reoperations after minimally invasive lumbar spine surgery

REOPERATIONS AFTER MINIMALLY INVASIVE LUMBAR SPINE REOPERATIONS AFTER MINIMALLY INVASIVE LUMBAR SPINE

SURGERY BECAUSE OF RECURRENT DISC HERNIATION: SURGERY BECAUSE OF RECURRENT DISC HERNIATION:

PROSPECTIVE STUDYPROSPECTIVE STUDY

MEMORIAL ŞİŞLİ HOSPITALNEUROSURGERY CLINIC

İSTANBUL, TURKEY

Yunus AYDIN, MD

Halit ÇAVUŞOĞLU, MD

Okan KAHYAOĞLU, MD

~No instability in patients with degenerative lumbar disc disease

and spinal stenosis before operation. Surgeons create it.

~Adjacent segment disease eliminated by avoiding fusion

~No more fusion, no more metal

~Discharge same day or 1 day after surgery

SIMPLY THE BEST!!

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Volume 57 (Issue1): pages 5-13, 2002

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Topic: 27 Spinal degenerative diseases

Title: LONGTERM OUTCOME AFTER UNILATERAL APPROACH FOR BILATERAL DECOMPRESSION OF LUMBAR SPINAL STENOSIS: 9-YEAR PROSPECTIVE STUDY

Author(s): Y. Aydın, H. Çavuşoğlu, A.M. Müslüman, A. Yilmaz, O. Kahyaoğlu, Y. Şahin

Institute(s): Neurosurgery Clinic, Şişli Etfal Education and Research Hospital, Istanbul, Turkey

Text: Introduction: The aim of our study is to evaluate the results and effectiveness of bilateral decompression via a unilateral approach in the treatment of degenerative lumbar spinal stenosis.Methods: We have conducted a prospective study to compare the midterm outcome of unilateral laminotomy with unilateral laminectomy. 100 patients with 269 levels of lumbar stenosis without instability were randomized to two treatment groups: unilateral laminectomy (Group 1), and laminotomy (Group 2). Clinical outcomes were assessed with the Oswestry Disability Index (ODI) and Short Form-36 Health Survey (SF-36). Spinal canal size wasmeasured pre- and postoperatively.Results: The spinal canal was increased to 4-6.1-fold (mean 5.1 ± SD0.8-fold) the preoperative size in Group 1, and 3.3-5.9-fold (mean 4.7± SD 1.1-fold) the preoperative size in Group 2. If theanteroposterior diameter of the spinal canal (APD) was normal, laminotomies provided adequate decompression. If the APD was reduced, laminectomies provided more adequate decompression. If the transverse diameter and APD were normal, removing the hypertrophic ligamentum flavum alone provided adequate decompression. The mean follow-up time was 9 years (range 7-10 years). The ODI scores decreased significantly in both early and late follow-up evaluations and the SF-36 scores demonstrated significant improvement in late follow-up results in our series. Analysis of clinical outcome showed no statistical differences between two groups.Conclusions: For degenerative lumbar spinal stenosis unilateral approaches allowed sufficient and safe decompression of the neural structures and adequate preservation of vertebral stability, resulted in a highly significant reduction of symptoms and disability, and improved health-related quality of life.

Author Keywords: Laminectomy, Laminotomy, Lumbar spinal stenosis, Unilateral approach, Vertebral stability.

Presentation Type: Oral Presentation

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OUR BIOMECHANICAL STUDY

~914 patients (group 1) with 1012 levels of lumbar disc

herniation underwent microdiskectomy

~1063 patients (group 2) with 2588 levels of degenerative

lumbar spinal stenosis

*patients underwent one or multilevel bilateral decompression

via unilateral approach

*228 patients underwent concomitant diskectomies at the

index level

~Totally 1240 levels microdiskectomy were done

~Mean follow-up time was 14 years,

MATERIAL & METHOD

(1) lumbar disc herniation with neurological deficits

(2) symptoms of neurogenic claudication referable to the lumbar spine

(3) radiological/neuroimaging evidence of lumbar disc herniation and/or

degenerative lumbar stenosis

(4) failure of conservative measures

(5) the absence of associated pathology such as instability, inflammation or

malignancy

INDICATIONS

• A 2 cm skin incision (for 1 level disc herniation)

• A modified mini Taylor retractor

• The ligamentum flavum was released and preserved as a 3-

sided flap

• Bipolar coagulation is avoided as much as possible !..

• The disk content was totally removed and ligamentum flavum

and a pediculated fat graft was used to cover the root at the

end.

