Pedicle-Lengthening Osteotomy for the Treatment of Lumbar Spinal Stenosis: the Surgical Technique (Pilot Clinical Study)

Stenosis of the lumbar spine is a common degenerative disease; its progression leads to a significant restriction in daily activities and quality of life. This pilot study presents a novel minimally invasive technology for surgical correction of lumbar stenosis; the technique involves a widening of the spinal canal and intravertebral foramen by percutaneous bilateral osteotomy of the vertebral pedicles and their subsequent lengthening.

Materials and Methods. Twenty patients with symptomatic lumbar stenosis were included in this prospective study (11 of them with stable anterolisthesis grade I). The patients underwent percutaneous osteotomy with lengthening of the vertebral pedicles at one or two levels. X-ray results were obtained from either standard radiography or computed tomography of the lumbar spine. The baseline patients’ condition and the clinical outcomes of the surgical treatment were assessed using a number of validated examination tests, including the Oswestry Disability Index (ODI), the Zurich Claudication Questionnaire (ZCQ), the 10-mm visual-analogue pain scale (VAS), the SF-12 non-specific quality of life questionnaire (version 2) with the physical (PCS) and mental (MCS) component summary scores. The minimal period of postoperative follow-up was 78 months (6.5 years).

Results. In all cases of surgical interventions, the percutaneous osteotomy proceeded without complications and with a minimal blood loss. As compared with the preoperative period, the patients’ quality of life (according to ODI) significantly improved from 48 to 15.5 points over 12 months (p=0.0002) and 5 years (p=0.0004), and up to 20 points in 6 and more years (p=0.0001). The SF-12 test also showed a statistically significant improvement in the quality of life throughout the observation period, with the exception of the MCS score taken soon (6 weeks) after the surgery. The pain syndrome (according to VAS) significantly diminished both in the back and in the lower extremity — from the preoperative 5.8 and 7.4 points to 2.25 and 0.05 points after 5 years (p=0.0004). However, after 6 years or more, the pain syndrome again increased to 3.2 and 2.4 points, respectively, but remained significantly better than that in the preoperative period (p=0.04 and p=0.0006, respectively). According to the ZCQ questionnaire, the patients’ condition improved from 2.0 points (6 weeks after surgery) to 1.5 points at 12 months (p=0.01) and to 1.67 after 5 years (p=0.011). However, after 6 years or more, the value of ZCQ increased to 1.83 points, which did not significantly differ from the preoperative level (p=0.14).

Conclusion. Percutaneous bilateral osteotomy of the vertebral pedicles followed by their lengthening in patients with symptomatic lumbar spinal stenosis (including stable spondylolisthesis grade I) is a promising innovative technology. This minimally invasive treatment is beneficial primarily for elderly patients and those suffering from comorbidity. The results of this pilot study followed up for more than 6 years indicate a good immediate and encouraging long-term outcome of this treatment.

