Staged surgery and simultaneous surgery associated with similar outcomes for patients with tandem spinal stenosis

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Peter Ahorukomeye

For the treatment of tandem spinal stenosis (TSS), staged and simultaneous surgery have comparable perioperative, functional and neurologic outcomes, as well as complication rates. This is according to a systematic literature review—the results of which were published by Peter Ahorukomeye (Case Western Reserve University School of Medicine, Cleveland, USA) et al in The Spine Journal—which also suggested that the careful selection of candidates for simultaneous surgery may reduce length of stay and consolidate rehabilitation, thereby reducing hospital associated costs.

The aim of the study was to compare surgical outcomes in patients undergoing staged versus simultaneous surgery for TSS.

A systematic review was conducted using PRISMA guidelines to identify original research articles for TSS. The PubMed, Cochrane, Ovid, Scopus, and Web of Science databases were used for electronic literature search.

Original articles from 2005–2021 with more than eight adult patients treated surgically for cervical and lumbar TSS in staged or simultaneous procedures were included. Articles including paediatric patients, primarily thoracic stenosis, stenosis secondary to neoplasm or infectious disease, minimally invasive surgery and non-English language were excluded.

Demographic, perioperative, complications, functional outcome and neurologic outcome data including mJOA (modified Japanese Orthopaedic Association), Nurick grade (NG) and Oswestry Disability Index (ODI) scores were extracted and summarised.

In total, 667 articles were initially identified. Following preliminary screening, 21 of these articles underwent full-text screening, with 10 meeting the inclusion criteria.

Within these 10 articles, a total of 831 patients were included, with 571 (68%) of them having undergone staged procedures, and 260 (32%) who underwent simultaneous procedures for TSS. Mean follow-ups ranged from 12–85 months.

The study found that there was no difference in estimated blood loss (EBL) between staged and simultaneous groups (p=0.639) and that simultaneous surgeries had shorter surgical time than staged surgeries (p<0.001).

In addition, mean changes in mJOA, NG and ODI were comparable between staged and simultaneous groups. Complications were similar between the groups and there was found to be more major complications reported in simultaneous operations, although this was not statistically significant (p=0.301).

Speaking to Spinal News International, Ahorukomeye said: “As our population ages, degenerative conditions such as spinal stenosis present more of a burden to the population than ever before. There have been data to suggest that non-contiguous level degenerative disease in cervical and lumbar spine is more prevalent than previously thought. We hope that this work not only increases the diligence in diagnosing tandem spinal stenosis but also helps shape the conversation for management of this condition.

“While tandem stenosis is traditionally tackled one site at a time, it is important to consider simultaneous procedures in carefully selected patients. Our work has examined the literature on patients managed in a traditional staged fashion and those managed with simultaneous procedures. We found no significant difference between staged and simultaneous procedures with regards to functional scores, perioperative parameters and complication rates. Our findings set up the prospect of consolidating perioperative care and costs from anaesthesia to rehabilitation.

“A special thanks is owed to the talented group at University Hospitals Cleveland Medical Center, Department of Orthopaedic Surgery (Cleveland, USA), who made this work possible.”


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