Reported success rates of surgery vary 

considerably in uncontrolled trials (50), but 

data from long-term studies are lacking. Over 

the past several years, minimally invasive 

surgical techniques have been introduced that 

use smaller incisions and more limited 

removal of the laminae and facet joints to 

achieve decompression. Early results from 

small observational studies are promising (51) 

Limitations:  

- longer surgery: 45 to 60 min per level 

-an insufficient exposure lead to intempestive 

manipulation of the thecal sac and cauda 

equina, generating temporary and/or 

permanent neurological deficits 

- unfavorable clinical outcomes by inadequate 

decompression, especially of the controlateral 

side 

-radiation exposure 

-dural tear 

-learning curve 

Before micro surgery for LSS, the patient must 

sign the informed consent on the risks of 

microsurgical mono or multilevel approaches 

to the lumbar spinal canal: nerve root, cauda 

equina and/or conus medullaris lesions with 

postoperative neurological deficits, inclusive 

bladder and bowel dysfunction; dural tears 

with menigocele and/or CSF fistulas, 

postoperative epidural hematoma, meningitis, 

spondylodiscitis with epidural abscess, 

compressive epidural scarring with permanent 

sciatica or even neurological deficits, 

segmental instability, chronic low back pain 



 

 

 

 

 
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and radicular symptoms (“failed back surgery 

syndrome”) requiring stabilizing surgical 

procedures. 

Micro surgery for LSS indications: 

-symptomatic LSS patients, congenital or 

acquired, with spinal claudication, stiffness of 

low back pain, loss of lumbar lordosis, uni or 

bilateral crural symptoms, with or without 

vertebral body translations 

-proof of neuroradiology of a narrowing of the 

central and/or lateral spinal canal, in relation 

to the topography of the affected lumbar nerve 

roots: dynamic MRI, myelo-CT, 

saccoradiculography (measurement of the 

sagittal and/or transverse diameter of the 

spinal canal are not helpful for the indication 

for surgery, since it is not the absolute width of 

the spinal canal). For a differential diagnosis, 

see peripheral radiculopathy: 

electromyograms – EMG (80), nerve 

conduction studies or somato-sensory-evoked 

potentials (SSE) are useful to rule out other 

diagnosis. 

-decompression without stabilization is 

performed in all patients without radiological 

signs of vertebral body translation, in patients 

without low back pain despite vertebral body 

translation or degenerative scoliosis, in 

patients older than 75 years, with severe 

osteoporosis and multi segmental pathology 

-decompression with segmental stabilization 

(usually posterior–anterior 270° fusion or 

TLIF) is performed in patients exhibiting 

grade I or higher type spondylolisthesis on rest 

or functional X-rays with significant low back 

pain, as well as in patients with unstable 

lumbar degenerative scoliosis. 

Micro surgery for LSS contraindications: 

unstable angina pectoris, severe arterial 

hypertension, severe respiratory insufficiency  

Micro surgery for LSS  - surgical technique 

(60) 

Preoperative planning is based on: 

-clinical  

-neuroradiologic studies:  

-X-rays of the lumbar spine using AP and 

lateral views 

-for instability functional X-rays in flexion and 

extension to reveal a degenerative scoliosis, 

segmental rotational or translational 

instability 

-MRI - the imaging technique of choice, using 

standard facilities: the thickness of the yellow 

ligament, its extension underneath the 

adjacent laminae as well as the thickness of the 

lamina itself; the size and topography of the 

neural structures at the level of compression as 

well as above and below to avoid damage 

during decompression; the epidural fat 

distribution which may lead to enter the spinal 

canal through a more medial posterior route 

where more epidural fat protecting the thecal 

sac especially in a extremely narrow lumbar 

canal; the shape of the spinal canal (round, 

oval, trefoil) and estimate whether it is mainly 

soft tissue (yellow ligament, joint capsule, 

intervertebral disc) or bone (superior facet, 

lamina, osteophytes) which leads to a 

compression of neural structures, preserving 

the bony structures as much as possible or 

dynamic facilities to discover instability 

-CT scan/post-myelographic CT-scan 

-electrophysiologic studies especially in a 

multilevel stenosis: EMG, NCV, 

somatosensory-evoked potentials (SSE) 



 

 

 

 

 
210          Rahman, Iacob          Treatment of lumbar spinal stenosis (LSS) and outcome 

 

 

 

 

 

 

 

The operation is performed under general 

anesthesia, requiring arterial blood pressure 

monitoring, central venous line, the 

introduction of a urinary catheter. If a 

multilevel decompressions is intended, blood 

collection for retransfusion or blood 

transfusions are nedded. The patient should be 

positioned as similar for lumbar micro 

discectomy in a prone “Mecca” position, 

restricting head rotation, padding the eyes, 

forehead and nose; also protecting shoulders, 

brachial plexus, ulnar nerve, the knees with as 

many gel cushions or pads as are needed. The 

level(s) which have to be approached for 

microsurgical decompression are localized. 

The skin incision is centered exactly over the 

lumbar segment of interest. For two or more 

adjacent levels the skin incision is enlarged; for 

nonadjacent levels two separate skin incisions 

are recommended. After the interlaminar 

space is approached a new intraoperative 

reperage is performed and under microscope, 

fascia is opened in a semicircular manner, 

leaving the medial parts attached to the 

supraspinous ligament and the lamina. The 

paravertebral muscles are retracted after 

subperiosteal elevation. Retraction does not 

extend beyond the lateral border of the facet 

joint in order to avoid disruption of segmental 

innervation. The laminae of the adjacent 

vertebrae are exposed, the interlaminar 

window is cleaned of soft tissue, the speculum-

retractor is inserted, the interspinous ligament 

is exposed, verifying that the visual axis toward 

the midline is not obstructed by a 

hypertrophied or dysplastic spinous process. 

Microsurgical ipsilateral decompression is 

started with the removal of the inferior parts of 

the cephalic lamina, using a high-speed burr. 