~ re-opening is easier when the ligament protected

SURGICAL PROCEDURE (disc herniation)

Lumbar microdiskectomy technique with preserving Lumbar microdiskectomy technique with preserving ligamentum flavumligamentum flavum

SURGICAL PROCEDURE (disc herniation + stenosis)

BBilateralilateral decompression via a unilateral approach and decompression via a unilateral approach and microdiskectomymicrodiskectomy

• A 2–4 cm skin incision (for 2–5 level stenosis)

• A linear median fascial incision (on the patient’s most symptomatic side)

• A modified mini Taylor retractor

• Ipsilateral decompression is made (with pneumatic kerrison rongeurs and a high-speed burr),

• The microscope is angulated medially and, the patient tilted contralaterally, to afford visualization across the midline beneath the deepest portion of the interspinous ligament.

• Resection of portions or all of the interspinous ligaments, and supraspinous ligaments is not performed.

SURGICAL PROCEDURE (disc herniation + stenosis)

BBilateralilateral decompression via a unilateral approach and decompression via a unilateral approach and microdiskectomymicrodiskectomy

• The contralateral portion of ligamentum then is resected sequentially

from cephalad to caudal with curved curettes and Kerrison rongeurs.

• The microscope then is angulated into the contralateral subarticular

zone and,

• Soft tissue and bony stenosing pathology is excised using high-speed

drill and pneumatic kerrison rongeurs.

• This is done sequentially until nerve root at the operative level is seen

exiting freely into the foramen.

• If necessary, disk material is removed (ipsi- or contralaterally).

• To reduce postoperative granulation, the decompressed nerve roots are

protected with small blocks of fat resected from subfascial tissue.

Intraoperative views;1, 2 - Contralateral diskectomy3 - View of after contralateral diskectomy.4,5,6 - Bilaterally decompressed dural sac. 7 - View of contralateral nerve root after the contralateral decompression (white arrow)

35 (3.8%) patients with 46 (4.5%) levels disc herniation were underwent reoperation.

~ Mean recurrence time was 45 months (range 1 – 84 months),

~ 6 patients with different level,29 (% 3,1) patients with same level

recurrence,

~ 4 patients with 2 times recurrence,

~ 2 patients with 3 times recurrence,

~ 1 patient with 4 times recurrence

~ 5 of them underwent bilateral decompression via unilateral approach and

microdiskectomy,

~ recurrence were seen at 3 patients but reoperation were not required.

Mean age were 39.4 years

RESULT (disc herniation)

13 (1.2%) patients with 14 (0.5%) levels disc herniation were underwent

reoperation.

~ Mean recurrence time was 19 months (range 1 – 54 months),

~ 4 patients with different level,9 (% 0,8) patients with same level

recurrence,

~ 1 patient with 2 times recurrence (one same, one

different level) ~ recurrence were seen at 1 patients but reoperation were

not required.

Mean age were 61,8 years

RESULT (disc herniation + stenosis)

• The ODI scores decreased significantly in both early and late follow-

up evaluations. (Newman-Keuls multiple comparison test, p < 0.0001)

RESULT (Oswestry Disability Index)

 Disc herniation

(Group1)Disc herniation and Stenosis (Group 2)

Preop. 29.62 ± 8.19 32.14 ± 9.27

Early postop. 12.22 ± 6.46 13.22 ± 9.88

Late postop. 12.40 ± 6.30 12.02 ± 9.27

Quality of life

The scores demonstrated a marked and

significant improvement

(except in the areas of emotional role)

RESULT (Short Form 36)

Group  

 Disc herniation (Group1)

