This document discusses the management of tandem spine stenosis, which refers to spinal canal narrowing in at least two regions of the spine. It presents epidemiological data showing tandem stenosis occurs in 4.3-9% of patients. Clinical presentation involves intermittent leg pain and gait disturbance with upper and lower motor neuron signs. Risk factors include ossification of the spinal ligaments. Diagnosis involves imaging of the cervical and lumbar spine. While treatment guidelines are lacking, evidence suggests cervical decompression first improves leg symptoms. Controversies in management include surgical approach and whether to operate on regions simultaneously or separately.

1. Case presentation on
Mgt of Tandem spine
stenosis

2. Outline
O Case summary
O Definition
O Epidemiology
O Mgt
O Outcome

3. Case summary

4. Definition
O Tandem spinal stenosis refers to spinal
canal diameter narrowing in at least 2
distinct regions of the spine, most
commonly the lumbar and cervical
regions.(why?)

5. Epidemiology
O highly variable: 7.6% to 60% of with spinal
stenosis
O Concurrent cervical and lumbar stenosis
in 4.3% asymptomatics.
O About 9% of patients with symptomatic
LSS have cervical spondylotic
myelopathy.

6. Clinical presentation
O Dagi triads
1. Intermittent lower extremity claudication,
2. Gait disturbance, and
3. Upper and lower motor neuron signs.
O Symptoms from one region may be
masked by more prominent symptoms
from another

8. Risks for TSS
O Ossification of the posterior longitudinal
ligament (OPLL) in any region
O A cervical torg pavlov ratio of < 0.787
(independent risk factor).
O Congenital stenosis

9. Dx
O clinical diagnosis centered on
maintaining a high index of suspicion
for cervical myelopathy in patients presenting
with predominantly lower extremity symptoms.
O Imaging: MRI of both cervical and lumbar
spine
1. UMN sx & sy
2. Presence of OPLL
3. provocative-maneuvers:(Lhermitte, Spurling)

10. RX
O No level 1 (RCT) Mgt recommendation.
O Universal precautions
1. avoidance of neck hyperflexion or
hyperextension with adequate padding,
2. minimization of long-acting paralytics
that impair the natural muscular, and
protective mechanisms
3. Neuromonitoring

11. Controversies
O Conservtive vs operative
O Staged vs simultaneous cervical and lumbar
procedures
O Lumbar vs cervical first?
O Anterior vs posterior
O A case-by case basis.
O Dual vs single surgeon strategy
O Age <60 vs >60 yrs
O Prophylactic decompression of asymptomatic LSS in patients
undergoing surgery for CSM
O Prophylactic decompression of asymptomatic CSM with/without T2
signal change in patients
undergoing surgery for LSS
O surgical sequence of decompression in TSS: cohort showed no
difference in
clinical outcomes
O Failure to diagnose asymptomatic cervical spine stenosis in patients
with LSS

12. Decisions
O Operative intervention, irrespective of the
sequence or approach, has been shown
to be efficacious; no preferred treatment
modality has been established,
although evidence suggests that primary
cervical decompression improves lumbar
symptomatology.

13. O cervical decompression should remain the primary
objective in cases of alternating approaches to
address each spinal
segment.
O lower-extremity symptoms resolved in most
patients who underwent primary cervical
decompression. In fact, a cohort of patients
averted planned secondary lumbar intervention
following an index cervical decompression.
O A minimum of 3 months of follow-up after cervical
decompression to allow for improvement of
residual lower-extremity symptoms before
proceeding to lumbar decompression.

14. Simultaneous decompression
O 2 separate operative teams
O Shorter operative time
O Less blood loss
O avoids the rare but devastating potential
complication of undue compression of
neural elements secondary to positioning
in the setting of severe stenosis
O No difference in clinical outcomes.

15. Tandem Spinal Stenosis:
A Systematic Review (2017)

18. Pathophysiology of CSM symptom
aggravation following lumbar
decompression
O Multifactorial and complicated.
O First, hyperextension positioning or accidental
hyperextension during anesthesia for lumbar spinal surgery
O Second, due to the natural course of the stenosis, 5–8% of
patients with symptomatic lumbar stenosis and
asymptomatic cervical stenosis will develop myelopathy per
year [19, 22, 23]. In contrast, 3–5% of patients with
asymptomatic lumbar stenosis and cervical myelopathy will
develop lower limb symptoms per year [18].
O Third, symptoms usually thought to be due to lower back
problems such as leg pain associated with weakness and
sensory deficits may be due to myelopathy.

19. Quality of Life Changes after Lumbar Decompression in Patients with Tandem
Spinal Stenosis, 2019

20. Our patient?
O Pre-op : sever
O Post op

21. THANK YOU.