Laminotomy is extended laterally and 

caudally. Depending on the size ofthe inferior 

facet, its medial aspect is removed until the 

medial parts of the superior facet can be 

identified. The yellow ligament is removed 

with rongeurs including the ventral parts of 

the interspinous ligament. Adhesions of the 

dura to the yellow ligament are gently 

dissected from medial to lateral. After removal 

of the yellow ligament and its insertion 

underneath the lamina in most of the cases the 

central portion of the spinal canal is already 

decompressed. However, if there is still 

narrowing by a hypertrophied lamina, 

undercutting has to be continued in cranial 

and caudal directions. “Subarticular” 

decompression can be the most difficult part 

of the operation. Usually there is no space 

between the lateral parts of the thecal sac, the 

nerve root and the superior facet. With a blunt 

micro dissector, the neural structures are 

gently mobilized from the yellow ligament, the 

lateral recess is opened with a 1.5 or 2 mm 

Kerrison rongeur, proceed first in a caudal 

direction, minimizing the risk of dural 

laceration or nerve injury. Decompression 

continue along the nerve until the medial 

border of the pedicle can be visualized and 

completed until the inferior border of the 

exiting nerve root can be identified or palpated 

with the blunt nerve hook. In cases with 

pronounced narrowing of the intervertebral 

space there is often impingement of the exiting 

nerve root by the tip of the superior facet. This 

tip can now be removed with a rongeur thus 

achieving a complete decompression of the 

exiting nerve root in the foramen. 



 

 

 

 

 
Romanian Neurosurgery (2015) XXIX 2: 200 - 229          211 

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Microsurgical controlateral decompression is 

realized tilting the table and adjusting the 

microscope to give an oblique view into the 

spinal canal. The ventral parts of the 

interspinous ligament, sometimes even ventral 

parts of the base of the spinous process should 

be resected, also the transition zone into the 

fibers of the contralateral yellow ligament are 

resected; the yellow ligament of the 

contralateral side are resected. It is necessary 

to continue undercutting of the supra and 

infradjacent lamina to increase the spinal canal 

volume as well as to have a free visual axis 

toward the controlateral recess and foramen 

entrance. Decompression is facilitated if the 

medial border of the controlateral inferior 

pedicle is identified by minimum retraction of 

the thecal sac. Then decompression by 

subarticular undercutting as well as by 

undercutting of the supradjacent lamina can 

be accomplished using a blunt dissector, a 

nerve hook or a metal sucker probe to 

temporarily retract the dura. At the end of the 

procedure the surgical field is irrigated with 

saline solution, hemostasis is achieved with 

small amounts of bone wax for the bone 

surface, avoiding to place into the spinal canal 

Gelfoam, Surgicel; fascia and the skin are 

closed with absorbable sutures. For the lumbar 

lateral recess stenosis a bilateral lateral recess 

decompression via subarticular fenestrations 

(57) is a less invasive technique, which enables 

to decompress the neural structures while 

preserving as much of the bony structures and 

ligamentum flavum as preferred. These 

technique will lead to early mobilization of 

patients without impending instability, less 

postoperative pain and immobility, minimal 

epidural fibrosis, providing an easier 

reoperation of the same area if required. 

2. endoscopic: not superior to “gold 

standard”(51)(54)(61)(62)(65-70).The micro 

endoscopic decompression technique used in 

spinal lumbar stenosis is a less invasive form of 

surgery, based on the micro endoscopic 

discectomy as developed by Foley and Smith in 

1996 (70). Using this method, it is possible to 

address problems on the controlateral side in 

addition to those on the ipsilateral side. 

Therefore there is no valid evidence from 

randomized controlled trials on the 

effectiveness of transforaminal endoscopic 

surgery for lumbar stenosis (67): 

• comprehensive systematic literature 
review  

• no randomized controlled trials, 
seven observational studies.  

• studies were of poor methodological 
quality 

• heterogeneous regarding patient 
selection, indications, operation 

techniques, follow-up period and 

outcome measures.  

• re-operation rate varied from 0 to 
20%.  

The micro endoscopic decompression 

technique is characterized by several 

advantages: 

-require local or regional anesthesia combined 

with conscious sedation 

-a small skin incision, useful even for two 

neighboring segments approach 

-less invasion of paraspinal muscle because the 

paraspinal muscle is not detached from the 

lamina, less tissue trauma, a small dead space 

-affords a safe procedure, minimizes resection 



 

 

 

 

 
212          Rahman, Iacob          Treatment of lumbar spinal stenosis (LSS) and outcome 

 

 

 

 

 

 

 

of the pathologic compression tissues 

-the ipsilateral approach and controlateral 

endoscopic decompression can be performed 

under the midline posterior structures the 

same as microsurgical decompression or even 

more easier tilting the tubular retractor about 

20° to 30° medially 

-damaged areas inaccessible by direct vision 

can be reach by an endoscope angled at 25°; it’s 

possible to see the compressed nerve root 

directly under the hypertrophied superior 

facet 

-minimal blood loss 

-less postoperative pain medication 

-earlier return to activities and work 

-easier operative approach in obese patients 

-excellent clinical outcome and patient 

satisfaction in most cases 

The micro endoscopic decompression 

technique disadvantages: 

-demanding technique, a steep learning curve; 

for LSS should be applied only after mastering 

the endoscopic procedure for lumbar disc 

herniation 

-the field of view through the endoscope is 

limited, which makes it difficult to appreciate 

the amount of bony resection that has been 

performed 

Indications: 

-initially for lateral recess stenosis, because the 

inter laminar space is relatively wide 

-for moderate central canal stenosis 

The micro endoscopic decompression 

technique in LSS: 

-after radiologic control, tubular retractor is 

inserted and a minimal skin incision is 

performed 

-different types of endoscopes angulations are 

used 

-using a curved chisel, the inferior part of the 

ipsilateral lamina and the medial side of the 

inferior facet is cut, the remnants of lamina are 

removed with Kerrison rongeurs 

-the ligamentum flavum is cut transversely, 

with a sheathed knife blade and removed piece 

by piece with the Kerrison rongeur 

- the tubular retractor is moved to the medial 

side through and beneath the interspinous 

ligament  controlateral; the ligamentum 

flavum and medial facet are removed by using 

the Kerrison rongeur - always oriented away 

from the nerve root during the decompression 

procedure, exposing the dural tube, ipsi and 

controlateral nerve roots, which could be 

retracted, using the Penfield retractor 

- using a curved chisel the additional medial 

facet are removed 

-also a small chip of shaved lamina could be 

removed by the use of a pituitary rongeur 

-hemostasis is realized using a bipolar 

coagulator, bone wax. 