Disc herniation and Stenosis

(Group 2) P

Physical Function

Preop 56.12 ± 11.43 55.16 ± 9.03 0.642

Early 71.62 ± 8.81 71.80 ± 7.71 0.811

Late 70.56 ± 9.90 72.78 ± 10.8 0.776

Physical Role

Preop 27.50 ± 11.57 28.50 ± 11.08 0.66

Early 44.80 ± 9.57 45.20 ± 10.38 0.841

Late 47.62 ± 11.32 46.20 ± 9.70 0.502

Body Pain

Preop 43.24 ± 11.77 42.60 ± 10.31 0.773

Early 61.78 ± 11.92 62.64 ± 9.52 0.7

Late 68.32 ± 9.92 69.64 ± 10.52 0.459

General Health

Preop 53.62 ± 10.54 52.66 ± 9.03 0.202

Early 60.62 ± 11.28 59.66 ± 10.52 0.202

Late 63.12 ± 9.61 60.96 ± 13.98 0.122

Vitality/Energy

Preop 41.84 ± 11.57 42.12 ± 13.90 0.326

Early 60.12 ± 10.57 59.38 ± 10.11 0.33

Late 61.62 ± 10.65 62.66 ± 11.67 0.202

Social Function

Preop 41.88 ± 11.35 42.96 ± 10.16 0.235

Early 49.63 ± 10.54 49.67 ± 9.03 0.202

Late 50.27 ± 9.65 50.31 ± 11.24 0.202

Emotional Role

Preop 61.28 ± 10.23 62.14 ± 11.58 0.459

Early 63.54 ± 9.54 63.24 ± 9.85 0.459

Late 62.74 ± 12.54 61.95 ± 10.35 0.788

Mental Health

Preop 60.98 ± 11.58 61.84 ± 10.35 0.459

Early 71.38 ± 12.65 72.24 ± 9.52 0.459

Late71.27 ± 9.68 70.49 ± 12.8 0.776

P showing comparison of the mean scores of two groups

Quality of life

As expected, in the elderly group were less likely to

recurrence.

For this group less mobile and/or fixed spine

advantages, disadvantages of fragility should be.

~ osteophytes with thickening of the ligaments result in decreased mobility of the spine as aging occurs, with natural fusion occurring between vertebral bodies by the osteophytes. ~ the addition of instrumentation to this natural process does not give any added advantage.

CONCLUSION

For degenerative compressive lumbar spinal lesions minimally invasive spine surgery with low recurrence rate

• allowed sufficient and safe decompression of the neural structures,

• allowed adequate preservation of vertebral stability,

• resulted in a highly significant reduction of symptoms and disability,

• improved health-related quality of life.

CONCLUSION

Case Samples Case Samples

BURAYA VİDEO LİNKİ YAPILACAK

Pre-Pre-opop

Post-op 7th monthsPost-op 7th months““RECURRENT DISC RECURRENT DISC HERNIATION”HERNIATION”

1 level 1 level stenosisstenosis

Pre-Pre-opop

2 levels 2 levels stenosisstenosis

Post-op 6th Post-op 6th monthsmonths “ “FAR LATERAL FAR LATERAL HNP”HNP”

Pre-Pre-opop

Post-Post-opopPost-op 6th monthsPost-op 6th months

Different level Different level “RECURRENCE”“RECURRENCE”

3 levels 3 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

1 level 1 level stenosisstenosis

Pre-Pre-opop

Post-Post-opop

1 level 1 level stenosisstenosis

Pre-Pre-opop

Post-Post-opop

1 level 1 level stenosisstenosis

ADJACENT SEGMENT ADJACENT SEGMENT DISEASEDISEASE

Pre-Pre-opop

Post-Post-opop

1 level 1 level stenosisstenosis

Pre-Pre-opop

Post-Post-opop

1 level 1 level stenosisstenosis

Pre-Pre-opop

Post-Post-opop

1 level 1 level stenosisstenosis

Pre-Pre-opop

Post-Post-opop

ADJACENT SEGMENT ADJACENT SEGMENT DISEASEDISEASE

Pre-Pre-opop

Post-Post-opop

2 levels 2 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

2 levels 2 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

2 levels 2 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

L4-5

L4-5L4-5

L5-S1 L5-S1

2 levels 2 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

2 levels 2 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

2 levels 2 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

DORSAL + LUMBAR DORSAL + LUMBAR STENOSISSTENOSIS

3 3 levelslevels

L3-4 L3-4

L4-5 L4-5

L5-S1 L5-S1

POST-OP.PRE-OP.

3 levels 3 levels stenosis stenosis and and disc disc herniationsherniations

Pre-Pre-opop

Post-Post-opop

3 levels 3 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

3 levels 3 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

3 levels 3 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

3 levels 3 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

3 levels 3 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

3 levels 3 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

L4-5 L4-5

L3-4 L3-4

L5-S1L5-S1

3 3 levels levels stenosstenosisis

Pre-Pre-opop

Post-Post-opop

2 incision

3 levels 3 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

3 levels 3 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

4 levels 4 levels stenosisstenosis

4 levels stenosis 4 levels stenosis and and L2 vertebroplastyL2 vertebroplasty

Pre-Pre-opop

Post-Post-opop

4 levels 4 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

4 levels 4 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

4 levels 4 levels stenosisstenosis

Pre-Pre-opop

Post-Post-opop

4 levels 4 levels stenosisstenosis

THANK YOUQ & A

MEMORIAL ŞİŞLİ HOSPITALNEUROSURGERY CLINIC

İSTANBUL, TURKEYYunus AYDIN, MD Halit ÇAVUŞOĞLU, MDOkan KAHYAOĞLU, MD