Tag Archives: Decompression
The Spinopelvic Alignment Hypothesis: Does Optimal PI–LL and PT Restoration Drive Better Patient-Reported Outcomes after Laminectomy?
Vol 11 | Issue 2 | July-December 2025 | page: 3-6 | Rahul Jaiswal, Shailesh Hadgaonkar, Ajay Kothari, Siddharth Aiyer, Pramod Bhilare, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2025.v11.i02.258
Author: Rahul Jaiswal [1], Shailesh Hadgaonkar [1], Ajay Kothari [1], Siddharth Aiyer [1], Pramod Bhilare [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Shivaji- nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Rahul Jaiswal,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Shivajinagar, Pune, Maharashtra, India.
E-mail: rj199116@gmail.com
Abstract
Background: Lumbar canal stenosis commonly causes leg pain, numbness and reduced walking distance in middle-aged and older adults. Degenerative loss of disc height, enlargement of facet joints and thickening of the ligamentum flavum narrow the spinal canal, compressing nerve roots and producing neurogenic claudication and disability. Conservative care—physiotherapy, medications and epidural injections—helps many patients, yet persistent symptomatic stenosis often requires surgical decompression to relieve nerve compression and restore walking tolerance and independence.
Hypothesis: The study proposes that decompression alone, applied to patients with degenerative lumbar canal stenosis and Grade I spondylolisthesis without clear instability, will yield meaningful and sustained reductions in leg and back pain and substantial improvement in daily function and overall health. It further proposes that measurable restoration of lumbar lordosis and pelvic alignment will be modest for most patients, and that symptomatic recovery will depend chiefly on relief of neural compression and reversal of pain-driven antalgic posture rather than on large radiographic corrections.
Clinical importance: If these expectations are met, a decompression-first strategy supports a less invasive pathway for most patients who lack objective instability, avoiding the additional morbidity of fusion while delivering reliable symptom relief. Emphasis on validated patient-reported outcomes—pain scores, the Oswestry Disability Index and general health measures—keeps decision-making focused on what matters to patients: reduced pain, improved mobility and better quality of life. Counseling should set realistic expectations about likely functional gains and the limited degree of radiographic change to be expected after decompression alone.
Future research: Randomized, multicentre trials comparing decompression alone with decompression plus fusion in patients who have borderline sagittal parameters are needed to define radiographic thresholds that justify fusion. Longer follow-up and objective measures—quantitative assessment of paraspinal muscle quality and gait analysis—will help predict who benefits most from fusion versus decompression alone. This study reports prospective medium-term outcomes using validated measures and standardized standing radiographs to examine the link between symptom relief and sagittal alignment. Findings aim to guide practical surgical decisions for everyday spine care. Durable outcomes.
Keywords: Lumbar canal stenosis, Decompression, Lumbar lordosis, Spinopelvic parameters, Oswestry Disability Index, Neurogenic claudication
Background
Lumbar canal stenosis is a common degenerative condition of the lower spine that produces leg pain, numbness and progressive difficulty with walking. Over time, loss of disc height, enlargement of the facet joints, osteophyte formation and thickening of the ligamentum flavum narrow the spinal canal and compress nerve roots. Patients typically report leg symptoms that worsen with standing and walking and ease with sitting or forward flexion; back pain often coexists but the dominant complaint is usually reduced walking tolerance and functional decline. [1–4]
Initial care is conservative: physiotherapy, analgesics, activity modification and epidural injections can relieve symptoms for many patients. When symptoms persist or progressive neurological deficit develops despite nonoperative care, surgery is considered. The surgical aim is straightforward — remove the compressive elements to free the nerves, reduce pain, and restore walking ability and day-to-day function. Traditional open laminectomy achieves reliable decompression but may injure paraspinal muscles or destabilize the posterior elements in some patients. Over the years, muscle-sparing laminotomies and other less invasive decompressive techniques have been developed to lower soft-tissue trauma while preserving the neural benefit. [5–9]
Beyond nerve decompression, modern practice considers spinal balance. Spinopelvic parameters — pelvic incidence, pelvic tilt, sacral slope and lumbar lordosis — describe how the spine and pelvis align in the sagittal plane and influence load distribution and long-term mechanical pain. In degenerative disease, patients commonly adopt a flexed, antalgic posture; relief of pain may permit a more erect stance and a measurable increase in lumbar lordosis. However, true structural correction depends on reversing degenerative disc collapse, facet arthropathy and muscle degeneration — changes that often cannot be corrected solely by decompression. Reported effects of decompression on sagittal metrics therefore vary: some series show modest improvement in lordosis, whereas others find little change. [10–13]
This uncertainty has important clinical consequences. For patients with clear instability or marked deformity, fusion with realignment may be necessary. For the majority with symptomatic stenosis and at most low-grade spondylolisthesis, the question is whether decompression alone will deliver the functional recovery they need without the added morbidity of fusion. Large cohort studies and randomized trials have demonstrated that decompression reliably reduces leg pain and improves disability and quality of life for many such patients, though a subset will later require fusion for mechanical symptoms or progression. [14, 15, 21]
Measuring both patient-reported outcomes (pain scores, Oswestry Disability Index, general health measures such as SF-36) and standing spinopelvic radiographs before and after surgery provides practical information. It shows whether symptom relief aligns with measurable changes in sagittal balance, and it helps surgeons decide when radiographic findings should push them toward fusion rather than decompression alone. The present work reports a prospective series that tracked validated clinical scores and standardized standing radiographs in patients undergoing lumbar decompression, with the aim of clarifying the relationship between symptomatic recovery and radiographic alignment. [16–20]
Hypothesis
Two linked hypotheses guided the study.
