The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 86, Issue 8

Scientific Articles | August 01, 2004

Clinical and Radiographic Results of Expansive Lumbar Laminoplasty in Patients with Spinal Stenosis

Yoshiharu Kawaguchi, MD¹; Masahiko Kanamori, MD¹; Hirokazu Ishihara, MD¹; Tasuku Kikkawa, MD¹; Hisao Matsui, MD²; Haruo Tsuji, MD¹; Tomoatsu Kimura, MD¹

¹ Department of Orthopaedic Surgery, Toyama Medical and Pharmaceutical University, Faculty of Medicine, 2630 Sugitani, Toyama 930-0194, Japan. E-mail address for Y. Kawaguchi: zenji@ms.toyama-mpu.ac.jp
² Division of Orthopaedic Surgery, Takaoka City Hospital, 4-1, Takaramachi, Takaoka, 933-8550 Toyama, Japan

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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopaedic Surgery, Toyama Medical and Pharmaceutical University, Toyama, Japan

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J Bone Joint Surg Am, 2004 Aug 01;86(8):1698-1703

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Abstract

Background: In 1981, we developed a technique of expansive lumbar laminoplasty to alleviate the problems of conventional laminectomy in the treatment of spinal stenosis. The purposes of this study were to assess the long-term outcome following expansive lumbar laminoplasty and to investigate the postoperative problems.

Methods: Fifty-four patients underwent expansive lumbar laminoplasty for the treatment of spinal stenosis. There were forty-three men and eleven women with a mean age of 52.6 years. The average length of follow-up was 5.5 years. Preoperatively, twenty-five patients had degenerative stenosis; thirteen, stenosis due to spondylolisthesis; twelve, combined stenosis (disc herniation and stenosis); and six, hyperostotic stenosis. (Two patients with hyperostotic stenosis and spondylolisthesis were included in both groups.) The clinical results were assessed with use of the Japanese Orthopaedic Association score, and the rate of recovery was calculated. Radiographic findings were analyzed on the basis of the cross-sectional area of the spinal canal, kyphosis, range of motion of the lumbar spine, and the rate of interlaminar fusion.

Results: The average recovery rate at the time of the last follow-up was 69.2% for patients with degenerative stenosis, 66.5% for patients with combined stenosis, 65.2% for those with hyperostotic stenosis, and 54.7% for those with spondylolisthesis. The factors resulting in a poor recovery were an older age and insufficient decompression of the lateral stenosis. During the follow-up period, the Japanese Orthopaedic Association score became worse for seven patients, six patients had lesions develop at the level adjacent to the laminoplasty, and five patients had spondylolisthesis develop. Interlaminar fusion was observed in twenty-two patients (41%).

Conclusions: The satisfactory results of expansive lumbar laminoplasty were maintained at an average of 5.5 years after surgery. The best indications for the lumbar laminoplasty procedure were young and active patients with central spinal stenosis.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Decompressive laminectomy has been widely used for the treatment of lumbar spinal stenosis^1-5. However, iatrogenic instability following laminectomy sometimes occurs in patients with degenerative or spondylolisthetic spinal stenosis^2-5. Furthermore, a so-called laminectomy membrane, consisting of an epidural scar, in the spinal canal might result in unfavorable sequelae after removal of the laminae^6-10. To avoid these problems, the technique of expansive lumbar laminoplasty was developed in 1982¹¹. This operation enlarges the spinal canal and preserves the posterior spinal structures, facilitating adequate decompression of the spinal nerves and reinforcement of spinal stability^12,13. We reported satisfactory results of expansive lumbar laminoplasty with a small number of patients in studies with less than ten years of follow-up^14,15. However, we encountered several postoperative problems with a longer follow-up period. The purpose of this study was to review the clinical and radiographic outcomes of expansive lumbar laminoplasty in a larger number of patients.

Materials and Methods

Materials and Methods | Results | Discussion | Appendix | References

Fifty-four patients with lumbar spinal stenosis underwent expansive lumbar laminoplasty between 1981 and 1999 at our university hospital. All patients who were followed for more than two years were included in the study. Forty-eight patients had a physical examination at the time of the final follow-up, and six patients were evaluated by means of a telephone interview. There were forty-three men and eleven women, and they had an average age of 52.6 years (range, thirty-three to sixty-nine years) at the time of the index operation. The pathological diagnosis was degenerative stenosis in twenty-five patients; spinal stenosis due to spondylolisthesis in thirteen patients; combined stenosis (disc herniation that required removal with spinal stenosis) in twelve patients; and hyperostotic stenosis, such as ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum, in six patients. Two patients with hyperostotic stenosis also had spondylolisthesis. These two patients were included in both the hyperostotic and spondylolisthesis groups. The average duration of follow-up for the entire group was 5.5 years (range, two to thirteen years).

