J Neurosurg 78:695-701, 1993

Decompressive lumbar laminectomy for spinal stenosis

H. RoY SILVERS, M.D., P. JEFFREY LEWIS, M.D., AND HAROLD L. ASCH, PH.D.
Southtowns Neurological Surgeons Associates, Buffalo, New York

A total of 258 consecutive decompressive lumbar laminectomies performed on 244 individuals presenting
with spinal stenosis were analyzed retrospectively. Spinal fusion was avoided in all but two patients. Outcome
in terms of pain relief and return to normal activity was evaluated in two stages, one derived from patient
charts and having a relatively short-term follow-up time (mean 8.4 months) and a second derived from patient
responses to a questionnaire (which also scored for satisfaction with the results of surgery), which had a longer
follow-up time (mean 4.7 years). More than 20 clinical and operative parameters were analyzed. Overall, a
high degree of success (93% pain relief, 95% return to normal activity) was achieved in the short term, which
was supported by the longer-term follow-up data (64% pain relief, 56% activity return, 75% satisfaction). The
following factors were not significantly correlated with outcome: patient age; sex; worker's compensation or
no-fault insurance status', employed versus not employed; a history of back surgery prior to the laminectomy
studied; existence of degenerative spondylolisthesis or scoliosis; complete versus incomplete myelographic
block; or the level of the lumbar spine undergoing surgery.
The major conclusions arising from these data are: 1) for all age groups through at least the eighth decade
of life, decompressive lumbar laminectomy is a relatively safe operation having a high medium-to-long-term
success rate; 2) lumbar instability following laminectomy is rare, even in individuals presenting prior to surgery
with degenerative instability conditions; and 3) lumbar fusion in addition to the decompressive laminectomy
procedure is rarely required for degenerative spinal stenosis.

KEY WORDS 9 decompressive lumbar laminectomy 9 spinal stenosis 9

degenerative spondylolisthesis

HE use of decompressive lumbar laminectomy Clinical Material and Methods

T for relief of pain, discomfort, and incapacitation

due to spinal stenosis was introduced at the turn
of the century, L29 and has been practiced extensively
since the reports of Verbiest, 4~ Blau and Logue, 2 and
Wiltse, et ai.,44 among others. Variations in results of
this procedure have been reported with most studies
indicating very high short-term success rates and, typi-
cally, two-thirds or better success rates in the long
t e r m . 5-7,9,24"27"30"36"43 Despite this success, there appears
to be increasing emphasis on the adjunctive use of
spinal fusion in order to mitigate the effects of spinal
instability purportedly caused by the laminectomy pro-
cedure. 3,14-16'26Spinal fusion, however, is costly to pa-
tients in terms of expense, hospitalization and recovery
times, postoperative discomfort, complications, and
high failure rates, s'3s Moreover, the recent trend toward
spinal instrumentation along with bone fusion has con-
tributed to these increased costs? In an effort to shed
some light on these controversies, we undertook a ret-
rospective analysis of our experiences with decompres-
sive lumbar laminectomy over the past 12 years. This
analysis is the subject of the present report.
Patient Population
Between January, 1978, and August, 1991, this neu-
rosurgical service performed 262 consecutive lumbar
laminectomies specifically for decompression of spinal
stenosis in 248 patients. Four patients died of causes
unrelated to their surgery; they were lost to follow-up
review within 2 months after surgery and, therefore,
were deleted from this study. Thus, 244 patients who
had undergone 258 lumbar laminectomies were entered
into this retrospective study. Fifteen (6%) of the lami-
nectomies were repeat procedures, and one patient
received a third operation. The mean time (_ standard
deviation) between repeat operations was 2.5 _+ 0.5
years (range 8 days to 5.9 years). Each repeat operation
was analyzed independently.
In all cases, the patients had received conservative
therapy including rest, medical therapy, and physical
therapy for periods of months and, in several cases,
years before admission for myelography. The response
of all had been inconsistent. The finding of lumbar
stenosis on myelography correlated with the clinical

J. Neurosurg. / Volume 78/May, 1993 695


finding of neurogenic (spinal) claudication or lumbar
radiculopathy, and a failure to respond to conserva-
tive therapy resulted in a recommendation for lami-
nectomy.
Surgical Procedure
All patients were operated on in the prone position.
A wide bilateral laminectomy was performed including
foraminotomies and a medial facetectomy. Forty-five
microsurgical discectomies were performed on 42 pa-
tients concurrently with the laminectomies because of
computerized tomography (CT) myelogram and oper-
ative findings of associated disc herniations. In all of
these patients, the lumbar stenosis was the major com-
pressive pathology.
Data Collection and Analysis
Most of the data were obtained from patient charts.
Twenty-six parameters were entered into the database
for analysis (see below). This follow-up information,
derived from patient records, represented reports of
office or hospital visits and occasionally was augmented
by subsequent communications from other physicians
or physical therapists. The mean follow-up time was
8.4 months (range 1 month to 6.8 years) and is herein
referred to as the "short-term" follow-up period. The
distribution of this and the long-term follow-up period
(described below) is depicted in Fig. 1.
A questionnaire was prepared in order to increase
the follow-up period (long-term results) and provide a
relatively uniform instrument for following outcome.
The form requested patients to score their level of
activity as well as pain relief in their back and right
and/or left leg as excellent, good, fair, or poor; success
was the sum of excellent and good scores. The degree
FIG. I. Bar graph showing the distribution of follow-up
time after decompressivelumbar laminectomy. Two types of
follow-up data are indicated, including short-term follow-up
data based on patient records (open bars; numbers atop bars
represent laminectomies; total 258 cases) and long-term fol-
low-up data based on responsesto a questionnaire (solid bars;
numbers atop bars represent responses; total 128 cases).
696
H. R. Silvers, P. J. Lewis, and H. L. Asch
of satisfaction with the results of surgery was scored as:
yes, yes with some limitation, and no; success was the
sum of the first two scores. Written comments by the
patients were also solicited on this form and were useful
in clarifying confusing responses. The questionnaire
was mailed in the fall of 1991 and all nonresponders
whose residence was traceable were contacted by tele-
phone several months later. A total of 128 long-term
responses were obtained with a mean follow-up time of
4.7 years (range 4 months to 14.5 years). According to
the parameters evaluated above, this patient population
closely resembled the overall patient population.
The computerized data were analyzed statistically
using the Statistical Package for the Social Sciences
(Version 4.01). Descriptive statistics such as cross-tab-
ulation, frequencies, and mean analyses were applied.
For some parameters (such as the vertebral level oper-
ated on), the total number of operations performed
(258) was counted whereas for other factors (such as
sex) the total number of patients (244) was used.
Preoperative Parameters
Sixty-one percent of the patients were women. The
mean age was 65 __ 0.6 years (range 30 to 87 years),
with 7% under 50 years, 69% over 60 years, 36% over
70 years, and 4% over 80 years (Fig. 2).
Employment and legal factors were considered in this
study: 72 patients were employed and 26 were involved
in worker's compensation claims, two in no-fault au-
tomobile accident insurance claims, and 17 in other
litigation. Forty-three (18%) of the patients had under-
gone previous back surgery, including discectomy in
35, fusion in four, and laminectomy in four. Most of
these procedures were performed many years (mean
13.3 years) before the laminectomies considered in this
study.
All patients had undergone plain x-ray studies, but
FIG. 2. Bar graph showing the age distribution of patients
at the time of lumbar laminectomy. Represented are all
laminectomies (258 procedures) performed on 244 patients
included in the present study.
J. Neurosurg. / Volume 78/May. 1993
Decompressive lumbar laminectomy for spinal stenosis

these were generally of limited value. Myeiography was study exhibited neither type of deficit. Thus, motor or
usually augmented by post-contrast C I and occasion- sensory deficits were not uncommon, but seldom pre-
ally by magnetic resonance (MR) imaging. The preop- sented as diagnostic features referable to a specific neu-
erative myelography reports indicated that 61% of the ral site of compromise, especially in view of their
patients presented with stenosis only, 13% with stenosis common occurrence in the elderly.
and herniated disc, 22% with stenosis and spondylolis- In 13 patients there was a coexisting diabetic periph-
thesis, and 2% with all three findings. When the types eral neuropathy. This group exhibited twice the rate of
of myelographic block were scored according to degree motor deficits and 2.6 times the rate of sensory, deficits.
of occlusion, 15% were found to be complete and 85% Only two patients were identified as having congenital
incomplete. stenosis, and in both cases degenerative changes aug-
The major clinical findings among these patients are mented the congenital contribution. Degenerative
as follows. The median duration of pain symptoms spondylolisthesis (52 patients) and degenerative scolio-
prior to initial medical consultation was 4.5 months sis (12 patients) were identified by plain x-ray films and
(mean 21.6 __. 3.3 months, range 3 days to 40 years). myelography.
Nearly all patients presented with leg pain; 88% of
patients had both leg pain and back pain. Radiculopa- Operative Parameters
thy (constant leg pain in a sciatic distribution) was Nearly one-half of the procedures involved stenosis
diagnosed in 92% of patients, and in one-fourth of the at a single level, most commonly at L4-5. One-third
cases it was supported by positive findings on electro- involved two levels, primarily L3-4 and L4-5 and
myography or nerve conduction studies when per- about one-fifth involved three levels, mostly L2-5.
formed. Leg pain was about equally apportioned be- Four-level procedures comprised 3% of the operations.
tween unilateral and bilateral presentations. Spinal Thus, the two most common procedures, accounting
claudication, defined as intermittent leg pain in a sciatic for 62% of the operations, were laminectomies at L4-
distribution brought on by ambulation and relieved by 5 and laminectomies at L3-5.
rest, appeared in 86% of patients. Seven percent of Microsurgical discectomy as an adjunct to wide lam-
patients had spinal (neurogenic) claudication without inectomy was performed in 45 (17%) of the 258 lami-
radiculopathy. Nearly one-half of all patients had par- nectomy procedures. More than 75% were carried out
esthesia of the lower extremities and one-third com- at the same level(s) as the laminectomy.
plained of weakness in legs upon standing or walking.
One-fifth of patients suffered from both motor and Results
sensory deficits, one-fifth had motor deficit without
Short-Term vs. Long-Term O u t c o m e
sensory deficit, and less than one-tenth had sensory
deficit only; more than one-half the patients in this In the short-term outcome (mean follow-up period
8.4 months), evaluated by physical examination, relief
of pain was successful in 93% and return to activity
was achieved in 95 % (Table 1). For the long-term results
(mean follow-up period 4.7 years), scored by the pa-
TABLE 1 tients in the questionnaire, 64% reported successful
Short-term outcome correlated with various factors in patients pain relief, 56% had returned to normal activity, and
who underwent lumbar laminectomy 75% reported overall satisfaction with the results of
% Successful surgery (Table 2).
Patient No. Mean Outcome*
Subgroups of Age
Cases (yrs) Pain Normal
Relief Activity
total cases 244 65 93 95 TABLE 2
females 147 66 90 95 Long-term outcome correlated with various factors in patients
males 97 63 96 93 who underwent lumbar laminectomy
previousback surgeryt 47 63 83 90
employed 69 56 96 93 % SuccessfulOutcome*
worker's compensation 26 56 89 89 Patient No. of
no-fault insurance/other litigation 18 58 88 88 Subgroupt Cases Pain Normal Satis-
spondylolisthesis 52 67 90 91 Relief Activity faction
scoliosis 12 69 100 100 total cases 128 64 56 75
complete myelographicblock 34 70 97 96 females 88 55 49 66
concurrent discectomy 37 61 92 97 males 40 83 70 95
"pure" claudication:[: 18 65 100 93 previous back surgery 31 52 42 65
peripheral neuropathy 13 67 93 89 employed 35 65 64 79
* Data obtained from patient's charts (ncurosurgeon's physical spondylolisthesis 32 75 72 84
evaluation at last follow-upexamination). Mean follow-uptime 8.4 complete myelographicblock 15 80 80 93
months. concurrent discectomy 20 85 75 85
t Discectomy,laminectomy,and/or fusion performed prior to this * Data obtained from patients' responses to questionnaire. Mean
laminectomy. follow-uptime 4.7 years.
~tPatients who presented with observed intermittent claudication ~ Includes only categories with sufficient responses for statistical
without radiculopathyand who exhibited pain only on ambulation. analysis.

