Eur Spine J
DOI 10.1007/s00586-014-3479-4
ORIGINAL ARTICLE
Reoperation rates after fenestration for lumbar spinal canal
stenosis: a 20-year period survival function method analysis
Toshimi Aizawa • Hiroshi Ozawa • Takashi Kusakabe • Yasuhisa Tanaka
Akira Sekiguchi • Ko Hashimoto • Haruo Kanno • Naoki Morozumi •
Yushin Ishii • Tetsuro Sato • Eiji Takahashi • Shoichi Kokubun • Eiji Itoi
Received: 24 March 2014 / Revised: 20 July 2014 / Accepted: 21 July 2014
Ó Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose Fenestration is the gold standard surgery for
lumbar spinal canal stenosis in Japan. Several previous
studies have analyzed the reoperation rates in large num-
bers of patients undergoing several surgical procedures
such as laminectomy with or without instrumented spinal
fusion; however, there have been few studies focusing
solely on fenestration. The purpose of this study was to
calculate the reoperation rates after fenestration using the
survival function method.
Methods Form 1988–2007, 6,998 surgeries for lumbar
spinal canal stenosis occurred in Miyagi prefecture, Japan,
and these patients were enrolled by the spinal surgery
registration system of the Department of Orthopaedic
Surgery, Tohoku University. Among these, 5,835 surgeries
involved fenestration as a primary surgery and for those
T. Aizawa (&)
H. Ozawa
K. Hashimoto
H. Kanno
E. Itoi
Department of Orthopaedic Surgery, Tohoku University School
of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai 980-8574,
Japan
e-mail: toshi-7@ra2.so-net.ne.jp
T. Kusakabe
A. Sekiguchi
Department of Orthopaedic Surgery, Tohoku Rosai Hospital,
Sendai, Japan
Y. Tanaka
Department of Orthopaedic Surgery, Tohoku Central Hospital,
Yamagata, Japan
N. Morozumi
Y. Ishii
S. Kokubun
Department of Orthopaedic Surgery, Sendai Nishitaga National
Hospital, Sendai, Japan
T. Sato
E. Takahashi
Department of Orthopaedic Surgery, Sendai Orthopaedic
Hospital, Sendai, Japan
•
who underwent C2 lumbar surgeries we analyzed the
reoperation rates using the Kaplan–Meier method.
Results Among the 5,835 patients undergoing primary
fenestration, 215 patients underwent 221 revisions; 112
included the same spinal levels and 103 were revised only
at other levels as primary fenestration. The overall reop-
eration rates were 0.8 % at 1 year, 2.9 % at 5 years, 5.2 %
at 10 years, 7.5 % at 15 years and 8.6 % at [17.7 years.
Reoperation rates for those at the same spinal levels were
0.6 % at 1 year, 1.7 % at 5 years, 2.7 % at 10 years, 3.8 %
at 15 years, and 4.1 % at [17.0 years.
Conclusions Fenestration can be performed at low cost
using standard spinal surgery equipments. The reoperation
rates of this procedure were lower than previously reported
for several other surgical procedures.
Keywords Lumbar spinal canal stenosis
Fenestration

Reoperation
Survival function method
Introduction
Lumbar spinal canal stenosis is one of the most common
lumbar disorders in older people [23]. The Japanese pop-
ulation is aging and approximately 25 % of the population
was older than 65 years in 2013 as reported by the Japa-
nese Ministry of Internal Affairs and Communications. The
number of operations performed for lumbar spinal canal
stenosis is reportedly the highest among all spine surgeries
[29].
The goal of the surgical treatment of lumbar spinal canal
stenosis is adequate decompression of the affected neural
elements and preservation of spinal stability. Many surgical
procedures have been developed for this purpose including
laminectomy with or without spinal fusion, fenestration,
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Fig. 1 Our fenestration surgical procedure. a Illustration of the area
of bone resection for fenestration (the shaded portion). b Showing
after fenestration. The upper and lower margins of the laminar
resection include the superior and inferior attachments of the
ligamentum flavum; the lateral end matches the margin of dural
tube, which goes through the medial margin of the pedicle. More than
half of the facet joint is preserved
and microendoscopic laminectomy [20, 27, 32]. Recently,
instrumented spinal fusion is being performed more fre-
quently for patients with lumbar spinal canal stenosis and it
has become the surgical trend for this disorder [9, 12].