Operative Procedure

Expansive lumbar laminoplasty, as described by Tsuji et al.^11-13, was used in all patients (Figs. 1-A and 1-B). The laminae were exposed, one side of the laminae was opened, and the other side served as the hinge. Bone grafts from excised spinous processes were placed in the opened laminae and were fixed with braided wire or nylon sutures. Bone chips were also placed along the hinged side. Care was taken not to damage the facet joints. The patients were required to stay in bed for the first week after surgery, and thereafter walking was allowed with a body cast or a rigid brace in order to reduce trunk motion¹⁶. The cast or brace was worn for up to one month after surgery, and a soft brace was recommended for two additional months.

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Figs. 1-A and 1-B: Schematic representation of the expansive lumbar laminoplasty. The arrow on the left side indicates bone chips, and the arrow on the right indicates grafted bone. (Reprinted, with permission, from: Tsuji H. Principle and fundamental technique in lumbar spine surgery. 3rd ed. Tokyo: Nankodo; 1996. p 211.)

Clinical Evaluation

The duration of the operation, blood loss during surgery, and blood transfusions were recorded for all patients. The postoperative complications related to the operation were also noted.

The neurological evaluation was graded with use of the scale devised by the Japanese Orthopaedic Association (see Appendix)¹⁷. With this scale, the highest (normal) score attainable is 29. The rate of recovery was calculated with use of the following formula: [postoperative score — preoperative score] × 100 /[29 (score for full recovery) — preoperative score].

Preoperative factors that might affect the clinical results were assessed^18,19. These included the age at the time of the operation, the Japanese Orthopaedic Association score, and the etiology of the lumbar spinal stenosis. For the patients who had neurological deterioration during the follow-up period, the causes of the deterioration were evaluated. Deterioration was defined as a decrease in the postoperative score of more than 4 points during the follow-up period.

Radiographic Evaluation

Computed tomographic images of the lumbar spine and anteroposterior and lateral (neutral and flexion-extension) radiographs were made preoperatively and postoperatively. The cross-sectional area of the spinal canal was measured on the computed tomographic images.

The extent of degenerative scoliosis (a Cobb angle of >10°) and the postoperative scoliotic angle from L1 to L5 and at the operative levels were measured on the anteroposterior radiographs. The postural alignment of the lumbar spine on the lateral radiograph with the spine in the neutral position was defined as lordosis or kyphosis on the basis of the angle between the lines passing through the upper margin of the L1 vertebral body and the lower margin of L5 and the operative levels. A positive value indicated a lordotic angle, and a negative value indicated a kyphotic angle. Retrolisthesis and/or anterolisthesis were evaluated on the lateral radiograph and were deemed to be present when the distance of the vertebral slip was >3 mm. The postoperative increase in spondylolisthesis was analyzed. The number of sites of interlaminar fusion was also determined radiographically.

Statistical Analysis

Data are presented as the mean and the standard deviation. A Wilcoxon signed-rank test was used for the statistical analysis of the difference in the preoperative and postoperative Japanese Orthopaedic Association scores. The Welch t test was used for the analysis of the difference in the average recovery rate between the older patient group (fifty-six years old or more) and the younger patient group (fifty-five years old or less). The same statistical method was used for the analysis of the difference in the recovery rate according to the etiology: degenerative stenosis, combined stenosis, hyperostotic stenosis, spondylolisthesis, and scoliosis. Radiographic results were also analyzed with the same statistical method. A p value of <0.05 was considered significant.

Results

Materials and Methods | Results | Discussion | Appendix | References

Clinical Evaluation

Laminoplasty was carried out on an average of 3.1 ± 0.7 laminae (range, two to five laminae). The average operative time was 186 ± 37 minutes, and the average blood loss was 664 ± 475 mL. Twenty-four patients (44%) had a blood transfusion. There were no systemic or neurological complications intraoperatively or postoperatively.