J. Neurosurg. / Volume 7 8 / M a y , 1993 697


Correlation of Parameters
Correlations among each of the 26 parameters ana-
lyzed, especially with regard to the five outcome param-
eters, were examined and some are indicated in Ta-
bles 1 and 2. In the follow-up questionnaire, responses
for certain parameters were too few to be evaluated
statistically. Also, the success rates did not correlate
with the long-term follow-up duration: for example,
responses obtained more than 5 years after surgery were
not significantly different from those less than 5 years
postoperatively.
There was no correlation between patient age and
outcome. In the short-term follow-up data there was no
statistical difference between men and women with
respect to pain relief or return to normal activity. In
the follow-up questionnaire men reported more success
than women with pain relief (p = 0.003), more satisfac-
tion with surgery (p = 0.001), and greater return to
normal activity (p = 0.03). The lower satisfaction re-
sponse for women correlated with a somewhat higher
mean age and especially with a significantly increased
likelihood that more than one vertebral level was ste-
notic. Employed individuals fared equal to the overall
population in both short-term and long-term evalua-
tions. Patients involved in worker's compensation
claims experienced about the same degree of success in
relief of pain as did the general patient population.
Those conducting no-fault automobile accident insur-
ance claims and other litigation were not significantly
different in outcomes when compared to the overall
population.
In most cases, patients were ambulatory within 24 to
48 hours after surgery. The mean postoperative hospital
stay was 9.8 _ 1.0 days (median 7 days, range 3 to 240
days). As the time spent in hospital after surgery in-
creased from 7 days or less to more than 14 days, both
long- and short-term success rates decreased signifi-
cantly (p < 0.001 and p < 0.05, respectively).
When the vertebral level of surgery was analyzed,
patients operated on at L3-5 and, especially, L4-5 had
superior postoperative activity when compared with
those undergoing laminectomies at other levels. The
same trend was apparent with regard to pain relief but
the differences were not significant. When single-level
operations were compared to multilevel procedures for
correlations with various parameters, there was a strong
(p < 0.001) linear correlation between the number of
vertebral levels operated on and the age of the patient,
as follows (level, mean age): single level, 63 years; two
levels, 65 years; three levels, 68 years; four levels, 69
years; and five levels, 74 years.
Differences in outcome were not found to be related
to associated peripheral neuropathy, whether or not
microdiscectomy was performed concurrently with
laminectomy (Tables 1 and 2), or to the preoperative
findings of motor or sensory deficits.
Previous Back Surgery
Patients who had undergone lumbar back surgery
(mostly discectomy) prior to the current laminectomy
fared no differently from the overall population in the
short-term and long-term analyses.
698
H. R. Silvers, P. J. Lewis, and H. L. Asch
Spondyl~)#sthesis v~s.Spinal Stenosis
The 52 patients with degenerative spondylolisthesis
experienced the same level of success as the overall
population in both the short term and the long term
(Tables i and 2). This group of patients was of similar
age (67 + 1 years), but included a higher proportion of
women (73%). The 12 individuals with degenerative
scoliosis (mean age 69 + 3.2 years; female:male ratio,
4:1) had an outcome at least as successful as any other
group in the short-term analysis (Table 1).
Complete vs. Incomplete Myelographic Block
The degree of stenosis identified by myelography was
tested for correlation with outcome. In comparison to
the overall population, severe stenosis (complete my-
elographic block) was associated with slightly but not
significantly better short-term and long-term outcomes
(Tables 1 and 2).
Spinal Claudication
Eighteen patients had "pure" claudication; by defi-
nition, their pain was not constant (no radiculopathy)
and they exhibited pain only with ambulation. These
patients had highly successful outcomes in the short-
term analysis (Table 1).
Complications
There were 57 complications among the 258 lumbar
laminectomy procedures carried out. The primary op-
erative complication was represented by 32 relatively
minor dural tears (representing 12% of surgeries). All
but two were immediately recognized and successfully
repaired as indicated by the lack of postoperative cere-
brospinal fluid (CSF) leakage. In one case, a pseudo-
meningocele developed which was successfully repaired
at surgery 7 months later. The second case required a
lumbar spinal drain for closure of the CSF leak. Occur-
rence of dural tears was not related to the presence of
other complications; patients who incurred dural tears
had short-term outcome success similar to that of the
overall population (32 cases: 94% pain relief, 93%
return to normal activity) and a similar success rate on
follow-up questionnaire (17 cases: 71% pain relief, 65 %
return to normal activity, and 71% satisfaction with
surgical outcome).