3. conventional 

Several techniques have been used, depending 

the LSS topography: central stenosis, lateral 

stenosis and mixed stenosis. 

- for central stenosis there are 
(33)(39)(43)(49-

51)(55)(56)(83)(87)(95-

97)(98)(99)(105) (108)(109)(111): 

-laminectomy with bilateral foraminotomy 

(yellow ligament removal, inferior 

facetectomy, respecting isthm, discectomy if 

needed, it could be made in block or by 

fragmentation = “the recalibration” – “the 

windows technique” 



 

 

 

 

 
Romanian Neurosurgery (2015) XXIX 2: 200 - 229          213 

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Laminectomy is still considered to be the 

treatment of choice in degenerative spinal 

stenosis without instability, used for adequate 

and safe decompression of lumbar stenosis, 

with highly significant reduction of symptoms 

and disability and improved health-related 

quality of life. Laminectomy is the traditional 

standard operation in lumbar spinal stenosis 

decompression, to remove the roof of the 

spinal canal. If no preoperative instability, 

laminectomy does not require fusion or 

fixation; only about 5% laminectomies (in 

most series) ended up requiring stabilization, 

if facet and discal anatomy is compromised. 

For congenital central spinal stenosis wide 

laminectomies are indicated because that 

narrowing of the spinal canal not only affects 

the interlaminar interval but also the 

sublaminar space in multiple segments. In a 

meta analysis, the success rate of this 

procedure has been shown to be 92.2% fair to 

excellent result (Finneson + Cooper Criteria), 

9.8% complications, including 6.8% 

durotomies, 11.2% re-operation rate (re-

stenosis, instability, complications)(76) Nerve 

compression is usually limited to the height of 

the intervertebral space in the area of the 

hypertrophied joint facets and the ligamentum 

flavum. Removing long sections is therefore 

not necessary, which has – aided by 

enormously increasing numbers of surgical 

procedures – resulted in the development of 

newer, less invasive techniques. 

-unilateral and bilateral laminotomy 

„recalibrage“ means lumbar decompression by 

partial removal of laminae. There are several 

techniques variants: unilateral 

hemilaminotomy (66) (one or several levels), 

partial decompressive lamino-arthrectomy 

uni/bilateral, hemilaminotomy + arthrectomy 

with  ligamentectomy & recess decompression 

(87-90). 

There are several alternatives to 

laminectomies: 

The “port-hole”technique is a surgical 

procedure for spinal stenosis developed by Dr. 

Kleeman in 1992 (88); instead of performing a 

laminectomy and removing the spinous 

processes, the spinal canal was decompressed 

through openings or “port holes” that left the 

spinal structures intact. 

Weiner et al. (100) used a procedure for 

lumbar decompression, with unilateral 

periosteal dissection of multifidus, to 

minimise denervation and subsequent 

atrophy. A modified Weiner technique is ”the 

hinge osteotomy technique” applied by El-

Abed K. et al. (101)(107); a safe unilateral 

approach for multi-level lumbar stenosis, 

allowing wide decompression of lumbar spine 

with significant symptom and functional 

improvement and no iatrogenic spinal 

instability 

”The hinge osteotomy technique” 

incorporate: unilateral subperiostal muscle 

dissection with osteotomy of the of the base of 

the spinous processes of the involved 

segments, just superficial to their junction 

with the lamina, bilateral complete 

laminectomies avoiding over-resection of the 

facet joints (less than 30%) and complete 

resection of the ligamentum flavum thereby 

providing excellent exposure, preserving the 

integrity of the posterior elements, while 

maintaining posterior column stability 



 

 

 

 

 
214          Rahman, Iacob          Treatment of lumbar spinal stenosis (LSS) and outcome 

 

 

 

 

 

 

 

A variant of bilateral laminotomies are “the 

transspinous median sublaminar 

decompression” which means bilateral 

laminotomies, with unilateral periosteal 

dissection of multifidus, to minimise 

denervation and subsequent atrophy, 

osteotomy of the spinous processes of the 

involved segments, just superficial to their 

junction with the lamina - Weiner procedure, 

(111) 

In most outcome parameters, bilateral 

laminotomies was associated with a significant 

benefit and thus constitutes a promising 

treatment alternative. 

-radical fenestration (93) 

As an alternative to laminectomy, 

interlaminar fenestration techniques have 

become established that spare the midline 

structures and thus the dorsal tension band, 

decompressing the nerve roots, by resecting 

the ligamentum flavum and parts of the medial 

facet joint; exceptionally disc removal. 

Encouraging results have been shown for 

bilateral fenestration and unilateral 

fenestration with undercutting controlateral 

decompression.  

