Chapter 63
Surgical Management of Lumbar
Spinal Stenosis
Rothman-Simeone and Herkowitz The Spine 7th Edition
Surgical Management of Lumbar
Spinal Stenosis
Indication of surgery
Laminectomy
Fenestration
Laminoplasty
Microendoscopic Decompressive laminotomy
Interspinous process device
Postoperative care
Complication
Indication of Surgery
Spinal stenosis is the most common reason for lumbar spine surgery in adults older than 65 years of
age.
Proper patient selection is critical to achieving a good outcome with spinal stenosis surgery.
The ideal patient has symptoms of neurogenic claudication, which include pain, numbness, and
paresthesias in the posterolateral legs and thighs associated with prolonged walking or with activities
that cause back extension
Surgical decompression can be performed on an elective basis unless the patient has a rapidly
progressing neurologic deficit or bowel/bladder dysfunction,
Indication of Surgery
before surgical intervention, we routinely obtain standing
anteroposterior, lateral, and flexion-extension radiographs, as well
as magnetic resonance imaging (MRI) or computed tomography
(CT) myelogram.
Surgical options include decompressive laminectomy with or
without fusion, laminectomy, minimally invasive decompression,
and placement of an interspinous process device
Laminectomy
Laminectomy has been the gold standard for the surgical treatment of
central, lateral recess, and foraminal stenosis in the absence of instability.
prefer to use a flat Jackson table with bolsters as long as the patient can be
supported with the abdomen hanging free. We believe that flexion of the
knees with the use of pillows under the shins is also important because it
has the potential to reduce tension on the sciatic nerve.
Laminectomy
Decompression begins by delineating the extent of
bony resection with a rongeur. For an L3-L5
decompression, this includes the inferior half of the
L3 spinous precess and the superior half of the L5
spinous process (shaded area). A horsley bone cutter
is used to remove the intervening spinous processes
down to the level of the spinous process/lamina
junction.
Laminectomy
A. In general, the ligamentum flavum originates from halfway up the lamina of the cephalad level and
inserts onto the superior aspect of the caudal lamina.
B. From the sagittal view, the laminae of the lower spine have a much greater proportion of their
anterior surface covered by the deep layer of the ligamentum flavum.
Laminectomy
a curette is used to dissect the underlying ligamentum flavum form the inferior aspect
of the lamina.
Laminectomy
A. In an L3 to L5 decompression, recommended beginning at the inferior aspect of the L4 lamina
and once the dura is identified, moving on to removing the inferior aspect of the L3 lamina.
B. A cottonoid is then placed between the dura and remaining L4 laminar bridge, which is removed
with a Kerrison punch
C. The central trough is finalized by removing the superior aspect of the L5 lamina and any residual
ligamentum flavum
In an L3 to L5 decompression, we recommend beginning at the inferior aspect
of the L4 lamina and, once the dura is identiied, moving on to removing the
inferior aspect of the L3 lamina. A cottonoid is then placed between the dura
and remaining L4 laminar bridge, which is removed with a Kerrison punch
Laterally, resection of more than 25% of the lamina immediately cepha- lad to
the inferior articular process at the level of the laminec- tomy (measured in a
medial to lateral direction) is associated with increased risk of postoperative
facet fracture
Laminectomy
The next step involves decompression of the
lateral recesses
the most common technical error resulting in
early failure after lumbar laminectomy is
inadequate neural decompression
Lateral recess decompression is performed
with a Kerrison punch
Laminectomy
At more cephalad levels, there is less
distance between the medial pedicle to the
midlateral pars (MLP).
Particular caution should be taken at levels
cephalad to L4 to not take too much of the
lamina, leaving a narrow pars susceptible
to fracture. As such, with a decompression
from L2 to S1, the laminectomy should
appear to be trapezoidal with a narrower
laminectomy trough in the more cephalad
levels and a wider trough in the more
caudal levels.
Laminectomy
A) Lateral recess decompression is performed with a Kerrison punch and should
preserve at least 50% of the facet joint (axial view).
B) Final decompression after undercutting the lateral recess.
Outcomes of Laminectomy
largest and most well-known study addressing this subject, the Spine Patient Outcomes
Research Trial (SPORT),
Treatment of conditions associated with low back and leg pain, including lumbar stenosis
showed a significant advantage for surgery compared with nonoperative treatment by 3 months
for the ODI and both SF-36 components.
