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PubMed1998

Effect of laminectomy on measured bone density.

Three cases are reported of women who had resection of the posterior vertebral elements. This permitted comparison of the density of the central or "void" area with that of the entire vertebra (L4), as well as with the mean value of bone at the right and left sides of the vertebral body, and with the results of both L2 and L3. The ratio-density of the center/density of the whole vertebra-was 0.497, 0.514, and 0.508 in these three cases (mean 0.506). The ratio of the density of the center/density of the right and left sides of the body of the three involved L4 vertebrae averaged 0.470. The results indicate that the posterior elements make a significant contribution to measured bone density. Further studies are needed regarding the variation of these values with the aging process and use of medications.

Journal Article↗
PubMed1989

Percutaneous posterolateral lumbar discectomy. An alternative to laminectomy in the treatment of backache and sciatica.

The evacuation and decompression of the herniated lumbar disc (HLD) through a sheath or cannula inserted dorsolaterally represent a new concept in the treatment of backache and sciatica associated with disc herniation. Under local anesthetic and Valium (Roche, Nutley, New Jersey) sedation, 20 patients with sciatica, restricted straight-leg raising, and neurological impairment were treated by this simple and safe technique. All patients had computed tomographic evidence of L4-L5 protrusion. The introduction of a sheath with an internal diameter of 4.9 mm permitted removal of the nuclear material by means of a small pituitary forcep. Using the self-assessment method of Coventry and Stauffer, it was concluded that 12 of the 20 patients had a good or fair result. Predictably, the compensation patients fared poorly. There were no complications. This technique appears applicable in HLD to properly selected patients, and it would seem that it is safe, effective, and cost efficient.

Adult↗
PubMed1996

Postchemonucleolysis discectomy versus repeat discectomy: a prospective 1- to 13-year comparison.

This long-term prospective study evaluates the clinical results of subsequent laminectomy in 103 consecutive patients who initially underwent chemonucleolysis (CNL) or laminectomy for lumbar disc herniation. Between 1981 and 1994, 53 patients who had received CNL initially and then underwent laminectomy and 50 patients treated initially with laminectomy underwent a repeat laminectomy. Clinical assessment at 6 weeks showed a success rate of 80.8% for post-CNL laminectomy and 78% for repeat laminectomy. At 6 months, the success rate for patients treated with CNL was 86% versus 78.7% for laminectomy. At 12 months, the overall success rate for the CNL group was 80.4% versus 83.3% for the laminectomy group, but in patients who had not obtained relief from the first procedure the success rate for the second procedure was higher for the post-CNL patients. A questionnaire was sent to all patients for 1- to 13-year follow-up review. The average follow-up period was 6.6 years for post-CNL laminectomy and 5.2 years for repeat laminectomy. The long-term success rate (81.8%) was higher in the post-CNL group compared to 64.4% in the repeat laminectomy group. Seven patients in the post-CNL group and nine in the repeat laminectomy group had undergone a third operation. When these originally successfully treated patients were reassigned after unsuccessful outcomes, the success rate for the CNL groups was 72.7%, versus 51.1% in the laminectomy group (p = 0.049). Employment rates were 80% for patients with CNL (21.8% changed jobs) and 76.3% for patients undergoing laminectomy (48.3% changed jobs) (p = 0.036). In conclusion, patients who underwent laminectomies after receiving CNL had significantly better long-term results than those who had repeat laminectomies.

Adult↗
PubMedDate not supplied

Topical high-molecular-weight hyaluronan and a roofing barrier sheet equally inhibit postlaminectomy fibrosis.