-foraminotomy (50)(51)(133) means radicular 

nerve decompression by classic or minimal 

invasive decompression technique removing 

ligamentum flavum, partial inferior 

arthrectomy. It can be associated with 

discectomy 

-open door expansive lumbar laminoplasty is 

another decompressive lumbar spinal canal 

technique without impairement of instability 

(50)(51)  

Today's conventional technique should 

provides excellent exposure, a safe approach 

even for multiple level stenosis, maintaining 

posterior column stability. This techniques are 

generally based on: 

-clinical evaluation, inclusive:  

-leg pain validation VAS (0-10),  

-Self-Reported Functional Status 

based on Likert scale (SRFS: pain 

interference with normal work:1 not 

at all - 5 extremely) 

-Likert Symptom-Specific Well-Being 

Score (SSWBS: 1 very dissatisfied - 5 

very satisfied) 

-Likert General Well-Being Score 

(GWBS - how would you rate your 

quality of life? 1 very bad - 5 very 

good) 

-Oswestry Disability Index for leg 

pain (ODI) 

-radiologic evaluation, lumbar spine CT and 

RM, standardised lumbo-sacral X-rays along 

with lateral flexion and extension radiographs 

– defining spinal instability as sagittal plane 

translation of 3 mm or more - White and 

Panjabi (1990) Clinical bio-mechnics of Spine 

(cited by 54); performed preop, at 6 months 

and 3 years post op to demonstrate evidence of 

progressive segmental instability. 

-operation is made under general anesthesia, 

using magnifying loops  

-the patient is placed in prone position, 

midline incision is made, after radiological 

level confirmation. 

-periosteal multifidus muscle dissection is 

carried out unilaterally  

-the electric pen burr is used to delineate the 

base of spinous process 

-the integrity of the posterior elements: the 

spinous process, interspinous/supraspinous 



 

 

 

 

 
Romanian Neurosurgery (2015) XXIX 2: 200 - 229          215 

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ligaments, and facet capsules are preserved 

-surgical retractors are spread to hinge the 

spinous process(es) off the midline 

-the spinal canal, the foraminal zones and 

nerve root canals are decompressed after 

bilateral laminectomies and complete excision 

of ligamentum flavum, as completely as 

possible, avoiding over-resection of the facet 

joints - less than 30% 

-fat pad is laid on the dura to avoid subsequent 

fibrosis 

-supraspinous ligament is sutured to dorso-

lumbar fascia 

-drain is used 

In general conventional open posterior lumbar 

approach and laminectomy generate tendon 

disruption, muscle devascularisation, atrophy, 

denervation, dysfunction, dysconfort, crusch 

injury; also produces the greatest changes in 

segmental motion during flexion, extension, 

left and right axial rotation. (85)(86)(92)(95-

99)(102)(105)(106) 

- for lateral stenosis: (81) 
In lateral lumbar spinal canal stenosis, 

radiculopathy is well recognized as expression 

a spinal nerve entrapment in the three zones: 

entrance zone, mid zone and exit zone. 

For entrance zone stenosis the most common 

causeis hypertrophic osteoarthritis of the facet 

joint, particularly involving the superior 

articular process. The appropriate surgical 

decompression technique are medial 

fatectomy, ranging from one-third to one-half. 

For mid zone stenosis localized facet 

degeneration under the pars interarticularis 

where the ligamentum flavum is attached are 

due by osteophyte formation, periarticular 

calcification, articular narrowing of the joint 

space, subchondral erosion and fibro-

cartilaginous hypertrophy at a spondylolytic 

defect. The surgical techniques focused on the 

symptomatic stenotic side have common 

hallmark of medial fatectomy, careful excision 

and curettage under the pars interarticularis; 

osteophytes trimming along the superior 

margins of the superior articular process and 

along the lateral margins of the corresponding 

inferior articular process or even laminectomy 

with total fatectomy. 

For exit zone stenosis the main causes are: 

hypertrophic osteoarthritis changes of the 

facet joints with subluxation and osteophytic 

ridge formation along the superior margin of 

the disc. The suggested technique are foramen 

approach from the interlaminar space below 

the level of the root. 

It’s to be remarked in congenital lateral recess 

stenosis a trefoil-shaped, the nerve root is 

entrapped under the superior articular facet by 

facet hypertrophies or by disk bulging, disk 

margin enlarges because of endplate spur. 

Surgical management consists of 

decompressing the nerve root emerging from 

the thecal sac along its entire course in the 

radicular canal with laminotomy and medial 

facetectomy. If lumbar disc herniation 

accompanies the pathology, removal of disc 

material is needed additionally.  

There is also a second form with an angled 

shape of the recess by progressive facet, 

endplate and disk margin changes with 

subsequent pinch of the nerve root. If early 

facet hypertrophy occurs, an acquired trefoil-

shaped canal ensues. 

-for mixed stenosis:  

laminectomy + partial artrectomy; the Wiltse 



 

 

 

 

 
216          Rahman, Iacob          Treatment of lumbar spinal stenosis (LSS) and outcome 

 

 

 

 

 

 

 

approach (63) with foraminotomy for isolated 

foraminal stenosis 

4. fusion:  

Current guidelines reject stabilization by 

default on the basis of an extensive literature 

search (33)(34)(48)(51)(54-56)(58)(113-127). 

Even after a laminectomy only 20% of cases 

need a fusion procedure (58). The reactive 

degenerative changes obviously prevent 

manifest segmental instability, even after 

decompression if more of 50-66% of articulary 

or isthme are conserved, without discal space 

violation (56) 

After White-Panjabi (cited by 54): 

instability means a loss of spine 's ability to 

maintain under physiological conditions its 

normal anatomical relationships at risk 

causing signs of irritation spinal cord/nerve 

root, pain or crippling deformities ". Instability 

could be responsible of stenosis; it could be 

associated with LSS symptomatic – with 

intermittent mechanical pains; iatrogene with 

symptomatic instability or without clinical 

signs (50)(51)(54)(55)(133).  

Spondylolisthesis, scoliosis may generate 

instability; also after decompression, the 

possibility of segmental instability should 

always be considered. Fusion procedures, 

especially those involving instrumentation, are 

associated with increases in cost and 

complications, are used for pre-op, 

intraoperative instability or postoperatory 

listhesis (58). Still there are several debatable 

aspects - subject of controversy: the criteria of 

instability, the  spondylolisthesis or scoliosis 

grade, what kind of stabilization should be 

used with or without motion preservation, 

minimally or invasive intervention, the 

approach used: posterior, anterior or 

“circumferential”, instrumentation increases 

the fusion rate ?, implant failures and adjacent 

joints degeneration (56). 