1. Amundsen T., Weber H., Lilleås F., Nordal H.J., Abdelnoor M., Magnaes B. Lumbar spinal stenosis. Clinical and radiologic features. Spine (Phila Pa 1976) 1995; 20(10): 1178–1186, https://doi.org/10.1097/00007632-199505150-00013.
2. Amundsen T., Weber H., Nordal H.J., Magnaes B., Abdelnoor M., Lilleâs F. Lumbar spinal stenosis: conservative or surgical management? A prospective 10-year study. Spine (Phila Pa 1976) 2000; 25(11): 1424–1436, https://doi.org/10.1097/00007632-200006010-00016.
3. Weinstein J.N., Tosteson T.D., Lurie J.D., Tosteson A., Blood E., Herkowitz H., Cammisa F., Albert T., Boden S.D., Hilibrand A., Goldberg H., Berven S., An H. Surgical versus nonoperative treatment for lumbar spinal stenosis four-year results of the Spine Patient Outcomes Research Trial. Spine (Phila Pa 1976) 2010; 35(14): 1329–1338, https://doi.org/10.1097/brs.0b013e3181e0f04d.
4. Fredman B., Arinzon Z., Zohar E., Shabat S., Jedeikin R., Fidelman Z.G., Gepstein R. Observations on the safety and efficacy of surgical decompression for lumbar spinal stenosis in geriatric patients. Eur Spine J 2002; 11(6): 571–574, https://doi.org/10.1007/s00586-002-0409-7.
5. Katz J.N., Lipson S.J., Brick G.W., Grobler L.J., Weinstein J.N., Fossel A.H., Lew R.A., Liang M.H. Clinical correlates of patient satisfaction after laminectomy for degenerative lumbar spinal stenosis. Spine (Phila Pa 1976) 1995; 20(10): 1155–1160, https://doi.org/10.1097/00007632-199505150-00008.
6. Asgarzadie F., Khoo L.T. Minimally invasive operative management for lumbar spinal stenosis: overview of early and long-term outcomes. Orthop Clin North Am 2007; 38(3): 387–399, https://doi.org/10.1016/j.ocl.2007.02.006.
7. Hamasaki T., Tanaka N., Kim J., Okada M., Ochi M., Hutton W.C. Biomechanical assessment of minimally invasive decompression for lumbar spinal canal stenosis: a cadaver study. J Spinal Disord Tech 2009; 22(7): 486–491, https://doi.org/10.1097/bsd.0b013e31818d7dc9.
8. Podichetty V.K., Spears J., Isaacs R.E., Booher J., Biscup R.S. Complications associated with minimally invasive decompression for lumbar spinal stenosis. J Spinal Disord Tech 2006; 19(3): 161–166, https://doi.org/10.1097/01.bsd.0000188663.46391.73.
9. Rahimi-Movaghar V., Rasouli M.R., Vaccaro A.R. Patient outcomes vs a minimally invasive approach in lumbar spinal stenosis: which is more important? Neurosurgery 2010; 67(4): E1180, https://doi.org/10.1227/neu.0b013e3181ee432f.
10. Yoshimoto M., Takebayashi T., Kawaguchi S., Tsuda H., Ida K., Wada T., Suzuki D., Yamashita T. Minimally invasive technique for decompression of lumbar foraminal stenosis using a spinal microendoscope: technical note. Minim Invasive Neurosurg 2011; 54(03): 142–146, https://doi.org/10.1055/s-0031-1279716.
11. Zucherman J.F., Hsu K.Y., Hartjen C.A., Mehalic T.F., Implicito D.A., Martin M.J., Johnson D.R. 2nd, Skidmore G.A., Vessa P.P., Dwyer J.W., Puccio S.T., Cauthen J.C., Ozuna R.M. A multicenter, prospective, randomized trial evaluating the X STOP interspinous process decompression system for the treatment of neurogenic intermittent claudication: two-year follow-up results. Spine (Phila Pa 1976) 2005; 30(12): 1351–1358, https://doi.org/10.1097/01.brs.0000166618.42749.d1.
12. Zucherman J.F., Hsu K.Y., Hartjen C.A., Mehalic T.F., Implicito D.A., Martin M.J., Johnson D.R. 2nd, Skidmore G.A., Vessa P.P., Dwyer J.W., Puccio S., Cauthen J.C., Ozuna R.M. A prospective randomized multi-center study for the treatment of lumbar spinal stenosis with the X STOP interspinous implant: 1-year results. Eur Spine J 2004; 13(1): 22–31, https://doi.org/10.1007/s00586-003-0581-4.
13. Bowers C., Amini A., Dailey A.T., Schmidt M.H. Dynamic interspinous process stabilization: review of complications associated with the X-Stop device. Neurosurg Focus 2010; 28(6): E8, https://doi.org/10.3171/2010.3.focus1047.
14. Brussee P., Hauth J., Donk R.D., Verbeek A.L., Bartels R.H. Self-rated evaluation of outcome of the implantation of interspinous process distraction (X-Stop) for neurogenic claudication. Eur Spine J 2008; 17(2): 200–203, https://doi.org/10.1007/s00586-007-0540-6.
15. Kim D.H., Tantorski M., Shaw J., Martha J., Li L., Shanti N., Rencu T., Parazin S., Kwon B. Occult spinous process fractures associated with interspinous process spacers. Spine (Phila Pa 1976) 2011; 36(16): E1080–E1085, https://doi.org/10.1097/brs.0b013e318204066a.