BACKGROUND CONTEXT: The relevance of epidural fibrosis to failed back surgical outcomes remains controversial. Previous studies on the correlation between epidural fibrosis and clinical outcome after laminectomy are inconclusive, and clinical approaches applied to reduce postlaminectomy spinal canal scarring have produced mixed outcomes. PURPOSE: Improved preclinical models are required to address the fundamental question of the relationship between postlaminectomy fibrosis and chronic pain. This study is directed at establishing small animal postlaminectomy models characterized by significantly reduced scar within the spinal canal postoperatively. Such preclinical models are offered as a platform for future studies to explore the potential relationship between postlaminectomy epidural fibrosis and persistent neuropathy with its potential for altered spinal mechanisms for pain processing, so-called spinal facilitation. Such experiments could be constructed in these models for comparison of pain behavior and its underlying neurochemistry both in the presence and absence of extensive postlaminectomy epidural scar. STUDY DESIGN/SETTING: A modified rat laminectomy model was employed to assess epidural fibrosis using a quantitative biochemical collagen assessment approach along with correlative histology. This group served as the control for comparison with groups in which antifibrotic measures were employed. We compared antifibrotic efficacy of a bioabsorbable roofing barrier sheet placed over the laminectomy defect with topical high-molecular-weight hyaluronan (HMW HA) gel, each applied postoperatively to prevent proliferative epidural scarring. Routine biomechanical tensile strength testing was employed to assess wound-healing strength. METHODS: A bilateral laminectomy (L5 and L6) with associated unilateral disc injury (L5-L6) was performed in 98 male Harlan Sprague-Dawley rats. The laminectomy models described incorporated a unilateral disc injury at L5-L6 because herniated disc material has been shown to contribute proinflammatory cytokines in the postoperative wound. Five groups were employed for the study: 1) normal controls without surgery; 2) a laminectomy-disc injury group without treatment; 3) a laminectomy-disc injury group treated with topical HMW HA gel; 4) a laminectomy-disc injury group treated with 0.2-mm thick bioabsorbable roofing barrier sheet in which a protected space was maintained between overlying paraspinous muscles and the dura and 5) a 0.02-mm thin barrier sheet treatment group in which the sheet was placed directly on the dura. The animals were sacrificed at 3- and 8-week postoperative intervals for analysis. The dissected specimens were studied biochemically for hydroxyproline content to estimate total collagen within the canal and on the dura between L4 and L7. Additional specimens were prepared histologically and stained with Masson-Goldner Trichrome stain to confirm presence of proliferative collagen and to describe the presence or absence of wound-healing scar adherence to the dura. The surgical incisions were studied biomechanically by uniaxial tensile testing to determine ultimate force, strain and prefailure stiffness. Statistics were performed using analysis of variance. RESULTS: Gross appearance and histology studies showed that the untreated laminectomy group demonstrated postoperative scar formation that is adherent between the wound and the dorsum of the dura mater in both 3- and 8-week groups. Proliferative scar was substantially increased grossly between the 3- and 8-week intervals. By gross observation there was adherence of the L5 spinal nerve to the underlying disc and adjacent pedicle on the disc injury side. Gross observation of treatment groups, in contrast, disclosed that both the 0.2-mm thick roofing barrier sheet and topical HMW HA gel each prevented scar attachment to the dural sleeve at both the 3- and 8-week postoperative intervals. Furthermore, both the HMW HA gel and 0.2-mm thick roofing barrier sheet treatment groups had significant reduction of total collagen content in the laminectomy specimens measured biochemically at the two time periods compared with the untreated controls. Histologically, the HMW HA gel and the 0.2-mm thick barrier sheet findings were consistent with the gross observations concerning lack of adherence between scar of the overlying wound and the dura. Notably, both the 0.2- and the 0.02-mm barrier sheets became enveloped by a fibrotic envelope consistent with a foreign body reaction. In the group in which the 0.02-mm thin sheet was placed within the canal on top of the dura, there was an increase of fibrosis around the sheet within the canal leading to a space-occupying mass within the canal. Although the 0.2-mm thick roofing barrier placed external to the canal became enveloped by scar, it appeared to attract proliferative scar away from the epidural space, leaving the dura relatively free of scarring or adherence to overlying tissues. The mechanical properties of the incisional wound increased significantly between 3 and 8 weeks. The ultimate strength, stress, strain and stiffness of the several groups were similar at each time point. CONCLUSION: These results provide two preclinical rat laminectomy models of potential usefulness for the future study of the relevance of epidural fibrosis to behaviorally defined pain states, and for the study of the potential of an altered neurochemical signature in postlaminectomy pain conditions. Such preclinical models have become standard in studies of pain behavior and its neurochemistry in preclinical sciatic nerve and spinal nerve injury models, and should be of utility in the studies of postlaminectomy fibrosis. There was progressive scar proliferation and maturation in the untreated postlaminectomy group in the postoperative interval between 3 and 8 weeks. HMW HA gel applied topically and a 0.2-mm thick bioabsorbable Macropore sheet used as a roofing barrier each significantly reduced postlaminectomy proliferative scar without affecting the integrity of incisional wound healing. However, if the 0.02-mm thin barrier sheet used in this study is placed within the canal in contact with the dura and adjacent to the pedicles, the process of reabsorption results in a fibrotic mass within the canal. The preferred barrier sheet placement for this model is clearly in a roofing position bridging over the open epidural space. It must be placed in a manner to block off the paraspinous muscle healing response and still leave a gap between the sheet and the dura.

