Minimally Invasive Lumbar Laminectomy

Minimally Invasive Lumbar Laminectomy

see also Lumbar microendoscopic spinal decompression surgery.

Minimally Invasive Lumbar Laminectomy via unilateral approach is one of the minimally invasive methods used for degenerative spinal stenosis.

Bilateral decompression through unilateral approach is an effective method without instability effect, which provides sufficient decompression in the degenerative stenosis and increases patient comfort in the postoperative period 1).

see Laminotomy

see Facetectomy

Microsurgical technique

Development of microsurgical techniques have provided innovations towards minimizing the surgical insult in surgical approaches to canal stenosis 2).

The advantage of a microsurgical approach is the posibility of a wide bilateral decompression of spinal canal or foramen at one or multiple levels, through a minimal paraspinal muscular dissection. As a result, it is possible to preserve important soft tissues and bones, which are vital for the stability of the spinal column, while at the same time being able to remove bilateral pathologies encroaching upon the spinal canal or foramina 3).

Several authors have developed various microdecompression procedures for lumbar canal stenosis, including microhemilaminotomy, interlaminar microdecompression, intersegmental microdecompression, resculpturing microlaminoplasty and segmental microsublaminoplasty 4).

Relevant articles were identified from six electronic databases. Predefined endpoints were extracted and meta-analyzed from the identified studies.

Satisfaction rates were significantly higher in the minimally invasive group (84% vs 75.4%; P = 0.03), while back pain VAS scores were lower (P < 0.00001). Minimally invasive laminectomy operative duration was 11 minutes longer than the open approach (P = 0.001), however this may not have clinical significance. However, there was less blood loss (P < 0.00001) and shorter hospital stay (2.1 days; P < 0.0001). Dural injuries and cerebrospinal fluid leaks were comparable, but reoperation rates were lower in the minimally invasive cohort (1.6% vs 5.8%; P = 0.02) however this was not significant when only randomized evidence was considered.

The pooled evidence suggests ULBD may be associated with less blood loss and shorter stay, with similar complication profiles to the open approach. These findings warrant verification in large prospective registries and randomized trials 5).

Using a decision-analytic model from the Medicare perspective, a cost-effectiveness analysis was performed comparing mild® to ESI or laminectomy surgery. The analysis population included patients with LSS who have moderate to severe symptoms and have failed conservative therapy. Costs included initial procedure, complications, and repeat/revision or alternate procedure after failure. Effects measured as change in quality-adjusted life years (QALY) from preprocedure to 2 years postprocedure. Incremental cost-effectiveness ratios were determined, and sensitivity analysis conducted. The mild® strategy appears to be the most cost-effective ($43,760/QALY), with ESI the next best alternative at an additional $37,758/QALY. Laminectomy surgery was the least cost-effective ($125,985/QALY) 6).

Trumpet laminectomy fenestration

In the Japanese Neurosurgical Society, one of the common procedures for microdecompression of lumbar spinal canal is trumpet laminectomy fenestration.

see Trumpet laminectomy microdecompression.

A 68-yr-old male entailing a 2-level minimally invasive lumbar laminectomy and foraminotomy at L2L3 and L3L4. The patient initially presented with symptoms of treatment-refractory lower extremity numbness and limited ambulation. His imaging demonstrated coronal scoliosis and severe lumbar central and foraminal stenosis at L2-L3 and L3-L4, with enlarged spinous processes, laminae, and facets. The patient consented to the procedure and publication of their image. The operation proceeded with the patient in a prone position with paramedian dissection to the lamina through a minimally invasive tubular retractor. Laminectomies and foraminotomies were performed at each level with high-speed drill and a Kerrison rongeur, with care to identify and protect the relevant spinal nerve roots. Postoperatively, the patient reported significantly reduced numbness and improved ambulation, with a well-healed surgical incision notably smaller than those produced in an open operation 7).


1)

Yaman O, Ozdemir N, Dagli AT, Acar E, Dalbayrak S, Temiz C. A Comparison of Bilateral Decompression via Unilateral Approach and Classic Laminectomy in Patients with Lumbar Spinal Stenosis: A retrospective Clinical Study. Turk Neurosurg. 2015;25(2):239-45. doi: 10.5137/1019-5149.JTN.8710-13.1. PubMed PMID: 26014006.
2)

Caspar W, Papavero L, Sayler MK, Harkey HL. Precise and limited decompression for lumbar spinal stenosis. Acta Neurochir (Wien) 1994;131:130–136.
3)

Guiot BH, Khoo LT, Fessler RG. A minimally invasive technique for decompression of the lumbar spine. Spine (Phila Pa 1976) 2002;27:432–438.
4)

Young JP, Young PH. The textbook of spinal surgery. Bridwell KH, Dewald RLPhiladelphia: Lippincott; 2012. pp. 101-109
5)

Phan K, Mobbs RJ. Minimally Invasive Versus Open Laminectomy for Lumbar Stenosis – A Systematic Review and Meta-Analysis. Spine (Phila Pa 1976). 2015 Oct 17. [Epub ahead of print] PubMed PMID: 26555839.
6)

Udeh BL, Costandi S, Dalton JE, Ghosh R, Yousef H, Mekhail N. The 2-Year Cost-Effectiveness of 3 options to Treat Lumbar Spinal Stenosis Patients. Pain Pract. 2014 Jan 3. doi: 10.1111/papr.12160. [Epub ahead of print] PubMed PMID: 24393198.
7)

Srinivasan ES, Crutcher CL, Wang TY, Grossi PM, Than KD. Two-Level Minimally Invasive Lumbar Laminectomy and Foraminotomy: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown). 2021 May 6:opab134. doi: 10.1093/ons/opab134. Epub ahead of print. PMID: 33956988.

