Prognostic Factors and Optimal Surgical Management for Lumbar Spinal Canal Stenosis in Patients with Diffuse Idiopathic Skeletal Hyperostosis

Lumbar spinal canal stenosis (LSS) and diffuse idiopathic skeletal hyperostosis (DISH) tend to develop in the elderly, resulting in an increased need for lumbar surgery. However, DISH may be a risk factor for poor clinical outcomes following lumbar decompression surgery, especially in patients with DISH extending to the lumbar segment (L-DISH). This study aimed to identify the prognostic factors of LSS with L-DISH and propose an optimal surgical management approach to improve clinical outcomes. Of 934 patients who underwent lumbar decompression surgery, 145 patients (15.5%) had L-DISH. In multivariate linear regression analysis of the JOA score improvement rate, the presence of vacuum phenomenon at affected segments (estimate: −15.14) and distance between the caudal end of L-DISH and decompressed/fused segments (estimate: 7.05) were independent prognostic factors. In logistic regression analysis of the surgical procedure with JOA improvement rate > 25% in L-DISH patients with both negative prognostic factors, the odds ratios of split laminotomy and short-segment fusion were 0.64 and 0.21, respectively, with conventional laminotomy as the reference. Therefore, to achieve better clinical outcomes in cases with decompression at the caudal end of L-DISH, decompression surgery without fusion sparing the osteoligamentous structures at midline should be considered as the standard surgery.