Elsevier

Medical Hypotheses

Volume 132, November 2019, 109357
Medical Hypotheses

Toward a cure for lumbar spinal stenosis: The potential of interspinous process decompression

https://doi.org/10.1016/j.mehy.2019.109357Get rights and content

Abstract

There is a growing impetus to treat aging as a disease in the quest to significantly extend the human life span through cellular regeneration methods. This approach, while promising, overlooks the fact that the evolutionary adaptation to bipedalism puts the human body in a distinctively vulnerable biomechanical and functional position. Orthograde human posture places unusually-high axial compressive loads on the weight-bearing joints of the skeleton, resulting in arthritic deterioration with aging. The effects are particularly robust in the lumbar spine were age-related degeneration, most commonly lumbar spinal stenosis (LSS), is ubiquitous among the elderly. It is postulated that re-establishing a favorable mechanical environment via interventions that unload the affected spinal joint complex may mitigate and potentially reverse the structural damage that is the cardinal pathoanatomical feature of this disease. The hypothesis of this paper is that a minimally-invasive surgical procedure, interspinous process decompression (IPD), which utilizes a stand-alone intervertebral spacer, effectively unloads the diseased spinal motion segment providing a healthy micro-environment to reverse and repair age-related and genetic deterioration of the spinal motion segment. Several lines of supporting evidence are provided from long-term follow-up results of a randomized controlled trial of IPD safety and effectiveness of the Superion® device including clinical outcomes, reoperation rates, opioid analgesic usage and advanced imaging utilization. All of these outcomes show uniquely-favorable trends with time that imply that the benefits of IPD are structural. The compendium of evidence suggests that IPD offers both a durable palliative effect due to direct blocking of back extension and a disease-modifying effect due to unloading of the spinal joint complex.

Section snippets

Background

Despite the tremendous accomplishments that modern medicine has achieved in defeating an impressive list of diseases, in developing potent biopharmaceuticals and effective devices, in elucidating pathology with advanced imaging, and in unraveling the human genome, humans continue to suffer from the inevitable ravages of aging and the chronic illnesses that accompany this process [1]. However, researchers on the “cutting edge” of medical technology advancement envision breakthroughs that would

Pathoanatomical features of lumbar spinal stenosis

Lumbar spinal stenosis (LSS) is the end-product of decades of compressive forces acting on the spine [17], [18], and remains the most common indication for back surgery in the elderly [19]. No portion of the spinal motion segment’s three-joint complex, consisting of two facet joints and the intervertebral disc, is spared the age-related degeneration caused by repetitive axial loading [15]. Consequently, LSS consists of a mosaic of pathoanatomical features including classic synovial joint

Interspinous process decompression

Interspinous process decompression (IPD) devices (“spacers”) were developed to build on the concept that back extension is a seminal factor in the causative chain that instigates neurogenic claudication in LSS. Spacers provide immediate symptom amelioration by serving as a spinal extension blocker to prevent the repetitive compression of neurovascular elements during back extension that is the primary source of neurogenic claudication and radicular symptoms. The Superion® Indirect Decompression

Reversing skeletal degeneration: the concept of joint unloading

It has been over four decades since renowned orthopedic surgeon, Professor Eric L. Radin, first advanced the now-accepted theory that arthritic degradation and progression, particularly of the large synovial joints, was principally facilitated through failed attempts at subchondral bone and cartilage repair secondary to excessive mechanical loading at the joint [32]. In his 1984 ambitiously-titled commentary Hypothesis: joints can heal, Radin postulated that repetitive impulse loading causes

Treating LSS with interspinous process decompression: core evidence

In the initial stages of IPD development, cadaveric studies with the first generation IPD device showed that the implant significantly increased spinal canal area by 18%, the sub-articular diameter by 50% and the foraminal width by 41% in extension [45]. Increases in spinal canal area have not been reported in clinical trials but are assumed to occur as a result of a similar mechanism of action.

The cadaveric findings were prima facie evidence that the underlying mechanism of action is indirect

Corollary

The legendary technology futurist Gene Roddenberry imagined a number of groundbreaking advances as foreshadowed in his iconic 1960s era television series, Star Trek: The Original Series – the wireless flip phone being perhaps the most famous. He also tackled the issue of life extension through cellular rejuvenation. In an episode entitled Mudd’s Women (Season 1, Episode 6), the starship intercepts a space-marauding con man accompanied by three stunningly beautiful women. It is quickly revealed

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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