Adjuvants, Immunologic↗
PubMed2001

[Efficacy of arthrodesis in the posterior approach of cervical myelopathy: comparative study of a series of 36 cases].

OBJECTIVE: The effectiveness of arthrodesis associated to laminectomy as a treatment for cervical myelopathy has been retrospectively evaluated analysing the clinical evolution of 36 patients as well as the change in cervical column saggittal curvature comparing a group of patients with a simple laminectomy to another in whom laminectomy was accompanied by posterior arthrodesis. MATERIAL AND METHODS: 36 posterior approaches were performed to treat patients diagnosed of spondyloartrosic myelopathy between 1992 and 1999; 19 cases were treated with a simple laminectomy and other 17 also underwent arthrodesis with posterior instrumentation. The clinical evolution (using grades 0-5 on the Nurick scale) and cervical curvature have been evaluated for an average time interval of 40 months. RESULTS: Patients treated with laminectomy plus arthrodesis showed an average 1.24 point improvement on the Nurick scale in comparison to the 0.84 point improvement observed in patients treated with laminectomy alone. The cervical curvature attained a more physiological angulation in 53% of the patients with an arthrodesis and in 29% of the patients with simple laminectomy; curvature worsened in 7% of the patients with arthrodesis and in 24 degrees/a of those with laminectomy alone. CONCLUSION: Cervical myelopathy cases requiring a posterior approach for laminectomy obtain a better clinical evolution when an arthrodesis with posterior instrumentation is associated with the laminectomy. These patients also present improved cervical curvature as compared to the group without instrumentation.

Adult↗
PubMed2006

Surgical treatment of 40 patients with thoracic ossification of the ligamentum flavum.

OBJECT: The authors evaluated different surgical methods used to treat thoracic ossification of the ligamentum flavum (OLF). METHODS: Data obtained in 40 patients who underwent posterior decompression for thoracic myelopathy caused by thoracic OLF were studied retrospectively. There were 32 men and eight women. All patients underwent posterior decompression in which laminoplasty was performed or laminectomy combined with lateral fusion. Every surgical specimen was stained with H & E, and scanning electron microscopy was performed in 20 cases. The mean follow-up period was 28 months. Postoperative outcomes were evaluated using a recovery scale based on the Japanese Orthopaedic Association classification. There were a total of 168 ossified segments in this series, 77.4% of which were located in the lower thoracic spine. Marginal osteophyte formation was found in 36 patients; in 32 of the 36 patients, these marginal osteophytes were located at the intervertebral space either higher or lower than the ossified segment. Scanning electron microscopy showed elastic fiber breakdown, proliferation of collagenous fibers, calcification, and OLF in the same microscopy region. Laminoplasty was performed in four patients. In three cases surgery resulted in unchanged or worse outcome (increased kyphotic deformity in two), and in one it resulted in good outcome. Laminectomy combined with lateral fusion was performed in 36 patients, in 30 cases of which it resulted in a good or fair outcome, and increased kyphotic deformity in only one. Of these 36 laminectomy-treated patients, an en bloc laminectomy-treated procedure was performed in 16 patients; in 11 of the 12 patients with lateral or diffuse-type lesions the surgery resulted in a good or fair outcome. En bloc laminectomy, however, seems ineffective in the treatment of patients with thickened, nodular-type thoracic OLF, as the procedure resulted in worse outcome in two of the four patients. The authors have thus developed a new modality of laminectomy that they have termed "separating laminectomy," which they performed in 16 patients with thickened, nodular-type OLF; in 13 cases it resulted in a good or fair outcome, and in only one case did it result in a worse outcome. CONCLUSIONS: The pathogenesis of thoracic OLF is mainly due to the localized mechanical stress on the ligament. Laminectomy combined with lateral fusion is the treatment of choice for thoracic OLF; furthermore, in terms of the configuration of the ossified lesion, en bloc laminectomy is suitable for the treatment of lateral-type and diffuse-type OLF, and the separating laminectomy is suitable for the thickened, nodular-type OLF.

