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.

Lumbar puncture for idiopathic normal pressure hydrocephalus diagnosis

Lumbar puncture for idiopathic normal pressure hydrocephalus diagnosis

see Opening pressure.

see Lumbar infusion test.

Cerebrospinal fluid tap test (CSF-TT), are often used in practice to provide further predictive value in detecting suitable patients for shunting.

Intracranial Elastance Index.

Anterior lumbar interbody fusion (ALIF)

Anterior lumbar interbody fusion (ALIF)

ALIF is an effective treatment for degenerative disc disease (with and without radiculopathy) and spondylolisthesis. Although results were promising for scoliosis, failed posterior fusion, and adjacent segment disease, further studies are necessary to establish the effectiveness of ALIF in these conditions 1).

Radiographic adjacent segment disease ASD is relatively common long-term finding associated with instrumented lumbar fusion. However, radiographic evidence of ASD does not necessarily correlate with a poor outcome. Results suggest that advanced age, anterior lumbar interbody fusion, and the restoration of the preoperative standing lumbar lordosis may have a protective effect against the development of ASD 2).

In degenerative disc disease, if conservative extensive care fails, anterior lumbar interbody fusion has proven to be an alternative form of surgical management.

Best for L5–1 (where the great vessels tend not to interfere with the access, and where every degree of correction produces a more significant amount of improvement in SVA than at other levels as a result of being at the lowest point in the spine).

Amount of lumbar lordosis that can be obtained (6º) 3)

Retroperitoneal usually through a Pfannenstiel’s abdominal incision.

Relatively contraindicated in males because of risk of retrograde ejaculation in 1–2% (as high as 45% in some reviews). Other risks: injury to great vessels, especially with calcified arteries, especially at L4–5. Bowel prep the day before surgery for complex cases.

Trendelenburg position, place the level of the iliac crests over the kidney rest, or use a sacral bump to increase lordosis. As a result of the bifurcation of the great vessels (aorta and inferior vena cava) which ranges from just above to just below the L4–5 disc space, this approach is best suited for access to L5–1. At L5–1, the anterior sacral artery runs down the midline of the VB and has to be sacrificed to do an ALIF.


Continuous wound infiltration with ropivacaine using an On-Q system may be effective for controlling postoperative pain after ALIF surgery 4).

see ALIF Cage

Anterior lumbar interbody fusion (ALIF) with percutaneous pedicle screw fixation (PPF) provides successful surgical outcomes to isthmic spondylolisthesis patients with indirect decompression through foraminal volume expansion. However, indirect decompression through ALIF followed by PPF may not obtain a successful surgical outcome in patients with isthmic spondylolisthesis accompanied by foraminal stenosis caused by a posterior osteophyte or foraminal sequestrated disc herniation. The microscopic anterior foraminal approach provides successful foraminal decompression. Combined with ALIF and PPF, this approach shows a good surgical outcome in patients with isthmic spondylolisthesis accompanied by foraminal stenosis caused by a posterior osteophyte or those with foraminal sequestrated disc herniation 5).

Posterior pedicle screw supplementation without posterolateral fusion improves the fusion rate of ALIF when using anterior cage and screw constructs 6).

The procedure is performed in close proximity to the large blood vessels.

Damage to these large blood vessels may result in excessive blood loss. Quoted rates in the medical literature put this risk at 1% to 15%, although this should be an uncommon complication in the hands of experienced vascular and spine surgeons.

Retrograde Ejaculation after ALIF Surgery

For males, another risk unique to this approach is that approaching the L5-S1 (lumbar segment 5 and sacral segment 1) disc space from the front has a risk of creating a condition known as retrograde ejaculation.

There are very small nerves directly over the disc interspace that control a valve that causes the ejaculate to be expelled outward during intercourse. By dissecting over the disc space, the nerves can stop working, and without this coordinating innervation to the valve, the ejaculate takes the path of least resistance, which is up into the bladder.

With retrograde ejaculation, the sensation of ejaculating is largely the same, but it makes conception very difficult (special harvesting techniques can be utilized). Fortunately, retrograde ejaculation happens in less than 1% of cases and tends to resolve over time (a few months to a year). This complication does not result in impotence as these nerves do not control erection.