First, in patients with degenerative lumbar canal stenosis — including those with Grade I spondylolisthesis but without clear mechanical instability — decompression alone will produce substantial and sustained reductions in leg and back pain, plus meaningful improvement in disability and overall health. Relief of direct neural compression reduces ongoing nociception and venous congestion of the nerve roots, allowing functional recovery and improved walking tolerance. Previous prospective studies support the expectation that decompression yields clinically important gains on VAS, ODI and general health measures. [7, 14, 15]
Second, measurable restoration of sagittal alignment after decompression will be modest for most patients and will not be essential for clinical recovery. Pain-driven forward-flexed posture and posterior pelvic tilt commonly accompany stenosis; when pain subsides, a degree of postural correction may occur, producing small increases in lumbar lordosis. Yet long-standing structural degeneration — disc height loss, facet arthropathy and fatty change of the paraspinal musculature — limits large or durable radiographic correction without reconstructive measures. Several reports document inconsistent changes in pelvic parameters after decompression, suggesting that functional recovery often occurs even in the absence of major alignment change. [10–13, 16–18]
To test these hypotheses, the study enrolled consecutive, eligible patients who met predefined inclusion criteria (symptomatic degenerative lumbar canal stenosis, age threshold, instability up to Grade I) and excluded those with higher-grade slips, prior fusion, infection or tumour. Each patient underwent decompression appropriate to the pathology (laminotomy, laminectomy or muscle-preserving techniques). Outcome assessment combined validated PROMs — VAS for back and leg pain, ODI for disability, and SF-36 for health-related quality of life — with standardized standing lateral radiographs that included the femoral heads to permit accurate measurement of pelvic incidence, pelvic tilt, sacral slope and lumbar lordosis. [20–22]
Follow-up extended to the medium term and compared baseline and postoperative PROMs and radiographic metrics. The core analytic questions were: how large are the clinical gains after decompression, do spinopelvic parameters change meaningfully, and are radiographic changes correlated with improvements in pain and function? The practical intent was to determine whether decompression-first remains the sound initial strategy for most patients without objective instability, reserving fusion for those with evidence of structural deformity or persistent mechanical symptoms. [21–25]
Discussion
The study observed consistent and clinically meaningful improvement in symptoms and function after lumbar decompression. Patients reported substantial drops in leg and back pain and marked reduction in disability scores; general health measures improved in parallel, reflecting greater mobility and daily independence. These clinical gains mirror those found in prior prospective cohorts and randomized studies that established decompression as the primary surgical treatment for symptomatic stenosis when instability is absent. [7, 14, 23]
On radiographs, changes in lumbar lordosis and pelvic parameters were generally modest. Some patients regained a measure of lordosis as pain relieved and antalgic posture resolved, but the cohort did not show large, uniform corrections of sagittal alignment. Importantly, the magnitude of radiographic change did not consistently predict the degree of functional recovery: many patients with little or no radiographic change experienced large symptomatic benefit, and conversely, radiographic improvement did not guarantee superior clinical outcomes. This dissociation underscores that relief of neural compression — not radiographic perfection — chiefly drives early to medium-term recovery after decompression. [10–12, 16–18]
Several considerations explain why radiographs and symptoms diverge. Decompression directly treats the proximate cause of neurogenic claudication, allowing nerve roots to recover function; this process improves pain and walking even when underlying degenerative deformity remains. Structural features such as disc collapse, facet joint arthropathy and paraspinal muscle atrophy restrict the scope for radiographic correction unless reconstructive procedures are performed. Measurement variability, heterogeneity in the number of levels decompressed, and patient factors (obesity, sarcopenia, and hip or knee compensation) further blur any simple relationship between angle changes and patient function. [11, 21, 22]
Clinically, the findings support a pragmatic approach. For patients whose principal problem is neurologic — leg pain and neurogenic claudication — and who lack clear dynamic instability or marked sagittal deformity, decompression alone is an appropriate initial strategy. It reduces operative morbidity compared with fusion while delivering predictable symptomatic relief. For patients whose predominant complaint is mechanical back pain linked to fixed sagittal imbalance, or those with high pelvic incidence–lumbar lordosis mismatch, fusion and alignment-restoring surgery should be considered to address the structural driver of pain and to prevent late progression. Thus, selection should integrate symptoms, objective instability assessment, radiographic measures and the patient’s functional goals. [23–25]
Limitations include single-centre design, potential selection bias, variability of surgical technique and medium-term rather than long-term follow-up. Radiographic measurement error and absence of quantitative paraspinal muscle assessment are additional constraints. Nonetheless, the results add to the body of evidence demonstrating that decompression alone provides meaningful symptom relief for the majority of appropriately selected patients and that substantial radiographic correction is not a necessary precondition for clinical benefit.
Clinical importance
Decompression without fusion reliably reduces leg pain, improves walking capacity and enhances quality of life in patients with degenerative lumbar canal stenosis and Grade I or absent spondylolisthesis when objective instability is not present. Prioritizing symptom-driven indications and validated patient-reported outcomes keeps decision-making focused on what matters to patients: less pain and better function. Fusion remains important for those with fixed deformity, progressive slip or predominant mechanical back pain, but for many patients a decompression-first pathway minimizes surgical risk while achieving the desired clinical goals. [21–24]
Future direction
Randomized, multicentre trials comparing decompression alone with decompression plus fusion in patients with borderline sagittal parameters are needed to define thresholds that justify adding fusion. Longer follow-up with objective measures — quantitative MRI of paraspinal muscles, gait analysis and standardized PROMs — will improve the ability to predict who will regain upright posture after decompression and who will progress to mechanical failure, enabling more precise, individualized surgical planning. [23–25]
References
1. Ferguson SA, Merryweather A, Thiese MS, Hegmann KT, Lu ML, Kapellusch JM, et al. Prevalence of low back pain, seeking medical care, and lost time due to low back pain among manual material handling workers in the United States. BMC Musculoskelet Disord. 2019; 20(1):1–8.
2. Magras I, Athanasiou A, Magra V. Lumbar spinal stenosis. Spine Surg A Case-Based Approach. 2019; 77–80.
3. Botwin KP, Gruber RD. Lumbar spinal stenosis: Anatomy and pathogenesis. Phys Med Rehabil Clin N Am. 2003; 14(1):1–15.
4. Divi SN, Goyal DKC, Bowles DR, Mujica VE, Guzek R, Kaye ID, et al. How do spinopelvic parameters influence patient-reported outcome measurements after lumbar decompression? Spine J. 2020; 20(10):1610–7.
5. Hatakka J, Pernaa K, Rantakokko J, Laaksonen I, Saltychev M. Effect of lumbar laminectomy on spinal sagittal alignment: a systematic review. Eur Spine J. 2021; 30(9):2413–26.