There are several surgical alternatives 

(50)(51)(113-128)(131)(133)(135): 

-open: bone deposition, iliac bone graft, 

instrumentation rigid or dynamic with 

pedicular screws, inserted with the help of a 

spinal navigation system, inter body cages 

-microscopy 

-percutaneous 

-facet arthroplasty 

-interspinous spacers (X-STOP, DIAM, 

COFLEX, HELIFIX) with 45% improvements 

after two years, an intermediate option 

between conservative and surgical treatment - 

“does not burn bridges”, for patients with mild 

symptoms, to those that cannot undergo or 

refuse more extensive surgery, as a temporary 

solution, “addressing the problem within the 

canal without entering the canal”. 

Interspinous spacers advantages are: disc not 

removed, no pedicles used, opening of 

foramens, unloading of the posterior part of 

the disc, of the facets. There are also less risk of 

significant complications, no direct 

manipulation adjacent to the neural 

structures; the risk of neurological deficit 

(paralysis; dural tears; etc) decrease to a 

minimum. Such interspinous spacers can’t be 

used in the following anatomic variants: 

markedly decreased interspinous distance 

(kissing spine–like), with concomitant facet 

joint hypertrophy, a posterior V-shaped 

interspinous area, limited accessibility of the 

space between the base and the tip of the 

spinous process because of facet joint 



 

 

 

 

 
Romanian Neurosurgery (2015) XXIX 2: 200 - 229          217 

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hypertrophy and variations in the shape of the 

inferior surface of the spinous process. 

The technique used for microsurgical 

decompression with instrumented fusion are 

based on the same principles (113)(114): 

-preoperative planning includes the 

acquisition of CT-scan, MRI data for intra 

operative navigation 

- general anesthesia: with the introduction of a 

central venous line, to perform arterial blood 

pressure monitoring, as well as the 

introduction of a urinary catheter, blood 

transfusion are not usually necessary. 

- patient positioning: in a prone, comfortable 

position, on a soft foam frame, on a 

radiolucent table; respecting the protection of 

neural structures and the skin. The hips and 

knees are slightly flexed (20–30°) and the 

anterior iliac crest is padded in order to avoid 

pressure on the lateral femoral cutaneous 

nerve. 

- screw insertion with the help of an intra 

operative navigation system or under 

fluoroscopic control 

-insertion of mono or multi segmental internal 

fixation system 

-reduction and reconstruction of normal 

curvature 

-microsurgical decompression (see above) 

-drain insertion and wound closure. 

-wound drains are inserted underneath the 

fascia without applying suction.  

- wound closure. 

Several complications could appear 

(38)(54)(56)(59)(60)(61)(95)(137): 

- dural tears leading to a 
pseudomeningocele or even CSF 

fistulas are the most common 

complications 

- nerve roots lacerations (the nerve 
roots could be vulnerable by chronic 

compression for years in LSS; by 

temporary direct compression of the 

cauda equina roots during 

decompression of the controlateral 

side; also the arterial supply may be 

diminished by other concomitant 

diseases: diabetic microangiopathy, 

microangiopathy due to arterial 

hypertension, etc.) 

- segmental instability 
- destabilization of the adjacent 

segment 

- arachnoiditis 
- epidural scar formation 
- epidural hematoma 
- complications secondary to 

positioning, especially postoperative 

blindness or corneal lesions after 

pressure on the eyes - higher as 

compared to microsurgical 

discectomy, since microsurgical 

decompression requires longer 

operating times 

- deep venous thrombosis 
- upper respiratory tract infection 
- urinary tract infection 
- superficial wound infection 

 

B. Lumbar Stenosis + Aggravating 
Factors (55)(56)(133) 

There are several situations which should 

be discussed: 

1.Co-existing multiple disk prolapses or single 

level disk prolapsed with a multistage lumbar 



 

 

 

 

 
218          Rahman, Iacob          Treatment of lumbar spinal stenosis (LSS) and outcome 

 

 

 

 

 

 

 

spinal stenosis, without scoliosis: - more 

common there is a single or two level 

prolapsed discs with LSS; the patient may 

present lombalgia, intermittent radicular 

claudication (walking perimeter, the caddie 

sign), isolated radicular pain, sciatic pain or 

cural nevralgia: for such cases medical 

treatment should be tried, in case of failure 

surgical attitude with LSS decompression plus 

disk surgery 

2.Combined LSS with degenerative listhesis and 

posterior arthrosis at one or several levels. In 

such cases it’s more frequent lateral LSS 

associated with disc hernia. Spondylolisthesis 

in itself is not an indication, except if there is > 

4 mm translation in sagittal plane and 10° 

angulation flexion/extension 

For such cases foraminal decompression, 

discectomy and fusion to all affected levels 

should be made (50)(132). It is uncertain 

whether instrumentation: use of pedicle 

screws or metal cages help to fuse adjacent 

vertebrae or biologic agents - bone 

morphogenetic protein should be used to 

enhance osseous fusion (50).  

3.Combined LSS with scoliosis  

Scoliosis and LSS can be explained in two 

ways: spinal deformation induce LSS or by 

arthrosis, massive joint hypertrophy may 

generate LSS and degradation of scoliosis. 

Saccoradiculography, dynamic MRI, EOS 

system osteodensitometry, 

electromyogramme are particularly useful  

examinations of reference for assessing 

instability and to measure the extent of 

curvature (54). 

LSS with scoliosis with a small radius of 

curvature: decompression should not be 

associated with fusion. 

