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European Spine Journal

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Open Access 01-01-2019 | Original Article

Staged surgery for tandem cervical and lumbar spinal stenosis: Which should be treated first?

Authors: Chi-An Luo, Arun-Kumar Kaliya-Perumal, Meng-Ling Lu, Lih-Huei Chen, Wen-Jer Chen, Chi-Chien Niu

Published in: European Spine Journal | Issue 1/2019

Abstract

Purpose

Tandem spinal stenosis (TSS) refers to lumbar and cervical spinal canal stenosis. Staged surgery is often chosen, but sometimes, mere decompression of one stenosis is adequate to relieve symptoms. Therefore, we intend to analyze whether starting with the cervical or the lumbar region is the most logical option.

Methods

We retrospectively reviewed the data of 47 patients with TSS, having first-stage decompression for the most symptomatic stenosis, and classified into two groups (Group A: lumbar decompression first, Group B: cervical decompression first). Postoperative outcomes were analyzed for at least 2 years, and they were cautiously watched for symptoms of the non-operated stenosis; if such symptoms were debilitating, second-stage surgery for the non-operated stenosis was done.

Results

The demographic characteristics of Group A (n = 11) and Group B (n = 36) were comparable. One patient (9%) in Group A and 25 patients (67%) in Group B had resolution of symptoms and good functional recovery. The need for a second-stage surgery for the non-operated stenosis was significantly high (p = 0.001) among patients in Group A. They suffered a significant worsening of both the mJOA score and the Nurick’s grade; whereas, patients in Group B experienced staged improvement of both scales.

Conclusion

First-stage surgery for the cervical stenosis significantly lowers the need of the second-stage surgery. In contrast, if lumbar stenosis was treated first, a dramatic exacerbation of the symptoms related to the cervical stenosis can occur soon. Therefore, treatment of cervical stenosis first seems to be more appropriate.

Graphical abstract

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Dagi TF, Tarkington MA, Leech JJ (1987) Tandem lumbar and cervical spinal stenosis. Natural history, prognostic indices, and results after surgical decompression. J Neurosurg 66(6):842–849. https://doi.org/10.3171/jns.1987.66.6.0842 CrossRefPubMed

van Eck CF, Spina Iii NT, Lee JY (2017) A novel MRI classification system for congenital functional lumbar spinal stenosis predicts the risk for tandem cervical spinal stenosis. Eur Spine J 26(2):368–373. https://doi.org/10.1007/s00586-016-4657-3 CrossRefPubMed

Krishnan A, Dave BR, Kambar AK, Ram H (2014) Coexisting lumbar and cervical stenosis (tandem spinal stenosis): an infrequent presentation. Retrospective analysis of single-stage surgery (53 cases). Eur Spine J 23(1):64–73. https://doi.org/10.1007/s00586-013-2868-4 CrossRefPubMed

Nagata K, Yoshimura N, Hashizume H, Ishimoto Y, Muraki S, Yamada H, Oka H, Kawaguchi H, Akune T, Tanaka S, Nakamura K, Yoshida M (2017) The prevalence of tandem spinal stenosis and its characteristics in a population-based MRI study: the Wakayama spine study. Eur Spine J 26(10):2529–2535. https://doi.org/10.1007/s00586-017-5072-0 CrossRefPubMed

Overley SC, Kim JS, Gogel BA, Merrill RK, Hecht AC (2017) Tandem spinal stenosis: a systematic review. JBJS Rev 5(9):e2. https://doi.org/10.2106/jbjs.rvw.17.00007 CrossRefPubMed

Kikuike K, Miyamoto K, Hosoe H, Shimizu K (2009) One-staged combined cervical and lumbar decompression for patients with tandem spinal stenosis on cervical and lumbar spine: analyses of clinical outcomes with minimum 3 years follow-up. J Spinal Disord Tech 22(8):593–601. https://doi.org/10.1097/BSD.0b013e3181929cbd CrossRefPubMed

Eskander MS, Aubin ME, Drew JM, Eskander JP, Balsis SM, Eck J, Lapinsky AS, Connolly PJ (2011) Is there a difference between simultaneous or staged decompressions for combined cervical and lumbar stenosis? J Spinal Disord Tech 24(6):409–413. https://doi.org/10.1097/BSD.0b013e318201bf94 CrossRefPubMed

Aydogan M, Ozturk C, Mirzanli C, Karatoprak O, Tezer M, Hamzaoglu A (2007) Treatment approach in tandem (concurrent) cervical and lumbar spinal stenosis. Acta Orthop Belg 73(2):234–237PubMed

Li WJ, Guo SG, Sun ZJ, Zhao Y (2015) Multilevel thoracic ossification of ligamentum flavum coexisted with/without lumbar spinal stenosis: staged surgical strategy and clinical outcomes. BMC Musculoskelet Disord 16:206. https://doi.org/10.1186/s12891-015-0672-5 CrossRefPubMedPubMedCentral

10.

Hsieh CH, Huang TJ, Hsu RW (1998) Tandem spinal stenosis: clinical diagnosis and surgical treatment. Changgeng Yi Xue Za Zhi 21(4):429–435PubMed

11.