6. Shin EK, Kim CH, Chung CK, Choi Y, Yim D, Jung W, et al. Sagittal imbalance in patients with lumbar spinal stenosis and outcomes after simple decompression surgery. Spine J. 2017; 17(2):175–82.
7. Haro H, Maekawa S, Hamada Y. Prospective analysis of clinical evaluation and self-assessment by patients after decompression surgery for degenerative lumbar canal stenosis. Spine J. 2008; 8(2):380–4.
8. Ghobrial GM, Al-Saiegh F, Heller J. Spinopelvic Balance. Oper Tech Spine Surg. 2018; 2(8):281–7.
9. Anna I, Gemma V-C, David C, Augusto C, Enric C, Ana Garcia DF, et al. Lumbar lordosis in patients undergoing non-instrumented spinal stenosis. Int J Spine Res. 2021; 3:004–10.
10. Liang C, Sun J, Cui X, Jiang Z, Zhang W, Li T. Spinal sagittal imbalance in patients with lumbar disc herniation: Its spinopelvic characteristics, strength changes of the spinal musculature and natural history after lumbar discectomy. BMC Musculoskelet Disord. 2016; 17(1):1–8.
11. Jeon CH, Lee HD, Lee YS, Seo HS, Chung NS. Change in Sagittal Profiles after Decompressive Laminectomy in Patients with Lumbar Spinal Canal Stenosis: A 2-Year Preliminary Report. Spine. 2015; 40(5):E279–85.
12. Kirkaldy-Willis WH. The three-joint complex and the pathogenesis of backache. J Bone Joint Surg Br. 1982; 64-B: 178–86.
13. Ashley P. Historical perspectives in spinal surgery. J Neurosurg. 1985; 62:394–8.
14. Genevay S, Atlas SJ. Lumbar Spinal Stenosis. Best Pract Res Clin Rheumatol. 2010; 24(2):253–65.
15. Postacchini F. Management of lumbar spinal stenosis. J Bone Joint Surg Br. 1996; 78(1):154–64.
16. Shenouda EF, Gill SS, Laing R, Johnston R. Laminal fenestration for the treatment of lumbar nerve root foraminal stenosis. Br J Neurosurg. 2002; 16(5):494–6.
17. Sengupta DK, Herkowitz HN. Lumbar spinal stenosis: Treatment strategies and indications for surgery. Orthop Clin North Am. 2003; 34(2):281–95.
18. Watanabe K, Hosoya T, Shiraishi T, Matsumoto M, Chiba K, Toyama Y. Lumbar spinous process-splitting laminectomy for lumbar canal stenosis. J Neurosurg Spine. 2005; 3(5):405–8.
19. Lin SM, Tseng SH, Yang JC, Tu CC. Chimney sublaminar decompression for degenerative lumbar spinal stenosis. J Neurosurg Spine. 2006; 4(5):359–64.
20. Benz RJ, Garfin SR. Current techniques of decompression of the lumbar spine. Clin Orthop Relat Res. 2001; 384:75–81.
21. Elder BD, Witham TF. Low Back Pain and Spondylosis. Semin Neurol. 2016; 36(5):456–61.
22. Ills A W, Olivieri S. Aging and musculoskeletal function. Aging Ment Health. 1998; 2:344–8.
23. Atlas SJ, Keller RB, Robson D, Deyo RA, Singer DE. Surgical and nonsurgical management of lumbar spinal stenosis: Four-year outcomes from the Maine lumbar spine study. Spine. 2000; 25(5):556–62.
24. Thomé C, Zevgaridis D, Leheta O, Bäzner H, Pöckler-Schöniger C, Wöhrle J, et al. Outcome after less-invasive decompression of lumbar spinal stenosis: a randomized comparison of unilateral laminotomy, bilateral laminotomy, and laminectomy. J Neurosurg Spine. 2005; 3(2):129–41.
25. Hatta Y, Shiraishi T, Sakamoto A, Yato Y, Harada T, Mikami Y, et al. Muscle-preserving interlaminar decompression for the lumbar spine: A minimally invasive new procedure for lumbar spinal canal stenosis. Spine. 2009; 34(8):276–80.
| How to Cite this Article: Jaiswal R, Hadgaonkar S, Kothari A, Aiyer S, Bhilare P, Sonawane D, Shyam A, Sancheti P. The Spinopelvic Alignment Hypothesis: Does Optimal PI–LL and PT Restoration Drive Better Patient-Reported Outcomes after Laminectomy?. Journal of Medical Thesis. 2025 July-December; 11(2):3-6. |
Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2022
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Optimizing Thoracolumbar Fracture Management: Hypothesis – Superiority of Long-Segment Posterior Pedicle Screw Fixation for Long-Term Stability
Vol 9 | Issue 2 | July-December 2023 | page: 26-30 | Sangmeshwar Siddheshwar, Shailesh Hadgaonkar, Ajay Kothari, Siddharth Aiyer, Pramod Bhilare, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2023.v09.i02.218
Author: Sangmeshwar Siddheshwar [1], Shailesh Hadgaonkar [1], Ajay Kothari [1], Siddharth Aiyer [1], Pramod Bhilare [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
Address of Correspondence
Dr. Sangmeshwar Siddheshwar,
Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India.
E-mail: dr.sangamms@gmail.com
Abstract
Background: Multilevel degenerative lumbar spinal stenosis commonly causes progressive leg pain, numbness and reduced walking capacity that interfere with daily activities and independence. This prospective study reports the one-year clinical and functional outcomes of 99 consecutive patients treated surgically between October 2016 and October 2017 after failing conservative management. Surgical approaches were tailored to each patient and included decompression alone, decompression with stabilization, or decompression combined with instrumented fusion when instability was present.
Hypothesis: We hypothesised that individualized decompression, with selective addition of stabilization or fusion when indicated by symptoms or imaging, would produce consistent and durable improvements in pain, disability and health-related quality of life across patients with stenosis at two or more lumbar levels.
Clinical importance: By one year most patients recorded meaningful gains. Most patients returned to routine activities within months. Mean disability scores fell from levels indicating marked functional limitation to scores compatible with mild residual disability, and median pain scores declined substantially. Broad improvements were evident in physical functioning, role limitation, bodily pain and social participation. Complication rates were acceptable; intraoperative dural tears were the most frequent event and were managed without lasting neurological deficit in the majority. A small number of patients developed adjacent segment problems or required further intervention, but these did not negate the overall functional gains achieved.
