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Journal of Spine & NeurosurgeryISSN: 2325-9701

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Research Article, J Spine Neurosurg Vol: 5 Issue: 6

Comparison of Classical Laminectomy and Transspinous- Split Laminectomy Techniques

Kitis S1*, Seyıthanoglu MH1, Papaker MG1, Cevık S2 and Emel E3
1Department of Neurosurgery, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
2Department of Neurosurgery, Agri State Hospital, Agri, Turkey
3Department of Neurosurgery, Bakirkoy Prof. Dr. Mazhar Osman Mental Health And Neurological Diseases Training And Research Hospital, Istanbul, Turkey
Corresponding author : Dr. Serkan Kitis
Faculty of Medicine, Department of Neurosurgery, Bezmialem Vakif University, Istanbul, Turkey
Tel: +905053743150
Fax: +902124531870
E-mail: [email protected]
Received: June 24, 2016 Accepted: July 12, 2016 Published: July 22, 2016
Citation: Kitis S, Seyıthanoglu MH, Papaker MG, Cevık S, Emel E (2016) Comparison of Classical Laminectomy and Transspinous-Split Laminectomy Techniques. J Spine Neurosurg 5:6. doi:10.4172/2325-9701.1000250

Abstract

Objective: The purpose of study is to compare clinical and radiological results of classical laminectomy and transspinous-split laminectomy which provides vertebral alignment and eliminates paraspinal muscle damage. Methods: Twenty patients in each group were evaluated (Total 40 patients). We analyzed oswestry scale, visual analog scale, pain score, and narcotic score of the patients. To demonstrate the damage of paraspinal muscles between two procedures, preoperative and postoperative MR images are compared and the ratio of atrophy was measured. Also incision size, volume of hemorrhage, bed time was evaluated. Results: Decrease of these oswestry scale, visual analog scale, pain score, and narcotic score values after transspinous-split laminectomy were found more than the decrease of those after classic laminectomy. Also, when we analyzed the responses of the patients to walking part of oswestry scale, we observed an important difference in favor of transspinous-split laminectomy group. Preoperative and postoperative MR images show that paraspinal muscle atrophy is less in transspinous-split laminectomy procedure. Hence, at these postoperative assessments, a significant difference in favor of transspinous-split laminectomy was determined. Conclusion: This study has showed that, transspinous-split laminectomy is a good alternative to classical laminectomy and minimal invasive technique by decreasing postoperative complications.

Keywords: Transspinous-split laminectomy; Minimal invasive surgery; Lumbar spinal stenosis, Spinous process

Keywords

Transspinous-split laminectomy; Minimal invasive surgery; Lumbar spinal stenosis, Spinous process

Introduction

Classical laminectomy (CL) is the gold standard treatment of lumbar spinal stenosis (LSS) and it succeeds at 56 to 85 percent of the patients [1-4]. However, in long term, it is associated with high complication ratios (back pain, spinal instability and paraspinal muscle atrophy) [1,3,5,6], long hospital rest and healing time, and high blood losses. After operation microscopes started to be used, minimal invasive operation techniques started to develop. In 2002, Shiraishi defined split laminectomy technique at cervical spine which protected the paraspinal muscles bilaterally and in 2005; it is modified to be used at lumbar vertebras by Kota Watanabe. In the following years, related publications supported the effectiveness of this surgical technique [7-9].
In our prospective randomized study, we aimed to compare clinical results of “Transspinous-Split Laminectomy” (TSSL) technique, which minimizes paraspinal muscle destruction and protects vertebral alignment, with clinical and radiological results of the patients who are operated by classical laminectomy technique.