However, surgical fusion may be associated with a higher
risk of complications [9, 12].
Fenestration, also called partial undercutting facetec-
tomy, involves partial laminectomy while maintaining the
spinous process and the posterior spinal ligaments and
removing the ligamentum flavum. The technique was
introduced by Kida and Tabata [10] in 1980 in Japan and
Getty and his colleagues [15] in 1981 in the United
Kingdom. It can preserve spinal stability without instru-
mented spinal fusion and is the gold standard surgical
treatment for lumbar spinal canal stenosis in Japan [2, 30].
Reoperation should be performed when patients exhibit
recurrent symptoms caused by failure of the primary sur-
gery and when they develop new problems related to the
primary operation. Therefore, reoperation may represent a
subset of patients with unfavorable outcomes or progres-
sive disease [9, 12]. In the present study, to assess the
utility of fenestration for lumbar spinal canal stenosis, we
attempted to calculate the reoperation rate for this surgical
procedure using the survival function method to estimate
the actual reoperation rate [4].
Our fenestration surgical procedure
Briefly, our surgical fenestration procedure is performed as
follows: following the induction of general anesthesia, the
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patient is placed in a kneeling position. The bilateral
laminae are exposed while preserving the interlaminar and
supraspinal ligaments. Bone resection is performed using
an air drill. The upper and lower margins of the resection
include the superior and inferior attachments of the liga-
mentum flavum, while the lateral end matches the margin
of the dural tube. Medial facetectomy is then performed to
clear the lateral margin of the corresponding nerve roots,
which travels through the medial margin of the pedicles. A
minimum of 50 % of the structure of a facet joint should be
preserved to prevent postoperative spinal instability [22,
26]. Finally, the ligamentum flavum is removed using a
curette or a Kerrison rongeur (Fig. 1).
Materials and methods
Since 1988, spine surgeries performed in the orthopaedic
departments in Miyagi Prefecture, locates in northeastern
Japan with a population of approximately 2.20 million in
1988 and 2.35 million in 2007, have been logged by the
registration system of the Department of Orthopaedic
Surgery, Tohoku University School of Medicine [4–7, 14,
25, 29]. As of 2007, a total of 14,046 surgeries for lumbar
spine disease were recorded in this registration system.
Among these, 6,998 surgeries were performed for patients
with lumbar spinal canal stenosis, including spondylolis-
thesis, and 5,835 of the 6,998 surgeries involved fenestra-
tion without spinal fusion as a primary surgical procedure.
Using the spinal surgery registration system data, we
first selected patients who had undergone C2 lumbar sur-
gical interventions with fenestration as a primary method.
We then analyzed their operative records for the surgical
procedures and spinal levels. Our registration system for
spinal surgeries can identify spinal disorders for surgery:
lumbar spinal canal stenosis, lumbar intervertebral disc
herniation, spondylolisthesis, cervical myelopathy or
radiculopathy, and others. However, the detailed patholo-
gies of revision surgery cannot be extracted from our
database, for example, worsening of spinal instability
caused by lamina fracture, and restenosis caused by new
bone formation or scar tissue formation. We excluded
patients who underwent reoperation for pathologies other
than spinal canal stenosis such as those with postoperative
epidural hematoma, surgical site infection, and lumbar disc
herniation.