Future research: Larger prospective studies and randomized trials should examine which clinical and radiological features best identify patients who benefit from fusion in addition to decompression, evaluate long-term durability beyond one year, and assess cost-effectiveness and patient-centred outcomes such as return-to-work and persistent analgesic use. Registries and standardized outcome reporting will strengthen evidence and guide clearer decision-making.
Keywords: Multilevel lumbar stenosis, Decompression, Instrumented fusion, Oswestry Disability Index, Quality of life, Dural tear.
Background
Degenerative narrowing of the lumbar spinal canal is a leading cause of walking difficulty, leg pain and lost independence in older adults. Over decades the spinal motion segments lose disc height, facet joints hypertrophy and the ligamentum flavum thickens and buckles; these changes reduce space for the nerve roots and the dural sac and create the classic picture of lumbar spinal stenosis. Symptoms usually include leg pain, numbness or weakness that worsen with standing and walking and improve with sitting or forward flexion of the spine — a pattern that distinguishes it from vascular claudication. Accurate diagnosis depends on combining the clinical story with imaging, since many people have degenerative changes on MRI without troubling symptoms. Verbiest and later clinical reviews set out the classic descriptions still used today. [1–3]
Multilevel involvement — where two or more levels show compressive change — becomes more common with age and often produces a mixture of axial low back discomfort and diffuse leg symptoms. That mixture can make it hard to localize a single symptomatic level on exam, and it makes imaging and functional assessment central to surgical planning. MRI is the preferred modality for showing soft-tissue causes of compression such as ligamentum flavum hypertrophy and facet overgrowth, while standing radiographs and dynamic films help reveal instability or slippage (spondylolisthesis) that may change the operation required. Grading systems and morphological descriptions on axial MRI help surgeons weigh where and how much decompression is needed. [2–4]
Conservative care is the first line for most patients: patient education, analgesics, structured physiotherapy, walking programs and selective epidural injections frequently yield meaningful improvement and delay or avoid surgery. Surgery is considered when symptoms — most importantly, walking limitation and leg pain — remain disabling despite adequate conservative management. Surgical options span from focused microsurgical decompression (unilateral or bilateral laminotomy, over-the-top decompression) to more extensive multilevel laminectomy. When instability is present or anticipated because decompression would remove stabilizing structures, instrumented fusion is added to restore or preserve alignment. Minimally invasive methods try to free nerves while preserving posterior elements and Para spinal muscles, with the goal of faster recovery and less postoperative back pain. [5–8]
A key practical question for surgeons is when to add fusion to decompression. Fusion stabilizes the segment, prevents progression of deformity and increases the chance of durable mechanical integrity when instability is present; however, it also increases operative time, blood loss, cost and the potential for implant-related complications. Several comparative studies show that fusion improves radiographic stability, but consistent clinical advantage for routine fusion in stable stenosis is not firmly established. Thus, careful patient selection and individualized planning are essential; fusion is generally reserved for clear instability, high-grade spondylolisthesis or cases where decompression would itself destabilize the spine. [9–12]
Patient-reported measures such as the Oswestry Disability Index (ODI), the Visual Analog Scale (VAS) for pain and general quality-of-life instruments are standard tools to judge surgical benefit. Most contemporary series report meaningful improvement in leg symptoms and walking tolerance after surgical decompression, whether fusion is performed or not, provided the operation and selection are appropriate. Common perioperative problems include dural tears, infection, wound healing problems, and in the long term, adjacent-segment degeneration. Careful surgical technique, perioperative optimization and rehabilitation reduce these risks and improve outcomes. The current thesis offers a prospective dataset of consecutive patients treated for multilevel stenosis, with standardized preoperative assessment and 6- and 12-month follow-up to evaluate these issues. [13–25]
Hypothesis.
Primary hypothesis
When patients with multilevel lumbar spinal stenosis are selected for surgery based on clear clinical-radiologic correlation, and the operative approach is tailored to the presence or absence of instability (decompression alone for stable segments versus decompression plus instrumented fusion when instability or deformity exists), most patients will experience substantial and clinically meaningful improvement in pain, function and quality of life at one year.
Why this matters
The clinical problem is practical and common: many older patients have multilevel degenerative changes, but not all of them are disabled by those changes. Surgery that is too limited may leave persistent compression; surgery that is too aggressive may create instability or needlessly expose patients to the extra risks of fusion. The surgeon’s task is to match the invasiveness of the operation to the mechanical and symptomatic needs of the patient. Existing literature suggests clear benefit from fusion when there is demonstrable instability, and good relief from decompression alone when the spine is stable; however, the evidence is mixed for borderline cases. A prospective cohort where selection criteria and outcomes are systematically recorded helps clarify real-world results. [9–12, 25]
Specific aims
1. To measure change in disability (ODI) from baseline to one year as the primary outcome. Secondary outcomes include changes in VAS pain scores and SF-36 quality-of-life domains, perioperative complications, reoperation rates and radiographic fusion status where fusion was performed.
2. To compare clinical outcomes and complication profiles among three operative strategies used in the cohort: decompression alone; decompression plus posterolateral stabilization; and decompression plus instrumented interbody fusion.
3. To examine whether the number of levels treated (two, three, or four and above) or the MRI severity of stenosis influences functional outcome or complication risk.
4. To identify perioperative predictors of less favorable outcomes (older age, greater comorbidity, larger blood loss, dural tear, and extent of decompression) to support shared decision-making.
Operational testable statements
• H1: Mean ODI and VAS will improve significantly at six months and be maintained at one year after appropriate surgery.
• H2: In patients with radiographic instability, adding fusion will yield comparable or better functional outcomes but with higher intraoperative resource use (longer operating time, more blood loss).
• H3: Higher-grade morphological stenosis on MRI predicts larger absolute symptomatic benefit from decompression, while the number of levels treated will not independently predict worse functional outcomes when operations are appropriately chosen.
• H4: Advanced age and increased comorbidity raise complication risk but do not necessarily prevent meaningful clinical gains in those who recover without severe complications.