Materials and Methods

20 patients who underwent transspinous split laminectomy (Group-1) and 20 patients who underwent classic laminectomy (Group-2) are included in the study. All of these 40 patients were operated by the same surgeon and the operation technique was selected randomly.
None of the patients who were pregnant, have a history of infectious, inflammatory or malignant diseases, have received previous treatment for spinal fractures or disc hernias, have previous iatrogenic dural injury, spondylolisthesis, spondylolysis or radiologically documented instability were included to the study.
Mean age of the patients was 54.8 ± 9.53. Mean age of the patients in group-1 and group-2 were 52.55 ± 9.70 and 57.05 ± 9.04, respectively. 24 of the patients were female and 16 were male. Group-1 (TSSL) was performed on 6 male and 14 female patients. Group-2 (CL) was performed on 10 male and 10 female patients. Period of time between onset of symptoms and surgery differs 1 to 15 years. Mean duration of symptoms was 4.88 ± 0.50 years. All of the patients had lower back pain and leg pain. 15 patients in group-2 and 10 patients in group-1 had numbness, and 8 patients in group-2 and 11 patients in group-1 had claudication. The length of postoperative follow-up was 1 to 4 years. Neurological findings of the patients on admission are shown in Table 1.
Table 1: The neurolgical findings of patients who involved with spinal stenosis in our study.
Preoperative direct lumbar AP – lateral x-rays, lumbar lateral hyperflexion-hyperextension x-rays, lumbar spinal MR images and lumbar CT scans had been obtained for all of the patients (Figure 1). Spinal stenosis is documented radiologically and supported by clinical findings (Figure 2). Examples of CT scans and MR images of patients operated TSSL technique are shown in (Figure 3).
Figure 1: Preoperative (A) and postoperative (B) CT images.
Figure 2: Postoperative early period taken control CT image.
Figure 3: Preoperative (a), postoperative (b) MRI, and postoperative CT (c) images.
Patients were evaluated with oswestry scale, visual analog scale, and narcotic scale preoperatively and postoperatively. Preoperative and postoperative first year paraspinal muscle atrophy was measured via MR images. Patients’ answers about walking in oswestry scale were quantitatively analyzed using the method of assuming A=0, B=1, C=2, D=3, E=4, F=5.
Muscle atrophy was evaluated by measuring two dimensions of preoperative and postoperative paraspinal muscles using T2 weighted magnetic resonance images at the level of intervertebral disc. In case of multi-level decompressions, average values had been calculated [10]. Muscle atrophy rating was calculated using following formula.
Atrophy Rating (%): (1 - Total postoperative area / total preoperative area) × 100
Surgical technique
Following the general anesthesia implications, the patients were positioned at the operating table at prone position, with semiflex waist. Level of spinous processes was marked with portable C arm fluoroscopy. Operating microscope was used in all stages of surgery. Skin and subcutaneous were passed to uncover spinous processes. Spinous processes were splited into two with split spinous process osteotomi applied by high speed tour motor and gelpi retractor was used to enlarge surgery area. Spinous process cortexes and paraspinal muscles bind to them were conserved. Tick ligamentum flavum and dural bag were released by stabbing inner cortex of spinous processes. Hipertrofic ligamentum flavum that presses the roots and the inner part of facet joints were cleaned to enlarge the decompression till lateral resesses and foraminal areas. During the processes, interspinous ligamans were splitted longitudinally in order to facilitate reaching subliminal area. After decompression and bleeding checks, 2 splitted sides of interspinous ligamans and spinous processes were sewed up together and proceeded to closure detailed information about the stages of surgery is shown in Figure 4.
Figure 4: Slides of the case underwent laminectomy with transspinous split technique that applied in our clinic under microscope; a: Start decompression above the spinous process with drill; b: Enter through the spinous process with drill; c: Interspinous ligament get resected longitudinally; d: Spinous process get divided by gelpi retractor; e: Hypertrophied ligamentum flavum get removed with kerisson; f: Thecal sac is seen; g: Control the intervertebral distance area; h: Control the nerve root and foramen.
Obtained data were analyzed using SPSS 17.00® software. P<0.05 was looked for statiscal significancy.

Findings

Statistical results
In group-2, 9 patients (45%) recieved single level, 9 patients (45%) received double level and 2 patients (10%) received triple level decompression. In group-1, 11 patients (55%) recieved single level, 6 patients (30%) received double level and 3 patients (15%) received triple level decompression.
Incision lengths (cm), operating times (hour), amounts of hemorrhage (cc), hospital stays (day), oswestry patient scores, oswestry grades, pain scores, narcotic scores, VAS scores, walking distances and paraspinal muscle atrophy grades were compared preoperatively and postoperatively for each group (Table 2). Preoperative and postoperative oswestry patient scores, oswestry grades, pain scores, narcotic scores, and VAS scores were analyzed using Wilcoxon Signed Ranks Test. Postoperative scores were statistically better than preoperative scores for both group-1 and group-2.
Table 2: Comparison between preoperative and postoperative results of both of TSSL(Group-1) and CL(Group-2) approaches.
Preoperative oswestry patient scores, oswestry grades, pain scores, narcotic scores, and VAS scores were analyzed using Mann – Whitney U Test. There were no statistical difference between group-1 and group-2, which implies the homogenity of patients in each group.
Postoperative oswestry patient scores, oswestry grades, pain scores, narcotic scores, and VAS scores were analyzed using Mann – Whitney U Test. Group-1 had statistically better results than group-2.
Patients’ answers to the questions about preoperative and postoperative walking were analyzed using Mann – Whitney U Test. Group-1 had statistically better scores than group-2.
Incision lenght and amount of hemorrhage were compared for group-1 and group-2. Incision length was shorter in group-1. Avoiding paraspinal muscle dissection in group-1 decreases amount of hemorrhage. Paraspinal muscle atrophy rating was lesser in group-1. Incision lengths, amounts of hemorrhage and muscle atrophy ratings were analyzed using Mann-Whitney U Test and statistically better results were found in group-1 (P=0.001). Minimal muscle atrophy in TSSL technique is due to minimal traction of muscles during dissection. Main reason of postoperative back pain is the loss of muscle function, which is better preserved in TSSL technique.