The operative mortality rate was 0.8%. An 84-year-
old diabetic patient died 2 months postoperatively fol-
lowing myocardial infarction, respiratory failure, and
congestive heart failure, and a 78-year-old patient de-
veloped pneumonia followed by respiratory failure and
died 1 month after surgery.
As with other operations in the elderly requiring
general anesthesia, it was not unusual for some patients
to experience some confusion or disorientation follow-
ing surgery. In our series, six patients exhibited transient
but severe episodes of confusion and disorientation. Of
10 patients requiring a Foley catheter for urinary reten-
tion, eight had predisposing conditions such as prostate
cancer, benign prostatic hyperplasia, osteoblastic me-
tastases, or a neurogenic bladder. One superficial and
two deep-vein thrombophlebitis cases were encoun-
J. Neurosurg. / Volume 78/May, 1993
Decompressive lumbar laminectomy for spinal stenosis
tered, one of which required several months of antico-
agulant therapy to resolve. Two epidural hematomas
were encountered. One was apparent on postsurgical
myelogram and was removed successfully without neu-
rological deficit. The second epidural hematoma was
accompanied by severe paraparesis. U p o n immediate
return of the patient to surgery, the hematoma was
evacuated. A partial recovery ensued, but this patient
continued to exhibit significant neurological deficit.
Three patients (1%) had postoperative wound infections
which were successfully treated by incision, drainage,
and antibiotic therapy.
Spinal Fusion
Spinal fusion was necessary in two patients. One was
a 72-year-old woman with diabetes who presented with
back and right-leg pain and myelographic block; she
failed to improve with a wide L3-5 decompressive
laminectomy. Repeat myelogram showed extradural
defects on the right side, and she underwent reoperation
with wide foraminotomy procedures on the right side 2
months after the first surgery. Because of the extensive
decompression it was considered that a fusion was
indicated. Despite some improvement in pain relief,
this procedure was not successful. The second patient
undergoing spinal fusion was a 45-year-old woman in
whom a decompressive laminectomy at L3-5 failed;
she required a lumbar fusion and wide foraminotomy
procedure for treatment of back and leg pain. She has
shown no significant leg or back pain relief.
Discussion
At the beginning of the 20th century, lumbar stenosis
or narrowing of the spinal canal was inferred as a
potential cause of back and leg pain from studies of
neurogenic claudication 32 and spinal osteoarthritis. ~'29
Subsequent studies also suggested thickening of the
ligamentum flavum 39 or local stenotic factors4 in the
etiology of spinal stenosis symptoms. Recognition of
this phenomenon by the medical community was pro-
moted by the landmark studies of Verbiest4~ as well
as those of Blau and Logue,2 Ehni, 5 Kirkaldy-Willis
and coworkers,2~ and others. For patients failing
conservative treatment, the main surgical approach to
relief of symptoms caused by spinal stenosis is decom-
pressive laminectomy. 2"~-7"9"13"17'19'2~176 Most
of these studies indicate favorable outcomes in the
majority of patients for whom laminectomy was per-
formed.
Correlations of Patient Parameters and Outcomes
The present study represents a retrospective analysis
of a relatively large number of patients (244 individu-
als) subjected to 258 laminectomies for spinal stenosis.
When evaluated according to records available from
patients' charts, relief of pain and return to normal
activity were extremely successful (93% and 95%, re-
spectively). When evaluated according to patient's re-
sponses to a questionnaire, which represented a longer
average follow-up time (mean 4.7 years), the success
rates for pain relief and resumption of activity were
J. Neurosurg. / Volume 78 / May, 1993
lower (64% and 56%, respectively), but the patient's
own satisfaction with the results of surgery remained
high (75%).
Patients who responded to the questionnaire tended
to rate their return to activity lower than their relief of
pain and satisfaction (Table 2). This may reflect the
advanced age and concomitant medical problems of
the present patient population.
