Lecture Spine ULBD

ULBD: Unilateral Laminectomy Bilateral

Decompression

August 14, 2015 Upper Chesapeake Medical Center

Mixter and Barr JBJS 1934 was the first description of herniated discs causing sciatica with surgery as a successful treatment

Henk Verbiest1909-1997Dutch neurosurgeon introduced the concept of a developmental spinal stenosis 1940 due to a small AP diameter spinal canal

Red flag Nocturnal

pain Pain at rest Progressive

neurological deficit

Suspicious for cancer or infection

High index of suspicion

H/O cancer Osteoporosis/

steroids/immunosuppression

AS 10/10 Weight loss IVDA UTI/sepsis

Case 1 continued 81 year old man with long h/o L>R LE pain LBP PMH: prostate seeds age 44, HTN SH: retired carpenter EXAM: 6’ 220lb neuro intact

Kleeman, T.J., Hiscoe, A.C., Berg, E.E.: “Patient Outcomes Following Minimally DestabilizingLumbar Stenosis Decompression: The ‘Port Hole’ Technique”, Spine, April 2000.

Toyoda et al. Clinical Outcome of Microsurgical Bilateral Decompression via Unilateral Approach for Lumbar Canal Stenosis. Spine 2011; 36:410-415 Poletti CE. Central Lumbar Stenosis caused by ligamentum flavum unilateral laminectomy for bilateral ligamentectomy. Neurosurgery 1995; 37: 343-347

Prone Position

OSI Jackson Table 1

Slide a Ligamentumflavum

Optimal anatomy

L5S1

L4L5

L3L4

L2L3

L1L2

T12L1

T11T12

85 year old man with LBP and Bilateral sciatica with ambulation thatResolves with sitting

L5S1

L4L5

L4

L3L4

L3

L2L3

L2

81 year old man with long h/o L>R LE pain LBP PMH: prostate seeds age 44, HTN SH: retired carpenter EXAM: 6’ 220lb neuro intact

Case 1

144 single level, korea, Trefoil canal stenosis patients were more difficult to decompression due to angle of approach and patients had worse outcomes

J Neurosurg Spine. 2014 Aug;21(2):179-86. doi: 10.3171/2014.4.SPINE13420. Epub 2014 May 30.

Outcomes after decompressive laminectomy for lumbar spinal stenosis: comparison between minimally invasive unilateral laminectomy for bilateral decompression and open laminectomy: clinical article.

Mobbs RJ1, Li J, Sivabalan P, Raley D, Rao PJ.

79 patients prospective 1:1 ULBD v. open laminectomy, oswestry disability andPatient satisfaction were similar, ULBD had shorter stay 55 h v 100 h, shorter timeTo mobilize 15h v 33 h and more people not requiring opiates 51% v 15%

Neurosurgery. 2006 Dec;59(6):1264-9; discussion 1269-70.Long-term results of microsurgical treatment of lumbar spinal stenosis by

unilateral laminotomy for bilateral decompression.Oertel MF1, Ryang YM, Korinth MC, Gilsbach JM, Rohde V.

133 patients mean fu 5.6 years up to 10 years

Reoperation 11%, 2 instability, 7 restenosis

85% excellent to fair long term results

Dr M F Oertel Department of Neurosurgery, University Hospital, School of Medicine, Aachen University, Pauwelsstrasse 30, 52057 Aachen, Germany

ULBD pitfalls complications Restenosis( contralateral side) Dural tear Nerve injury Instability Persistent pain from facet Pars fracture Inadequate decompression

Normal?

Boden article: JBJS Vol. 72-A, No. 8, Sept 1990

<40 years N=167

<40 years >40 years N=97

>40 years

MAJOR MINORHerniated disc

3% 4% 1% 4%

Bulging disc 0 5% 1% 5%Foraminal stenosis

3% 4% 9% 14%

Disc space narrowing

2% 11% 16% 22%

Degenerative disc

8% 37%

Spurs 3% 14% 6% 34%Abnormal cord

9% 9% 1% 18%

FEATURE CASE: 77 year old woman cc L leg pain LBP s/p previous decompression 2 years ago

Short pedicles developmental/congenital stenosis

Case 2 58 year old man L>R LE pain s/p L L5S1 disc years ago

Case 2 58 year old man L>R LE pain s/p L L5S1 disc years ago

Case 2 58 year old man L>R LE pain s/p L L5S1 disc years ago

Case 2 58 year old man L>R LE pain s/p L L5S1 disc years ago

Case 2 58 year old man L>R LE pain s/p L L5S1 disc years ago

Case 2 58 year old man L>R LE pain s/p L L5S1 disc years ago

Case 3: 84 year old woman with L sciatica

Case 3: 84 year old woman with L sciatica

Case 3: 84 year old woman with L sciatica

Case 3: 84 year old woman with improved LBP postoperatively but worsened L sciatica

Thanks!