Sixty-one patients who underwent ALIF surgery were enrolled. For thirty-one of them, a continuous local anesthetics infiltration system was used at the abdominal site. They collected data regarding the patients’ sleep quality; satisfaction with pain control after surgery; abilities to perform physical tasks and the additional application of opioids in the postoperative 48 hours.

The On-Q system group showed reduced visual analog scale scores for pain at the surgical site during rest and movement at 0, 12, 24, and 48 hours; and more were satisfied with pain control management at the first postoperative day (7.0 ± 1.2 vs. 6.0 ± 1.4; P = 0.003) and week (8.1 ± 1.6 vs. 7.0 ± 1.8; P = 0.010) than the control group. The number of additional patient-controlled analgesia (PCA) bolus and pethidine injections was lower in the On-Q group (PCA: 3.67 ± 1.35 vs. 4.60 ± 1.88; P = 0.049 and pethidine: 2.09 ± 1.07 vs. 2.73 ± 1.38; P = 0.032). Patients who used the On-Q system performed more diverse activity and achieved earlier ambulation than those in the control group.

Continuous wound infiltration with ropivacaine using an On-Q system may be effective for controlling postoperative pain after ALIF surgery 7).

2017

study retrospectively reviewed 82 patients who underwent MO-ALIF with self-anchored standalone cages (n = 42) or TLIF (n = 40) for the treatment of lumbar disc herniation between April 2013 and October 2014. Patient demographics, intraoperative parameters, and perioperative complications were collated. Clinical outcomes were evaluated using the visual analog scale (VAS) scoring, the Oswestry Disability Index (ODI) for pain in the leg and back, and radiological outcomes, including fusion, lumbar lordosis (LL), disc height (DH), and cage subsidence were evaluated at each follow-up for up to 2 years.

Patients who underwent TLIF had a significantly higher volume of blood loss (295.2 ± 81.4 vs. 57.0 ± 15.2 mL) and longer surgery time (130.7 ± 45.1 vs. 60.4 ± 20.8 min) than those who had MO-ALIF. Compared with baseline, both groups had significant improvements in the VAS and ODI scores and DH and LL postoperatively, though no significant difference was found between the two groups regarding these indexes. All patients reached solid fusion at the final follow-up in both groups. Three patients (3/42) with three levels (3/50) suffered from cage subsidence in the MO-ALIF group; meanwhile, no cage subsidence occurred in the TLIF group.

MO-ALIF with self-anchored stand-alone cages is a safe and effective treatment of lumbar disc herniation with less surgical trauma and similar clinical and radiological outcomes compared with TLIF 8).

2015

84 consecutive patients who underwent anterior lumbar interbody fusion from 2004 to 2009 were reviewed. The operative time, intraoperative blood loss, hospital stay, Oswestry Disability Index (ODI), visual analog scale (VAS) results, and complication rate were recorded separately.Medical indications were degenerative disc disease (73.8%), postdiscectomy disc disease (16.1%), and disc herniation (9.5%). Patients with severe spondylolysis or disc degeneration, with more than 3 or multilevel lesions, were excluded.The mean operative time was 124.5 ± 10.9 min (range 51-248 min), the mean intraoperative blood loss was 242.1 ± 27.7 mL (range 50-2700 mL), the mean hospital stay was 3.9 ± 1.1 days (range 3-6 days), the mean preoperative VAS score was 7.5 ± 1.4, and the mean preoperative ODI score was 60.0 ± 5.7. At the 1-year follow-up, the mean postoperative VAS score was 3.3 ± 1.3 and the mean postoperative ODI score was 13.6 ± 3.4 (P < 0.05). L4-L5 disc fusion led to better clinical results than 2-level L4-L5/L5-S1 disc fusion. Additionally, the 2-level fusion of L4-L5/L5-S1 had better clinical results than the L5-S1 disc fusion at both the 1 and 2-year postoperative follow-ups regarding the VAS score and the ODI score. The rate of complications was more frequent in the 2-level L4-L5/L5-S1 group (27.3%) (group C) than in the L4-L5 group (9.1%) (group A) and the L5-S1 group (12.5%) (group B). There was no difference between the L4-L5 group (9.1%) and the L5-S1 group (12.5%). A venous tear occurred during surgery and was successfully repaired in 6 of the 84 patients. Also, out of the 84 patients, 6 were found with pseudarthrosis during the follow-up, and these patients underwent a spinal fusion with instrumentation, with a posterior approach after a mean of 1 year. The complications secondary to the surgical approach were persistent abdominal pain (1/84, 1.2%) and wound dehiscence (1/84, 1.2%). Anterior lumbar interbody fusion for L4-L5 had better clinical results than the 2-segmental L4-L5/L5-S1 disc fusion, and the 2-segmental L4-L5/L5-S1 disc fusion had better clinical results than the L5-S1 disc fusion. Also, the 2-segmental L4-L5/L5-S1 disc fusion had a higher complication rate (27.3%), but there was no difference between the L4-L5 group (9.1%) and the L5-S1 group (12.5%) 9).