LSS with scoliosis and a big radius of curvature 

installed in adolescence, it’s stable and has 

similar therapeutic strategy 

LSS with scoliosis and a big radius of curvature, 

with rapid evolution 5-100 in one year 

generating both radiculalgia and instability 

can not be neglected; also in scoliosis with 

rotation and rapid evolution to 30-500, with 

arthrosis in concavity which should be 

decompressed and fused (55). If scoliosis affect 

several levels a multilevel fusion should be 

tried (133). 

4.Combined stenosis and facet joint cyst should 

be decompressed as usual, but the major risk is 

a dural tear which should be avoided 

5. LSS with severe polineuropaty with or 

without uni/bilateral paresis should be 

decompressed and fused as well, but prognosis 

is different and should be explained to the 

patient (133) 

The outcome in operated lumbar spinal 

stenosis 

Despite several published studies, a lot of 

aspects should be clarified: 

-functional outcome valuation should be made 

using (107)(135): Self-reported leg pain on 

VAS (0-10), Self-Reported Functional Status 

based on Likert scale (SRFS)(pain interference 

with normal work:1 not at all - 5 extremely), 

Likert Symptom-Specific Well-Being 

Score(SSWBS) If you had to spend the rest of 

your life with the symptoms you have right 

now (1 very dissatisfied - 5 very satisfied), 

Likert General Well-Being Score (GWBS) 

How would you rate your quality of life? (1 

very bad - 5 very good), Oswestry Disability 

Index (ODI) for leg pain, Dallas Pain 



 

 

 

 

 
Romanian Neurosurgery (2015) XXIX 2: 200 - 229          219 

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Questionnaire (DPQ) Lawlis et al. Spine, 1989, 

Low Back Pain Rating Scale (LBPR) Manniche 

et al. Pain, 1994, SF-36 Ware, Spine 2000, EQ-

5D, Swiss Spinal Stenosis Stucki et al, Spine 

1996, Oxford Claudication Score Makan et al, 

JBJS, 1998. 

-time – mean follow up 24 months or more: 

advantage of surgery was noticeable at 3-6 

months, remained for up to 2-4 years 

(4)(44)(128-130). Cohort studies indicate that 

although more than 80% of patients have some 

degree of symptomatic relief after surgery for 

spinal stenosis, 7 to 10 years later, at least one 

third of patients report back pain (33)(56). 

Patients with the most severe nerve-root 

compression preoperatively are the most likely 

to have symptomatic relief. Reoperation rates 

are on the order of 10 to 23% over a period of 

7 to 10 years of follow-up. Systematic review 

are necessary to compare the effectiveness of 

surgery vs. conservative treatment on pain, 

disability, loss of quality of life 

(19)(38)(50)(51)(136). 

739 citations reviewed, several publications 

studies, showed surgery better results for pain, 

disability and quality of life, although not for 

walking ability. Results were similar among 

patients with and without spondylolisthesis. 

Advantage of surgery was noticeable at 3-6 

months, remained for up to 2-4 years (1-17). 

32,152 operations for lumbar stenosis in the 

first 11 months of 2007 (137): surgical rates 

declined slightly from 2002-2007, rate of 

complex fusion procedures increased 15-fold, 

life-threatening complications increased 2.3% 

to 5.6%, rehospitalization within 30 days, 7.8% 

decompression and 13.0% complex fusion, 

medical expenses were $23,724 compared with 

$80,888, preoperatory predictors for post 

operative outcome in lumbar spinal stenosis - 

based on 21 prospective studies (4)(38)(43-

45)(52)(56)(133), despite reported success 

rates of surgery vary considerably in trials: 

� good preoperatory walking predict a 
better walking capabilities two years 

later 

� less co-morbidities: patients with 
cardio-vascular co-morbidities, 

severe scoliosis, lumbar spine surgery 

history had bad prognosis; also preop. 

depression predict: pain, less good 

satisfaction, less walking capabilities 

� surgery appears to lead to better 
outcomes if there are ongoing 

symptoms after three to six months of 

conservative treatment, in those who 

worsen despite conservative 

treatments, surgery leads to 

improvement in 60–70% of cases 

(3)(50)(51)(76)(138)(139) 

� poor pre operatory indications for 
surgery are bad predictors for 

outcome 

� age < 65 years good post operative 
outcome  

� back pain predominance compared 
with radicular pain has bad prognosis 

� pre operatory motor deficit mono-
radicular and unilateral, installed less 

than 6 weeks has complete recovery 

40%, no recovery 20% 

� stenosis to one level with real 
compressive disc herniation, predict a 

better function especially on walking 

and pain 



 

 

 

 

 
220          Rahman, Iacob          Treatment of lumbar spinal stenosis (LSS) and outcome 

 

 

 

 

 

 

 

� insufficient decompression are a bad 
predictor 

� an important stenosis: A-P diameter < 
6 mm predict less pain to 5 years 

� therefore the timing for surgery has 
not been clearly decided. Data 

comparing the outcomes of patients 

who underwent surgery earlier vs 

later in the disease suggest no 

difference in outcome 

-overall rating of post-operatory results of 

operated LSS: improved – 85% better quality 

of life-walking distance improvement - 95%, 

pain improvement (VAS) - 85%, low 

improvement – 5%, no improvement –

disability 5%, worse – very rare, mortality 0 -

3% (12)(33)(38)(56). Daily life activities are 

post-operatory: normal 82%, modification of 

life/work style - 13%, stopped working - 5% 

(17)(133)(140). In general surgery affords 

earlier and greater pain relief and 

improvement in functional status and that 

these gains begin to narrow over the course of 

follow-up. 

-although technical errors during time were 

noted, they seemed to have less influence on 

the outcome than did appropriate selection of 

patients; also complication rates did not differ 

based on patient age or fusion. The most 

common complications (up to 

3%) (50)(133)(136)(137) are: epidural 

haematoma, CSF fistula +/- 

pseudomeningocele, inadequate - insufficient 

decompression, decompression at wrong 

level, root trauma or avulsion, infection up to 

4%, arachnoiditis, epidural fibrosis, 

recurrence of stenosis with reoperation rates 

as high as 21%, instability, pseudarthrosis, flat 

back syndrome, general complications such as 

deep venous thrombosis, pulmonary 

embolism, urinary infection, wound healing 

disturbances; also by the co-morbidity of the 

patients. 

