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Indonesian Journal of Rheumatology Vol 15 Issue 1 20231. Introduction
Degenerative spinal pathology remains a frequent reason for patient consultation in our practice.1 It affects all the spinal segments (cervical, thoracic, or lumbar) in isolation or association. Several studies have focused on the stenosis of an isolated spinal segment: lumbar2,3 or cervical.4-8 The management of degenerative spinal stenosis poses few problems concerning a single segment. This is not the case when it affects both the cervical and lumbar segments.
Bipolar or tandem spinal stenosis is a radio-clinical entity in which both cervical and lumbar segments of
the spinal canal are simultaneously narrowed.9-11 The clinic is sometimes misleading because the cervical signs can mask the lumbar signs. The CT scan, sometimes along with the MRI, makes it possible to retain the diagnosis.12,13
The treatment involves medical and surgical approaches in a multidisciplinary setting (rheumatologists, neurosurgeons, physical medicine, and rehabilitation doctors). Conservative treatment ranks first in non plegic cases. Surgery is only indicated in plegia, hyperalgesia, or disabling pain (after the failure of conservative treatment). However,
Simultaneous Cervical and Lumbar Spinal Degenerative Stenosis: Diagnostic and Treatment Challenge
Wendlassida Joelle Stéphanie TIENDREBEOGO/ZABSONRE1*, Denlewende Sylvain ZABSONRE2, Abdoulaye SANOU2, Amitandi Armand 1er Jumeau OGOABIGA2, Yakouba HARO2, Inoussa ZOUNGRANA2, Fulgence KABORE1, Dieu-Donné OUEDRAOGO1
1Rheumatology Department of Bogodogo Teaching Hospital of Ouagadougou (BURKINA FASO)
2Neurosurgery Department of Yalgado Ouedraogo Teaching Hospital of Ouagadougou (BURKINA FASO)
ARTICLE INFO Keywords:
Bipolar
Degenerative spine Stenosis
Tandem
*Corresponding author:
Wendlassida Joelle Stéphanie
TIENDREBEOGO/ZABSONRE
E-mail address:
joelle.tiendrébeogo@ujkz.bf
All authors have reviewed and approved the final version of the manuscript.
https://doi.org/10.37275/IJR.v15i1.243
A B S T R A C T
Background: In simultaneous cervical and lumbar degenerative stenosis (tandem spinal stenosis), the cervical clinical signs may mask the lumbar ones. Treatment is initially conservative in non-plegic cases. In the event of surgery, there is no consensus regarding the segment to be approached first.
The purpose of this work was to describe our management of this condition.
Methods: This was a 6-year retrospective study in the rheumatology and neurosurgery departments. All usable medical records of cases of simultaneous degenerative stenosis of the cervical and lumbar spine were included. Results: We retained 84 squares. The average age was 57.1 years;
the sex ratio 0.9. All the patients presented cervical and lumbar clinical signs. They had started at the lumbar spine in 46 cases (54.8%) and cervical in 38 cases (45.2%). A full spinal MRI had been performed in 50%.
Conservative treatment was effective in 36 patients (42.9%). Of the 32 patients (66.7%) operated, 16 had been operated both the cervical and lumbar spine (7 simultaneous surgeries including percutaneous discolysis in one of the segments in 4 cases). The cervical spine had been operated on first in 7 of the 9 cases of staggered surgery. After an average follow-up of one month, the evolution was favorable in 47 cases (56%); stationary 21 (25%). Conclusion: Conservative treatment was effective in about half of the cases. Full spine MRI and staggered surgery were the most commonly performed. However, simultaneous surgery prioritizing the least aggressive gestures seems better.
Indonesian Journal of Rheumatology
Journal Homepage: https://journalrheumatology.or.id/index.php/IJR
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there is no consensus regarding which spinal segment to decompress first in case of simultaneous surgical indication for both spinal segments.12,13 This decompression can be done either simultaneously or staggered (deferred).14-17 The purpose of this work was to describe the diagnostic aspects and our therapeutic attitude to this condition.
2. Methods
This was a cross-sectional, descriptive study with retrospective data collection carried out in the rheumatology and neurosurgery departments, respectively, of the University Hospitals of Bogodogo and Yalgado Ouedraogo in Ouagadougou, over six years period, from 1 January 2014 to 31 December 2019.
