The effect of postlaminectomy spinal instability on the outcome of lumbar spinal stenosis patients

Between 1986 and 1990, 37 of 72 patients undergoing decompressive lumbar laminectomy with medial facetectomy for lumbar stenosis at The Ohio State University were seen in follow-up at a mean of 31 months (range, 14-63 months) after their laminectomy and were evaluated by questionnaire, detailed neurologic examination, and static and dynamic lumbar radiographs. Thirteen patients who had undergone fusion or who had extenuating medical circumstances were excluded, leaving 24 patients for whom laminectomy was the sole treatment for lumbar stenosis. Postoperatively, normal walking improved from 4 to 45% of patients, sensory deficits decreased from 63 to 25%, and ability to perform most or all desired activities increased from 25 to 70%. Urinary function was unchanged. Thirteen patients (54%) showed radiographic signs of instability. All patients who were declared radiographically stable could walk without a prosthetic aid or normally; 62% of the unstable patients required aid for walking. All of the patients with a poor ambulatory outcome were radiographically unstable. Compared with stable patients, unstable patients had a significant (p < 0.01) decrease in their ambulatory ability. There was a clear correlation between the degree of listhesis and postoperative ambulatory status (p < 0.01). The unstable patients with a poor ambulatory outcome followed one of three clinical courses: improvement with later deterioration, improvement with a plateau at a poor functional level, or failure to improve from a poor functional level. In conclusion, (a) although instability did not necessarily preclude a good outcome, a poor ambulatory outcome was always associated with instability; (b) laminectomy can effectively ameliorate the symptoms of lumbar stenosis; however, there is a subset of patients in whom laminectomy is associated with instability and a poor clinical course.