Patients with pure spinal claudication had signifi-
cantly better outcomes than did the overall patient
population. A similar trend was noted for patients with
complete myelographic block as compared to those with
incomplete block, but the differences were not statisti-
cally significant. We are examining this question more
closely in a prospective study of decompressive lumbar
laminectomy currently in progress. These two results
are consistent with the historical development of de-
compression of lumbar stenosis by laminectomy in
that, in the early literature, the classical clinical pres-
entation was "cauda equina syndrome" (spinal claudi-
cation) and the most striking radiological feature is
complete blockage of contrast material due to degen-
erative stenosis.
An interesting finding was the strong linear correla-
tion between the number of vertebral levels operated
on and mean patient age. This probably reflects the
progressive nature of the disease. This relationship may
be consistent with the common experience of neuro-
surgeons that some patients who undergo a laminec-
tomy at L4-5 require a subsequent laminectomy at a
higher level several years later.
Essentially, none of the other parameters analyzed
showed a correlation with outcome. The lack of corre-
lation for some parameters such as age or neurological
deficit was not unexpected, but noncorrelation for
worker's compensation cases or for patients who had
previously undergone back surgery was unforeseen.~2"37
Males predominate in most studies on lumbar lami-
nectomy. 7'~'~5"24"36~37In the present study, unlike our
report on discectomy,3s there was a preponderance of
female patients. This, together with the advanced age
of most of these patients, is consistent with the low
number of workers or worker's compensation cases.
Spinal Fusion
In an attempt to improve on the success rates for
decompressive laminectomy, some surgeons have
turned to spinal fusion. However, as stated by Nasca, 26
the indications for decompression in spinal stenosis are
well delineated, but the reasons for spinal fusion are
not so well defined. Gartland 8 summarized the current
status of spinal fusion in general and noted that the
role of spinal fusion in the surgical treatment of spinal
stenosis has not yet been totally clarified. The realiza-
tion that a thickened posterior midline fusion can, of
itself, cause spinal stenosis has been disturbing? Still
unsettled is the frequency of postoperative instability
after surgical decompression for spinal stenosis and, if
it does occur, whether it is symptomatic enough to
warrant the addition of spinal fusion to the decompres-
sion procedures. Dissatisfaction with the results ob-
tained by current lumbar spine fusion techniques has
B99

led to the introduction of different forms of internal
fixation devices as internal stabilizers to help attain a
higher rate of successful lumbar fusion. The evidence
to date is inconclusive that any of these devices is
effective in improving fusion rates. 8 Moreover, statisti-
cal analysis has shown that lumbosacral fusion, when
added to appropriate decompressive surgery, has failed
to significantly improve the results over decompressive
surgery alone. 38
Among patients with spinal stenosis, the strongest
candidates for simultaneous fusion and decompression
would appear to be those with degenerative instability
conditions, namely, degenerative spondylolisthesis l~
1823.26.31 and scoliosis. 2j22 Nonetheless, some authors
have successfully treated degenerative spondylolisthe-
sis ~ or scoliosis 33 by decompression alone. The present
study supports this treatment in that patients who were
operated on for spinal stenosis and who had coexisting
degenerative spondylolisthesis (52 cases) or scoliosis (12
cases) fared as well as the overall patient population.
These results support our contention that fusion is
rarely needed when decompressive lumbar laminec-
tomy is performed to relieve symptoms of spinal ste-
nosis, even in patients with degenerative spondylolis-
thesis or scoliosis. Similar findings and conclusions
appear in an abstract of a recently presented study of
206 cases of lumbar stenosis in the elderly where only
six patients needed repeat surgery for fusion, z~
Two qualifying points should be noted. One is that
there are patients who require lumbar decompression,
but whose major complaints relate to instability. For
example, in our practice, the infrequently encountered
patients with congenital spondylolisthesis undergo fu-
sion procedures with laminectomy; these have not been
included in the present study. Also, although the aver-
age outcome in the 52 cases of degenerative spondylo-
listhesis was good, a small subset of these patients (six
cases) accounted for 40% of the 15 patients who re-
quired repeat laminectomy. Nonetheless, five of these
individuals reported successful long-term results. Spinal
fusion was not performed in any of these patients.
Conclusions
Elderly patients suffering from sciatica with or with-
out claudication are debilitated and become dependent
on others for care. Our results indicate that the majority
of these individuals show considerable improvement
with surgical treatment and that age was not a factor in
determining outcome. Thus, intervention is recom-
mended in the older patient who is able to undergo
surgery3 '24 Because the symptoms of spinal stenosis
most commonly result from progressive spinal
degeneratio# t and the general population of elderly in
developed countries continues to increase, decompres-
sive lumbar laminectomy can be expected to play an
increasing role in relief of sciatica and spinal claudi-
cation.