The study population was represented by all the medical records of patients in whom the diagnosis of degenerative stenosis of the spinal canal (any segment) had been retained on medical imaging. The inclusion criteria for the studies were: all the relevant medical records of patients who presented on admission with clinical signs related to the cervical and the lumbar spine and in whom the diagnosis of degenerative stenosis of the cervical and lumbar spinal canal has retained at the same time on the medical imaging (bipolar or tandem spinal stenosis).
The exclusion criteria consisted of: the relevant medical records of patients having the inclusion criteria; medical records of patients in whom the diagnosis of degenerative bipolar spinal stenosis was not made at the same time, i.e. the diagnosis at one segment was made while other segments of the canal stenosis had already been treated; the medical records of patients admitted for degenerative stenosis of the spinal canal limited to a single segment or 2 segments (including the thoracic) or concerning all 3 spinal segments (cervical, thoracic, and lumbar).
3. Results
Frequency and socio-demographic data
During the 6-year study period, 3132 medical records of patients admitted for degenerative spinal
stenosis were identified. There were 2611 lumbar cases (83.4%), 349 cervical cases (11.1%), 34 thoracic cases (1.1%), and 138 tandem (cervical and lumbar) stenosis (4.4%). Among these cases of tandem stenosis, 54 records were excluded (because they were not usable) and 84 were included in the study.
The sex ratio was 0.9 (40 men/44 women). The average age of the patients was 57.1 years, with extremes of 30 and 86 years and a standard deviation of 10. Seventy-six cases (90.5%) were over 40 years old. Professions with major constraints for the spine (workers, homemakers, farmers, teachers, men in uniform, dressmakers) were represented in 52 cases (61.9%) and those with moderate constraints (office workers, health workers, merchants, religious) in 32 cases (38.1%).
Diagnostic data
The average consultation time was 27.6 months, with extremes ranging from 2 weeks to 24 years.
Symptoms began at the lumbar spine in 46 cases (54.8%) and at the cervical level in 38 cases (45.2%).
Functional signs were related to cervical and lumbar involvement in all patients. It was low back pain in 39 cases (46.4%); lumboradiculalgia/paresthesia in 32 cases (38.1%); cervicobrachial neuralgia/paresthesia in 30 cases (35.7%); neck pain in 24 cases (28.6%); the association of cervicobrachial neuralgia/cervical pain with lumboradiculalgia/low back pain in 21 cases (25%); functional impotence of the limbs in 18 cases (21.4%) and genito-sphincter disorders in 27 cases (32.1%)
No history of pathology was noted in 28 patients (3- 3.3%). The others had high blood pressure in 20 cases (23.8%), intermittent neck pain in 17 cases (20.2%), intermittent low back pain in 15 cases (17.9%) and gastroduodenal ulcer pain in 7 cases (8.3%).
On physical examination, it was noted in connection with the cervical spine, cervicobrachial neuralgia in 43 cases (51.2%), including 3 cases of unilateral and bilateral in the other cases. This neuralgia was monoradicular in 30 cases (35.7%), multiradicular in 13 cases (15.5%). It was well-
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systematized in 35 cases (41.7%) and poorly systematized in 8 cases (9.5%). The most affected roots were C7 (16 cases or 19%), C6 (13 or 15.5%), and C8 (13 or 15.5%). Medullary signs were noted in 61 patients (72.6%), including 39 (46.4%) cases of spastic tetraparesis and 5 cases (6%) of spastic tetraplegia.
Related to the lumbar spine, 23 patients (27.4%) had lumboradiculalgia, including 7 cases of unilateral and bilateral in the other cases. This lumboradiculalgia was monoradicular in 7 cases (8.3%), multiradicular in 16 cases (69.2%). It was well systematized in 20 cases (87.5%) and poorly systematized in 3 cases
(2.5%). The most affected roots were L4 (6 or 7.1%), L5 (9 or 10.7%), and S1 (6 or 7.1%).