The Appendix provides a table showing the clinical data on expansive lumbar laminoplasty. Overall, the Japanese Orthopaedic Association score rapidly improved and continued to improve after surgery. The scores for subjective symptoms, clinical signs, and restriction of the activities of daily living improved after the laminoplasty (Table I). The average total recovery rate at the last follow-up examination for the twenty-one patients who were fifty-six years old or more (44.8% ± 37.1%) was significantly lower than that for the thirty-three patients who were fifty-five years old or less (78.8% ± 17.1%) (p = 0.0006). The average recovery rate at the time of the last follow-up was 69.2% ± 21.1% for patients with degenerative stenosis, 66.5% ± 44.5% for patients with combined stenosis, and 65.2% ± 26.1% for patients with hyperostotic stenosis.

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TABLE I Japanese Orthopaedic Assocation Scores Preoperatively and at the Latest Follow-up Review

	Japanese Orthopaedic Association Scores^*
	Preoperative	Latest Follow-up	P Value
Subjective Symptoms
Low-back pain	1.4 ± 0.8	2.3 ± 0.6	<0.0001
Leg pain and/or numbness	0.9 ± 0.6	2.2 ± 0.8	<0.0001
Walking capacity	1.0 ± 0.9	2.5 ± 0.8	<0.0001
Clinical signs
Straight-leg-raising test	1.6 ± 0.6	2.0 ± 0.2	0.0003
Sensory function	0.6 ± 0.6	1.4 ± 0.7	<0.0001
Motor function	1.0 ± 0.8	1.6 ± 0.7	<0.0001
Bladder function	-0.8 ± 1.4	-0.4 ± 1.2	0.15
Restriction of activities of daily living	5.6 ± 2.7	11.4 ± 2.9	<0.0001
Total	11.2 ± 4.1	23.0 ± 5.6	<0.0001

The values are given as the mean and the standard deviation

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TABLE I Japanese Orthopaedic Assocation Scores Preoperatively and at the Latest Follow-up Review

	Japanese Orthopaedic Association Scores^*
	Preoperative	Latest Follow-up	P Value
Subjective Symptoms
Low-back pain	1.4 ± 0.8	2.3 ± 0.6	<0.0001
Leg pain and/or numbness	0.9 ± 0.6	2.2 ± 0.8	<0.0001
Walking capacity	1.0 ± 0.9	2.5 ± 0.8	<0.0001
Clinical signs
Straight-leg-raising test	1.6 ± 0.6	2.0 ± 0.2	0.0003
Sensory function	0.6 ± 0.6	1.4 ± 0.7	<0.0001
Motor function	1.0 ± 0.8	1.6 ± 0.7	<0.0001
Bladder function	-0.8 ± 1.4	-0.4 ± 1.2	0.15
Restriction of activities of daily living	5.6 ± 2.7	11.4 ± 2.9	<0.0001
Total	11.2 ± 4.1	23.0 ± 5.6	<0.0001

The values are given as the mean and the standard deviation

The recovery rate was 63.7% ± 29.5% for the patients with scoliosis and 66.1% ± 32.1% for the patients without scoliosis; the difference was not significant, on the basis of the numbers available. The recovery tended to be poorer in the patients with spondylolisthesis (54.7% ± 37.4%). Four patients showed poor recovery (=25%) throughout the follow-up period. The causes of the poor recovery were an insufficient decompression of lateral stenosis due to scoliosis and spondylolisthesis (Cases 21 and 34), lateral disc herniation (Case 9), and a neurological complication of diabetes mellitus (Case 6). For nine patients, the Japanese Orthopaedic Association scores worsened during the follow-up period. Seven of these patients had lesions develop at the segment adjacent to laminoplasty postoperatively.

Radiographic Evaluation

Forty-nine patients (91%) had more than two years of radiographic follow-up. The average cross-sectional area per level was expanded from 1.8 ± 0.9 cm² to 3.0 ± 0.9 cm² after the laminoplasty (Figs. 2-A and 2-B). For the patients with scoliosis, the postoperative Cobb angle (17.0° ± 5.5°) was the same as the preoperative angle (17.6° ± 5.2°). The preoperative sagittal alignment of L1-L5 was 25.7° ± 13.0°, and the postoperative alignment was 16.8° ± 10.3°.

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Figs. 2-A and 2-B: Fig. 2-A Preoperative computed tomography scan. Fig. 2-B Computed tomography scan made four years after laminoplasty, showing the rectangular shape of the enlarged spinal canal.

