Tandem spinal stenosis: clinical pattern, diagnosis and surgical tactics

The purpose of this review is to present an up-to-date look at the features of diagnosis and treatment of tandem spinal stenosis. Tandem spinal stenosis is a degenerative narrowing of the spinal canal of two or more parts of the spine column. Diagnosis of the one-level degenerative spinal stenosis is commonly quite easy in the practice of a spinal surgeons, while the diagnosis of tandem spinal stenosis is often difficult. The clinical presentation of tandem spinal stenosis presents a constellation of different symptoms and often cause late diagnosis. Data on the prevalence of tandem spinal stenosis are very variable, and the etiology cannot be fully studied. Thereby, comprehensive assessments of the symptoms and imaging provide assistance with the accurate and timely diagnosis. The choice of surgical method should consider possibility of staged decompression of each stenotic levels with priority for proximal parts of spine column.

Simultaneous or staged operation for tandem spinal stenosis: surgical strategy and efficacy comparison

Background Tandem spinal stenosis (TSS) has a complex clinical presentation, and there is no consensus on the optimal surgical strategy. This study retrospectively compared the efficacy of different staged operations and simultaneous decompression for patients with TSS. Methods We reviewed data from 132 patients with TSS who received surgical procedures from January 2011 to June 2018. Patients were classified into three groups according to the most symptomatic area of compression (group C: first-stage surgery for cervical compression; group L: first-stage surgery for lumbar compression; group CL: simultaneous surgery for both). Medical records were reviewed for age, gender, comorbidities, operation time, combined estimated blood loss, and time of hospitalization. The JOA-C, JOA-L, NDI, and ODI scores, and complications were also examined. Results Postoperative outcomes were followed for 32.1 ± 5.4 months. There were significant differences in the re-operation rate and the interval time between the two types of staged operations (p = 0.005 and p = 0.001, respectively). There were no significant differences in gender (p = 0.639), operation time (p = 0.138), combined estimated blood loss (p = 0.116), or complications (p = 0.652) among the three groups, while the simultaneous group was significantly younger (p = 0.027), with fewer comorbidities (p < 0.001) and a shorter hospitalization time (p < 0.001). At the final follow-up, the JOA-C and JOA-L scores were increased, while the NDI and ODI scores were decreased, compared with the preoperative scores. Conclusions TSS can be effectively managed by either simultaneous or staged decompressions. First-stage surgery for cervical stenosis significantly lowers the requirement for second-stage lumbar surgery. One-stage simultaneous decompression is safe and effective with the advantage of reduce hospitalization time, without an increase in operative time or bleeding. However, the surgical indications should be strictly controlled and is recommended for younger patients with fewer comorbidities.

The value of cervical MRI in surgical lumbar canal stenosis patients

Background The prevalence of cervical canal stenosis alone is estimated to be present in 4.9% of the adult population. Co-existence of dual pathology may complicate clinical presentation and necessitates a wise and individually based decision process. Objectives To estimate the co-existence of cervical canal stenosis in surgical lumbar canal stenosis patients and its reflection on decision-making regarding surgery. Methods It is a prospective study that was conducted on 70 cases with symptomatic lumbar canal stenosis by investigating them for cervical canal stenosis clinically and radiologically. Results The co-existence of cervical and lumbar canal stenoses was seen in 62 cases (88.57%); cases with relative cervical stenosis were 25 (35.714%) and absolute cervical stenosis was 37 (52.857%). Cases with no cervical stenosis were 8 (11.428%) and cases with relative lumbar stenosis were 22 (31.428%), while cases with absolute lumbar stenosis were 48 (68.571%). Cases with symptomatic cervical canal stenosis were 30 (42.857%). Cases with asymptomtic cervical canal stenosis were 32 (45.71%). Conclusion Tandem spinal stenosis (TSS) is not uncommon and MRI cervical spine should be done for every lumbar canal stenosis patient especially if indicated by history or clinical examination.

Degenerative cervical myelopathy presenting as subjective lower limb weakness could be a trap towards misdiagnosis

When patients presenting with subjective lower limb weakness (SLLW) are encountered, it is natural to suspect a lumbar pathology and proceed with related clinical examination, investigations and management. However, SLLW could be a sign of degenerative cervical myelopathy (DCM) due to an evolving cord compression. In such circumstances, if symptoms are not correlated to myelopathy at the earliest, there could be potential complications over time. In this study, we intend to analyse the outcomes after surgical management of the cervical or thoracic cord compression in patients with SLLW. Retrospectively, patients who presented to our center during the years 2010–2016 with sole complaint of bilateral SLLW but radiologically diagnosed to have a solitary cervical or thoracic stenosis, or tandem spinal stenosis and underwent surgical decompression procedures were selected. Their clinical presentation was categorised into three types, myelopathy was graded using Nurick’s grading and JOA scoring; in addition, their lower limb functional status was assessed using the lower extremity functional scale (LEFS). Functional recovery following surgery was assessed at 6 weeks, 3 months, 6 months, one year, and two years. Selected patients (n = 24; Age, 56.4 ± 10.1 years; range 32–78 years) had SLLW for a period of 6.4 ± 3.2 months (range 2–13 months). Their preoperative JOA score was 11.3 ± 1.8 (range 7–15), and LEFS was 34.4 ± 7.7 (range 20–46). Radiological evidence of a solitary cervical lesion and tandem spinal stenosis was found in 6 and 18 patients respectively. Patients gradually recovered after surgical decompression with LEFS 59.8 ± 2.7 (range 56–65) at 1 year and JOA score 13.6 ± 2.7 (range − 17 to 100) at 2 years. The recovery rate at final follow up was 47.5%. Our results indicate the importance of clinically suspecting SLLW as an early non-specific sign of DCM to avoid misdiagnosis, especially in patients without conventional upper motor neuron signs. In such cases, surgical management of the cord compression resulted in significant functional recovery and halted the progression towards permanent disability.