We analyzed the 20-year overall reoperation rates for
lumbar spinal canal stenosis and the rates for reoperation at
the same spinal level as primary fenestration using the
Kaplan–Meier method. The number of years between the
primary surgery and reoperation was calculated by sub-
tracting the date of the primary surgery from the reopera-
tion date or by subtracting the date of the surgery from the
Eur Spine J

date of the termination of the present study, i.e., December Table 1 Demographic data of patients who had undergone fenestra-
31, 2007. Subsequently, the reoperation rates were esti- tion as primary decompression surgery for lumbar spinal canal ste-
nosis in Miyagi Prefecture between 1988 and 2007
mated using the date of reoperation as the end point. If a
patient underwent a third reoperation after the fenestration Total number of patients 5,835
as the second surgery following the primary fenestration, Male:female 3,258:2,577
then we calculated the amount of time between the first and Non-spondylolisthesis: 4,609:1,226
second fenestration and that between the second fenestra- spondylolisthesis
tion and third reoperation. All statistical analyses were Averaged age at surgery 66 years (range 19–93 years)
performed using commercially available software (Prism, Male 65 years (range 19–93 years)
GraphPad Software Inc., San Diego, CA, USA). Female 67 years (range 20–90 years)
Age distribution (years)
B19 4
Results 20–29 30
30–39 82
The demographic data for the 5,835 patients who 40–49 281
underwent fenestration as primary decompression for 50–59 1,064
lumbar spinal canal stenosis are shown in Table 1. The 60–69 1,943
male/female ratio was 1.26, and approximately 21 % of 70–79 2,077
patients had a secondary diagnosis of spondylolisthesis. C80 354
In total, 412 (13 %) male and 814 (32 %) female
underwent surgery for spondylolisthesis. Approximately
70 % of patients were C60 years old. The annual
changes in the number of patients who underwent fen-
estration as primary decompression in Miyagi prefecture
are shown in Fig. 2. This rate had been increasing each
year, and in 2006 and 2007, C500 patients were treated
with fenestration.
Among the 5,835 patients with primary fenestration, 215
patients underwent 221 revisions: 112 included the same
spinal levels (Same level group) and 103 were revised only
at other spinal levels (Other level group) as primary fen-
estration. The characteristics of patients who underwent
reoperation after primary fenestration are summarized in
Table 2. Among the 112 patients in the Same level group,
110 and 2 patients underwent 1 and 2 revision procedures,
Fig. 2 Annual changes in the number of patients who underwent
respectively, after fenestration. Conversely, among the 103 fenestration as primary decompression for lumbar spinal canal
patients in the Other level group, 100, 2 and 1 patient stenosis in Miyagi Prefecture
underwent 1, 2, and 3 reoperations after primary fenestra-
tion, respectively. The procedures used for the revision
surgeries in the Same level group included fenestration in fenestration. Four patients underwent the second surgery
45 surgeries, laminectomy without spinal fusion in 26, within a month after the primary surgery in the Same level
decompression with posterolateral spinal fusion in 19, and group: three because of inadequate decompression during
instrumented spinal fusion involving posterior or trans- the primary surgical procedure and one because of spinal
foraminal lumbar interbody fusion in 24. The procedures in instability owing to fracture of the inferior articular process
the Other level group were fenestration in 89 surgeries, after the primary operation.
laminectomy in 9, decompression with posterolateral Figure 3 shows the results of the Kaplan–Meier analysis
fusion in 2 and instrumented spinal fusion in 7. of the overall reoperation rates during the 20-year period:
The average interval between reoperation and the pre- 0.8 % at 1 year after the primary surgery, 2.2 % at 3 years,
vious fenestration was 4.0 years in the Same level group 2.9 % at 5 years, 5.2 % at 10 years, 7.5 % at 15 years and
and 5.4 years in the Other level group: C50 % of the 8.6 % at 17.7 years, following which there was a plateau.
