Multilevel Decompression Surgery for Degenerative Lumbar Spinal Canal Stenosis Is Similarly Effective With Single-Level Decompression Surgery

Tatsuya Yamamoto, MD, PhD; Mitsuru Yagi, MD, PhD; Satoshi Suzuki, MD, PhD; Yohei Takahashi, MD, PhD; Satoshi Nori, MD, PhD; Osahiko Tsuji, MD, PhD; Narihito Nagoshi, MD, PhD; Jun Ogawa, MD, PhD; Morio Matsumoto, MD, PhD; Masaya Nakamura, MD, PhD; Kota Watanabe, MD, PhD


Spine. 2022;47(24):1728-1736. 

In This Article

Abstract and Introduction


Study Design: Retrospective case series.

Objective: The purpose of this study was to investigate the outcome of multilevel posterior decompression surgery for degenerative lumbar spinal stenosis compared with single-level surgery.

Summary of Background Data: The clinical outcomes of multilevel decompression surgery are still controversial because previous studies have not been designed to randomize or adjust the patient background.

Materials and Methods: A retrospective review of prospectively collected data from 659 surgically treated lumbar spinal stenosis patients with a minimum 2-year follow-up was performed. Among them, we compared baseline and 2-year postoperative patient-reported outcomes (PROs) including the Visual Analog Scale and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire scores of 122 patients who underwent three or more levels of surgery (M group) and 304 patients who underwent single-level surgery (S group). Further analyses were performed of 116 paired patients from both groups who were propensity score matched by age and baseline PROs.

Results: The number of perioperative complications including extradural hematoma, surgical site infection, and spinal fluid leakage [M vs. S: 10 (8%) vs. 19 (6%), P = 0.47], and frequency of revision surgery [5 (4%) vs. 23 (8%), P = 0.10] were similar between the two groups. In the analysis of propensity score–matched patients, there were comparable improvements in the Visual Analog Scale score for lower back pain (2.6 vs. 2.4, P = 0.55), buttock-leg pain (3.1 vs. 3.4, P = 0.48), and buttock-leg numbness (2.9 vs. 2.9, P = 0.77) in both groups. There were also similar improvements in the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire scores including lower back pain, lumbar function, walking ability, and mental health domains, except for the social life function domain (20.7 ± 26.5 vs. 28.0 ± 27.5, P = 0.04).

Conclusions: Despite the longer surgical time and a larger volume of estimated blood loss, multilevel decompression surgery showed similar improvement to that of single-level surgery in terms of recovery of PROs and frequency of revision surgery. Multilevel decompression surgery provides good clinical outcomes with acceptable complication and revision rates when selecting appropriate patient and spinal levels.


Lumbar spinal canal stenosis (LSS) is a common degenerative disorder that presents as lower back pain (LBP), radicular leg pain, and intermittent claudication. The prevalence of LSS in the United States was previously reported to range from 11% to 38% in individuals between the ages of 60 and 69.[1] Conservative treatment for LSS is effective in patients with mild to moderate symptoms, whereas surgical treatment is desirable for patients presenting with severe gait disturbance, lower extremity muscle weakness, or bladder and bowel dysfunction.[2,3] Laminectomy has been the gold-standard technique for lumbar decompression surgery, however, several potential postoperative issues must be acknowledged. Damage to the posterior element and subsequent spinal instability are associated with LBP.[4] Biomechanical studies have indicated that multilevel decompression surgery induces the lumbar spinal instability in flexion.[5] Furthermore, paravertebral muscle atrophy due to enthesis injury may cause trunk extensor weakness and LBP. The damage to posterior supporting structures, such as the ligamentum complex and paravertebral muscles, tends to increase in severity with the number of decompression levels. As a result, the incidence of postoperative spondylolisthesis was reported to increase in patients treated with multilevel laminectomy than in those treated with single-level laminectomy.[6] Intraoperative bleeding also tends to increase with the number of decompression levels, which leads to a high incidence of postoperative spinal epidural hematoma.[7] To date, only a few previous studies have reported the results of posterior decompression surgery for multilevel LSS cases only. Since these preceding studies have not been designed to randomize or adjust the patient background, the clinical outcomes of multilevel decompression surgery are still controversial. When selecting the decompression level in multilevel LSS cases, these information may help us to decide whether to decompress mild stenosis level in addition to severe stenosis level. The purpose of this study was to investigate the various outcomes of multilevel posterior decompression surgery for LSS compared with those of single-level decompression surgery after adjusting the patient background.