Acknowledgments
Dr. Okhee Suh, Department of Cancer Control and Epi-
demiology, Roswell Park Cancer Institute, performed the sta-
700
H . R. Silvers, P. J. Lewis, a n d H . L. A s c h
tistical analysis and evaluation. Assistance in data entry was
provided by David Clabeaux, Robert Vinci, and Jason Silvers.
References
1. Bailey P, Casamajor L: Osteoarthritis of the spine as cause
of compression of the spinal cord and its roots. With
reports of five cases. J Nerv Dis 38:588-609, 1911
2. Blau JN, Logue V: Intermittent claudication of the cauda
equina. An unusual syndrome resulting from central
protrusion of a lumbar intervertebral disc. Lancet 1:
1081-1086, 1961
3. Coffer JM, Cotler HB: Spinal Fusion: Science and Tech-
nique. New York: Springer-Verlag, 1990
4. Cramer F: A note concerning the syndrome of cauda
equina radiculitis. Bull Neuroi Inst NY 3:501, 1934
5. Ehni G: Significance of the small lumbar spinal canal:
cauda equina compression syndromes due to spondylosis.
Part 1: Introduction. J Neurosnrg 31:490-494, 1968
6. Fast A, Robin GC, Floman Y: Surgical treatment of
lumbar spinal stenosis in the elderly. Arch Phys Med
Rehabil 66:149-151, 1985
7. Ganz JC: Lumbar spinal stenosis: postoperative results in
terms of preoperative posture-related pain. J Neurosurg
72:71-74, 1990
8. Gartland JJ: The future of spinal fusions, in Cotler JM,
Coffer HB (eds): Spinal Fusion: Science and Technique.
New York: Springer-Verlag, 1990, pp 391-395
9. Hall S, Bartleson JD, Onofrio BM, et al: Lumbar spinal
stenosis. Clinical features, diagnostic procedures, and re-
suits of surgical treatment in 68 patients. Ann Intern Meal
103:271-275, 1985
10. Hanley EN Jr: Decompression and distraction-derotation
arthrodesis for degenerative spondylolisthesis. Spine 11:
269-276, 1986
11. Hen'on LD, Trippi AC: L4-5 degenerative spondylolis-
thesis. The results of treatment by decompressive lami-
nectomy without fusion. Spine 14:534-538, 1989
12. Herron LD, Turner J, Clancy S, et al: The differential
utility of the Minnesota Multiphasic Personality Inven-
tory. A predictor of outcome in lumbar laminectomy for
disc herniation versus spinal stenosis. Spine 11:847-850,
1986
13. Hood SA, Weigl K: Lumbar spinal stenosis: surgical
intervention in the older person. Isr J Med Set 19:
169-172, 1983
14. Hopp E, Tsou PM: Postdecompression lumbar instability.
Clin Orthop 227:143-151, 1988
15. Johnsson KE, Redlund-Johnell l, Uden A, et al: Preop-
erative and postoperative instability in lumbar spinal
stenosis. Spine 14:591-593, 1989
16. Johnsson KE, Wi[lner S, Johnsson K: Postoperative in-
stability after decompression for lumbar spinal stenosis.
Spine 11:107-110, 1986
17. Johnsson KE, Willner S, Pettersson H: Analysis of oper-
ated cases with lumbar spinal stenosis, Aeta Orthop Scand
52:427-433, 1981
18. Kaneda K, Kazama H, Satoh S, et al: Follow-up studyof
medial facetectomies and posterolatera[ fusion with in-
strumentation in unstable degenerative spondylolisthesis.