Aged↗
PubMed2007

Ossification of ligamentum.

OBJECT: The authors evaluated different surgical methods used to treat thoracic ossification of the ligamentum flavum (OLF). METHODS: Data obtained in 40 patients who underwent posterior decompression for thoracic myelopathy caused by thoracic OLF were studied retrospectively. There were 32 men and eight women. All patients underwent posterior decompression in which laminoplasty was performed or laminectomy combined with lateral fusion. Every surgical specimen was stained with H and E, and scanning electron microscopy was performed in 20 cases. The mean follow-up period was 28 months. Postoperative outcomes were evaluated using a recovery scale based on the Japanese Orthopaedic Association classification. There were a total of 168 ossified segments in this series, 77.4% of which were located in the lower thoracic spine. Marginal osteophyte formation was found in 36 patients; in 32 of the 36 patients, these marginal osteophytes were located at the intervertebral space either higher or lower than the ossified segment. Scanning electron microscopy showed elastic fiber breakdown, proliferation of collagenous fibers, calcification, and OLF in the same microscopy region. Laminoplasty was performed in four patients. In three cases surgery resulted in unchanged or worse outcome (increased kyphotic deformity in two), and in one it resulted in good outcome. Laminectomy combined with lateral fusion was performed in 36 patients, in 30 cases of which it resulted in a good or fair outcome, and increased kyphotic deformity in only one. Of these 36 laminectomy-treated patients, an en bloc laminectomy-treated procedure was performed in 16 patients; in 11 of the 12 patients with lateral or diffuse-type lesions the surgery resulted in a good or fair outcome. En bloc laminectomy, however, seems ineffective in the treatment of patients with thickened, nodular-type thoracic OLF, as the procedure resulted in worse outcome in two of the four patients. The authors have thus developed a new modality of laminectomy that they have termed "separating laminectomy," which they performed in 16 patients with thickened, nodular-type OLF; in 13 cases it resulted in a good or fair outcome, and in only one case did it result in a worse outcome. CONCLUSIONS: The pathogenesis of thoracic OLF is mainly due to the localized mechanical stress on the ligament. Laminectomy combined with lateral fusion is the treatment of choice for thoracic OLF; furthermore, in terms of the configuration of the ossified lesion, en bloc laminectomy is suitable for the treatment of lateral-type and diffuse-type OLF, and the separating laminectomy is suitable for the thickened, nodular-type OLF.

Adult↗
PubMed1997

Incidence of postlaminectomy kyphosis after Chiari decompression.

STUDY DESIGN: In this retrospective study, a 5-year series of a pediatric population undergoing Chiari decompressions is reviewed. OBJECTIVES: To review the experience with children treated with suboccipital craniectomy and uni- or multilevel cervical laminectomy for Chiari malformation, to determine the incidence of kyphosis and to identify factors predictive of cervical instability. SUMMARY OF BACKGROUND INFORMATION: Upper cervical laminectomy in the pediatric population has a significant risk of postoperative kyphosis. To decrease the incidence of this complication, a concerted effort was made to avoid violation of the facet joint during cervical laminectomy. METHODS: Thirty-two patients (mean age 4.9 years, range 1 day to 18 years) had surgical decompression of Chiari I or II malformations throughout a 5-year period (1989-1994). Radiographs and operative records were analyzed to determine the number of cervical levels decompressed and extent of laminectomy. RESULTS: Mean follow-up was 3.7 years (range 9 months to 7 years). Only one patient had clinical and radiographic evidence of kyphosis and required C2-C3 fusion. Two others had radiographic signs of mild cervical kyphosis but remained asymptomatic. These three patients had two-level complete laminectomies. Twenty-nine patients had no clinical or radiographic evidence of cervical instability. A mean of three cervical levels were decompressed (range 0-4), including partial laminectomies, complete laminectomies, and one osteoplastic laminotomy to drain a lower cervical syrinx. The overall frequency of kyphosis in this series (9%) was substantially lower than in previous reports. Although the number of cervical levels decompressed did not correlate with cervical instability, the one patient with clinical instability had inadvertent violation of the facet joint, suggesting that overaggressive laminectomy may be a critical factor that predisposes patients to postoperative kyphosis. CONCLUSION: Cervical kyphosis after Chiari decompression is a recognized complication of cervical laminectomy in children, the frequency of which may be decreased by careful attention to operative technique.

