What Comes First: Cervical or Lumbar Surgery for Tandem Spinal Stenosis?

Peer Reviewed

Patients with tandem spinal stenosis who are most symptomatic in the upper limbs and undergo cervical decompression as first-stage surgery are significantly less likely to need second-stage surgery than patients who are more symptomatic in the lower limbs and receive lumbar decompression first, according to a retrospective review published by Luo et al online ahead of print in the October issue of European Spine Journal.

“This might be true even in circumstances where symptoms due to lumbar and cervical stenosis coexist with equal severity,” said lead author Chi-An Luo, MD, Department of Orthopaedic Surgery, Spine Division, Chang Gung Memorial Hospital, Taoyuan, Taiwan. “Even in circumstances where the lumbar stenosis seems to be more symptomatic than the cervical stenosis, it should be noted that the lumbar stenosis may not allow apparent myelopathy to manifest in the lower limbs.”
Man with pain from the neck to low back, pain region highlighted in yellow.The study evaluated whether decompression of cervical or lumbar stenosis alone is adequate to relieve symptoms of tandem spinal stenosis. Photo Source: 123RF.com“This study reinforces a common practice to treat the ‘proximal lesion’ first,” commented Choll W. Kim, MD, PhD, Associate Clinical Professor of Orthopaedic Surgery, University of California San Diego. “In most cases, the final decision is dictated by which lesion is causing the more severe symptom along with patient-specific goals. However, this study provides additional support for treating the ‘proximal lesion’ first when the severity of stenosis symptoms is similar at the cervical spine and the lumbar spine,” Dr. Kim told SpineUniverse.

Retrospective Review of 47 Patients

The study was designed to evaluate whether decompression of cervical or lumbar stenosis alone is adequate to relieve symptoms of tandem spinal stenosis. The study authors reviewed records from 47 patients who underwent spinal decompression surgery performed by the same spine surgery team between January 1, 2010, and December 31, 2015.

The researchers noted that identifying the most symptomatic stenosis was challenging and, in general, they used the following protocol to decide which area to operate on first:

  • Cervical surgery (ie, anterior cervical discectomy and fusion, or posterior laminoplasty using Hirabayashi’s method) was performed first if the patient had upper motor neuron signs or predominant neurological signs in the upper extremities.
  • Lumbar surgery (ie, laminectomy with or without posterior stabilization and fusion) was performed first if the patient had greater neurological signs in the lower limbs versus the upper limbs.

The majority of patients (n=37) received cervical decompression as first-stage surgery, and the remaining 11 patients underwent lumbar decompression first. The patients were followed for approximately 35-37 months on average in both groups.

Nearly 70% of Patients Required Cervical Decompression Only

After the first-stage surgery, 25 patients (69%) who received cervical decompression first experienced complete resolution of symptoms, compared with only one patient (9%) who received lumbar surgery first.

Development of new cervical stenosis symptoms (eg, cervical radiculopathy or myelopathy) occurred in 8 patients (73%) who underwent lumbar decompression first, while development of new lumbar stenosis symptoms (eg, back pain, leg pain, or neurogenic claudication) occurred in 8 patients (22%) who underwent cervical decompression first. The mean time to development of new symptoms in the non-operated area was 4.8 months for patients who underwent lumbar decompression first and 18.8 months for those who underwent cervical decompression first.

Second-stage surgery was required by a significantly greater proportion of patients who received lumbar versus cervical decompression first (91% vs 31%; P=0.001).

“Therefore, while managing patients with TSS in two stages, there are certain advantages to consider addressing the cervical stenosis first,” Dr. Luo told SpineUniverse. “However, a first-stage lumbar surgery is still essential to alleviate symptoms if that is what the patient needs for the moment; provided, a second-stage cervical surgery is planned.”

Treat the Symptomatic Lesion First, Expert Says

SpineUniverse Editorial Board member Khoi D. Than, MD, commented that “most surgeons, myself included, will treat the symptomatic lesion first. If both cervical and lumbar regions are symptomatic, it makes sense to treat the cervical region first to address upper motor neuron findings.”

“The findings are a bit dubious,” added Dr. Than, who is Assistant Professor, Department of Neurological Surgery, Oregon Health & Science University, Portland, OR. “The authors state that 27 patients total were symptomatic only to one area. If that is the case, how/why was tandem spinal stenosis diagnosed? Usually, imaging is obtained only of areas that are symptomatic.”

Dr. Luo responded that “Even though we concentrate on the symptomatic stenosis, our radiological evaluation routinely consisted of a whole spine screening MRI. This helped to identify pathologies at multiple levels.”

“We are always provided with MRI images of the requested region and also a series of mid sagittal screening images showing the entire spine,” Dr. Luo said. “We believe that this should be practiced universally, but it needs group communication with radiologists. With this sagittal screening image, if we have to look at different regions, then it was requested subsequently.”

“It should be noted that, 18 of these 27 patients later developed new symptoms, especially those in whom cervical stenosis was found incidentally,” Dr. Luo said. In addition, “there is a slim chance that the symptoms from the incidental stenosis could have been masked by the other stenosis at the time of initial presentation.”

Dr. Kim commented that the study was “well done despite the difficulty of performing a study of this nature.”

Limitations of the study include the retrospective and non-randomized design, small number of patients who received lumbar decompression as first-stage surgery, and relatively short follow-up period, according to the researchers.

The researchers are “currently following these patients for longer periods to see what happens with regard to the non-operated stenosis,” Dr. Luo said. “We are also including patients with less severe Nurick myelopathy grade with intention of a larger study.”

Dr. Luo has no relevant disclosures.
Dr. Kim is a consultant for Globus Medical, Elliquence, Spinal Elements, K2M, Allen Medical/Hill-Rom, and ORHub.
Dr. Than is a consultant for Medtronic and Bioventus.

Updated on: 01/18/19
Continue Reading
ISASS Recommends Lumbar Decompression with Interlaminar Stabilization in Select Patients with Lumbar Spinal Stenosis
Chi-An Luo, MD
Department of Orthopaedic Surgery, Spine Division
Chang Gung Memorial Hospital
Taoyuan, Taiwan
Choll W. Kim, MD, PhD
Associate Clinical Professor of Orthopaedic Surgery
University of California San Diego
Khoi D. Than, MD
Assistant Professor
Department of Neurological Surgery
Oregon Health & Science University

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