Study approach and measures
A prospective cohort design of consecutive patients with two or more levels operated for symptomatic stenosis, with standardized collection of ODI, VAS and SF-36 at baseline, six months and one year, together with detailed perioperative data and radiographs/MRI, provides the necessary structure to test these hypotheses and to develop risk-stratified guidance for practice. [25]
Discussion
What the outcomes usually show
When surgery is chosen for patients with disabling symptoms and concordant imaging, decompression reliably reduces leg pain and improves walking capacity. In most cohorts, including the present thesis cohort, patients report large early gains in leg pain and functional ability by six months that tend to persist at one year. The magnitude of benefit commonly relates to how closely symptoms and imaging match — patients with clear neurogenic claudication and compressive lesions on MRI gain the most. [13–15]
Fusion: when it helps and when it does not
Instrumented fusion restores stability and alignment when clear instability exists, and it reduces the chance of postoperative mechanical failure where wide decompression would otherwise destabilize the spine. That mechanical benefit is evident radiographically and in some series leads to better long-term outcomes for selected patients. At the same time, fusion increases operative time, blood loss and implant-related complexity, and in otherwise stable stenosis it does not consistently produce better patient-reported outcomes than decompression alone. Therefore, fusion is best reserved for cases with objective instability, high-grade spondylolisthesis or deformity that needs correction; routine fusion for all multilevel disease is not supported by the balance of evidence. [9–12, 16–18]
Surgical technique and tissue preservation
Wherever possible, techniques that decompress the neural elements while preserving midline structures and paraspinal musculature reduce early postoperative back pain and may hasten recovery, especially in older or frail patients. Muscle-sparing and minimally invasive decompression approaches can achieve adequate neural decompression in many cases, leaving fusion for those with instability or unavoidable destabilizing resections. Proper selection minimizes the overall physiological burden without compromising decompression. [5–8, 19–21]
Complications and mitigation
Dural breaches during decompression are a common intraoperative event; careful microsurgical technique and prompt repair keep long-term consequences uncommon. Infection, thromboembolism and wound problems are important perioperative concerns and are reduced by standard prophylactic measures (antibiotics, early mobilization, and DVT prophylaxis as appropriate) and by optimizing medical comorbidities before surgery. Fusion adds risk of implant-related issues and potential future adjacent-segment degeneration; this underlines the need for precise indications and for long-term follow-up in registries and trials. [22–25]
Limitations and remaining questions
Most single-center cohorts have relatively short follow-up, making it hard to judge long-term adjacent-segment problems and fusion durability over many years. Randomized trials directly comparing decompression alone and decompression plus fusion in multilevel stenosis with borderline instability are limited. Future research should focus on longer follow-up, standardized imaging metrics, and pragmatic comparative designs that reflect real-world patient selection. These efforts would help surgeons and patients choose the operation that best balances relief of symptoms and procedural risk. [12, 24, 25]
Clinical importance
Multilevel lumbar spinal stenosis causes real and reversible disability for many older adults. When symptoms and imaging agree and conservative measures have failed, carefully planned surgery can restore walking capacity and reduce pain in most patients. The key to good results is matching the technical plan to the mechanical needs of the spine: perform muscle-sparing decompression when the spine is stable, and reserve fusion for segments with true instability or deformity. Using standardized outcome measures supports honest, evidence-based counseling about expected benefits and risks, and thorough perioperative optimization reduces complications. Personalized decision-making preserves function while avoiding unnecessary surgical burden.
Future directions
1. Set up large, long-term patient registries that follow people for five to ten years after surgery so we can see how often fusion holds up, how often adjacent segments fail, and which patients need repeat operations.
2. Run practical, real-world clinical trials that focus on patients with borderline or uncertain instability to find out when adding a fusion truly improves pain, function and quality of life.
3. Build simple, usable risk scores that combine the MRI picture, dynamic X-rays and basic patient factors (age, health, activity level) so surgeons and patients can make clearer, personalized choices before operating.
4. Study muscle-sparing and less invasive decompression methods in older and medically frail patients to see whether they speed recovery, reduce early pain and lower the need for further surgery — and include cost and rehab outcomes so hospitals can plan better.
References
1. Verbiest H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal. J Bone Joint Surg Br. 1954; 36-B (2):230–237.
2. Postacchini F. Management of lumbar spinal stenosis. J Bone Joint Surg Br. 1996; 78(1):154–164.
3. Arbit E, Pannullo S. Lumbar stenosis: a clinical review. Clin Orthop Relat Res. 2001; 384:137–143.
4. Möller H, Hedlund R. Surgery versus conservative management in adult isthmic spondylolisthesis — a prospective randomized study: part 1. Spine. 2000; 25(17):1711–1716.
5. Tsai RY, Yang RS, Bray RS Jr. Microscopic laminotomies for degenerative lumbar spinal stenosis. J Spinal Disord. 1998; 11(5):389–394.
6. Young S, Veerapen R. Relief of lumbar canal stenosis using multilevel subarticular fenestrations as an alternative to wide laminectomy. Neurosurgery. 1988; 23(5):628–633.
7. Steven Young et al. Multilevel fenestration technique. Neurosurgery. 1988; 23(5):628–633.
8. Herron LD, Mangelsdorf C. Lumbar spinal stenosis: results of surgical treatment. J Spinal Disord. 1991; 4(3):263–273.
9. Roy-Camille R, Saillant G, Mazel C. Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop Relat Res. 1986; 203:7–17.
10. Krag MH, Beynnon BD, Pope MH, et al. An internal fixator for posterior application to short segments of the thoracic, lumbar, or lumbosacral spine: design and testing. Clin Orthop Relat Res. 1986; 203:75–98.
11. France JC, Yaszemski MJ, Lauerman WC, et al. A randomized prospective study of posterolateral lumbar fusion: outcomes with and without pedicle screw instrumentation. Spine. 1999; 24(5):553–560.
12. Fritzell P, Hägg O, Wessberg P, Nordwall A. Lumbar fusion versus nonsurgical treatment for chronic low back pain: Swedish Lumbar Spine Study. Spine. 2001; 26(23):2521–2534.
13. Park DK, an HS, Lurie JD, et al. Does multilevel lumbar stenosis lead to poorer outcomes? Subanalysis of the SPORT trial. Spine (Phila Pa 1976). 2010; 35(10):439–444.
14. Whitecloud TS 3rd, Roesch WW, Ricciardi JE. Transforaminal interbody fusion versus anteroposterior interbody fusion of the lumbar spine: a financial analysis. J Spinal Disord. 2001; 14(2):100–103.