1)

Rao PJ, Loganathan A, Yeung V, Mobbs RJ. Outcomes of anterior lumbar interbody fusion surgery based on indication: a prospective study. Neurosurgery. 2015 Jan;76(1):7-24. doi: 10.1227/NEU.0000000000000561. PubMed PMID: 25255259.
2)

Min JH, Jang JS, Jung Bj, Lee HY, Choi WC, Shim CS, Choi G, Lee SH. The clinical characteristics and risk factors for the adjacent segment degeneration in instrumented lumbar fusion. J Spinal Disord Tech. 2008 Jul;21(5):305-9. doi: 10.1097/BSD.0b013e318142b960. PubMed PMID: 18600137.
3)

Hsieh PC, Koski TR, O’Shaughnessy B A, et al. Anterior lumbar interbody fusion in comparison with transforaminal lumbar interbody fusion: implications for the restoration of foraminal height, local disc angle, lumbar lordosis, and sagittal balance. J Neurosurg Spine. 2007; 7:379–386
4) , 7)

Lee SM, Yun DJ, Lee SH, Lee HC, Joeng KH. Continuous wound infiltration of ropivacaine for reducing of postoperative pain after anterior lumbar fusion surgery: a clinical retrospective comparative study. Korean J Pain. 2021 Apr 1;34(2):193-200. doi: 10.3344/kjp.2021.34.2.193. PMID: 33785671.
5)

Shin SH, Choi WG, Hwang BW, Tsang YS, Chung ER, Lee HC, Lee SJ, Lee SH. Microscopic anterior foraminal decompression combined with anterior lumbar interbody fusion. Spine J. 2013 Oct;13(10):1190-9. doi: 10.1016/j.spinee.2013.07.458. Epub 2013 Oct 2. PubMed PMID: 24094988.
6)

McCarthy MJ, Ng L, Vermeersch G, Chan D. A radiological comparison of anterior fusion rates in anterior lumbar interbody fusion. Global Spine J. 2012 Dec;2(4):195-206. doi: 10.1055/s-0032-1329892. Epub 2012 Nov 19. PubMed PMID: 24353968; PubMed Central PMCID: PMC3864421.
8)

Kuang L, Wang B, Lü G. Transforaminal Lumbar Interbody Fusion Versus Mini-open Anterior Lumbar Interbody Fusion With Oblique Self-anchored Stand-alone Cages for the Treatment of Lumbar Disc Herniation: A Retrospective Study With 2-year Follow-up. Spine (Phila Pa 1976). 2017 Nov 1;42(21):E1259-E1265. doi: 10.1097/BRS.0000000000002145. PubMed PMID: 28277385.
9)

Ni J, Fang X, Zhong W, Liu N, Wood KB. Anterior Lumbar Interbody Fusion for Degenerative Discogenic Low Back Pain: Evaluation of L4-S1 Fusion. Medicine (Baltimore). 2015 Oct;94(43):e1851. doi: 10.1097/MD.0000000000001851. PubMed PMID: 26512594.
WhatsApp WhatsApp us
%d bloggers like this: