Minimally Invasive Bilateral Decompressive Lumbar Laminectomy with Unilateral Approach Among Obese versus Nonobese Patients

OBJECTIVE

Decompressive lumbar laminectomy (DLL) is a common procedure for lumbar stenosis. A unilateral approach, unlike the traditional open approach, spares the posterior elements to mitigate the risk of iatrogenic instability associated with a DLL. Various minimally invasive techniques have been described but little attention has been aimed toward this specific microsurgical approach, particularly regarding obese patients. We aimed to compare operative details, perioperative outcomes, and complication profiles between obese and nonobese patients.

METHODS

One hundred and ninety-four patients who underwent bilateral laminectomy with a unilateral approach by the study surgeon from July 2013 to June 2018 were included. Of these patients, 105 were classified as obese, with body mass index (BMI) ≥30.0 kg/m2, and 89 were nonobese, with BMI <30.0 kg/m2. The obese and nonobese groups were compared; operative time, blood loss, and complications were assessed.

RESULTS

Operative time was nonsignificantly increased in the obese group (177 vs. 166 minutes; P = 0.21) and estimated blood loss was nonsignificantly lower (91 mL vs. 97 mL; P = 1.00) in the obese group. Durotomy rates (3 [2.9%] obese vs. 2 [2.2%] nonobese; P = 0.789) and postoperative wound drainage rates (4 [3.8%] obese vs. 2 [3.8%] nonobese; P = 0.92) did not significantly differ between the 2 groups. Length of stay was significantly longer in the obese group (1.5 vs. 1.0 days; P = 0.0005).

CONCLUSIONS

Compared with the nonobese group, the obese group had significantly longer length of hospitalization, as well as nonsignificantly increased length of operation and decreased blood loss. The 2 groups had similar perioperative complication rates.

Microscopic Unilateral Approach for Bilateral Decompression of Lumbar Spinal Stenosis

BACKGROUND

This is a study based on single-surgeon data on spinal stenosis surgery via microscopic approach. The aim is to evaluate the effectiveness of the unilateral approach to bilateral decompression and the usage of Taylor retractors and brain spatula in patients with spinal stenosis.

METHODS

This is a retrospective study on bilateral decompression for lumbar spinal stenosis using a microscopic unilateral approach by a single surgeon, between April 2015 and March 2018. In total, 50 patients were operated due to single level lumbar spinal stenosis. All patients were evaluated by preoperative and postoperative plain radiographs and magnetic resonance (MR) images. Walking distance (WD), visual analog scale (VAS) for pain and Odom's criteria were evaluated for follow-up.

RESULTS

One level of the lumbar spine was surgically decompressed in all patients. The median age of patients was 64.6 (51- 82). Of the patients, 72% (36) were women, and 28% (14) were men. Most patients had refractory low back pain (96%) after conservative treatment. The stenotic levels of the cases were as follows: L3-4, 23(46%); L4-5, 24(48%); and L5-S1, 3 (6%). VAS scores decreased in all patients after surgery. According to Odom's criteria, an excellent or good score was found in 43 patients at the 12th follow-up examination. WDs increased up to 1000 meters for 41 patients.

CONCLUSION

The microscopic unilateral approach to bilateral decompression is an effective method for decompression in spinal stenosis. Via this approach, surgical trauma is reduced and surgically induced instability is avoided as much as possible.

Closed chest unilateral thoracoscopic ablation: box lesion with radiofrequency clamps only

In this article we describe the modified technique of a unilateral closed chest thoracoscopic ablation and left atrial appendage closure including a box lesion that is made by radiofrequency clamps only for the treatment of atrial fibrillation. By abandoning the unidirectional pen devices and replacing these by radiofrequency clamps, we aim to further improve the procedural efficacy and shorten operation time while minimizing surgical exposure for the patient.

[A novel trans-muscular approach for microsurgical bilateral decompression via unilateral approach for degenerative lumbar stenosis: a series study]

Objective: To compare clinical outcomes of microsurgical bilateral decompression via unilateral approach (MBDU) between trans longissimus and iliocostalis approach, a novel lateral paraspinal approach(LPA), and classic Wiltseapproach for single level degenerative lumbar stenosis. Methods: LPA approach was researched by imaging measurement and cadaver anatomy. Retrospective analysis of a total 124 cases(male/female 75/49, aged(55±14) years) received single-level MBDU due to degenerative lumbar stenosis from 2016 to 2018 in Beijing Tiantan Hospital. Patients were categorized into two groups according to spinal canal morphology. Group A: trefoil shape (n=48), received MBDU via LPA; Group B: round & oval shape (n=76), received MBDU via Wiltse approach. Clinical parameters, including visual analogue scale (VAS) of pain, OswestryDability Index (ODI), satisfaction rate were assessed before the operation and at the latest follow-up. The internal fixation and intervertebral fusion were evaluated by X-ray and CT.The data were compared with single sample t test between the two groups. Results: The feasibility of trans longissimus and iliocostalis approach was proved by imaging measurement and anatomic study. The tube's maximum tilt angle in LPA group was 65°, and it was 40°in Wiltse group. There was no significantly difference in the operating time, bleeding and drainage volume between the two groups((120±27) min vs (115±32) min, (104±31) ml vs (110±41) ml, (50±15) ml vs (47±18) ml, respectively, t=1.246,-1.917,1.730,all P>0.05). In both groups, VAS and ODI scores significantly improved at the latest follow-up when compared with those before the operation (all P<0.05), but those were all comparable between the two groups(all P>0.05). The excellent rate of subjective satisfaction for the clinical efficacy in group A and B was 89.6%(43/48) and 86.8%(66/76) respectively (χ(2)=0.208,P>0.05). Conclusions: LPA approachfor microsurgical bilateral decompression via unilateral approach (MBDU) in degenerative lumbar stenosis is safe and effective, it has advantages in direct vison of contralateral nerve root canal decompression for trefoil shaped spinal canal.

Application of unilateral multiple channels approach in percutaneous vertebroplasty for osteoporotic vertebral fractures

This study aimed to investigate the application valuable of percutaneous vertebroplasty (PVP) with unilateral multiple channels approach in osteoporotic vertebral fractures patients. A retrospective review was conducted on 685 consecutive patients with osteoporotic vertebral fracture from March 2003 to October 2012. Among them, 82 cases were given PVP procedure by unilateral multiple channels approach. The timing of surgery, bone cements injection, and complications were analyzed. By using the X-ray film, the distribution of cement was detected and scored. The visual analogue scale (VAS) score and Oswestry disability index (ODI) system were used to evaluate the pain relief and improvement of daily activity function after operation. The excellent and good rate of cement distribution was 98.8% (98/99). Before surgery, the VAS score was 2.5±0.43. After surgery, the VAS score was significantly decreased to 2.0±0.33 at 1 h. Before surgery, ODI was 40.94±2.72. ODI was significantly decreased at 1 month after surgery (9.64±2.60) and at the final follow-up (7.77±2.15).  No spine or nerve injury, bone cement leakage, pulmonary embolism, pneumothorax, bleeding or infection occurred intraoperatively. Thus, the PVP with unilateral multiple channels approach effectively relieve the pain and improve the functional activity, without occurrence of complications.

Clinical and radiographic outcomes of bilateral decompression via a unilateral approach with transforaminal lumbar interbody fusion for degenerative lumbar spondylolisthesis with stenosis

BACKGROUND CONTEXT

Laminectomy with posterior lumbar interbody fusion (PLIF) has been shown to achieve satisfactory clinical outcomes, but it leads to potential adverse consequences associated with extensive disruption of posterior bony and soft tissue structures.

PURPOSE

This study aimed to compare the clinical and radiographic outcomes of bilateral decompression via a unilateral approach (BDUA) with transforaminal lumbar interbody fusion (TLIF) and laminectomy with PLIF in the treatment of degenerative lumbar spondylolisthesis (DLS) with stenosis.

STUDY DESIGN

This is a prospective cohort study.

PATIENT SAMPLE

This study compared 43 patients undergoing BDUA+TLIF and 40 patients undergoing laminectomy+PLIF.

OUTCOME MEASURES

Visual analog scale (VAS) for low back pain and leg pain, Oswestry Disability Index (ODI), and Zurich Claudication Questionnaire (ZCQ) score.

METHODS

The clinical outcomes were assessed, and intraoperative data and complications were collected. Radiographic outcomes included slippage of the vertebra, disc space height, segmental lordosis, and final fusion rate. This study was supported by a grant from The National Natural Science Foundation of China (81572168).

RESULTS

There were significant improvements in clinical and radiographic outcomes from before surgery to 3 months and 2 years after surgery within each group. Analysis of leg pain VAS and ZCQ scores showed no significant differences in improvement between groups at either follow-up. The mean improvements in low back pain VAS and ODI scores were significantly greater in the BDUA+TLIF group than in the laminectomy+PLIF group. No significant difference was found in the final fusion rate at 2-year follow-up. The BDUA+TLIF group had significantly less blood loss, shorter length of postoperative hospital stay, and lower complication rate compared with the laminectomy+PLIF group.

CONCLUSIONS

When compared with the conventional laminectomy+PLIF procedure, the BDUA+TLIF procedure achieves similar and satisfactory effects of decompression and fusion for DLS with stenosis. The BDUA+TLIF procedure appears to be associated with less postoperative low back discomfort and quicker recovery.

Usefulness of Contralateral Indirect Decompression through Minimally Invasive Unilateral Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective study.

PURPOSE

This study aims to investigate the clinical and radiological results of contralateral indirect decompression through minimally invasive unilateral transforaminal lumbar interbody fusion (MI-TLIF).

OVERVIEW OF LITERATURE

Several studies have proposed that blood loss and operation time could be reduced through a unilateral approach, although many surgeons have forecast that satisfactory foraminal decompression is difficult to achieve through a unilateral approach.

METHODS

The study included 30 subjects who had undergone single-level MI-TLIF. Visual analogue scale (VAS) and Oswestry disability index (ODI) were analyzed for clinical assessment. Disc height, segmental lordosis, and lumbar lordosis angle were examined for radiological assessment. The degree of contralateral indirect decompression was evaluated through a comparative analysis, with a magnetic resonance imaging (MRI) performed preoperatively and at one year postoperatively.

RESULTS

Intraoperative blood loss volume was 308.75 mL in the unilateral approach group (UAP), and 575.00 mL in the bilateral approach group (BAP), showing a statistically significant difference. Operation time was 139.50 minutes in the UAP group, and 189.00 minutes in the BAP group, exhibiting a statistically significant difference (p<0.05). On the other hand, no significant difference was found in VAS, ODI, disc height, lordosis angles and the degree of nerve decompression in the vertebral foramen, using MRI, between the two groups (p>0.05).

CONCLUSIONS

Satisfactory results were acquired with MI-TLIF conducted through the unilateral approach of contralateral indirect decompression, in alignment with the bilateral approach. Therefore, contralateral indirect decompression is thought to be a useful procedure in reducing the operation time and volume of blood loss.

Management of Thoracal and Lumbar Schwannomas Using a Unilateral Approach without Instability: An Analysis of 15 Cases

Study Design

Retrospective case series.

Purpose

The objectives of this study were to determine and discuss the surgical planning of patients who underwent operations following diagnoses of thoracal and lumbar spinal schwannomas. We also aimed to discuss the application of unilateral hemilaminectomy for the microsurgery of schwannomas.

Overview of Literature

Schwannomas are located in different regions and sites. These differences require several surgical approaches. Unilateral laminectomy without stabilization of the spine provides a more minimally invasive removal of the tumor.

Methods

In this retrospective study, 15 patients with spinal schwannomas were evaluated with regards to age, sex, onset history, neurological findings, tumor locations, McCormick scale, surgical procedure, and operational results. The lateral approach provides exposure of intradural structures and posterior paraspinal regions. Extensions of tumors cause problem for the surgeon in terms of approach, resectability of the tumor, and stability of the spine. Gross total resection was achieved in all cases, and none of the patients necessary required a fusion procedure.

Results

Five patients were males and 10 were females. The age interval was 29-65 years. The tumor was located in the lumbar region in 9 patients, in the thoracic region in 2 patients, and in the thoracolumbar junction in 4 patients. The intradural lesions were removed by laminectomy and the extradural lesions were resected with hemilaminectomy. The paramedian route was used to explore the extraspinal part of the tumor. Costotransversectomy was for the thoracic region. Subtotal resection was performed in 1 patient. Patient symptoms recovered gradually in the postoperative period.

Conclusions

Resection of giant schwannomas is challenging and usually requires a different approach. We describe the complete resection of complex dumbbell or paraspinal schwannomas of the thoracic and lumbar spine by unilateral hemilaminectomy.

Comparative Study of Posterior Lumbar Interbody Fusion via Unilateral and Bilateral Approaches in Patients with Unilateral Leg Symptoms

OBJECTIVE

We investigated the clinical and radiological advantages of unilateral laminectomy in posterior lumbar interbody fusion (PLIF) procedure comparing with bilateral laminectomy, under the same procedural condition including bilateral instrumentation and insertion of two cages, in patients with degenerative lumbar disease with unilateral leg symptoms.

METHODS

We retrospectively reviewed 124 consecutive cases of PLIF via unilateral or bilateral approach between January 2006 and April 2010. In 80 cases (bilateral group), two cages were inserted via bilateral laminectomy, and in 44 cases (unilateral group), via unilateral laminectomy. The average follow-up duration was 29.5 months. The clinical outcomes were evaluated with the Visual Analogue Scale (VAS) and the Oswestry disability index (ODI). The fusion rates and disc space heights were determined by dynamic standing radiographs and/or computed tomography. Operative times, intra-operative and post-operative blood losses and hospitalization periods were also evaluated.

RESULTS

In clinical evaluation, the VAS and ODI scores showed excellent outcomes in both groups. There were no significant differences in term of fusion rate, but the perioperative blood loss and the operative time of the unilateral group were lower than that of the bilateral group.

CONCLUSION

Unilateral laminectomy can minimize the operative time and perioperative blood loss in PLIF procedure. However, the different preoperative disc height between two groups is a limitation of this study. Despite this limitation, solid fusion and satisfactory symptomatic improvement could be achieved uniquely by our surgical method. This surgical method can be an alternative surgical technique in patients with unilateral leg pain.