Clin Orthop 203:159-167, 1986
19. Kirkaldy-Wi[lis WH, Mclvor GWD: Lumbar spinal ste-
nosis. Cliu Orthop 115:2-3, 1976 (Editorial)
20. Kirkaldy-Willis WH, Paine KWE, Cauchoix J, et al:
Lumbar spinal stenosis. Clin Orthop 99:30-50, 1974
21. Kostuik JP: Recent advances in the treatment of painful
adult scoliosis. Clin Orthop 147:238-252, 1986
22. Kostuik JP, Errico TJ, Gleason TF: Techniques of inter-
nal fixation for degenerative conditions of the lumbar
J. Neurosurg. / Volume 78 / M a y , 1993
Decompressive lumbar laminectomy for spinal stenosis
spine. Clin Orthop 203:219-231, 1986
23. Lombardi JS, Wiltse LL, Reynolds J, et at: Treatment of
degenerative spondylolisthesis. Spine 10:821-827, 1985
24. MauersbergerW, Nietgen T: Surgicaltreatment of lumbar
stenosis: long-term results. Neurosurg Rev 12:291-295,
1989
25. McIvor GWD, Kirkatdy-Willis WH: Pathological and
myelographic changes in the major types of lumbar spinal
stenosis. Clin Orthop 115:72-76, 1976
26. Nasca RJ: Rationale for spinal fusion in lumbar spinal
stenosis. Spine 14:451-454, 1989
27. Nasca RJ: Surgical management of lumbar spinal steno-
sis. Spine 12:809-816, 1987
28. Pappas CT, Sonntag VK, Harrington T: A prospective
study of 206 cases of lumbar stenosis in the elderly to
determine surgical contraindications and spinal instabil-
ity. J Neurosurg 76:373A-374A, 1992 (Abstract)
29. Parker HL, Adson AW: Compression of the spinal cord
and its roots by hypertrophic osteo-arthritis. Diagnosis
and treatment. Surg Gyneeol Obstet 41:1-14, 1925
30. Petropoulos BP: Lumbar spinal stenosis syndrome. Clin
Orthop 246:70-80, 1989
31. Reynolds JB, Wiltse LL: Surgical treatment of degenera-
tive spondylolisthesis. Spine 4:148-149, 1979 (Abstract)
32. Sachs B, Fraenkel J: Progressive ankyiotic rigidity of the
spine. J Nerv Ment Dis 27:1-15, 1900
33. San Martino A, D'Andria FM, San Martino C: The
surgical treatment of nerve root compression caused by
scoliosis of the lumbar spine. Spine 8:261-265, 1983
34. Shibata T, Moil V, Mori M: A new surgical procedure
for the treatment of lumbar spinal canal stenosis espe-
cially recommendable for degenerative and combined
stenosis. Nippon Geka Hokan 54:397-405, 1985
35. Silvers HR: Microsurgical versus standard lumbar discec-
J. Neurosurg. / Volume 78/May, 1993
tomy. Neurosurgery 22:837-841, 1988
36. Spanu G, Messina AL, Assietti R, et al: Lumbar canal
stenosis: results in 40 patients surgically treated. Aeta
Neurochir 94:144-149, 1988
37. StreflingMS, NessDA: Lumbarlaminectomy. Experience
in 228 consecutive cases. Minn Med 67:143-147, 1984
38. Sypert GW: Low back pain disorders: lumbar fusion? Clin
Nenrosurg 33:457-483, 1986
39. Towne EB, Reichert FL: Compression of the lumbosacral
roots of the spinal cord by thickened ligamenta flava. Ann
Surg 94:327-336, 1931
40. Verbiest H: Further experiences on the pathological influ-
ence of a developmental narrowness of the bony lumbar
vertebral canal. J Bone Joint Surg (Br) 37:576-583,
1955
41. Verbiest H: Pathomorphologic aspects of developmental
lumbar stenosis. Orthop Clin North Am 6:177-196,
1975
42. Verbiest H: A radicular syndrome from developmental
narrowing of the lumbar vertebral canal. J Bone Joint
Surg (Br) 36:230-237, 1954
43. Verbiest H: Results of surgical treatment of idiopathic
developmental stenosis of the lumbar vertebral canal. A
review of twenty-seven years' experience. J Bone Joint
Surg (Br) 59:181-188, 1977
44. Wiltse LL, Kirkaidy-Willis WH, Mclvor GWD: The treat-
ment of spinal stenosis. Clin Orthop 115:83-91, 1976
Manuscript received February 18, 1992.
Accepted in final form September 3, 1992.
Address reprint requests to: H. Roy Silvers, M.D., South-
towns Neurological Surgeons Associates, 550 Orchard Park
Road, Buffalo, New York 14224.
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