There were 17 cases (20.2%) of cauda equina syndrome, of which 6 (35.29%) were paraplegia, and 11 (64.7%) were paraparesis. Terminal cone syndromes were noted in 15 cases (17.9%) including Babinski's sign in all cases, flasco-spasmodic paraparesis in 11 (73.3%), and flasco-spasmodic paraplegia in 4 (26.7%). Table 1 shows the distribution of physical signs.
Table 1: Distribution of physical signs.
Cervical stenosis Lumbar stenosis
(n) (%) (n) (%)
Spinal signs 7 8.3 13 15.5
Pain on palpation of the spinous processes 7 8.3 13 15.5
Contracture of the paravertebral muscles 3 3.6 5 6.0
Spinal stiffness 3 3.6 5 6.0
Root signs 77 91.7 84 100.0
Cervico brachial neuralgia 43 51.2 0 0.0
Brachial monoparesis 17 20.2 0 0.0
Single root paresis 9 10.7 2 2.4
Root hypoesthesia 8 9.5 14 16.7
Abolition of deep tendon reflexes 7 8.3 28 33.3
Single root plegia 1 1.2 5 6.0
Lumboradiculalgia 0 0.0 23 27.4
Lasegue sign 0 0.0 12 14.3
Flaccid paraparesis 0 0.0 11 13.1
Crural monoparesis 0 0.0 7 8.3
Flaccid paraplegia 0 0.0 6 7.1
Medullary signs 52 61.9 15 17.9
Spastic tetraparesis 39 46.4 0 0.0
Spastic tetraplegia 5 6.0 0 0.0
Exaggeration of deep tendon reflexes 44 52.4 0 0.0
Hoffmann's sign 30 35.7 0 0.0
Babinski's sign 39 46.4 15 17.9
Global hypoesthesia (sensitive level) 8 9.5 14 16.7
Flaccid spastic paraplegia 0 0.0 4 4.8
Spastic flaccid paraparesis 0 0.0 11 13.1
All patients who had performed cervical and lumbar imaging were distributed as follows: 42 patients (50%) full-spine MRI (combined with 4 cervical CT and 7 lumbar CT); Thirty-seven patients (44.0%) cervical and lumbar CT (combined with 3 standard cervical radiographs and 2 standard lumbar X-rays); 4 patients (4.8%) cervical MRI and lumbar CT;
1 patient (1.2%) a lumbar MRI and a cervical CT. Thus,
MRI was performed in 46 cases (54.8%) at the cervical spine and 48 cases (57.2%) at the lumbar spine. There were signs of spinal cord pain in 28 cases (60.9%) using MRI. Figure 1 presents full spine MRI images in sagittal section T2-weighted sequences of 3 patients.
Table 2 shows the distribution of all signs noted on CT and MRI.
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Figure 1: Full spine MRI in sagittal T2-weighted sequences of 3 different patients (a, b and c). We note on the image of the patient (a) a moderate stenosis C4 to C6 without an intramedullary hypersignal and a moderate lumbar stenosis from L3 to L5. Conservative treatment was effective in this patient (a). On the image of patient (b), we objectivize a C3C4, C4C5 and C6C7 stenosis with an intramedullary hyper signal next to C4C5 and a lumbar stenosis by an L4L5 disc herniation. This patient (b) underwent the same day (simultaneous surgery) of cervical laminectomy and percutaneous discolysis with ozone at the lumbar spine. Patient (c), there is a severe and staggered cervical and lumbar stenosis. This patient (c) underwent L3L5 and C3C6 laminectomy the same day.
Table 2: Lesions objectified on medical imaging.