Thirteen patients had spondylolisthesis preoperatively, and eighteen patients had spondylolisthesis postoperatively. All of the new levels of spondylolisthesis occurred at the segment adjacent to the upper extent of the laminoplasty. The recurrence of low-back pain and neurological deterioration was a result of spinal stenosis due to newly developed spondylolisthesis in two patients (Cases 4 and 13) (Figs. 3-A, 3-B, and 3-C). The mean range of motion of L1-L5 was 22.1° ± 11.7° preoperatively. It was decreased to a mean of 14.4° ± 9.4° after surgery. At the operative levels, interlaminar fusion was observed in twenty-one patients (43%) of the forty-nine patients with complete radiographic follow-up. Even in the patients without an interlaminar fusion, the range of motion was reduced to 58% of the preoperative range at the time of the last follow-up.

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Figs. 3-A, 3-B, and 3-C: Case 13. A sixty-nine-year-old man who underwent expansive lumbar laminoplasty at the L3-L5 levels. Fig. 3-A Preoperative lateral myelograph. Note the spondylolisthesis at L4-L5. Spinal stenosis was remarkable at the L3-L4 and L4-L5 levels. Fig. 3-B Immediate postoperative lateral radiograph.

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Fig. 3-C: Lateral radiograph made seven years after the laminoplasty. Disc degeneration and retrolisthesis developed at L2-L3 (arrows). The patient complained of recurrent low-back pain. The neurological findings had deteriorated because of spinal stenosis due to newly developed spondylolisthesis.

Discussion

Materials and Methods | Results | Discussion | Appendix | References

We believe that our method of laminoplasty is a safe procedure since no postoperative complications were observed. However, the operation took longer and blood loss was larger, on the average, than that in our previous study of patients who underwent laminectomy²⁰. Thus, we believe that the best indications for expansive lumbar laminoplasty are young and active patients with spinal stenosis.

Our findings showed that expansive lumbar laminoplasty resulted in satisfactory neurological recovery within one year, and this recovery was maintained at an average follow-up of more than five years for most patients. The relief of pain and/or numbness in the lower extremity and the improvement in walking ability indicate that this operation was effective in achieving decompression of the spinal nerves. The recovery rate in the older patient group (fifty-six years old or more) was poorer than that in the young patient group (fifty-five years old or less). The poorer recovery in the older patients may have been due to age-related decreases in the motor neurons and myelinated fibers^21,22. Three patients with lateral stenosis had poor recovery in the present study, and laminoplasty may not be appropriate in patients with lateral stenosis due to scoliosis. Another method involving decompression and arthrodesis, such as posterior lumbar interbody arthrodesis, might be indicated for this condition.

Although good results after the laminoplasty were maintained at an average follow-up of more than five years, seven patients had late functional deterioration that was caused by degenerative change in the motion segments adjacent to the laminoplasty. Adjacent segment disc degeneration and/or herniation is known to occur after arthrodesis^23-25 and is thought to be due to the mechanical stress on the involved disc²⁶. We believe that the adjacent segment degeneration and/or herniation after laminoplasty is caused by the same mechanism. The limitation of range of motion might induce mechanical stress in the adjacent segment. To minimize problems at the adjacent levels, the operative levels must be carefully planned.

Spondylolisthesis developed in five patients postoperatively, and symptoms worsened in two patients who had had preoperative spondylolisthesis. Therefore, it is necessary to pay attention to the occurrence or progression of spondylolisthesis after laminoplasty. The development of an interlaminar fusion did not affect the recovery. In addition, the nonunion of an interlaminar fusion did not appear to result in either malalignment or segmental instability. The postoperative range of motion was reduced even in the patients without interlaminar fusion. This reduction in motion might bring about the reinforcement of spinal stability.

Appendix

Materials and Methods | Results | Discussion | Appendix | References

Tables showing the Japanese Orthopaedic Society scoring system and the clinical data on all patients in this series are available with the electronic versions of this article, on our web site at (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

References

Materials and Methods | Results | Discussion | Appendix | References

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Topics

constriction, pathologic ; spinal stenosis ; spondylolisthesis ; laminaplasty

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Yoshiharu Kawaguchi, Masahiko Kanamori, Hirokazu Ishihara, Tasuku Kikkawa, Hisao Matsui, Haruo Tsuji, Tomoatsu Kimura; Clinical and Radiographic Results of Expansive Lumbar Laminoplasty in Patients with Spinal Stenosis. The Journal of Bone & Joint Surgery. 2004 Aug;86(8):1698-1703.

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