Comparison of 1-Stage versus 2-Stage Decompression, Fusion and Instrumentation Surgery in Patients with Coexisting Cervical and Lumbar Degenerative Spondylotic Disorders; A Prospective, Randomized, Controlled Clinical Trial Study

Document Type : Original Article (s)

Authors

1 Assistant Professor, Department of Neurosurgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

2 Student of Medicine, School of Medicine AND Student Research Committee, Isfahan University of Medical Sciences, Isfahan, Iran

Abstract

Background: Coexistent involvement of cervical and lumbar spine with destructive spondylotic degenerative processes such as tandem spinal stenosis (TSS) can be managed with simultaneous or staged decompressions; though, a controversy exists regarding the surgical staging strategy and limited research is available on its operative management which are mostly retrospective. This randomized clinical trial was conducted to compare outcomes of simultaneous decompression, fusion and instrumentation of cervical and lumbar spine versus 2-stage operations.Methods: Twenty patients with TSS were randomly assigned to either of two groups; in the 1-stage group, simultaneous decompression, fusion and instrumentation of both cervical and lumbar spine were performed by two teams in a single operation. The 2- stage group underwent staged cervical and lumbar surgeries in 2 separate operations. Combined blood loss, transfused packed cells, operation time, recovery time, days of hospitalization, overall expenses, Oswestry Disability Index (ODI) and complications were compared between the two groups. Student T-test, Chi-square test and Pearson correlation were used for analyzing the data.Findings: Operation time, recovery time, days of hospitalization and overall expenses were significantly reduced in 1-stage surgery group. There were no significant differences between the two groups in terms of combined blood loss, transfused packed cells or postoperative complications. Early cervical and lumbar clinical outcomes which were evaluated by Oswestry neck and back disability index, respectively, were similar in two groups (P > 0.05).Conclusion: Single-stage surgery had comparable clinical outcomes compared to 2-stage operations without exposing the patients to unnecessary risks.