Cervical Lumbar
(n) (%) (n) (%) Computed tomography (CT) scan 42 100.0 48 100.0 Staged protrusive disc disease 21 50.0 30 62.5 Zygapophyseal osteoarthritis 15 35.7 15 31.3
Herniated discs staged 20 47.6 7 14.6
Osteophytes 3 7.1 6 12.5
Ligament hypertrophy 7 16.7 13 27.1
Static disorder 3 7.1 4 8.3
Spondylolisthesis 2 4.8 6 12.5
Isthmic lysis 2 4.8 4 8.3
Magnetic resonance imaging (MRI) 46 100.0 43 100.0 Intramedullary T2 hypersignal 28 60.9 7 16.3
Staged disc herniation 24 52.2 43 100.0
Staged protrusive disc disease 17 37.0 31 72.1
Ligament hypertrophy 7 15.2 10 23.3
Zygapophyseal osteoarthritis 8 17.4 3 7.0
Spondylolisthesis 1 2.2 0 0.0
Isthmic lysis 0 0.0 1 2.3
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Therapeutic and evolution data
All patients received spinal hygiene measures and systematic drug treatment consisting of World Health Organization level I and II analgesics. Nonsteroidal anti-inflammatory drugs or steroids by systemic routes were associated par in 30 cases (83.3%) and 29 cases (80.6%), respectively. Conservative treatment was effective in 36 patients (42.9%). Figure 2 shows
the different types of treatment performed. This conservative treatment included, in addition to the molecules raised: muscle relaxants in 31 cases (36.9%); antidepressants in 21 cases (25%); lumbar spinal infiltration of corticosteroids in 11 cases (13.1%), physiotherapy in 8 cases (9.5%) and cervical collar in 2 cases (2.4).
Figure 2: Treatment performed.
A surgical indication was retained in 48 (57.1%) patients, including 15 (31.3%) cervical only, 11 (22.9%) lumbar only, and 22 (45.8%) both cervical and lumbar. These surgical indications were represented by 28 cases of spastic motor deficits (including 10 cervicals; 18 lumbar and cervicals); 18 cases of non- spastic plegia (including 4 cervicals, 10 lumbar and 4 lumbar and cervical), and 2 cases of hyperalgesia (including 1 cervical and 1 lumbar). However, 48 patients (57.1%) in whom a surgical indication was placed, 32 (66.7%) patients underwent surgery, and 16 (33.3%) were lost to follow-up and therefore not operated. Among the operated cases, 16 (50%) had
been operated on both (2) segments (lumbar and cervical); 9 (28.1%) of the cervical spine alone and 7 (21.9%) of the lumbar spine alone. Among the 16 patients in whom the indication to operate on both the cervical spine and the lumbar spine had been retained, 9 were operated by a conventional open surgery in a delayed manner starting with the cervical spine in 7 cases or the lumbar spine in 2 cases before operating the other spinal segment secondarily after an average duration of 177 days with extremes of 7 and 660 days.
The other 7 were operated simultaneously on the same day, including 3 by conventional surgery and 4 by the combination of conventional surgery and
Bipolar spinal stenosis (84 cas)
Conservative treatment (36 cas; 42,9%)
surgery Indications (48 cas; 57,1%)
Non operated Lost of follow up
(16 cas; 33,3%)
Opereted (32 cas; 66,7%)
operated on a single cervical or lumbar spinal
segment (16 cas; 50%)
Cervical spine (9 cas; 56,3%)
Lumbar spine (7 cas; 43,7%)
operated on the 2 segments (cervical and
lumbar) (16 cas; 50%)
Deferred classic open surgery (9 cas; 56,3%)
simultaneous surgery (7 cas; 43,7%)
Classic open surgery (3 cas)
Classic open surgery on one segment combined with percutaneous ozone surgery on the
other segment (4 cas)
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percutaneous ozone discolysis (2 cases of lumbar discolysis + classic cervical surgery and 2 cases of cervical discolysis + conventional lumbar surgery). A total of 48 surgical procedures were performed for the 32 operated patients. These were 20 (41.7%) laminectomies (10 cervical, 10 lumbar), 16 (33.3%) ozone discolysis (7 cervical, 9 lumbar) and 12 (25%) discectomy (8 cervical, 4 lumbar).
The average hospital stay after surgery was 6 days, with extremes between 2 and 13 days. In the short term (less than one month after treatment), the evolution was favourable in 15 (46.9%) operated
patients and 32 (61.5%) non-operated patients. In the medium term (from 1 to 6 months with an average of 4.3 months), the evolution was favourable in, 23 (71.9%) operated patients and 15 (28.84%) not operated. In the long term (more than 6 months with an average of 16.5 months and extremes of 8 and 29 months), there was recovery without neurological sequelae in 19 (59.4%) operated patients and recovery with minimally disabling sequelae 23 (44.2%) patients without surgery. Table 3 illustrates the evolution of patients in the short, medium and long term.