Idiopathic normal pressure hydrocephalus

Cangrelor

Cangrelor

Emergent stenting of both extra- and intracranial occlusions during acute ischemic stroke procedures is complicated by the need for immediate platelet inhibition to prevent thromboembolic complications.

Cangrelor is a new antiplatelet therapy with a P2Y12 inhibiting effect, with a rapid onset and offset of action, owing to its short half-life 1).

Cangrelor may be a feasible alternative for patients requiring immediate intervention with the use of endoluminal devices. It allows the possibility for a secure transition to long-term ticagrelor and progression to surgery in the setting of unexpected complications 2).

Cangrelor presents many advantages compared to standard therapy in patients undergoing stent placement related to its pharmacokinetic profile, rapid onset of action, ease of transition to oral P2Y12 antiplatelet agents, and measurability 3)

Findings suggest that cangrelor is a promising alternative in acute stenting for the treatment of cerebrovascular pathology. However, further studies with larger samples are required to accurately elucidate its safety and effectiveness in neuroendovascular procedures 4).

Five prior case series have been published evaluating the results of IV cangrelor in neurointerventional procedures. Paul et al. sought to combine the data from all prior studies and analyze only ischemic stroke interventions.

A prospectively maintained database was reviewed to identify all cases of IV cangrelor administration during acute ischemic stroke intervention. Nine additional patients were identified who have not been previously published. In addition, a literature search was performed to identify five prior publications of cangrelor in neurointervention. The data from these was combined with our institution in a pooled-analysis.

Overall, 129 patients who received IV cangrelor during an acute ischemic stroke intervention were identified. The asymptomatic intracranial hemorrhage rate was 12.6%(11/87). The symptomatic intracranial hemorrhage rate was 6.2% (8/129). The rate of retroperitoneal hematoma and gastrointestinal bleeding were also low (1.5% and 0.8%, 2/129 and 1/129). There was one case of intraprocedural thromboembolic complication (0.8%) and no cases of intraprocedural in-stent thrombosis(0%).

IV cangrelor during endovascular intervention for ischemic stroke treatment appears to be safe, with a symptomatic intracranial hemorrhage rate of 6.2%. More research is needed to determine the ideal dosing regimen 5).

The recommended duration of dual antiplatelet therapy after drug-eluting stent placement presents a dilemma for patients with recent stenting who require urgent or emergency noncardiac surgery. We present the case of a patient with recent drug-eluting stent placement (<6 months) on dual antiplatelet therapy who underwent successful emergency cervical spine surgery with antiplatelet therapy bridged using cangrelor, an intravenous P2Y12 inhibitor antiplatelet agent. Our experience illustrates the multidisciplinary approach to a patient with high thrombotic and bleeding risk who underwent neurosurgery off both aspirin and a P2Y12 inhibitor 6)


1)

Abdennour L, Sourour N, Drir M, Premat K, Shotar E, Taylor G, Godier A, Mathout J, Lenck S, Bernard R, Carpentier A, Degos V, Clarençon F. Preliminary Experience with Cangrelor for Endovascular Treatment of Challenging Intracranial Aneurysms. Clin Neuroradiol. 2020 Sep;30(3):453-461. doi: 10.1007/s00062-019-00811-2. Epub 2019 Jul 15. PMID: 31309241.
2)

Cortez GM, Monteiro A, Sourour N, Clarençon F, Elhorany M, Grigoryan M, Mirza S, Dabus G, Linfante I, Aguilar-Salinas P, Murtaza Y, Aghaebrahim A, Sauvageau E, Hanel RA. The use of cangrelor in neurovascular interventions: a multicenter experience. Neuroradiology. 2020 Nov 11. doi: 10.1007/s00234-020-02599-2. Epub ahead of print. PMID: 33174182.
3)

Entezami P, Holden DN, Boulos AS, Paul AR, Field NC, Nourollahzadeh E, Yamamoto J, Dalfino JC. Cangrelor dose titration using platelet function testing during cerebrovascular stent placement. Interv Neuroradiol. 2021 Feb;27(1):88-98. doi: 10.1177/1591019920936923. Epub 2020 Jul 1. PMID: 32611215; PMCID: PMC7903542.
4)

Aguilar-Salinas P, Agnoletto GJ, Brasiliense LBC, Santos R, Granja MF, Gonsales D, Aghaebrahim A, Sauvageau E, Hanel RA. Safety and efficacy of cangrelor in acute stenting for the treatment of cerebrovascular pathology: preliminary experience in a single-center pilot study. J Neurointerv Surg. 2019 Apr;11(4):347-351. doi: 10.1136/neurintsurg-2018-014396. Epub 2018 Dec 14. PMID: 30552167.
5)

Paul AR, Entezami P, Holden D, Field N, Dalfino J, Boulos A. Use of intravenous cangrelor and stenting in acute ischemic stroke interventions: a new single center analysis and pooled-analysis of current studies. Interv Neuroradiol. 2021 May 4:15910199211014417. doi: 10.1177/15910199211014417. Epub ahead of print. PMID: 33945341.
6)

Hu TY, Peeters SM, Nagasawa DT, Kamdar NV, Brook RP, Sun J, Park S, Moreland NC, Cruz D, Macyszyn L, Press MC. Cangrelor Bridging Within 6 Months of a Drug- Eluting Stent in a Patient for Emergency Cervical Spine Surgery: A Case Report. A A Pract. 2019 Jul 15;13(2):69-73. doi: 10.1213/XAA.0000000000000994. PMID: 30864953.
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