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{\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/50\\\/32\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/50\\\/32\u0022}],\u0022ac\u0022:{\u0022spmdc;14\\\/50\\\/32\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;14\\\/50\\\/32\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003ELumbar spinal stenosis is among the most common conditions treated by spine practitioners. This session focused on the evaluation and management of patients with complex spinal stenosis, including recurrent or residual stenosis, stenosis and degenerative scoliosis, and thoracolumbar stenosis. The speakers reviewed the clinical and radiographic presentations of patients with complex stenosis and discussed strategies for appropriate nonsurgical and surgical management.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ESpine Conditions\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EOrthopaedic Procedures\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ESpine Conditions\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EOrthopaedic Procedures\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EOrthopaedics\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \n         \u003Cp id=\u0022p-2\u0022\u003ELumbar spinal stenosis is among the most common conditions treated by spine practitioners. This session focused on the evaluation and management of patients with complex spinal stenosis, including recurrent or residual stenosis, stenosis and degenerative scoliosis, and thoracolumbar stenosis. The speakers reviewed the clinical and radiographic presentations of patients with complex stenosis and discussed strategies for appropriate nonsurgical and surgical management.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EMANAGEMENT OF RECURRENT AND RESIDUAL SPINAL STENOSIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EJoseph D. Smucker, MD, Indiana Spine Group, Carmel, Indiana, USA, discussed the challenges of managing recurrent or residual spinal stenosis at the index level. Positive revision outcomes have been demonstrated for adjacent and noncontiguous nonindex segment degeneration [Shabat S et al. \u003Cem\u003EJ Spinal Disord Tech\u003C\/em\u003E. 2011]. The SPORT trial [Radcliff K et al. \u003Cem\u003ESpine\u003C\/em\u003E. 2013] found overall reoperation rates of 13% within 4 years. Diminished outcomes also were observed for stenosis reoperation at index and adjacent levels combined compared with index surgery.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EThe clinical features and treatment strategies for recurrent stenosis are shown in \u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E.\u003C\/p\u003E\n         \u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15394\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15394\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15394\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003ERecurrent Spinal Stenosis: Causes and Treatment Techniques\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EAmong the possible causes of residual stenosis in which symptoms are not relieved are an incorrect initial diagnosis, failed healing of neurologic structures, and permanent nerve damage. Inadequate decompression, inadequate preoperative or intraoperative imaging, and iatrogenic causes may also result in residual stenosis. Inadequate decompression may be avoided with the use of intraoperative myelography, which has been shown to improve outcome scores [Pao JL, Wang JL. \u003Cem\u003EJ Spinal Disord Tech\u003C\/em\u003E. 2012]. Using surgical probes and computer-assisted navigation may also be useful. Standing preoperative examinations, such as standing radiographs and standing myelography may assist with assessment of previously unrecognized instability. Upright magnetic resonance imaging (MRI) is becoming more common for preoperative assessment. Treatment options for residual stenosis include revision decompression, revision decompression with instrumentation, and revision decompression with fusion. An advantage of fusion is preservation of the decompression.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003ERecurrent and residual stenosis may represent a challenging diagnostic and therapeutic scenario. Dr Smucker concluded that an understanding of diagnostic tools and treatment options can lead to reasonable patient outcomes.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ESURGICAL TREATMENT OF ADULT DEGENERATIVE SCOLIOSIS AND STENOSIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-9\u0022\u003ESheeraz A. Qureshi, MD, Mount Sinai Hospital, New York, New York, USA, discussed the management of adult degenerative scoliosis and stenosis. Patients with degenerative scoliosis typically present with neurogenic pain, back pain, and deformity. The goals of surgical treatment are to decompress neural elements and achieve coronal and sagittal balance. There are 6 tiers of surgical treatment options for degenerative scoliosis [Silva FE, Lenke LG. \u003Cem\u003ENeurosurg Focus\u003C\/em\u003E. 2010].\u003C\/p\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EDr Qureshi described 4 types of osteotomies for correcting specific deformities (\u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/15395\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/15395\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15395\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-11\u0022 class=\u0022first-child\u0022\u003EOsteotomies for Correcting Specific Deformities\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-12\u0022\u003ESurgery for adult degenerative scoliosis is associated with a high rate of complications. In a retrospective multicenter review of 306 patients, wound infection occurred in 4% of the patients [Charosky S et al. \u003Cem\u003ESpine\u003C\/em\u003E. 2012]. Dr Qureshi suggested considering use of topical vancomycin powder to lower the risk of infection. Neurologic deficits were reported in about 8% of the patients; these can occur as a result of a dural tear or nerve root compromise. Peripheral nerve deficits occurred in 5% of patients and 20% of patients needed revision surgery due to mechanical complications. Mechanical complications included pseudoarthrosis and adjacent segment disease, such as proximal junctional kyphosis, a sharp angular kyphosis above the upper instrumented vertebra.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EFinally, according to Dr Qureshi, there is a role for minimally invasive surgery in adult patients with degenerative scoliosis, using tubular decompression, percutaneous screws, and lateral access surgery.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EDECOMPRESSION FOR THORACOLUMBAR STENOSIS\u003C\/h2\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EJung U. Yoo, MD, Oregon Health and Science University, Portland, Oregon, USA, reviewed available evidence on the management of thoracic spinal stenosis. Thoracic stenosis is a degenerative disorder that produces enlargement of the structures surrounding the dural sac, with mainly posterior compression. Thoracic stenosis is classified as primary, secondary, and iatrogenic stenosis.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EMost patients with thoracic spinal stenosis present with sensory abnormalities of the lower extremities, often in a stocking or nondermatomal distribution. Lower-extremity weakness occurs in 90% of patients, and 30% to 40% have bowel and bladder dysfunction. In a series of 26 patients in a 1987 study by Yonenobu and colleagues, those with lesions above T9 tended to have spastic paresis, while those with lesions in the region of T11\u2013T12 had flaccid paralysis.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EThe diagnosis of thoracic stenosis is confirmed by postmyelogram computed tomography or MRI. It is important to determine whether the primary compression is caused by anterior or posterior structures. Patients with thoracic stenosis often have lumbar stenosis as well. Two studies have reported the presence of lumbar stenosis in 80% [Epstein NE, Schwall G. \u003Cem\u003EJ Spinal Disord\u003C\/em\u003E. 1994] and 66% [Palumbo MA et al. \u003Cem\u003ESpine\u003C\/em\u003E. 2001] of patients with thoracic stenosis. In lumbar stenosis, accurate determination of the involved spinal levels is critical. Complete 3-D imaging of the lumbar spine should be performed to ensure that a more caudal lesion is not present.\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EObservation may be appropriate for patients with myelopathy without incapacitating claudication or weakness. Patients who present with weakness and gait abnormality should be treated with surgery. Laminectomy is sufficient treatment for most patients with posterior compression caused by hypertrophy of the posterior structures and fusion generally is not required. Patients with ossification of the posterior longitudinal ligament may need anterior decompression. Surgery requires careful positioning and neuromonitoring. The decompression must be wide enough to include the medial aspects of the facet joints and must include all potentially compressive levels.\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EAdequate decompression results in resolution of neurologic symptoms in most patients. Epstein and Schwall reported good or excellent results of laminectomy in the majority patients with primary thoracic stenosis in a 1994 study. A 1979 study documented partial recovery in 4 patients treated with laminectomy, although some continued to experience weakness, and stenosis recurred at the decompressed levels in one patient. All 6 patients in a 1987 study improved following laminectomy, with complete recovery in 2 of the patients.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/50\/32.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzltkd\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzltkd\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}