patients in the former group underwent reoperation within The reoperation rates for the Same level group are shown
3 years, whereas approximately 50 % of the patients in the in Fig. 4. These rates gradually increased from 0.6 % at
latter group underwent reoperation C5 years after primary 1 year to 1.3 % at 3 years, 1.7 % at 5 years, 2.7 % at

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Table 2 Characteristics of the Same level group Other level group

patients with reoperation
No. of patients 112 103
Male:female 70:42 68:35
Age at primary fenestration
Male 63 years (31–80 years) 61 years (24–83 years)
Female 61 years (32–76 years) 64 years (40–79 years)
Non-spondylolisthesis:spondylolisthesis 81:31 82:21
No. of reoperation after primary fenestration
1 110 100
2 2 2
3 1
Duration between the surgeries 4.0 years (3 days–17.0 years) 5.4 years (4 months–17.7 years)
B1 year 31 surgeries (27 %) 10 surgeries (10 %)
1–3 years 30 surgeries (26 %) 33 surgeries (31 %)
3–5 years 15 surgeries (13 %) 14 surgeries (13 %)
5–10 years 26 surgeries (23 %) 33 surgeries (31 %)
C10 years 12 surgeries (11 %) 17 surgeries (16 %)

Fig. 3 Overall reoperation rates of fenestration for lumbar spinal Fig. 4 Reoperation rates at the same spinal levels as primary
canal stenosis as calculated using the Kaplan–Meier analysis. The fenestration using the Kaplan–Meier analysis. The cumulative rate of
cumulative overall reoperation rates gradually increased to 8.6 % at reoperation at the same level gradually increased and plateaued 4.1 %
17.7 years after primary fenestration, following which it plateaued at 17.0 years after primary fenestration

10 years, 3.8 % at 15 years, and 4.1 % at 17.0 years, fol-
lowing which there was a plateau.
Discussion
In Japan, the reoperation rates of fenestration for lumbar
spinal canal stenosis including at the same and other spinal
levels were reported to be 4–19 %, with the rate of reop-
eration solely at the same spinal levels being 0–12 % [13,
21, 24, 30, 31]. Regrettably, these values were calculated
using simple division of the number of reoperations by the
total number of primary fenestration during a study period
of 3–12 years. Also, the number of patients who had
undergone primary fenestration was modest, ranging from
50 to 639 patients in these studies [13, 21, 24, 30, 31]. To
ascertain the actual reoperation rates, a large number of
patients and a long period of observation are necessary, and
the actual rates should be calculated using survival function
methods such as the Kaplan–Meier method or the Cox
proportional hazards model. Our study is the first to our
knowledge to calculate these values from 5,835 primary
fenestration procedures over a 20-year study period. Our
data show that the overall reoperation rate was 8.6 % at

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[17.7 years, while the rate of reoperation at the same
spinal levels was 4.1 % at [17 years after surgery.
Several recent nationwide or statewide studies have
reported the reoperation rates for lumbar spinal canal ste-
nosis. Jansson et al. [11] analyzed 9,664 operations over a
10-year period in Sweden and reported a reoperation rate of
11 %. In the Maine Lumbar Spine Study, 23 % of patients
underwent repeat surgical procedures within 10 years [3].
Deyo et al. [9] analyzed the database of American Medi-
care hospital claims and reported a reoperation rate of
11.0 % over 4 years among 31,543 patients. The reopera-
tion rates in Washington State, USA were 12.4–14.0 %
within 4 years [16], and the rates in a Korean nationwide
study were 7.2 % at 1 year, 11.2 % at 3 years, 14.2 % at
5 years and 22.9 % at 10 years [12]. These studies inclu-
ded several surgical procedures such as decompression
only and decompression with instrumented spinal fusion,
which tend to show higher reoperation rates than those for
fenestration reported in the present study.
Decompression and instrumented spinal fusion have
been increasingly used as surgical methods for lumbar
spinal canal stenosis to avoid postoperative spinal insta-
bility, which is defined both by radiological measurements
and by symptoms that might originate from what is con-
sidered to be an instability [1, 9, 12, 19]. Certainly,
decompression with spinal fusion may show excellent
results at the fused spinal levels for several years [8];
however, spinal fusion may not be associated with signifi-
cantly lower rates of repeat surgical intervention [8, 9, 12,
16]. The complication rate with this method is approxi-
mately twice as high as for procedures without fusion [9]
and 62.5 % of reoperations are associated with a diagnosis
suggesting device complications or pseudarthrosis after
spinal fusion [17]. Symptomatic adjacent segmental
pathology may be another complication of spinal fusion [8].