Adolescent↗
PubMed1999

Long-term outcome of patients with intraspinal neuroblastoma.

BACKGROUND: Chemotherapy, radiotherapy, and surgical decompression with laminectomy are effective therapeutic options in the treatment of cord compression from neuroblastoma (NB). We report the long-term outcome of patients with intraspinal NB treated with or without laminectomy at two large pediatric oncology centers. PROCEDURE: We reviewed the medical records and radiographs of 26 children with intraspinal NB treated at Children's Memorial Hospital in Chicago, Illinois, between 1985 and 1994 or at St. Jude Children's Research Hospital in Memphis, Tennessee, between 1967 and 1992. RESULTS: Twenty-four of the 26 patients are alive and disease-free (follow-up of 2-29 years; median, 10 years 2 months). Fifteen of the 23 patients with neurologic impairment underwent initial laminectomy. Nine of these 15 patients recovered neurologic function, including 3 patients who presented with paraplegia. Eleven of the 15 patients who underwent laminectomy have developed mild to severe spinal deformities. Eight patients with neurologic symptoms consequent to cord compression were treated with initial chemotherapy and/or surgery, but did not undergo laminectomy. Three patients with mild to moderate deficits recovered neurologic function. Four of 11 patients with intraspinal NB who did not undergo laminectomy have mild to severe scoliosis. CONCLUSIONS: A low incidence of neurologic recovery was seen in patients with long-standing severe cord compression regardless of treatment modality. For patients with partial neurologic deficits, recovery was seen in most patients following chemotherapy or surgical decompression with laminectomy. A higher incidence of spinal deformities was seen in the patients treated with initial laminectomy.

Child↗
PubMed2005

Experimental rabbit hemilaminotomy model in the evaluation of peridural fibrosis: a minimally invasive peridural fibrosis model.

The neuronal adhesions of newly synthesized scar tissue to dura mater after spinal peridural operations represent an unsolved problem in neurosurgical practice. This experimental study was planned to compare the success of a rabbit hemilaminotomy procedure with the total laminectomy model in the evaluation of peridural fibrosis in terms of proposing a lesser invasive peridural adhesion model. Fourteen New Zealand white rabbits were used in this experiment. Laminectomy was performed in one level, and hemilaminotomy was done in another level. Four weeks after operation the rabbits were sacrificed by perfusion with 10 % neutral buffered formalin solution. The lumbar spines were removed and immersed in 10 % neutral buffered formalin for approximately 24 hours. Then each specimen was decalcified in 5 % formic acid for approximately 3 weeks. Specimens were cut coronally for gross inspection. Two blocks of tissue were taken from each laminectomy site to be processed and embedded in paraffin. In seven (50 %) of the laminectomy sites of the rabbits, fibrous tissue penetrated the spinal canal through the laminectomy defect and produced neural compression (Grade III). Eight (57 %) hemilaminotomy sites were in Grade III fibrosis. There was no difference between laminectomy and hemilaminotomy in regard to the dural adhesions. In this experimental study, we modified the rabbit total laminectomy model by using a hemilaminotomy procedure in the study of peridural scar formation. The authors conclude that this procedure is more simple, reliable, and lesser invasive than the total laminectomy model.

Animals↗
PubMed1997

Postlaminectomy adhesion of the cauda equina. Changes of postoperative vascular permeability of the equina in rats.