Arthrodesis After Laminectomy
Arthrodesis be performed when stenosis is associated with spondylosis and substantial low
back pain or with instability
Grob and Colleagues
randomized 45 patients with lumbar spinal stenosis (LSS) without instability to receive
decompression with and without arthrodesis.
All patients had signiicant clinical improvement compared with preoperative values at an average of
28-month follow-up with no signiicant diferences between fusion and nonfusion groups.
Herkowitz and colleagues
instrumentation increased the fusion rate compared to noninstrumented arthrodesis (82% vs. 45%)
in the 67 patients available for 2-year follow-up, clinical outcomes were similar between the groups
Top, Postoperative three-dimensional reconstructions of lumbar computed tomographic (CT)
scans following bilateral laminotomy (B), laminectomy (L), and unilateral laminotomy for
bilateral decompression (U). In each technique, diferent osseous windows are created to
access the spinal canal (yellow). Bottom, Axial postoperative CT scans and corresponding
illustrations demonstrating the surgical corridors (gray).
Laminotomy
Decompression through a microdisectomy-like approach to target the stenotic levels either
unilaterally or bilaterally.
Caudal aspect of superior lamina and the cephalad portion of the inferior lamina at the
stenotic level are resected
Approach:
Unilateral Unilateral pathology, bilateral decompression
Bilateral Bilateral stenosis
Laminotomy
Advocates: Leaving the midline structures intact Decrease the chance of iatrogenic
instability and back pain
Multiple laminotomies Additional stability provided by intervertebral disc and the
facet-joint capsule complex
Gurelik and colleagues Laminectomy resulted in a significantly larger increase in dural
sac area than laminotomy but postoperative instability are not found in laminotomy
patients
Laminotomy
Thome and colleagues Bilateral laminotomy demonstrated the best overall outcomes
compared to unilateral laminotomy for bilateral decompression, and laminectomy for
lumbar stenosis. Dural tear was the most common compliaction
Celik and colleageuse
Laminectomy More perioperative complications and postoperative instability.
Laminotomy No significant trend toward superior walking distance, pain control, and
disability
Fu and colleaguse Laminotomy resulting in good long term result with few
complications
Laminotomy
Bilateral laminotomy Better perceived recovery at final follow-up & less severe
postoperative low back pain
Unilateral laminotomy for bilateral decompression and bilateral laminectomy lower
rates of iatrogenic instability
Less invasive unilateral or bilateral laminoforaminotomy One or two-level lateral recess
stenosis without significant central stenosis
Fenestration
Treat stenosis with variability surgical techniques similar to traditional laminotomy.
Aim to preserve the midline structures and minimize soft tissue and bony resection while
addressing sites of neurologic compression
Fenestration
Decompression through a 5-mm drill hole in the pars
interarticularis below the superior facet
exposing inerior aspect of the pedicle and the nerve root
in the foramen
Drilling the inferior aspect of the superior pedicle
through 2-mm diamond drill bit and operating microscope
Dorsal aspect of the nerve root is decompressed by
undercutting the lamina and hypertrophied facet
Preserve spinal stability and allows early mobilization
and shortening hospital length of stay
Laminoplasty
O'Leary and colleagues
Distraction laminoplasty and expansive lumbar laminoplasty are two alternatives to
standard laminectomy. Distraction laminoplasty is a technique for decompression of
central lateral recess stenosis with minimal bony resection.
Tsuji and colleagues
Expansive lumbar laminoplasty provide osteoplastic enlargement of the spinal canal while
retaining spinal stability
Sangwan and colleagues
Patients experienced an average enlargement in anteroposterior spinal canal diameter of 124% (as
measured on CT scan), and 22 had good or excellent results. However, because of the inability of
this operation to fully address lateral recess stenosis, mediocre clinical outcomes, and the high
interlaminar fusion rate
Distraction Laminoplasty
Distraction laminoplasty is a technique for decompression of central and lateral recess
stenosis with minimal bony resection.
This technique involves mechanical distraction of the stenotic interspace to facilitate spinal
canal access.