Table 3. Short-, medium- and long-term evolution.
Operated
cases Non-operated Cases
Total
(n=32) (n = 52) (N=84) (%) Short-term evolution (up to 1 month)
Favorable 15 32 47 56.0
Stationary 17 4 21 25.0
Loss to follow-up 0 16 16 19.0
Medium-term evolution (1-6 months)
Favorable 23 15 38 45.2
Stationary 4 6 10 11.9
Recurrences 1 4 5 6.0
Loss to follow-up 4 27 31 36.9
Long-term evolution (more than 6 months)
Healing without sequelae 19 0 19 22.6
Mildly disabling sequelae 8 23 31 36.9
Very debilitating sequelae 1 2 3 3.6
Loss to follow-up 4 27 31 36.9
4. Discussion
Epidemiological aspects
Degenerative lumbar spine stenosis (83.4%) and cervical spine stenosis (11.1%) were more common in our series. Thoracic spine accounted for only (1.1%).
The high mobility and strain on the lumbar and cervical spine segments during daily activities could explain their frequent degenerative involvement in isolation or simultaneously. Thus, we noted bipolar or tandem (cervical and lumbar) involvement in 4.4% of cases. The first study on bipolar, degenerative and symptomatic spinal stenosis was performed in 1964 by Teng and Papatheodorou18, who called it "tandem spinal stenosis". Subsequently, further work was
carried out and revealed that the frequency of tandem spinal stenosis varied and ranged from 5 to 28%.12,18-
21
The average age of patients in our study was 57.1 years. It was superimposed on that noted in Congo, which was 57 years and slightly lower than those noted in India, the USA and Japan, respectively 63.3 years, 66.5 years, 62.8 years. 14,19,22,23 Age would be a risk factor for the occurrence of spinal degenerative stenosis. In addition, age increases the risk of complications, regardless of the surgical algorithm chosen to treat degenerative bipolar spinal canal stenosis.14
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We note a female predominance in our study, with 51.81% of cases. Most authors noted a female predominance of 51.1%, 53%, and 64.15%, respectively.14,22,24 On the other hand, in India, a male predominance was noted in 70% of cases.9 This predominance of the female sex in most studies could be explained by the fact that women combined both professional and domestic activities, including carrying heavy loads and anteflexion of the trunk on the pelvis, causing rapid spine degeneration.
Diagnostic aspects
The average consultation time was 17 months and 17.6 months.19,25 Elsewhere, it was 28.96 months for the lower limbs and 17.02 months for the upper limbs.22 This long consultation time was noted in our series (27.6 months). These long consultation times could be explained in our context by the insufficient number of medical specialists (rheumatologists, neurosurgeons), self-medication, the low socioeconomic level of populations, and the absence of universal health insurance to meet the expenses related to care.
The association of cervicobrachial neuralgia/neck pain and lumbar radiculopathy/low back pain was noted in 61%26 and 25% (our series). The inaugural manifestations were most often lumbar (62.3%22 and 54.8% in our series). They sat mainly on the lower limbs.27 This frequency of manifestations in the lower limbs could be because the fact that the involvement of the lumbar spine is generally inaugural and, therefore older than cervical involvement. However, the frequency of symptoms in the lower limbs is not necessarily attributable to the involvement of the lumbar spine. A study on myelopathy by cervical osteoarthritis, the symptomatology had begun in the lower limbs with gait disorders, ranging from simple spinal cord claudication to the inability to walk in 73.68% of patients.4
On physical examination, there were 20.2% cauda equina syndromes. In a study of lumbar stenosis, there were 13.9% cauda equina syndromes.3 We had 72.6% of medullary signs in our study. The authors
noted 100% spinal cord syndrome in work on the cervical canal stenosis.8 The spinal cord signs were most often due to damage of the cervical spinal cord and, in very few cases of the terminal cone (17.85%).
These spinal signs can sometimes mask a cauda equina syndrome in the case of degenerative bipolar stenosis.
In medical imaging, full spine MRI was the most commonly performed diagnosing of spinal bipolar stenosis (50%), followed very probably for cost reasons by the combination of cervical and lumbar CT (44%).