STUDY DESIGN: The authors evaluated the vascular permeability changes of the cauda equina after lumbar laminectomy in rats. OBJECTIVES: To clarify the early vascular responses in postlaminectomy adhesive arachnoiditis. SUMMARY OF BACKGROUND DATA: Laminectomy-induced cauda equina adhesion has been visualized by postoperative serial magnetic resonance imaging in humans. In laminectomized rats, fibrinous exudation was apparent among the adhered cauda equina. To date, there has been no report of substantial changes in vascular permeability in the cauda equina after lumbar laminectomy. METHODS: Wistar rats laminectomized from L5-L6 were used for four studies; 1) Evans blue albumin tracer study; 2) horseradish peroxidase tracer study; 3) lanthanum tracer study; and 4) fluoroscein isothiocyanate-dextran (molecular weights: 20K, 70K, and 150K) tracer study. Untreated rats were used as controls. RESULTS: 1) In the laminectomized (L5-L6) area, the cauda equina tended to conglomerate from 3 hours after surgery; this was relatively resolved by 6 weeks. Extravascular leakage of Evans blue albumin in the cauda equina appeared at 3 hours after surgery and reached a plateau at 24 hours; it mostly disappeared by 6 weeks. At 24 hours after surgery, the extent of Evans blue albumin extravasation was seen in one or more levels adjacent to the laminectomized area. Evans blue albumin leakage and cauda equina adhesion started to appear in nearly a same phase after laminectomy, followed by a plateau of vascular permeability facilitating complete cauda equina adhesion by 24 hours after surgery. The restoration of Evans blue albumin leakage was noted 1 week after surgery, and tended to precede recovery of the cauda equina adhesion; 2) in the laminectomy group, Horseradish peroxidase penetrated from the lumen to the extracellular space beyond the basal laminae of the endothelial cells. Numerous horseradish peroxidase-labeled vesicles in the endothelial cells were found; 3) There was a significant increase in lanthanum distribution in the endothelial cytoplasm at the laminectomized levels. Lanthanum filled the interendothelial clefts beyond the tight junction, but did not penetrate through the perivascular basal laminae; 4) Fluoroscein isothiocyanate-dextran (20K, 70K, 150K) permeability increased in the laminectomy group, but there was no difference in extravasation of fluoroscein isothiocyanate-dextran, irrespective of the molecular weight. CONCLUSION: Laminectomy consistently induced an increase in vascular permeability in the cauda equina, an increase of vesicular transport in the endothelial cell, and opening of the tight junction early after laminectomy, suggesting breakdown of the blood nerve barrier in the cauda equina. The accelerated permeability may enhance cauda equina adhesion.

Animals↗
PubMed2003

Biomechanical evaluation of cervical double-door laminoplasty using hydroxyapatite spacer.

STUDY DESIGN: In vitro three-dimensional kinematic changes after double-door cervical laminoplasty, with and without spacer, and laminectomy were studied in a human cadaveric model. OBJECTIVES: To evaluate the effects of multilevel double-door laminoplasty and laminectomy as compared with the intact and to assess the influence of the spinous process spacer on the stability of the cervical spine. SUMMARY OF BACKGROUND DATA: Double-door type cervical laminoplasty has been widely used in the treatment of multisegmental stenotic conditions. However, its biomechanical advantages over laminectomy remain controversial. Also, the biomechanical effects of spacers between the split laminae have not been investigated. METHODS: Using fresh cadaveric C2-T1 specimens, sequential injuries were created in the following order: intact, double-door laminoplasty (C3-C6) with insertion of hydroxyapatite spacers, laminoplasty without spacer, and laminectomy. Motions of each vertebra in each injury status were measured in six loading modes: flexion, extension, right and left lateral bending, and right and left axial rotation.RESULTS Cervical laminectomy showed significant increase in motion compared with intact control in flexion [25% (P < 0.001)], extension [19% (P < 0.05)], and axial rotation [24% (P < 0.001)] at maximum load. Double-door laminoplasty with hydroxyapatite spacer indicated no significant difference in motion in all loading modes compared with intact. Laminoplasty without spacer showed intermediate values between laminoplasty with spacer and laminectomy in all loading modes. Initial slack of each injury status showed trends similar to that of maximum load, although mean percent changes of laminectomy and laminoplasty without spacer were greater than that of maximum load. CONCLUSIONS: Double-door laminoplasty with hydroxyapatite spacer appears to restore the motion of the decompressed segment back to its intact state in all loading modes. The use of HA spacers well contributes to maintaining the total stiffness of cervical spine. In contrast, laminectomy seems to have potential leading postoperative deformity or instability.

Adult↗