-if operated patients present recurrent 

symptoms it’s mandatory to resume lumbar 

MRI and CT, contrast studies, EMG and NCS 

to demonstrate (50)(51)(133): residual 

stenosis at operative site due to inadequate 

first surgery, stenosis at adjacent levels to 

surgical site, new disc herniations, epidural 

and arachnoidal adhesions, instability and/or 

spondylolisthesis following first surgery 

-outcome depends on surgical type of 

operation used; also the pathological situation 

(56)(133):  

� one level lumbar stenosis or a 
multistage lumbar spinal stenosis, 

without scoliosis 

There are several meta analyseses :  

Turner (38) on retrospective studies reffering 

to surgery for lumbar spine stenosis between 

1970-1993 revealed 64% satisfied people by 

surgery 

Marjerko (cited by 56) on degenerative lumbar 

spondylosis between 1970-1993 find 69% 

satisfaction by decompression without fusion 

and more than 80% satisfaction if 

decompression was made with fusion. 

Updated Cochrane review 2005 (34) several 

studies, for a short time, are reffering to 

different techniques applied, to pain 

symptomatology, but few informations about 

functional results, with limited conclusions. 

Amundsen (7) on 19 patients operated of 50 

patients, assert that conservatory treatment is 

compared with immediately post op on 4/5 



 

 

 

 

 
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patients without a significative diffference; 

after 10 years good surgical results in 5/11 

patients, compared to 4/14 treated 

conservatory. 

Postacchini 1993 (87) laminectomy versus 

staged laminotomies no difference ; Herkowitz 

1991 (94), Grob 1995 (131) laminectomy with 

or without fusion - no difference on 139 

patients during 3 years. 

Fritzell Spine 2001 (cited by 56) fusion versus 

physiotherapy 294 patients of which 98% were 

reevaluated at two years; in 46% of cases 

surgery has good or very good results, 

compared with 18% good results by 

physiotherapy,  p<0,0001. 

Brox Spine 2003, Keller Spine 2004 (cited by 

56) postero-lateral fusion with transpedicular 

screws compared with physiotherapy alone 

demonstrate the value of physiotherapy on 

avoidance beliefs, flexion, force and muscular 

endurrancy.  

Another 3 studies with IDET without 

encouraging results ; also studies  McAfee 

Spine 2003, Zigler J.Spin Disord 2003, Geisler  

J Neurosurg 2004 (cited by 56) reffering to disc 

prothesis no superiority versus simple fusion 

Cochrane updated review 2005 (34) Surgery 

for degenerative lumbar spondylosis 

Conclusion: few controlled trials, most 

retrospective, few are interested about 

symptoms. 

Zucherman (120) made a prospective 

multicentric randomised study on 191 patients 

during 15 months; patients were >50 years 

with sciatalgic predominance, with or without 

lombalgia, intermitent claudication, surgical 

treatment consist in laminectomy with spacer 

versus medical traitement – at least one 

epidural infiltration before the study and 1-4 

infiltration during study. At 2 years for 

operated patients 45% amelioration on 

severity score versus 7% in control groupe 

p<0,001); 56 of 93 operated patients has 

significant amelioration compared with 15 of 

81 medically treated patients with a 

satisfaction index of 73% versus 36%. He foud 

that predictive factors were influenced by 

comorbidities. 

Conclusion: the first precise study on 

methodological aspects is a plea to proof 

surgical treatment superiority versus 

conservatory in intermitent radicular 

claudication. 

Atlas (4) published in Spine 2005 a prospective 

study on 10 years on 105/148 patients of which 

97 are survivors; inclusion criteria: LSS on 

clinical argues, half of the patients with a 

radiculalgia monitorised at 3, 6, 12 months, 

after that annually. He found surgery 

superiority for radiculalgia 67% versus 41% 

p=0,04; satsfaction 42% versus 28% p=0,24; 

23% of patients have a second spinal operation 

and 39% of medically treated patients were 

operated too.  

Duquesnoy & Assaker  (56)(62) on 168 

operated cases: 

Excellents results : retourn to anteriorly life 

condition, good results: good waking, retourn 

to professional activities, medium results: 

persistent invalidity, bad results: no 

amelioration. 

124 patients                  at 2 months    at 2 years 

excellent results                      68%               21% 

good results                             33%               41% 

medium results                           17%               19,5% 

bad results                                   12%               18,5% 



 

 

 

 

 
222          Rahman, Iacob          Treatment of lumbar spinal stenosis (LSS) and outcome 

 

 

 

 

 

 

 

On intermittent claudication: excellents 

results in 47% of cases and good results in only 

28% of cases; reffering on radiculalgia: 

excellents results in only 26% of cases; good 

results in 44% of cases. 

For an operated multistage lumbar spinal 

stenosis, without scoliosis, without 

arthrodesis, walking troubles may be 

generated by (56): 

- iterative stenosis (rare, by osseous 
aposition, Forestier illness) 

- insufficient decompression to only 
symptomatic level, lateral partial 

decompression especially by 

incomplete lateral flavum ligament 

resection 

- iatrogene instability (articulary 
resection, even isthm rupture may 

generate radiculalgia) 

- concomitant cervical canal stenosis (if 
walking troubles are persistent, 

correlated with profound sensibility 

troubles)  

- coxartrosis could be concomitant 
with LSS.  Surgical indication for 

spinal decompression should be made 

on clinics and dynamic MRI or 

saculography. 

