Symptomatic single stage treatment for TSS

1. CLINICAL OUTCOMES OF
SINGLE STAGE SURGICAL
TREATMENT FOR
SYMPTOMATIC TANDEM
STENOSIS
DR DEEPAK BS

2. INTRODUCTION
• Tandem spinal stenosis (TSS) - Narrowing of spinal
canal diameter in at least two distinct regions of
spine, most commonly cervical & lumbar regions(1)
• Incidence - 5% - 25%(2)
• Clinical triad - Lower extremity intermittent
neurogenic claudication, gait disturbance &
combined upper & lower motor neuron symptoms.

3. BACKGROUND
• TSS may impact surgeon decision-making when
planning either cervical or lumbar spine surgery.
• Currently no consensus in literature regarding
treatment algorithm for operative intervention.

4. •In 1964,Teng et al - Described combined cervical &
lumbar spondylosis in 12 patients (4)
•In 1987, Dagi et al - First used term TSS & first reported
a one-staged combined surgical treatment of TSS (2)
•There are few studies recommending single stage
surgery

5. Objectives
•To study clinical outcomes of surgery for TSS
•To study safety of single stage surgery in elderly patients with
comorbities
•To study role of Minimally invasive surgery
•Its Effectiveness
•Analgesic requirement

6. Materials &Methods
• Study Duration - Jan 2014 to Jan 2021
• Study Design - Retrospective cohort
• Inclusion Criteria : All patients operated for TSS in
a single stage at our centre
• Total cases - 50

7. • Clinical results were evaluated by -
Nurick’s grade for Myelopathy
Oswestry disability index (ODI) for Back pain
Visual analogue scale (VAS) for back pain and
leg pain.
• Follow up - 6 months & 1 year.

8. Cervical Spine Thoracic spine Lumbar spine
1) <3 segment disease -
ACDF
Laminectomy & excision
of Ossified Ligamentum
flavum
MIS tubular decompression
for Lumbar canal stenosis
2) > 3 segment disease -
Laminectomy & Lateral
mass / Pedicle screw
fixation
MIS Transforaminal lumbar
interbody fusion (MIS-TLIF) for
patients showing instability on
dynamic radiographs.
Following procedures were performed for -

9. Tandem Sites Numbers
Cervical & Lumbar 35
Thoracic & Lumbar 8
Cervical & Thoracic 5
Cervical, Thoracic &
Lumbar
2

10. Type of Surgery Numbers
MIS TLIF 29
Cervical Laminectomy &
Fusion
28
ACDF 14
Excision of Thoracic Ossified
Lig Flavum
7
MIS Lumbar canal
decompression
12

11. RESULTS
Patient Demographics Results
Total patients (n) 50
Mean age (years) 67.52+/- 9.07
Sex
Male 39
Female 11

12. Comorbidities Numbers
Diabetes &
Hypertension
19
Diabetes,
Hypertension &
IHD
20
Diabetes 6
Hypertension 5

13. Duration of Surgery
(mins)
240+/-100
Blood Loss( ml) 150+/-50
Post op Stay ( days) 2 -3

14. Post op course
• IV PCT TID for 2 days & Oral paracetamol from POD2.
• Mobilization on POD 1
• Discharge on POD 2 or 3
• Philadelphia collar
• No Lumbar corset

15. 3.8
1.9
1.2
0.
1.
2.
3.
4.
PRE OP POST OP 1 YR
NURICK’S GRADING
67.78
22.78 20.34
0.
17.5
35.
52.5
70.
87.5
PRE-OP POST -OP 6
MONTHS
POST - OP 1YR
OSWESTRY DISABILITY
INDEX
POST OP
6 MONTHS
POST OP
6 MONTHS

16. VAS - BACK
PAIN
6.3
1.6
1.3
0.
1.8
3.5
5.3
7.
PRE-OP POST-OP 6
MONTHS
Post op 1 Yr
7.14
1.24 0.98
0.
2.
4.
6.
8.
PRE OP Post op 6 months POST OP 1 YR
VAS - LEG PAIN

17. Complications Numbers
Superficial Wound infection 3
Dural Tear 3

18. Studies
No of
patients
Blood
loss(ml)
Surgical
time( min)
ODI Nurick’s score
Pre op Post op Pre op Post op
Molinari et
al (2011)
9 558 159 NA NA NA NA
Krishnan et
al (2014)
53
394.71+/-
131.44
171.28+/-
48.13
68.15 24.93 3.83 1.96
Singrakhia
et al (2019)
82
353.41+/-
92.85
173.71+/-
39.31
55.39 31.95 3.65 1.43
Abbas et al
( 2021)
32 350.47 154.83 68.6 26.29 3.5 1.5
Our
150+/-

19. DISCUSSION
• Neurological & functional outcomes - comparable to other
studies.
• Blood loss was less compared to other studies.
• Analgesia requirement was less
• No major complications in elderly patients with comorbidities
• Early discharge ( 2-3 days )

21. CONCLUSION
• Symptomatic TSS can be safely managed by single stage surgical
intervention with good post operative results without a significant
increase in complication rates.
• The addition of MIS technique opens yet another possibility in these
cohort of patients who are predominantly elderly & with comorbities
as a safe alternative with added advantage.

22. Limitations
•Retrospective design
•No comparison with staged procedure
•Long term follow up

23. REFERENCES
1. Jannelli G, Baticam NS, Tizi K, Truffert A, Lascano AM, Tessitore E. Symptomatic tandem
spinal stenosis: a clinical, diagnostic, and surgical challenge. Neurosurg Rev, 2020, 43: 1289–
1295.
2. Dagi TF, Tarkington MA, Leech JJ. Tandem lumbar and cervical spinal stenosis. Natural history,
prognostic indices, and results after surgical decompression. J Neurosurg, 1987, 66: 842–849

24. 3. Sun, W.-z., Yan, X., Yang, Y.-l., Song, H., Xia, Z.-w., Yang, S.-c., Chen, F.-l.,
Li, W.-h., Yu, Z.-q., Liu, B., Liu, Y.-x., Wang, K. and Zhang, L. (2021),
Simultaneous or Staged Decompressions for Patients with Tandem Spinal
Stenosis. Orthop Surg, 13: 1149-1158.
4. TENG P, PAPATHEODOROU C. Combined Cervical and Lumbar Spondylosis.
Arch Neurol. 1964;10(3):298–307. doi:10.1001/archneur.1964.00460150068007