Discussion

Lumbar spinal stenosis is the most common degenerative disorder of the lumbar spine which affects approximately 1 out of every 1,000 people over the age of 60. The incidence of the disease increases with age [11,12].
The gold standard for the surgical treatment of lumbar spinal stenosis is decompression. The surgical technique used is the conventional laminectomy for the decompression of the neural elements which was first described by Mixter and Barr 75 years ago [7,13].
According to the 7-10 years surgery results of Katz et al., 27% of the patients were re-operated and 33% of the patients presented with lower back and hip pain after the operation [4].
Standard laminectomy includes wide complete laminectomy and partial or complete facetectomy [14,15]. Although this classical surgery provides adequate neural decompression, the posterior column, which has an important role in spinal stabilization, is completely removed with this operation. Removal of the spinous process and lamina causes tissue loss, dead space formation, skin contour and cosmetic problems, facilitates local wound complications such as infection, and causes an increase in the dura and nerve root scar adhesions. This, in turn may increase pain and lead to failed back syndrome in the following period [7,11,16-18].
Since it does not have an intersegmental branch like the other paraspinal muscles and it is innervated only by the medial branch of the dorsal ramus; the multifidus muscle is the most vulnerable to injury during posterior spinal surgery. The lateral deflection of the muscle mass during the operation and subsequent compression of the medial part of the dorsal ramus can result in paraspinal muscle denervation and postoperative muscle atrophy [19].
Kim et al showed paraspinal muscle atrophy following lumbar surgery in their study of 3 different operation technique comparison including 71 patients. Their study shows that techniques that are less invasive and which give less injury to paraspinal muscles cause less postoperative lumbar surgery failure syndrome [10].
In his study of 178 patients, Sihvonen stated that reasons for postoperative lumbar surgery failure syndrome include; loss in muscle support and corrupted muscle innervation resulting in increased biomechanical tension, and weakness [20].
During conventional laminectomy, the stripping of the paravertebral muscles and the resection of the posterior elements, which are done to improve the surgical field of view, lead to loss in midline supraspinous and interspinous ligament complex and decrease in flexion stability. This increases the risk of spinal instability [21-24].
Although there is slight or none instability problem with limited surgical resection, this partial resection precipitates recurrence of the pathology. Nevertheless there are studies showing favorable results which fusion was performed after basic decompression. However complicated or fusion surgery in elderly patients with systemic pathologies brings serious additional weight and morbidity [25].
To reduce the complications caused by laminectomy, especially postoperative instability, less invasive techniques have been developed [11,26,27]. Various techniques such as Multi-level laminoplasty, micro decompression, unilateral approach with bilateral decompression and distraction laminoplasty, have been developed. Most of these surgeries cannot provide adequate decompression. They minimize the paraspinal muscle damage but cannot eliminate it. Maintaining stability while increasing the decompression is a dilemma for the surgeon [10,11].
Shiraishi identified the cervical split laminectomy technique which protected the paraspinal muscles and posterior elements of the vertebrae to decrease the instability after laminectomy in 2002 [28] and in 2005 Watanabe carried this cervical technique to the lumbar area then called this technique as “lumbar spinous processsplitting laminectomy”. This technique was compared with the classic laminectomy in 18 cases in 2005 and 41 cases in 2011, and the results showed that paraspinal muscle damage and muscle atrophy were minimalized [8,9].
Watanabe et al demonstrated that the muscle atrophy rates were lower in LSPSL technique compared to conventional laminectomy in 2001. Their study results showed that this change in muscle atrophy rates was correlated to serum CRP and CPK levels. They concluded that postoperative pain and paraspinal muscle damage was related [8,9].
Lin and his colleagues, in their study of 18 patients, demonstrated the “chimney sublaminar decompression (CSD)” method which minimalized the muscle damage with good neurological outcomes in 2006. In their publication, they stated that the stripping of the paraspinal muscles from the vertebra resulted in muscle denervation and devascularisation. The retraction of the muscle disrupts the local blood flow and the increase in oxidative stress, inflammatory cell infiltration and the increase in nuclear factor KB related COX-2 expression induces progressive muscle fiber edema. The postoperative wound pain is decreased with the new CSD technique, since it does not involve the stripping and the retraction of the paraspinal muscles. More importantly, with this technique, early recovery, short hospital stay, decrease in complications related to hospital stay such as embolism and urinary tract infections were also noted [7].
“Marmot operation” developed by Cho et al., is similar to Watanabe and Lin’s sublaminar decompression method. They noted that with this method tunneled split spinous laminotomy and even discectomy was performed instead of laminectomy [11].
Shetty et al., in their study using the LSPSL technique, indicated that this method provided adequate surgical field of view. They also noted that postoperative recovery was faster with minimal midline ligament and muscle damage [29].

Conclusion

In this study, the minimally invasive technique used was shown to provide sufficient expansion of the spinal canal diameter by the postoperative control MR and CT imaging.
Concordantly, the decrease in the postoperative Oswestry pain scale values of the patients compared to the other group clinically proves that sufficient decompression was achieved. Smaller incision size, and less intraoperative hemorrhage and paraspinal muscle injury results in less postoperative pain and therefore faster recovery.
In conclusion, as a minimally invasive technique; TSSL is a good alternative to conventional laminectomy. The disadvantage of this study is the low number of patients.

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