Felbaum DR, Fayed I, Stewart JJ, Sandhu FA (2016) Relief of lumbar symptoms after cervical decompression in patients with tandem spinal stenosis presenting with primarily lumbar pain. Cureus 8(12):e940. https://doi.org/10.7759/cureus.940 CrossRefPubMedPubMedCentral

12.

Epstein NE, Epstein JA, Carras R, Murthy VS, Hyman RA (1984) Coexisting cervical and lumbar spinal stenosis: diagnosis and management. Neurosurgery 15(4):489–496CrossRef

13.

Baron EM, Young WF (2007) Cervical spondylotic myelopathy: a brief review of its pathophysiology, clinical course, and diagnosis. Neurosurgery 60(1 Supp1 1):S35–S41. https://doi.org/10.1227/01.neu.0000215383.64386.82 CrossRefPubMed

14.

Nurick S (1972) The pathogenesis of the spinal cord disorder associated with cervical spondylosis. Brain 95(1):87–100CrossRef

15.

Kang Y, Lee JW, Koh YH, Hur S, Kim SJ, Chai JW, Kang HS (2011) New MRI grading system for the cervical canal stenosis. AJR Am J Roentgenol 197(1):W134–W140. https://doi.org/10.2214/ajr.10.5560 CrossRefPubMed

16.

Lee GY, Lee JW, Choi HS, Oh KJ, Kang HS (2011) A new grading system of lumbar central canal stenosis on MRI: an easy and reliable method. Skeletal Radiol 40(8):1033–1039. https://doi.org/10.1007/s00256-011-1102-x CrossRefPubMed

17.

Park MS, Moon SH, Kim TH, Oh JK, Lyu HD, Lee JH, Riew KD (2015) Asymptomatic stenosis in the cervical and thoracic spines of patients with symptomatic lumbar stenosis. Glob Spine J 5(5):366–371. https://doi.org/10.1055/s-0035-1549031 CrossRef

18.

Tsutsumimoto T, Shimogata M, Yui M, Ohta H, Misawa H (2012) The natural history of asymptomatic lumbar canal stenosis in patients undergoing surgery for cervical myelopathy. J Bone Jt Surg Br 94(3):378–384. https://doi.org/10.1302/0301-620x.94b3.27867 CrossRef

19.

Ghobrial GM, Oppenlander ME, Maulucci CM, Viereck M, Prasad S, Sharan AD, Harrop JS (2014) Management of asymptomatic cervical spinal stenosis in the setting of symptomatic tandem lumbar stenosis: a review. Clin Neurol Neurosurg 124:114–118. https://doi.org/10.1016/j.clineuro.2014.06.012 CrossRefPubMed

20.

Deem S, Shapiro HM, Marshall LF (1991) Quadriplegia in a patient with cervical spondylosis after thoracolumbar surgery in the prone position. Anesthesiology 75(3):527–528CrossRef

21.

Wilkes LL (1980) Paraplegia from operating position and spinal stenosis in non-spinal surgery: a case report. Clin Orthop Relat Res 146:148–149

22.

Wilson JR, Barry S, Fischer DJ, Skelly AC, Arnold PM, Riew KD, Shaffrey CI, Traynelis VC, Fehlings MG (2013) Frequency, timing, and predictors of neurological dysfunction in the nonmyelopathic patient with cervical spinal cord compression, canal stenosis, and/or ossification of the posterior longitudinal ligament. Spine (Phila Pa 1976) 38(22 Suppl 1):S37–S54. https://doi.org/10.1097/BRS.0b013e3182a7f2e7 CrossRef

23.

Bednarik J, Kadanka Z, Dusek L, Novotny O, Surelova D, Urbanek I, Prokes B (2004) Presymptomatic spondylotic cervical cord compression. Spine (Phila Pa 1976) 29(20):2260–2269CrossRef

24.

Li F, Chen Z, Zhang F, Shen H, Hou T (2011) A meta-analysis showing that high signal intensity on T2-weighted MRI is associated with poor prognosis for patients with cervical spondylotic myelopathy. J Clin Neurosci 18(12):1592–1595. https://doi.org/10.1016/j.jocn.2011.04.019 CrossRefPubMed

25.

Tetreault LA, Dettori JR, Wilson JR, Singh A, Nouri A, Fehlings MG, Brodt ED, Jacobs WB (2013) Systematic review of magnetic resonance imaging characteristics that affect treatment decision making and predict clinical outcome in patients with cervical spondylotic myelopathy. Spine (Phila Pa 1976) 38(22 Suppl 1):89–110. https://doi.org/10.1097/BRS.0b013e3182a7eae0 CrossRef

Title: Staged surgery for tandem cervical and lumbar spinal stenosis: Which should be treated first?
Authors: Chi-An Luo
Arun-Kumar Kaliya-Perumal
Meng-Ling Lu
Lih-Huei Chen
Wen-Jer Chen
Chi-Chien Niu
Publication date: 01-01-2019
Publisher: Springer Berlin Heidelberg
Published in: European Spine Journal / Issue 1/2019
Print ISSN: 0940-6719
Electronic ISSN: 1432-0932
DOI: https://doi.org/10.1007/s00586-018-5795-6

At a glance: The STEP trials

Springer Medicine

Staged surgery for tandem cervical and lumbar spinal stenosis: Which should be treated first?

Abstract

Purpose

Methods

Results

Conclusion

Graphical abstract

At a glance: The STEP trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Graphical abstract

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