Fenestration can adequately decompress the affected
neural elements and favorable surgical outcomes are
reported in both the Japanese and English literature; the
recovery rate of the Japanese Orthopaedic Association
score (full score = 29) was approximately 60 %, which is
similar to that by laminectomy [18, 20, 28, 31]. Fenestra-
tion does not require spinal fusion because, when more
than half of the facet joints are preserved, postoperative
spinal instability should be prevented [22, 26]. Therefore,
the rates of device complications, pseudo-arthrosis, and
adjacent segmental pathology should be lower with fen-
estration than with decompression and instrumented spinal
fusion. These data may explain the relatively low reoper-
ation rate for fenestration.
Fenestration has been our preferred procedure for lum-
bar spinal canal stenosis. Our surgical indications for fen-
estration for this disorder are similar to other
decompression procedures: (1) definitively, patients with
bladder and bowel paralysis, intermittent priapism, and
severe, progressive muscle weakness; and (2) relatively,
patients with intractable pain recalcitrant to nonsurgical
treatment and with concomitant impairment of lifestyle
because of severe intermittent claudication and those with
severe radicular pain that cannot be adequately relieved by
nerve root block. The indications for lumbar spinal fusion
basically depend on the surgeons’ preference. Some sur-
geons may prefer to instrumented spinal fusion for the
patients with mild spinal instability while others prefer
fenestration for those with grade 2 spondylolisthesis. Our
surgical philosophy is that less instrumentation and less
spinal fusion are both better and most of our patients with
lumbar spinal canal stenosis have been operated by fen-
estration only. Spinal fusion may be applied to those who
have not only spinal instability, but also symptoms origi-
nating from the spinal instability.
The main limitation of the present study is the unknown
reliability of our spine registration system; it is unclear
whether this system actually included all operated patients
in Miyagi prefecture. Tohoku University is one of the
seven oldest national universities in Japan, and its medical
school is the only one in this prefecture. Historically,
hospitals in Japan have generally been affiliated with cer-
tain university hospitals; in Miyagi prefecture, all hospitals
have been cooperating with our hospital [4]. Almost all
hospitals where spine surgeries are performed have been
included in our spinal surgery registration system and spine
surgeries in this prefecture have been accurately included
in this registry system since 1988. Using data from this
registration system, we have published several epidemio-
logical studies in high-quality English journals [4–7, 14,
25, 29]. There are likely patients who underwent revision
surgeries in other Japanese prefectures or the Tokyo
metropolitan area; however, the number of such patients
should be small. The older people, who are the most
commonly affected with this disorder, tend to lead an
immobile lifestyle in Japan. They can go to any hospitals
depending on their preference, but the chosen hospitals are
usually those in the same cities or same prefectures where
the primary surgery was performed. The population of
Miyagi prefecture has not been changed significantly dur-
ing this 20-year period of this study, increasing by only
150,000 (from the Miyagi Prefectural Government web-
site). Accordingly, although the reoperation rates indicated
by this study were approximations, they should not differ
greatly from the actual results.
Another limitation is the presence of bias in the selec-
tion of the fenestration procedure for lumbar spinal canal
stenosis. Patients should be selected for fusion procedures
according to the severity or extent of their spine problems,
such as spinal instability; patients with a more stable spine
may be treated with fenestration. Also, the detailed reasons
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for the reoperations were not specified in the database
study as this study [12]. As stated, there are several limi-
tations to the present study and the reoperation rates were
approximate. However, this is the first study to our
knowledge to assess the reoperation rates following fene-
strations among a large number of spinal surgeries using
the survival function method; such rates should be close to
the actual reoperation rates.
Conclusion
Fenestration for lumbar spinal canal stenosis can be per-
formed at low cost using standard equipments for spinal
surgical procedures and it has been the gold standard
treatment for this disorder in Japan. As per the Kaplan–
Meier analysis, the reoperation rates for this procedure,
including those at the same and other spinal levels, were
8.6 % at [17.7 years after surgery, with the rates for
reoperation at the same spinal levels being 4.1 % at
[17 years.
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