15. Mummaneni PV, Kaiser MG. Cervical spine surgery in patients older than 65 years: outcomes and complications. Neurosurg Clin N Am. 2008; 19(4):581–592.
16. Postacchini F, Cinotti G. Bone regrowth after surgical decompression for lumbar spinal stenosis. J Bone Joint Surg Br. 1992; 74-B (1):86–92.
17. Solini A, Paschero B, Ruggieri N, Paladini Molgora A. Lumbar stenosis surgery: “recalibrage” according to Senegas. Chir Organi Mov. 1992; 77(1):55–59.
18. Murthy H, Reddy TVS. VAS score assessment for outcome of posterior lumbar interbody fusion in cases of lumbar canal stenosis. Int J Res Orthop. 2016; 2(3):164–169.
19. Hur JW, Kim SH, Lee JW, Lee HK. Clinical analysis of postoperative outcome in elderly patients with lumbar spinal stenosis. J Korean Neurosurg Soc. 2007; 41(3):157–160.
20. Herron LD. Surgical considerations in lumbar stenosis: techniques and outcomes. Spine J. 2002; 2(6):123–129.
21. Getty R. Degenerative lumbar pathology — clinical overview. J Bone Joint Surg Br. 1980; 62(4):481–?
22. Aryanpur J, Ducker T. Multilevel laminotomies — an alternative to laminectomy in the treatment of lumbar stenosis. Spine. 1990; 15(3):429–433.
23. Roy-Camille R. Spine instrumentation: evolution and current concepts. Clin Orthop Relat Res. 1990; 257:15–28.
24. Herron LD, Mangelsdorf C. Outcome predictors after lumbar decompression. J Spinal Disord Tech. 1998; 11(4):300–307.
25. To study functional outcome of surgical treatment of multilevel lumbar spinal stenosis.
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Institute Where Research was Conducted: Department of Orthopaedics, Sancheti Institute of Orthopaedics and Rehabilitation, Shivajinagar, Pune, Maharashtra, India.
University Affiliation: MUHS, Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2019
| How to Cite this Article: Siddheshwar S, Hadgaonkar S, Kothari A, Aiyer S, Bhilare P, Sonawane D, Shyam A, Sancheti P. Optimizing Thoracolumbar Fracture Management: Hypothesis - Superiority of Long-Segment Posterior Pedicle Screw Fixation for Long-Term Stability. Journal of Medical Thesis. July-December 2023; 9(2):26-30. |
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Functional Recovery Following Surgical Intervention for Multilevel Lumbar Spinal Stenosis: A Prospective Cohort Analysis
Vol 7 | Issue 2 | July-December 2021 | page: 1-4 | Sangmeshwar Siddheshwar, Shailesh Hadgaonkar, Ajay Kothari, Siddhart Aiyer, Pramod Bhilare, Darshan Sonawane, Ashok Shyam, Parag Sancheti
https://doi.org/10.13107/jmt.2021.v07.i02.160
Author: Sangmeshwar Siddheshwar [1], Shailesh Hadgaonkar [1], Ajay Kothari [1], Siddhart Aiyer [1], Pramod Bhilare [1], Darshan Sonawane [1], Ashok Shyam [1], Parag Sancheti [1]
[1] Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Darshan Sonawane,
Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
Email : researchsior@gmail.com.
Abstract
Background: Multilevel degenerative lumbar spinal stenosis produces neurogenic claudication and radicular pain with marked functional limitation. This prospective study evaluates outcomes after tailored surgical care — decompression alone, decompression with stabilization, or decompression with instrumented interbody fusion — selected after careful clinico-radiological correlation.
Methods: Ninety-nine consecutive patients with two or more levels of stenosis who failed nonoperative therapy were treated surgically at our tertiary centre. Selection for decompression alone or decompression plus stabilization/interbody fusion was based on clinical features, dynamic radiographs and axial T2 MRI morphological grading. Functional outcomes were measured using the Oswestry Disability Index (ODI), Visual Analog Scale (VAS) and Short Form-36 (SF-36) preoperatively and at six months and one year.
Results: Patients demonstrated substantial reduction in disability and pain scores with improved SF-36 domains at follow-up. Complications were infrequent and manageable.
Conclusion: When selected carefully, decompression with or without stabilization leads to durable symptom relief and functional improvement in multilevel lumbar canal stenosis. Perioperative measures included antibiotic prophylaxis, thromboprophylaxis, early mobilization and a structured rehabilitation plan to support recovery and reduce complications. Institutional ethical approval and written informed consent were obtained for all participants prior to enrolment.
Keywords: Lumbar spinal stenosis, Decompression, Fusion, Oswestry Disability Index, Neurogenic claudication
Introduction
Degenerative lumbar spinal stenosis most commonly results from progressive disc degeneration, facet joint hypertrophy, ligamentum flavum thickening and osteophyte formation that, in combination, narrow the spinal canal and encroach upon neural elements [1]. Multilevel involvement typically affects adjacent motion segments and is frequently encountered in routine clinical practice; patients often present with neurogenic claudication characterized by leg pain and paresthesia provoked by walking or standing and relieved by sitting or forward flexion [2]. Symptoms may be unilateral or bilateral and are commonly accompanied by variable low back pain and intermittent motor or sensory deficits. Radiological assessment with high-resolution axial T2 magnetic resonance imaging is central to diagnosis and permits morphological grading of canal compromise to help correlate clinical findings with imaging [3]. Plain radiographs including flexion–extension views are important when assessing segmental instability and sagittal alignment [4]. Conservative measures such as activity modification, analgesia, physiotherapy and selective epidural injections are the initial approach, but patients with progressive, disabling or function-limiting symptoms despite adequate nonoperative care are candidates for surgical intervention [5]. The primary surgical objective is durable neural decompression to relieve neurogenic symptoms while minimising the risk of postoperative instability. Traditional wide laminectomy achieves extensive decompression but may disrupt posterior stabilising elements and paraspinal musculature, potentially predisposing to late instability and unsatisfactory outcomes [6]. For this reason, techniques that limit collateral damage — unilateral or bilateral laminotomy, selective fenestration, microscopic decompression and minimally invasive approaches — have been developed to preserve stabilisers while providing effective neural decompression [7]. Surgical decision-making balances the extent of decompression with the need to preserve anatomical stabilisers; when dynamic radiographs or intraoperative findings indicate instability or facet destruction, instrumented fusion with interbody support may be required to restore stability and promote long-term functional benefit. Patient factors such as age and comorbidity influence planning and expected recovery. Standardized outcome instruments (ODI, VAS, SF-36) were used to quantify disability, pain and quality of life at defined intervals.
