The original surgical technique of expansive lumbar laminoplasty was
described by Tsuji et
al.1-5.
The step-by-step procedure is described below.
CRITICAL CONCEPTSINDICATIONS:Multilevel degenerative spinal stenosis accompanied by developmental spinal
stenosis in physically active patientsMultilevel combined stenosis accompanied by lumbar disc herniation or
intraspinal ossified lesionsMultilevel degenerative spinal stenosis with instability of the lumbar
segments when reinforcement of the instability is requiredIntraspinal tumors in young patientsCONTRAINDICATIONS:Lateral stenosis due to degenerative scoliosis or spondylolisthesisLateral lumbar disc herniationElderly patients, i.e., those who are more than seventy years oldPITFALLS:Bleeding can be extensive with this procedure, and preoperatively we try to
have the patient donate 400 to 800 mL of autologous blood for transfusion.When the grooves are made in the laminae, the spinous process should be
removed carefully at its base and preserved for use as a bone graft, the outer
edge of the groove should reach the lateral one-third of the articular facets,
and the groove on the hinged side should be wider and more conical than the
groove on the open side in order to obtain sufficient rotation of the laminae
(Fig. 5).A special awl, pusher, and perforator are used for making the tunnels
(Fig. 6).The entrance to each drill-hole should be widened with use of a high-speed
air drill to facilitate easy passage of the wire or thread.During rotatory elevation of the lamina, the internal cortex on the hinged
side should not be completely removed. If there is a possibility of the lamina
becoming depressed into the spinal canal on the hinged side, the wires should
be passed before the lamina is rotated.If the amount of the graft obtained from the spinous processes is not
enough, corticocancellous bone from the posterior aspect of the ilium is
obtained.Decortication of the surface of the laminae must be performed
carefully.Postoperatively, a cast or hard brace is applied and worn for up to one
month after surgery and then a soft brace is recommended for two additional
months.AUTHOR UPDATE:We have found that lateral recess decompression within the spinal canal can
be performed on the hinged side. If there is a symptomatic lumbar disc
herniation, discectomy can be performed through the open gap. Intraspinal
tumors can also be removed through the open gap.
CRITICAL CONCEPTS
INDICATIONS:
Multilevel degenerative spinal stenosis accompanied by developmental spinal
stenosis in physically active patientsMultilevel combined stenosis accompanied by lumbar disc herniation or
intraspinal ossified lesionsMultilevel degenerative spinal stenosis with instability of the lumbar
segments when reinforcement of the instability is requiredIntraspinal tumors in young patients
Multilevel degenerative spinal stenosis accompanied by developmental spinal
stenosis in physically active patients
Multilevel combined stenosis accompanied by lumbar disc herniation or
intraspinal ossified lesions
Multilevel degenerative spinal stenosis with instability of the lumbar
segments when reinforcement of the instability is required
Intraspinal tumors in young patients
CONTRAINDICATIONS:
Lateral stenosis due to degenerative scoliosis or spondylolisthesisLateral lumbar disc herniationElderly patients, i.e., those who are more than seventy years old
Lateral stenosis due to degenerative scoliosis or spondylolisthesis
Lateral lumbar disc herniation
Elderly patients, i.e., those who are more than seventy years old
PITFALLS:
Bleeding can be extensive with this procedure, and preoperatively we try to
have the patient donate 400 to 800 mL of autologous blood for transfusion.When the grooves are made in the laminae, the spinous process should be
removed carefully at its base and preserved for use as a bone graft, the outer
edge of the groove should reach the lateral one-third of the articular facets,
and the groove on the hinged side should be wider and more conical than the
groove on the open side in order to obtain sufficient rotation of the laminae
(Fig. 5).A special awl, pusher, and perforator are used for making the tunnels
(Fig. 6).The entrance to each drill-hole should be widened with use of a high-speed
air drill to facilitate easy passage of the wire or thread.During rotatory elevation of the lamina, the internal cortex on the hinged
side should not be completely removed. If there is a possibility of the lamina
becoming depressed into the spinal canal on the hinged side, the wires should
be passed before the lamina is rotated.If the amount of the graft obtained from the spinous processes is not
enough, corticocancellous bone from the posterior aspect of the ilium is
obtained.Decortication of the surface of the laminae must be performed
carefully.Postoperatively, a cast or hard brace is applied and worn for up to one
month after surgery and then a soft brace is recommended for two additional
months.
Bleeding can be extensive with this procedure, and preoperatively we try to
have the patient donate 400 to 800 mL of autologous blood for transfusion.
When the grooves are made in the laminae, the spinous process should be
removed carefully at its base and preserved for use as a bone graft, the outer
edge of the groove should reach the lateral one-third of the articular facets,
and the groove on the hinged side should be wider and more conical than the
groove on the open side in order to obtain sufficient rotation of the laminae
(Fig. 5).
A special awl, pusher, and perforator are used for making the tunnels
(Fig. 6).
The entrance to each drill-hole should be widened with use of a high-speed
air drill to facilitate easy passage of the wire or thread.
During rotatory elevation of the lamina, the internal cortex on the hinged
side should not be completely removed. If there is a possibility of the lamina
becoming depressed into the spinal canal on the hinged side, the wires should
be passed before the lamina is rotated.
If the amount of the graft obtained from the spinous processes is not
enough, corticocancellous bone from the posterior aspect of the ilium is
obtained.
Decortication of the surface of the laminae must be performed
carefully.
Postoperatively, a cast or hard brace is applied and worn for up to one
month after surgery and then a soft brace is recommended for two additional
months.
AUTHOR UPDATE:
We have found that lateral recess decompression within the spinal canal can
be performed on the hinged side. If there is a symptomatic lumbar disc
herniation, discectomy can be performed through the open gap. Intraspinal
tumors can also be removed through the open gap.
A groove is created in the laminae. After the spinous processes of the
target laminae are removed, the laminae are cut with use of a high-speed air
drill.A tunnel is made for wire passage (Fig.
1). Just prior to mobilization of the laminae, small holes are
made in each lamina on the side to be opened. The holes pass from the area of
the removed spinous process to the groove and from the groove to the lateral
surface of the laminae.The wire is passed through the holes. A 0.3-mm braided steel wire, a 0.4-mm
monofilament steel wire, or a number-1 braided nylon suture is passed through
the holes of the lamina.Rotatory elevation of the lamina and intraspinal intervention are performed
(Fig. 2). The laminae are
completely detached along the groove on the side to be opened with use of a
diamond burr, and the ligamentum flavum is also dissected free on the same
side with a knife. On the hinged side, an incomplete separation of the laminae
is created by means of interrupted perforations of the internal cortex with
use of a diamond burr. Then, the laminae are turned up to an angle of at least
45°. The undersurface of the groove facing the lateral recess of the
spinal canal is trimmed with a rongeur and curet, and the remaining ligamentum
flavum is removed as completely as possible.The spinous processes are trimmed to make bone grafts and bone chips. The
spinous processes are reformed into cubes measuring 15 to 20 mm by 10 to 15 mm
and are used for bone graft. A transverse hole is made in each graft. Any
remaining bone is used to make bone chips.The wire is inserted, and the opened rotated laminae are fastened
(Fig. 3). The wire or the nylon
suture is passed through the holes in the lamina, the bone graft, and the
articular process. The wire or suture is firmly tightened after the bone graft
is interposed into the gap on the open side.Bone graft and fat-tissue graft are inserted (Figs.
4-A,
4-B, and
4-C). After completion of the
wiring, the hinged side of the laminae, including the articular processes, is
thoroughly decorticated with a power drill and bone chips or corticocancellous
strips of bone harvested from the iliac crest are applied over the
decorticated area. Free fat tissue is placed in the epidural spaces, which are
open between the laminae.After a suction drain is placed, the wound is closed.
A groove is created in the laminae. After the spinous processes of the
target laminae are removed, the laminae are cut with use of a high-speed air
drill.
A tunnel is made for wire passage (Fig.
1). Just prior to mobilization of the laminae, small holes are
made in each lamina on the side to be opened. The holes pass from the area of
the removed spinous process to the groove and from the groove to the lateral
surface of the laminae.
The wire is passed through the holes. A 0.3-mm braided steel wire, a 0.4-mm
monofilament steel wire, or a number-1 braided nylon suture is passed through
the holes of the lamina.
Rotatory elevation of the lamina and intraspinal intervention are performed
(Fig. 2). The laminae are
completely detached along the groove on the side to be opened with use of a
diamond burr, and the ligamentum flavum is also dissected free on the same
side with a knife. On the hinged side, an incomplete separation of the laminae
is created by means of interrupted perforations of the internal cortex with
use of a diamond burr. Then, the laminae are turned up to an angle of at least
45°. The undersurface of the groove facing the lateral recess of the
spinal canal is trimmed with a rongeur and curet, and the remaining ligamentum
flavum is removed as completely as possible.
The spinous processes are trimmed to make bone grafts and bone chips. The
spinous processes are reformed into cubes measuring 15 to 20 mm by 10 to 15 mm
and are used for bone graft. A transverse hole is made in each graft. Any
remaining bone is used to make bone chips.
The wire is inserted, and the opened rotated laminae are fastened
(Fig. 3). The wire or the nylon
suture is passed through the holes in the lamina, the bone graft, and the
articular process. The wire or suture is firmly tightened after the bone graft
is interposed into the gap on the open side.
Bone graft and fat-tissue graft are inserted (Figs.
4-A,
4-B, and
4-C). After completion of the
wiring, the hinged side of the laminae, including the articular processes, is
thoroughly decorticated with a power drill and bone chips or corticocancellous
strips of bone harvested from the iliac crest are applied over the
decorticated area. Free fat tissue is placed in the epidural spaces, which are
open between the laminae.
After a suction drain is placed, the wound is closed.