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Spacing The Spine
Minimally-invasive Surgery For Lumbar Stenosis
Fame and fortune have smiled on golf champion Lee Trevino many times in the 50-plus years he has played the game. Throughout most of that time, Trevino returned the favor to the sport he loves, his quick wit eliciting smiles from playing partners and fans alike. His quick-with-a-joke personality and dazzling smile earned him the nickname “the Merry Mex.” But, due to complications following back surgery, his smile turned to a grimace when low back pain brought him to his knees.
Like two million other Americans, Trevino suffered from lumbar spinal stenosis, a condition characterized by narrowing in one or more parts of the spine that puts pressure on the spinal cord and nerves, causing pain, weakness, and disability.
Trevino, whose condition worsened following a fall in a golf course bunker in 2004, endured numerous steroid epidural injections that only relieved the pain for a short time. The pain always returned, and the active lifestyle he had enjoyed came to an end.
But now, at the age of 70, Trevino is back in the swing of things and enjoying time on the golf course once more. The reason? Trevino had a minimally invasive surgery that implanted a device known as the X-Stop Interspinous Process Decompression System (commonly referred to as the X-Stop or X-Stop Spacer) into his spine in Germany in 2004. The X-Stop received FDA approval for use in the U.S. in 2005.
Less Is More
The X-Stop is a titanium implant that fits between the spinous processes of the lumbar spine, intended to keep the posterior vertebral elements away from spinal nerve roots. It consists of two components: a spacer assembly and a wing assembly. The X-Stop is designed to limit spinal extension in the affected area, which may relieve the symptoms of lumbar spinal stenosis brought on when standing upright. The minimally invasive surgery requires no screw fixation and does not result in spinal fusion.
According to the Web site of the company that makes the product, St. Francis Medical Technologies Inc., the X-Stop implant is indicated for treatment of patients who are 50 or older and suffering from pain or cramping in the legs due to a confirmed diagnosis of lumbar spinal stenosis.
Arya Shamie, MD, associate clinical professor in the departments of neurosurgery and orthopaedic surgery at Santa Monica-UCLA Medical Center and Orthopaedic Hospital, says prior to the X-Stop, surgeons treated lumbar spinal stenosis with a laminectomy, with or without fusion.
Many people, including the elderly and sick, are unable to undergo laminectomy due to surgical risk and the extended recovery time. Inserting the X-Stop takes a trained surgeon around 45 minutes, which minimizes surgical impact and shortens recovery time. Patients are able to get up and move about the same day without pain, Shamie says, compared with two to three days in the hospital and several weeks of postoperative back pain after a laminectomy.
“The X-Stop is less invasive with less morbidity for the patient,” Shamie says. “The technique is relatively simple. Picking the correct patient for this procedure is the more difficult aspect.”
More Info
Resources
• Kondrashov DG, Hannibal M, Hsu KY, Zucherman JF. Interspinous process decompression with the X-Stop device for lumbar spinal stenosis: a 4-year follow-up study. J Spinal Disord Tech. 2006; 19(5): 323-327.
• Lauryssen C. Appropriate selection of patients with lumbar spinal stenosis for interspinous process decompression with the X Stop device. Neurosurg Focus. 2007; 22(1): E5.
• Siddiqui M, Karadimas E, Nicol M, Smith FW, Wardlaw D. Influence of X Stop on neural foramina and spinal canal area in spinal stenosis. Spine. 2006; 31(25): 2958-2962.
• Verhoof OJ, Bron JL, Wapstra FH, van Royen BJ. High failure rate of the interspinous distraction device (X-Stop) for the treatment of lumbar spinal stenosis caused by degenerative spondylolisthesis. Eur Spine J. 2008; 17(2): 188-192.
Choosing Wisely
The NIH reports that nonsurgical treatments for spinal stenosis should be considered first, including medicines to reduce swelling and relieve pain, limits on physical activity, exercises, physical therapy, and a brace for the lower back. Surgery should be considered when symptoms impede walking, affect bowel or bladder function, or when nervous system problems occur.
Research findings suggest that the X-Stop is most appropriate for patients with neurogenic intermittent claudication whose pain is unresponsive to conservative care and in whom imaging confirms evidence of lumbar spinal stenosis. For one- or two-level lumbar spinal stenosis, X-Stop implantation appears to increase the space within the central canal and neural foraminal areas as viewed on functional spinal MRIs. However, a recent European study examining the use of the X-Stop for patients with lumbar stenosis secondary to degenerative spondylolisthesis reports that the need for surgical re-intervention is high in this patient cohort despite an initial postoperative period of symptom relief.
Thomas Ragan, PT, a therapist at Arlington Orthopedic Associates, in Texas, says patients who receive the X-Stop represent less than 5% of patients seen by the 15 orthopedic surgeons affiliated with the practice.
“It’s probably for someone with strict indications with just spinal stenosis in one segment or other medical implications that would preclude them from having a more formal surgery of three to six hours,” he says.
Therapy for these patients is much like therapy for anyone experiencing problems standing erect, Ragan says. That includes pain medication, working on good body mechanics, and improving abdominal strength and flexibility.
The X-Stop surgery has a complication rate of less than 1%, Shamie says. “The most common complication is that in 20% of patients, the surgery may not work, and the patient may need to continue with the treatment algorithm and have a laminectomy with or without fusion.”
Scott Williams is a medical writer for the Gannett Healthcare Group.To comment, e-mail pteditor@gannetthg.com.