In conclusion: for a multistage lumbar spinal 

stenosis, without scoliosis, surgery even to 

oldest patients has proved his efficacy in 

intermittent medullar claudication and 

radiculalgia on one or several levels, 

decompressing LSS, also performing 

discectomies, fusions techniques; the patients 

should be inform that lombalgia is not 

treated. 

� Combined LSS with degenerative 
listhesis and posterior arthrosis at one 

or several levels 

For surgical point of vue decompressing roots 

in a LSS may affect isthm, may generate 

iatrogene instability because of arthrectomy, 

especially in a  LSS with degenerative listhesis 

and posterior arthrosis. We should treat only 

the instable level (56). 

Several complication could be seen : overlying 

stenosis (by recurrence of a degenerative 

spondylolisthesis, hypertrophic flavum 

ligaments), disassembly of osteosynthesis by 

fracture instrumentation short and medium 

term as a sign of pseudarthrosis. 

In conclusion: large laminectomies should be 

avoided, lumbar decompression with fusion, at 

the symptomatic level should be made if 

medical traitement fails. 

� Combined LSS with scoliosis may be 
generated by two mechanisms: 

-deformation generate stenosis – see stable 

scoliosis since adolescence 

-degeneration induce a hypertrophic articular 

process with LSS - evolutive scoliosis with 

severe torsion 

Always deformation should be evaluated, 

severe scoliosis should be operated (55)(133) 

- if deformation is responsible for LSS 
the reduction arthrodesis treats 

claudication 

- if the deformation is not the cause of 
LSS - rahisynthesis is imperative to 

avoid iatrogenic instability after 

decompression laminectomy  

For old patients with severe ostheoporosis, LSS 

with scoliosis may generate complications: 



 

 

 

 

 
Romanian Neurosurgery (2015) XXIX 2: 200 - 229          223 

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-fails of rahisynthesis 15-20% especially in the 

lumbo-sacral area 

-overlying osteoporothic fracture or 

settlement may be seen in 10-15% of cases, 

imposing : arthrodesis extension, 

vertebroplasty 

- disorder sagittal echilibre should be 

corrected by subtraction osteotomy 

A Scoliosis Research Society (SRS) database: 

10.329 patients with LSS, treated with either 

decompression alone (64%) or decompression 

with concomitant fusion (36%) between 2004 

– 2007 (140): complications (7.0%), including 

13 deaths (0.1%); complication rates did not 

differ based on patient age or fusion.  

In conclusion in LSS with scoliosis: limited 

surgical indication; indisputably effective 

surgery in intermittent claudication root and 

radicular pain, but surgical indications are on 

demand; surgery measuring if the 

predominant low back pain or joint pain; 

preeminence of the clinic on neuro-radiologic 

data; no proved superiority of multistage 

laminectomy compared to one level 

laminectomy, adjusted to the demand, with 

rahisynthesis 

Final conclusions 

� Initial management in LSS should be 
non-surgical unless very severe; also 

conservative treatment is able to give 

satisfactory results even for 10 years. 

It’s important to survey scoliosis after 

climax, to use a lombostat.  

� Clinical argues for surgical 
traitement: severe lumbar stenosis 

with waking perimeter limited, 

radicular pain and claudication, to a 

patient in good health condition, 

without comorbidities - clinical 

findings are prevalent compared with 

neuro radiological data. 

� Surgical interventions are more 
frequent corresponding to increasing 

number of older patients and to their 

request for a bigger autonomy 

� LSS surgery is a functional one, 
balance bony and soft tissue 

decompression while maintaining 

spinal stability, surgical interventions 

have to be tailored and rigourous 

applied to the unique pathological 

situation in the persistently 

symptomatic patient; explored by 

MRI, dynamic flexion and extension 

x-rays, EMG (electrophysiological 

testing correlated to thorough 

neurological examination is more 

accurate than radiological evaluation 

alone in choosing the roots to be 

decompressed) 

� Adaptation of the surgical strategy 
according to the therapeutic 

objectives, constraints and 

physiological analysis of imbalances: 

never preventive, minimize tissue 

damage minimally invasive 

decompressive technique and/or 

fusion technique, clearly precised in 

the informed consent who 

correspond with patients 

expectations. 

� Selective decompression only at the 
neurological responsible level 

improved neurogenic  intermittent  

claudication in the majority of 

patients, - un operated radiological 



 

 

 

 

 
224          Rahman, Iacob          Treatment of lumbar spinal stenosis (LSS) and outcome 

 

 

 

 

 

 

 

stenotic  levels or previously 

borderline stenotic level rarely 

became symptomatic in later follow 

up 

� There is still a lack of evidence - based 
data regarding the different surgical 

techniques for lumbar spinal 

decompression, this explains why the 

success rate of decompression for LSS 

ranges from 57% to 95%;  

microsurgical decompression is 

useful in pain decrease and analgesic 

consumption, but also in functional 

improvement 

� Surgery for LSS is efficacy for short 
and medium term; compared with 

medical treatment; for short time, 

surgery is better, nearly 80% of 

patients enjoyed excellent results: less 

pain and better functional status than 

those who had non operative 

treatment. 

� Randomized trials are required to 
produce better guidelines for 

minimally invasive procedures, 

avoiding more extensive surgery 

� The outcome after surgical 
decompression of LSS could be 

influenced by general complications 

such as deep venous thrombosis, 

pulmonary embolism, urinary 

infection, wound healing 

disturbances; also by the co-

morbidity of the patients. Each 

additional decade could increase the 

ASA score and could worsen the 

postoperative result of the patients in 

their 60s to 90s. Most aggravating 

factors do not really make outcome 

worse; in particular degenerative 

spondylolisthesis and disk prolapses 

do not affect outcome. 

The medium and long term outcome may 

be complicated by postsurgical instability after 

extensive multilevel surgery, osteoporosis; the 

more rapid progression of degenerative 

changes, the suboptimal decompression of the 

contro-lateral side because of the impaired 

view of the target area and a slower 

postoperative rehabilitation. 

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