Aims and objectives
The primary aim was to evaluate functional outcome following surgical management of multilevel lumbar canal stenosis. Specific objectives were to
(1) Quantify change in ODI, VAS and SF-36 at six months and one year;
(2) Record perioperative and early postoperative complications; and
(3) Analyse the relationship of functional recovery with morphological MRI grade, number of levels and patient age to better inform surgical selection and patient counselling at a tertiary referral centre in India.
Review of literature
The surgical literature emphasises balancing adequate neural decompression with preservation of posterior stabilising structures [8]. Early series established degenerative changes as the principal cause of symptomatic stenosis and cautioned that excessive posterior element removal may produce iatrogenic instability and restenosis [9]. Instrumentation such as pedicle screw constructs and interbody techniques improved fusion reliability and provided stabilisation when fusion was indicated [10]. Technical descriptions of internal fixators and pedicle plating informed subsequent stabilisation strategies [11]. Clinical analyses indicate that elderly patients can achieve meaningful symptom relief when procedures are selected carefully and perioperative care is optimised, though complication rates increase with age [12]. Cost and resource pressures have encouraged less invasive fusion strategies alongside targeted decompression approaches [13]. Comparative trials suggest that increased radiographic fusion with instrumentation does not uniformly translate into superior symptomatic benefit, supporting selective fusion for documented instability [14]. Minimally invasive and muscle-sparing techniques such as microdecompression reduce paraspinal muscle trauma while achieving effective neural decompression [15]. Microdecompression and microscopic laminotomy have been reported to deliver similar short-term outcomes with reduced soft-tissue disruption compared with wide laminectomy in selected series [16]. Alternative decompressive procedures such as multilevel subarticular fenestrations and laminoplasty were proposed to preserve stabilisers and reduce late instability [17]. Earlier clinical series documented reasonable outcomes with fenestration techniques as an alternative to extensive laminectomy [18]. Long-term issues after decompression and fusion include bone regrowth, implant-related difficulties and adjacent segment degeneration, which require ongoing surveillance [19]. Overall, careful patient selection, tailored decompression and selective fusion remain the foundation of contemporary management of multilevel lumbar canal stenosis [20], and these topics remain under study worldwide.
Materials and Methods
This prospective study enrolled ninety-nine consecutive patients between October 2016 and October 2017 who presented with clinical and radiological evidence of lumbar canal stenosis affecting two or more levels and who failed conservative treatment. Inclusion criteria were age >30 years, symptomatic neurogenic claudication limiting walking distance despite adequate nonoperative care, and MRI evidence of multilevel canal compromise. Exclusion criteria included prior lumbar surgery, active infection, malignancy and acute fracture. Clinical evaluation comprised detailed neurological examination, assessment of claudication distance and straight leg raise testing. Baseline investigations included standing lumbosacral radiographs with flexion–extension views to detect dynamic instability and MRI axial T2 sequences for morphological grading. Treatment was individualised: decompression alone was performed when clinical and radiological features showed no instability; decompression with posterolateral fusion or decompression with instrumented transforaminal lumbar interbody fusion (TLIF) was used where dynamic films or facet destruction indicated instability. Procedures were performed under general anaesthesia with standard positioning and prophylactic antibiotics. Meticulous microsurgical technique was used to preserve posterior tension bands while achieving neural release; pedicle screw constructs and interbody cages were employed where indicated. Perioperative data were recorded and complications tracked. Postoperative care was standardised: thromboembolism prophylaxis, analgesia and a short course of intravenous antibiotics followed by oral therapy were used; early in-bed exercises began within 24 hours and ambulation with support was encouraged by 48 hours. Suture removal occurred at about two weeks and a structured rehabilitation programme was commenced and continued regularly. Functional outcomes (ODI, VAS, SF-36) were recorded preoperatively and at six months and one year. Statistical analysis consisted of paired comparisons of preoperative and postoperative scores and subgroup analyses by age, number of levels and morphological grade with significance set at p<0.05.
Results
Ninety-nine patients completed one-year follow-up. The cohort comprised 43 males and 56 females with ages ranging from 32 to 82 years; most (61) were aged 50–70. Two-level stenosis was present in 49 patients, three-level disease in 37 and four or more levels in 13. Morphological grading on axial MRI demonstrated a range from moderate to severe central canal compromise. Functional outcomes improved markedly: mean preoperative ODI was 53.07 (SD 5.93), improving to 20.91 (SD 9.93) at six months and 14.48 (SD 11.97) at one year, representing a clinically important reduction in disability. Median VAS for leg pain fell from 9 preoperatively to 3 at six months and 1 at one year. SF-36 domains showed statistically and clinically meaningful gains, especially in physical functioning and bodily pain. Subgroup analyses by age, number of levels treated and morphological grade did not reveal significant differences in one-year ODI or SF-36 outcomes. Complications were uncommon: dural tear was the most frequent intraoperative event and was managed intraoperatively without persistent morbidity; isolated cases of implant loosening, transient neurological deficit and adjacent segment symptoms occurred. Most patients were discharged within three to five days. Early mobilization aided recovery, and the sustained improvements at one year reflect durable symptomatic relief and functional recovery in the majority, with low reoperation rates.
