Journal de la colonne vertébrale

Tandem Spinal Stenosis (TSS): Literature Review and Report of Patients Treated with Simultaneous Decompression

Abstract

Robert W Molinari, William L Gruhn and Christine Molinari

Summary:

There is a paucity of published literature involving the incidence and management of tandem spinal stenosis (TSS). A retrospective study evaluating both the incidence and surgical management of TSS with simultaneous decompressive surgery in different regions of the spine was performed in a busy university degenerative spine treatment center. Simultaneous spinal surgery is associated with high perioperative morbidity, but appears to be safe and effective in this small subset of adult patients.

Introduction: Tandem spinal stenosis is defined as spinal stenosis that involves 2 different regions of the spine with the stenosis typically appearing the cervical and lumbar spine. The purpose of this study is review the existing literature and to evaluate the safety and efficacy of simultaneous decompressive surgery in different regions of the spine in a small subset of adult patients who require surgical treatment for TSS.

Methods: During the period from 2003-2010, 1023 consecutive patients were treated surgically for symptomatic spinal stenosis by the same surgeon (RWM) at a university medical center. 9 of the 1023 patients (0.88%) had signs, symptoms and imaging studies consistent with the diagnosis of tandem spinal stenosis (TSS). Each of the 9 patients presented with clinical manifestations of TSS to include neurogenic claudication, complex gait disorder, and a mixed pattern of diffuse upper and lower motor neuron signs and symptoms. All 9 TSS patients underwent simultaneous decompressive surgery in different regions of the spine performed by the same fellowship-trained spinal surgeon (RWM) and his team. The average age of the patients was 67 yrs (range 52-81 yrs). 7 patients had combination cervical/lumbar stenosis and 2 patients had combination thoracic/lumbar stenosis. Operative times, blood loss, length of hospital stay, major and minor complications, and preoperative pain scores were recorded for all patients. The average follow-up was 24 months (range 6-48 months). Functional outcomes (NDI and Oswestry scores), pain, and satisfaction scores were recorded at the time of ultimate follow-up. Addtionally, preoperative pain scores were compared with pain scores at ultimate follow-up.

Results: Mean operative time was 2 hours 39 minutes (range 1 hr 51 min - 4 hrs 17 min). Blood loss for the simultaneous procedures averaged 558 cc (range 150 –1300 cc). Hospital stay length averaged 7.4 days (range 3-18 days) and 6 patients required prolonged postop rehabilitation. There were no major postoperative complications in all 9 patients. 7 patients (78%) were available for long-term follow-up at average 24 months postop. Analog pain scores demonstrated an average 5-point improvement at ultimate followup, and there was a statistically significant difference between preoperative and postoperative analog pain scores (Preop 7.8, Postop 1.9, p=0.0001). Functional outcomes at the time of ultimate follow-up demonstrated an average NDI score of 15.6 points (range 2-25) and an Oswestry score of 21 points (range 8-34)- both consistent with mild disability. Scores for patient satisfaction scores were high, averaging 8.7 points on a 0-10 scale.

Conclusion: The incidence of TSS among patients requiring surgery for spinal stenosis is extremely low, and there is a paucity of existing literature on this topic. Simultaneous surgery in different regions of the spine appears to be an effective treatment option for the few patients who present with the classic findings of TSS. In this case series, patient morbidity is higher than reported for isolated spinal decompressive procedures. However, functional outcomes do not appear to be adversely affected by the simultaneous technique, and patient satisfaction is high.

Significance: Simultaneous decompressive surgery is a viable treatment option for the small subset of adult patients who present with symptomatic TSS.