Begins with removal of the inferior half as the cephalad vertebra’s spinous process and
lamina as well as the superior edge of the caudal vertebra
Distraction across the spinous processes of the segments opening the interlaminar
working space by mobilizing the cephalad lamina proximally and the caudad lamina
distally
Motion improved visualization
Removal of ligamentum flavum Decompression of the lateral recesses by removing 10-
20% of the facet joint
Expansive lumbar laminoplasty
Expansive lumbar laminoplasty is a technique that aims to provide osteoplastic
enlargement of the spinal canal while retaining spinal stability in the treatment of spinal
stenosis
Analogous to cervical laminoplasty and involves opening one side of the lamina by using
the contralateral side as hinge
Spinous process is removed Using a high-speed burr to make a groove in either
side of the lamina One groove extends completely, while the other is incomplete
The lamina is hinged open through the site of the incomplete groove and held open
with autograft from the excised spinous process Fixed with braided wire or nylon
suture
Additional bone graft is packed dorsally over the osteotomy sites
Expansive lumbar laminoplasty
Higher intraoperative blood loss and longer operative time
Post operative Japenese Orthopaedic Association (JOA) score improved significantly.
Patients >56 years had significantly less improvement
The best indications : Young and active patients with isolated central spinal stenosis
Microendoscopic Decompressive
Laminotomy (MEDL)
Microendoscopic Decompressive
Laminotomy (MEDL)
MEDL minimally invasive decompression, involves
decompression of the neural elements through a smaller skin
incision with preservation of soft tissue and bony anatomy
Surgical technique for bilateral decompression through a unilateral
MEDL approach using the METRx system (Medtronic).
Technique
Under fluoroscopic guidance, a Steinmann pin is inserted from a
starting point approximately 3 cm of midline on the side of the
approach to lie on the spinolaminar junction.
A 2.5-cm longitudinal incision is made about the guide pin, over
which a series of dilators are passed until the final 18-mm tubular
retractor can be inserted
Technique
The tubular retractor is angled medially and a high-speed burr used to drill
the anterior aspect of the lamina at the superior aspect of the interlaminar
space continue drill until the contralateral lateral recess and foramen are
reached
Specialized endoscopic Kerrison rongeurs are used to complete the
laminotomy and partial medial facetectomy.
The ipsilateral side is then addressed by angling the tubular retractor laterally
toward the junction of the ipsilateral lamina and medial facet. Drilling is
again performed, followed by completion of the decompression with
endoscopic curettes.
MEDL Outcome
A study were presented Four-year outcomes of MEDL in patients with lumbar
central and/or lateral recess stenosis but no instability or deformity:
80% had an increase in walking endurance
88% of patients reported an improvement in
symptoms
No cases of neurologic injury or subsequent
instability requiring fusion
Comparison of MEDL and Conventional Open
Laminectomy
Less operative blood Shorter time to
loss mobilization
Lower chance of
Less muscle
requiring opioids for
destruction
postoperative pain
Less low back and
leg pain
Interspinous process Device
Two types Static Dinamic
Not Low bone
recommended for mineral density
Lower postoperative
Faster Less perioperative
Use complication rate
operative time blood loss
Postoperative Care
All patients are encouraged to get out of bed with physical therapy
and ambulate as soon as possible.
All patients are advised to avoid bending, lifting, or twisting for 6 to
12 weeks postoperatively.
Complications
Complications of lumbar decompressive surgery include
dural tear, nerve root injury, infection, vascular
complications, epidural hematoma, nonunion or hardware
failure following fusion, instability, bony regrowth, and
adjacent-segment degeneration.
Dural tears
Well-known complication of lumbar stenosis surgery (1.8%-17.4%),
Most commonly created while the surgeon is using the Kerrison punch,
Greater chance of headaches and lower Tegner scores for general activities of daily living.
Vascular Complications
• Include deep vein thrombosis (DVT), pulmonary embolism (PE),
postoperative hematoma, and catastrophic vascular events,
• Major vascular injury during lumbar decompression is rare,
• DVT is a more common vascular complication, with rates of 5% after
lumbar laminectomy and 3.1% after lumbar fusion procedures
(Glotzbecker et al)
Infection
Fang and colleagues
• majority of infections occurred during the early postoperative period (<3
months)
Deyo and colleagues
• Thirty days rate of superficial wound infection, deep wound
infection, and wound disruption were 1.9%, 1.2%, and 0.3%
Infection
Meningitis is a rare complication of spinal surgery
Measuring C-reactive protein (CRP) levels has
been shown to be a useful adjunct to physical
examination findings.
Prophylactic antibiotics significantly reduce the
risk of postoperative spinal wound infections.
Pearl and pittfall
1. The surgical exposure should clearly identify
the midlateral pars and facet capsule to prevent
overresection of bone.
2. Laminectomy should begin centrally, starting
from the caudal portion of the lamina, followed
by decompression of the lateral recesses.
3. Distraction laminoplasty using a laminar
spreader
4. Decompression of the lateral recess and
foramen should be performed from the
contralateral side