Discussion
This prospective series demonstrates that carefully planned surgical decompression, with stabilization or fusion reserved for demonstrable instability, provides meaningful and sustained improvement in pain, disability and overall quality of life for patients with multilevel lumbar canal stenosis. The magnitude of improvement in ODI, VAS and SF-36 in this cohort confirms that appropriate decompression remains the foundation of effective surgical care for neurogenic claudication and radicular pain. The lack of significant difference in one-year outcomes between age groups, numbers of levels treated and morphological grades suggests that multilevel involvement alone should not preclude consideration of surgery when symptoms and functional limitation warrant intervention. Complications were relatively infrequent and manageable; dural tear was the commonest intraoperative event and was addressed promptly without long-term consequence in this series. Implant-related issues and adjacent segment symptoms were limited to a small minority and were managed according to standard practice. Early mobilisation, standardised perioperative prophylaxis and a structured rehabilitation pathway likely contributed to low morbidity and rapid functional gains. Limitations include single-centre recruitment and one-year follow-up; longer observation is needed to characterise the durability of benefit and the incidence of late adjacent segment degeneration. Objective metrics such as gait analysis and longer-term imaging correlation would strengthen understanding of structural evolution after decompression and fusion. Future multicentre studies with extended follow-up will help refine indications and improve shared decision-making with patients and health policy too. Overall, a pragmatic strategy that provides adequate neural decompression tailored to symptoms and imaging, preserves stabilising structures when possible and reserves fusion for demonstrable instability maximises benefit while minimising unnecessary instrumentation.
Conclusion
In this prospective cohort of ninety-nine patients with multilevel lumbar canal stenosis, individualized decompression informed by careful clinico-radiological assessment produced substantial and sustained reductions in disability and pain and improved quality of life at one year. Functional measures showed statistically and clinically important gains. Complication rates were acceptable, with dural tear the most frequently encountered intraoperative event; implant problems and adjacent segment symptoms were uncommon. Outcomes were not markedly influenced by age, number of levels treated or morphological grade, supporting the principle that multilevel involvement alone is not a contraindication to surgery when clinical indications exist. Continued clinical surveillance and longer-term studies will clarify durability and late adjacent segment effects.
References
1. Jia LS, Yang L. The modern surgery concept of degenerative lumbar spinal stenosis. Chin Orthop J. 2002; 29:509–512.
2. Osenbach RK. Lumbar laminectomy. In: Sekhar L, Fessler RG, editors. Atlas of Neurosurgical Techniques: Spine and Peripheral Nerves. 1st ed. Vol. 2. Thieme; 2006.
3. Arbit E, Pannullo S. Lumbar stenosis: A clinical review. Clin Orthop Relat Res. 2001; 384:137–143.
4. Gupta P, Sharma S, Chauhan V, Maheshwari R, Juyal A, Agarwal A. Interlaminar fenestration in lumbar canal stenosis—A retrospective study. Indian J Orthop. 2005; 39(3):148–150.
5. Park DK, an HS, Lurie JD, et al. Does multilevel lumbar stenosis lead to poorer outcomes? Subanalysis of the SPORT lumbar stenosis study. Spine. 2010; 35:439–444.
6. Postacchini F. Management of lumbar spinal stenosis. J Bone Joint Surg Br. 1996; 78:154–164.
7. Murthy H, T.V.S. Reddy. VAS score assessment for outcome of posterior lumbar interbody fusion in cases of lumbar canal stenosis. Int J Res Orthop. 2016; 2(3):164–169.
8. Krag MH, Beynnon BD, Pope MH, Frymoyer JW, Haugh LD, Weaver DL. An internal fixator for posterior application to short segments of the thoracic, lumbar, or lumbosacral spine: design and testing. Clin Orthop Relat Res. 1986; 203:75–98.
9. Roy-Camille R, Saillant G, Mazel C. Internal fixation of the lumbar spine with pedicle screw plating. Clin Orthop Relat Res. 1986; 203:7–17.
10. Hur JW, Kim SH, Lee JW, Lee HK. Clinical analysis of postoperative outcome in elderly patients with lumbar spinal stenosis. J Korean Neurosurg Soc. 2007; 41:157–160.
11. Whitecloud TS 3rd, Roesch WW, Ricciardi JE. Transforaminal interbody fusion versus anteroposterior interbody fusion of the lumbar spine: a financial analysis. J Spinal Disord. 2001; 14:100–103.
12. France JC, Yaszemski MJ, Lauerman WC, Cain JE, Glover JM, Lawson KJ, et al. A randomized prospective study of posterolateral lumbar fusion: outcomes with and without pedicle screw instrumentation. Spine. 1999; 24:553–560.
13. Möller H, Hedlund R. Surgery versus conservative management in adult isthmic spondylolisthesis—a prospective randomized study: part 1. Spine. 2000; 25:1711–1715.
14. Fritzell P, Hagg O, Wessberg P, Nordwall A. Lumbar fusion versus nonsurgical treatment for chronic low back pain: a multicentre randomized controlled trial. Spine. 2001; 26:2521–2534.
15. Tsai RY, Yang RS, Bray RS Jr. Microscopic laminotomies for degenerative lumbar spinal stenosis. J Spinal Disord. 1998; 11:389–394.
16. Weiner BK, Walker M, Brower RS, McCulloch JA. Microdecompression for lumbar spinal canal stenosis. Spine. 1999; 24:2268–2272.
17. Young S, Veerapen R, O’Laoire SA. Relief of lumbar canal stenosis using multilevel subarticular fenestrations as an alternative to wide laminectomy: preliminary report. Neurosurgery. 1988; 23:628–633.
18. Johnson B, Annertz M, Sjoberg C, Stromqvist B. A progressive and consecutive study of surgically treated lumber spinal stenosis. Part I: Clinical features related to radiographic findings. Spine. 1997; 22:2932–2937.
19. Shenkin HA, Hash CJ. Spondylolisthesis after multiple bilateral laminectomies and facetectomies for lumbar spondylosis. J Neurosurg. 1979;50:45–47.
20. Verbiest H. A radicular syndrome from developmental narrowing of the lumbar vertebral canal. J Bone Joint Surg Br. 1954 May;36-B(2):230–237.
| How to Cite this Article: Siddheshwar S, Hadgaonkar S, Kothari A, Aiyer S, Bhilare P, Sonawane D, Shyam A, Sancheti P| Functional Recovery Following Surgical Intervention for Multilevel Lumbar Spinal Stenosis: A Prospective Cohort Analysis | Journal of Medical Thesis | 2021 July-December; 7(2): 01-04. |
Institute Where Research was Conducted: Sancheti Institute of Orthopaedics and Rehabilitation PG College, Sivaji Nagar, Pune, Maharashtra, India.
University Affiliation: Maharashtra University of Health Sciences (MUHS), Nashik, Maharashtra, India.
Year of Acceptance of Thesis: 2019
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