Keywords


  1. Carragee EJ. The increasing morbidity of elective spinal stenosis surgery: Is it necessary? JAMA 2010; 303(13): 1309-10.
  2. Deyo RA, Gray DT, Kreuter W, Mirza S, Martin BI. United States trends in lumbar fusion surgery for degenerative conditions. Spine (Phila Pa 1976) 2005; 30(12): 1441-5.
  3. Ciol MA, Deyo RA, Howell E, Kreif S. An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations. J Am Geriatr Soc 1996; 44(3): 285-90.
  4. Taylor VM, Deyo RA, Cherkin DC, Kreuter W. Low back pain hospitalization. Recent United States trends and regional variations. Spine (Phila Pa 1976) 1994; 19(11): 1207-12.
  5. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 2010; 303(13): 1259-65.
  6. Deyo RA, Mirza SK, Martin BI. Error in trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 2011; 306(10): 1088.
  7. Zulkefli A, Ramanathan R. Tandem spinal stenosis. Malaysian Orthopaedic Journal 2010; 4(1): 46-9.
  8. Bajwa NS, Toy JO, Young EY, Ahn NU. Is congenital bony stenosis of the cervical spine associated with lumbar spine stenosis? An anatomical study of 1072 human cadaveric specimens. J Neurosurg Spine 2012; 17(1): 24-9.
  9. la Ban MM, Green ML. Concurrent (tandem) cervical and lumbar spinal stenosis: A 10-yr review of 54 hospitalized patients. Am J Phys Med Rehabil 2004; 83(3): 187-90.
  10. Epstein NE, Epstein JA, Carras R, Murthy VS, Hyman RA. Coexisting cervical and lumbar spinal stenosis: diagnosis and management. Neurosurgery 1984; 15(4): 489-96.
  11. Dagi TF, Tarkington MA, Leech JJ. Tandem lumbar and cervical spinal stenosis. Natural history, prognostic indices, and results after surgical decompression. J Neurosurg 1987; 66(6): 842-9.
  12. Teng P, Papatheodorou C. Combined cervical and lumbar spondylosis. Arch Neurol 1964; 10(3): 298-307.
  13. Eskander MS, Aubin ME, Drew JM, Eskander JP, Balsis SM, Eck J, et al. Is there a difference between simultaneous or staged decompressions for combined cervical and lumbar stenosis? J Spinal Disord Tech 2011; 24(6): 409-13.
  14. Kikuike K, Miyamoto K, Hosoe H, Shimizu K. 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 2009; 22(8): 593-601.
  15. Aydogan M, Ozturk C, Mirzanli C, Karatoprak O, Tezer M, Hamzaoglu A. Treatment approach in tandem (concurrent) cervical and lumbar spinal stenosis. Acta Orthop Belg 2007; 73(2): 234-7.
  16. Symons NR, Almoudaris AM, Nagpal K, Vincent CA, Moorthy K. An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery. Ann Surg 2013; 257(1): 1-5.
  17. Krishnan A, Dave BR, Kambar AK, Ram H. Coexisting lumbar and cervical stenosis (tandem spinal stenosis): An infrequent presentation. Retrospective analysis of single-stage surgery (53 cases). Eur Spine J 2014; 23(1): 64-73.
  18. Williams SK, Eismont FJ. Concomitant cervical and lumbar stenosis: Strategies for treatment and outcomes. Seminars in Spine Surgery 2007; 19(3): 165-76.
  19. Hsieh CH, Huang TJ, Hsu RW. Tandem spinal stenosis: Clinical diagnosis and surgical treatment. Changgeng Yi Xue Za Zhi 1998; 21(4): 429-35.
  20. Caron TH, Bell GR. Combined (tandem) lumbar and cervical stenosis. Seminars in Spine Surgery 2007; 19(1): 44-6.
  21. Molinari RW, Flanigan R, Yaseen Z. Tandem spinal stenosis (TSS): Literature review and report of patients treated with simultaneous decompression. Current Orthopaedic Practice 2012; 23(4): 356-63.
  22. Jennett B, Pickard J. Economic aspects of neurosurgery. New York, NY: Springer Publishing Company; 1992.
  23. Kolb KS, Day T, McCall WG. Accuracy of blood loss determination by health care professionals. CRNA 1999; 10(4): 170-3.
  24. Larsson C, Saltvedt S, Wiklund I, Pahlen S, Andolf E. Estimation of blood loss after cesarean section and vaginal delivery has low validity with a tendency to exaggeration. Acta Obstet Gynecol Scand 2006; 85(12): 1448-52.
  25. Lawthers AG, McCarthy EP, Davis RB, Peterson LE, Palmer RH, Iezzoni LI. Identification of in-hospital complications from claims data. Is it valid? Med Care 2000; 38(8): 785-95.
  26. Cho KJ, Suk SI, Park SR, Kim JH, Kim SS, Choi WK, et al. Complications in posterior fusion and instrumentation for degenerative lumbar scoliosis. Spine (Phila Pa 1976) 2007; 32(20): 2232-7.
  27. Fairbank JC, Pynsent PB. The Oswestry disability index. Spine (Phila Pa 1976) 2000; 25(22): 2940-52.
  28. Mehra A, Baker D, Disney S, Pynsent PB. Oswestry disability index scoring made easy. Ann R Coll Surg Engl 2008; 90(6): 497-9.
  29. Monticone M, Baiardi P, Ferrari S, Foti C, Mugnai R, Pillastrini P, et al. Development of the Italian version of the Oswestry Disability Index (ODI-I): A cross-cultural adaptation, reliability, and validity study. Spine (Phila Pa 1976) 2009; 34(19): 2090-5.
  30. Lauridsen HH, Hartvigsen J, Manniche C, Korsholm L, Grunnet-Nilsson N. Danish version of the Oswestry disability index for patients with low back pain. Part 2: Sensitivity, specificity and clinically significant improvement in two low back pain populations. Eur Spine J 2006; 15(11): 1717-28.
  31. Mousavi SJ, Parnianpour M, Montazeri A, Mehdian H, Karimi A, Abedi M, et al. Translation and validation study of the Iranian versions of the Neck Disability Index and the Neck Pain and Disability Scale. Spine (Phila Pa 1976) 2007; 32(26): E825-E831.
  32. Ament JD, Kim KD. Standardizing cost-utility analysis in neurosurgery. Neurosurg Focus 2012; 33(1): E4.
  33. Lattig F, Fekete TF, O'Riordan D, Kleinstuck FS, Jeszenszky D, Porchet F, et al. A comparison of patient and surgeon preoperative expectations of spinal surgery. Spine (Phila Pa 1976) 2013; 38(12): 1040-8.
  34. Lattig F, Grob D, Kleinstueck FS, Porchet F, Jeszenszky D, Bartanusz V, et al. Ratings of global outcome at the first post-operative assessment after spinal surgery: how often do the surgeon and patient agree? Eur Spine J 2009; 18(Suppl 3): 386-94.
  35. Mannion AF, Junge A, Elfering A, Dvorak J, Porchet F, Grob D. Great expectations: really the novel predictor of outcome after spinal surgery? Spine (Phila Pa 1976) 2009; 34(15): 1590-9.