Evaluation and Treatment of Tandem Spinal Stenosis

Joseph F. Baker, MCh, FRCSI

Disclosures

J Am Acad Orthop Surg. 2020;28(6):229-239. 

In This Article

Simultaneous or Staged Surgery?

The decision to perform simultaneous surgery at all sites of stenosis or to stage the procedures depends on multiple factors including disease severity and the patient's ability to undergo a prolonged surgical procedure. The level of invasiveness at each region and the availability of less invasive techniques may also be considered.[31] Consideration should also be given to the patients' general condition—a single anesthetic may be more desirable rather than exposing comorbid patients to two separate procedures (Figure 5).[32] One needs to consider patient factors including age, body mass index, and the presence of comorbidities such as diabetes, ischemic heart disease, arrhythmia, chronic liver disease, and autoimmune disease, as these elevate the risk of surgical site infection.[33]

Figure 5.

T2-weighted sagittal (A) and axial (B) and (C) images of the thoracolumbar spine. Axial images of the T11/12 (B) and L4/5 (C) stenoses. A 77-year-old woman with notable medical comorbidities presented with a mixed myeloradiculopathy. Imaging of the remainder of the spine did not demonstrate stenosis elsewhere. Accepting significant potential overlap in symptoms from the two sites of stenosis and taking into account patient wishes to have a single surgical procedure, simultaneous decompression was performed, resulting in relief from neurogenic claudication and halting progression of imbalance.

In 202 patients with TSS, Yamada et al[26] noted that in those undergoing delayed decompression of the cervical spine after lumber decompression, an improvement in both cervical and lumbar symptoms was seen as measured by the L-JOA and C-JOA—in their study, cohort patients presented predominantly with lumbar symptoms and so had the lumbar region addressed first. In a very small subgroup that underwent simultaneous surgery of both lumbar and cervical spinal disease, no advantage in terms of recovery was seen.

In reviewing the outcomes of 43 patients undergoing either simultaneous or staged cervical and lumbar decompression, Eskander et al[34] suggested that age greater than 68 years, estimated blood loss over 400 mL, and surgical time over 150 minutes should prompt the clinician to consider staged rather than single-setting surgery. They noted that beyond the age of 68 years, the risk of both major and minor complications rose and the functional gains, although still evident, began to decline. Countering this, of 50 patients with thoracic stenosis undergoing surgical decompression, compared with 15 with isolated disease, the 35 with concomitant cervical and/or lumbar stenosis also undergoing decompression did not experience any greater degree of complication regardless of age.[18]

Hu et al[35] documented outcomes from single-stage surgery on tandem stenosis affecting the cervical and thoracic spine. In this cohort of 16 patients, the stenotic levels were contiguous across the cervicothoracic junction, and a number of cases had OPLL of the thoracic spine. CSS was treated either with an open-door laminoplasty or laminectomy and instrumented fusion, whereas the more distal stenosis addressed using laminectomy alone, laminectomy and fusion, or circumferential decompression and fusion. Although 62.5% of the group reported instant improvement after surgery, 37.5% were initially worse—circumferential decompression, massive blood loss, and cerebrospinal fluid leak were associated with a deterioration. When considering the outcomes based on surgical strategy in a separate report—17 undergoing single-stage and 13 two-stage procedures—transient neurologic deterioration was seen in 7, and the authors recommended that staged procedures should be planned if the stenoses were not immediately adjacent.[2]

Although these studies provide somewhat conflicting conclusions, some generalization can be made. Staged surgery appears a reasonable and safe strategy, although simultaneous decompression may be considered in a young, robust patient or if the stenosis is adjacent. Risk stratification may be complemented by the use of predictive tools to provide a more definitive risk profile—it is the authors' practice to use a surgical risk calculator to guide patient counseling. Table 4 summarizes some of the key considerations when considering treatment strategy in TSS.

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