Elsevier

Medical Hypotheses

Volume 143, October 2020, 110130
Medical Hypotheses

Building block osteotomy, a new back muscle-preserving laminoplasty for lumbar spinal stenosis

https://doi.org/10.1016/j.mehy.2020.110130Get rights and content

Abstract

In order to preserve paravertebral muscles and posterior ligaments complex (PLC), this paper proposes a new lumbar laminoplasty surgery for lumbar spinal stenosis (LSS). According to the anatomy of back muscles insertions, building block osteotomy (BBO) which aimed to achieve precise osteotomy and reconstruction based on modular design theory was firstly put forward, and supposed to be achieved by an ultrasound bone scalpel (UBS). In details, lumbar spinous processes are longitudinally split, then supraspinous and interspinous ligaments are sharply cut off longitudinally. After converting to lumbar flexion, lamina osteotomy is innovatively finished by an UBS through interspinous space. After decompression, hollow screws are firstly suggested to be used on each side to fix lamina and spinous processes, and PLC is reconstructed by interrupted suture. Feasibility of this method is evaluated in details. Challenges, advantages and disadvantages are also discussed.

Introduction

Laminectomy is the most commonly used method for treatment of spinal stenosis [1], [2]. However, the back muscles attached to lamina must be peeled off during the operation, resulting in muscle denervation, nutritional deficiency, and loss of acting points. Eventually, paravertebral muscles got atrophy and was infiltrated by fat tissues [3], [4], [5]. In addition, traditional posterior decompression often requires removal of part or all of the facet joints, this structure damage together with reduction of back muscles’ strength are apt to cause postoperative back pain, lumbar spine instability, accelerated degeneration of the adjacent segments and other complications [6], [7]. To this end, scholars have proposed a variety of laminoplasties that preserve PLC, paravertebral muscles, and other supporting structures [8], [9]. For example, the approach through the paravertebral muscle space [10], the tubular minimally invasive surgery (Microscopic Discectomy) [11], the unilateral approach for bilateral decompression [12], etc. Although the above methods are more minimally invasive than the traditional methods, they still need to peel off part of the paravertebral muscles, besides, the operation channel is too narrow to achieve satisfactory decompression.

In 2005, Kota Watanabe proposed lumbar spinous process–splitting laminectomy for the treatment of LSS, that is, splitting the spinous process in the middle longitudinally, osteotomy at the junction of spinous process and lamina, stripping the muscles outside to the junction of the lamina and articular process, and then finish laminectomy [13]. In 2018, Shunsuke Kanbara improved this method by splitting the spinous process longitudinally without breaking through the second cortical plate, then osteotomy to outsides along lamina medullary space to the junction of the vertebral arch and articular processes. After the bone flaps were retracted to both sides, the remaining lamina were removed, decompression was completed, and then the split spinous process was reconstructed [14]. Compared with the former, the latter method can reduce the damage to paravertebral muscles, but results in more bleeding during osteotomy. Both surgical methods have difficulties in exposure and, even worse, reconstruction is unreliable.

Section snippets

To solve the problems, this paper proposes an idea of BBO, in which, osteotomy is finished from bone to bone without any injury of back muscles and PLC. Just like assembly of modular pieces, BBO can not only preserve back muscles and PLC, but also reliably reconstruct the posterior spinal structures after decompression. In details, an UBS is used to split spinous process longitudinally, then cut off lamina through interspinous space.

Preoperative evaluation

Anterior and posterior (AP), lateral, hyperextension and flexion X-ray film of lumbar spine, lumbar CT and MR images are needed. Indications for this operation are moderate to severe LSS, and strict conservative treatment for 6 months is invalid. Contraindications are lumbar spine instability, lumbar spondylolisthesis, serious scoliosis and contraindications of general anesthesia.

Surgical procedures

  • (1)

    Prone position, abdominal suspension, preoperative fluoroscopy is taken to mark the level of operation; after

Summary

In short, for the surgical treatment of LSS, any attempt to preserve paravertebral muscles, PLC and articular processes is meaningful. Familiar with the anatomical knowledge of paravertebral muscles, and inspired by modular building block designs, this paper proposes a minimally invasive surgical method that spinal canal decompression can be achieved with functional structures of lumbar well retained.

Declaration of Competing Interest

None.

Acknowledgement

This work was funded by Peking University Third Hospital Clinical Key Program/BYSYZD2019001. Except for that, neither I nor any other authors has received financial support from any institutes or companys.

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  • 1

    These authors contributed equally to this work.

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