The association of cervical MRI and lumbar CT was performed in 4.8%. This last combination could be a better alternative for diagnosing of spinal bipolar stenosis in case of financial difficulties in performing a full spine MRI. Indeed, this association is less expensive than the full spine MRI. However, it is less interesting than MRI for the management of bipolar spinal stenosis because not only does it not allow exploration of the thoracic spine, the involvement of which may be masked by that of the cervical spine, but also it does not allow a finer analysis of lumbar lesions as would MRI. In the literature, a CT scan was the most requested examination to explore lumbar degenerative lesions 71.42%, 82.6%, and MRI for cervical lesions 68.75%.3,5,19
Therapeutic and evolution aspects
Conservative treatment was indicated at the 2 spinal poles (cervical and lumbar) in 57.14%.
Elsewhere, it was in (66.3%); 19.04%.25,28 This shows the most often important place of this treatment in the spinal degenerative disorders, whether they concern one or more spinal segments. In the event of a surgical indication concerning the 2 segments from the outset, the discussion arises around simultaneous surgery and staggered (or deferred) surgery. Similarly, in the case of deferred surgery, there is the problem of which segment should be decompressed first.
The surgical indication concerning the 2 poles (cervical and lumbar) was more represented in 45.83%. In other series, this indication was retained in 87.5% and in 14.1%.19,28 These indications are
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functions of the clinics at the admission of patients because the indications remain classic, namely hyperalgesia, invalid radiculopathy, or plegia.
Staggered surgery was performed in half of the cases operated after an average delay of 177 days.
Elsewhere, this period was 112 to 140 days, 42 to 56 days, 90 days.19,25,28 In our series, the predominance of signs related to one or the other spinal poles has been oriented towards the segment to be operated initially. However, when the symptoms towards one or the other spinal poles were considered "equitable", the initial surgery was done primarily in the cervical spine.
The advantage of this two-stage surgery would be the reduction of the operative risk, including bleeding, especially since it is usually performed in elderly people with a general condition that is not always good. According to almost all authors, cervical spine surgery was performed in the first position when the patient was admitted with signs indicating surgery at the 2 poles. 10,19,25,28,29 Authors found that cervical decompression had little effect on lumbar symptoms.
In addition, when subsequent lumbar decompression was done, there was minimal impact on the overall quality of life.25 Simultaneous surgery, therefore gives the patient more chance to improve his quality of life more quickly. In addition, it allows the use of a single anaesthesia to perform of both gestures, which would be a significant advantage, especially in older people in good general condition.15 This simultaneous surgery was performed in very few cases in our series (7 cases or 21.9% of operated cases) as in other series (12.5%).19 To reduce the operating time (and therefore the risk of certain complications), authors performed this simultaneous surgery with two teams of neurosurgeons, one operating in cervical and the other lumbar.9 For the same purpose, we carried out, whenever indicated, percutaneous ozone surgery on one spinal segment and conventional open surgery on the other. This had the advantage of reducing operation time and intraoperative blood spoliation by keeping very interesting clinical results known as ozone discolysis.30,31 However, the surgical procedure depends on the appreciation of the surgeon and the
technical platform available. Studies have revealed that performing heavy procedures such as arthrodesis or spinal fusion did not necessarily lead to better results on clinical signs. 22,25 Moreover, according to several authors, the evolution would be more decisive when the duration of the appearance of the signs and the speed of realization of the surgical act was reduced.9,15,24,32
5. Conclusion
Bipolar, degenerative, and symptomatic spinal stenosis had a low frequency and predominated in elderly females. The diagnosis was often late and motivated by at least one cervical and lumbar symptom. Complete spine MRI was the most widely used radiological tool.
The treatment was primarily conservative.
Recourse to surgery was determined by the onset of plegia or after well-conducted conservative treatment in the face of paresis or pain (hyper algesia or disabling). The challenge of this therapeutic management lay in the surgical treatment, i.e., the type of surgery (simultaneous or staggered); if staggered, determined by the spinal pole to start. We mainly performed staggered surgeries because of our modest technical platform. In the case of simultaneous surgery, we have most often associated conventional open surgery on one spinal pole with percutaneous surgery on the other. The results of this management were generally satisfactory. However, simultaneous surgery with a less aggressive approach could give much better results.
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