16. Pratt R.K., Fairbank J.C., Virr A. The reliability of the Shuttle Walking Test, the Swiss Spinal Stenosis Questionnaire, the Oxford Spinal Stenosis Score, and the Oswestry Disability Index in the assessment of patients with lumbar spinal stenosis. Spine (Phila Pa 1976) 2002; 27(1): 84–91, https://doi.org/10.1097/00007632-200201010-00020.
17. Stucki G., Daltroy L., Liang M.H., Lipson S.J., Fossel A.H., Katz J.N. Measurement properties of a self-administered outcome measure in lumbar spinal stenosis. Spine (Phila Pa 1976) 1996; 21(7): 796–803, https://doi.org/10.1097/00007632-199604010-00004.
18. Stucki G., Liang M.H., Fossel A.H., Katz J.N. Relative responsiveness of condition-specific and generic health status measures in degenerative lumbar spinal stenosis. J Clin Epidemiol 1995; 48(11): 1369–1378, https://doi.org/10.1016/0895-4356(95)00054-2.
19. Byval’tsev V.A., Belykh E.G., Sorokovikov V.A., Arsent’eva N.I. The use of scales and questionnaires in vertebrology. Zhurnal nevrologii i psikhiatrii im. S.S. Korsakova 2011; 111(9 Pt 2): 51–56.
20. Deyo R.A., Mirza S.K., Martin B.I., Kreuter W., Goodman D.C., Jarvik J.G. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 2010; 303(13): 1259–1265, https://doi.org/10.1001/jama.2010.338.
21. Cho D.Y., Lin H.L., Lee W.Y., Lee H.C. Split-spinous process laminotomy and discectomy for degenerative lumbar spinal stenosis: a preliminary report. J Neurosurg Spine 2007; 6(3): 229–239, https://doi.org/10.3171/spi.2007.6.3.229.
22. Mobbs R.J., Li J., Sivabalan P., Raley D., Rao P.J. Outcomes after decompressive laminectomy for lumbar spinal stenosis: comparison between minimally invasive unilateral laminectomy for bilateral decompression and open laminectomy: clinical article. J Neurosurg Spine 2014; 21(2): 179–186, https://doi.org/10.3171/2014.4.spine13420.
23. Mannion R.J., Guilfoyle M.R., Efendy J., Nowitzke A.M., Laing R.J., Wood M.J. Minimally invasive lumbar decompression: long-term outcome, morbidity, and the learning curve from the first 50 cases. J Spinal Disord Tech 2012; 25(1): 47–51, https://doi.org/10.1097/bsd.0b013e31820baa1e.
24. Fu K.M., Smith J.S., Polly D.W. Jr., Perra J.H., Sansur C.A., Berven S.H., Broadstone P.A., Choma T.J., Goytan M.J., Noordeen H.H., Knapp D.R. Jr., Hart R.A., Zeller R.D., Donaldson W.F. 3rd, Boachie-Adjei O., Shaffrey C.I. Morbidity and mortality in the surgical treatment of 10,329 adults with degenerative lumbar stenosis. J Neurosurg Spine 2010; 12(5): 443–446, https://doi.org/10.3171/2009.11.spine09531.
25. Ng K.K.M., Cheung J.P.Y. Is minimally invasive surgery superior to open surgery for treatment of lumbar spinal stenosis? A systematic review. J Orthop Surg (Hong Kong) 2017; 25(2): 2309499017716254, https://doi.org/10.1177/2309499017716254.
26. Yamazaki K., Yoshida S., Ito T., Toba T., Kato S., Shimamura T. Postoperative outcome of lumbar spinal canal stenosis after fenestration: correlation with changes in intradural and extradural tube on magnetic resonance imaging. J Orthop Surg (Hong Kong) 2002; 10(2): 136–143, https://doi.org/10.1177/230949900201000206.
27. Siddiqui M., Karadimas E., Nicol M., Smith F.W., Wardlaw D. Influence of X Stop on neural foramina and spinal canal area in spinal stenosis. Spine (Phila Pa 1976) 2006; 31(25): 2958–2962, https://doi.org/10.1097/01.brs.0000247797.92847.7d.
28. Weinstein J.N., Lurie J.D., Tosteson T.D., Zhao W., Blood E.A., Tosteson A.N., Birkmeyer N., Herkowitz H., Longley M., Lenke L., Emery S., Hu S.S. Surgical compared with nonoperative treatment for lumbar degenerative spondylolisthesis: four-year results in the Spine Patient Outcomes Research Trial (SPORT) randomized and observational cohorts. J Bone Joint Surg Am 2009; 91(6): 1295–1304, https://doi.org/10.2106/jbjs.h.00913.
29. Lee M.J., Bransford R.J., Bellabarba C., Chapman J.R., Cohen A.M., Harrington R.M., Ching R.P. The effect of bilateral laminotomy versus laminectomy on the motion and stiffness of the human lumbar spine: a biomechanical comparison. Spine (Phila Pa 1976) 2010; 35(19): 1789–1793, https://doi.org/10.1097/brs.0b013e3181c9b8d6.
30. Tai C.L., Hsieh P.H., Chen W.P., Chen L.H., Chen W.J., Lai P.L. Biomechanical comparison of lumbar spine instability between laminectomy and bilateral laminotomy for spinal stenosis syndrome — an experimental study in porcine model. BMC Musculoskelet Disord 2008; 9: 84, https://doi.org/10.1186/1471-2474-9-84.

Mlyavykh S.G., Bokov A.E., Yashin K.S., Anderson D.G. Pedicle-Lengthening Osteotomy for the Treatment of Lumbar Spinal Stenosis: the Surgical Technique (Pilot Clinical Study). Sovremennye tehnologii v medicine 2018; 10(3): 58, https://doi.org/10.17691/stm2018.10.3.7