This document summarizes a study on reoperations after minimally invasive lumbar spine surgery due to recurrent disc herniations. The study included 914 patients who underwent microdiskectomy for lumbar disc herniations and 1063 patients who underwent bilateral decompression via a unilateral approach for degenerative lumbar spinal stenosis, with a mean follow-up time of 14 years. The results showed low recurrence rates of 3.8% for disc herniations and 1.2% for disc herniations with stenosis. Clinical outcomes improved significantly based on Oswestry Disability Index and SF-36 scores. The techniques allowed safe decompression while preserving stability, resulting in reduced symptoms and improved quality of life.

1. REOPERATIONS AFTER MINIMALLY INVASIVE LLUUMMBBAARR SSPPIINNEE
SSUURRGGEERRYY BBEECCAAUUSSEE OOFF RREECCUURRRREENNTT DDIISSCC HHEERRNNIIAATTIIOONN::
PPRROOSSPPEECCTTIIVVEE SSTTUUDDYY
MEMORIAL ŞİŞLİ HOSPITAL
NEUROSURGERY CLINIC
İSTANBUL, TURKEY
Yunus AYDIN, MD
Halit ÇAVUŞOĞLU, MD
Okan KAHYAOĞLU, MD

2. SIMPLY THE BEST!!
~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

3. OOuurr aarrttiiccllee
Volume 57 (Issue1): pages 5-13, 2002
Citation (n=50)

4. OOuurr aarrttiiccllee
Citation (n=59)

5. OOuurr aarrttiiccllee

7. 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

8. OOuurr aarrttiiccllee
Citation (n=14)

9. OUR BIOMECHANICAL STUDY

10. MATERIAL & METHOD
~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,

11. (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

12. SURGICAL PROCEDURE
(disc herniation)
Lumbar microdiskectomy technique with preserving lliiggaammeennttuumm ffllaavvuumm
• 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

13. SURGICAL PROCEDURE
(disc herniation + stenosis)
BBiillaatteerraall ddeeccoommpprreessssiioonn vviiaa aa uunniillaatteerraall aapppprrooaacchh aanndd mmiiccrrooddiisskkeeccttoommyy
• 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.

14. SURGICAL PROCEDURE
(disc herniation + stenosis)
BBiillaatteerraall ddeeccoommpprreessssiioonn vviiaa aa uunniillaatteerraall aapppprrooaacchh aanndd mmiiccrrooddiisskkeeccttoommyy
• 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.

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

16. 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)

17. 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)

18. RESULT
(Oswestry Disability Index)
• The ODI scores decreased significantly in both early and late follow-up
evaluations. (Newman-Keuls multiple comparison test, p < 0.0001)
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

19. RESULT
(Short Form 36)
The scores demonstrated a marked and
significant improvement
(except in the areas of emotional role)
Quality of life
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
Late 71.27 ± 9.68 70.49 ± 12.8 0.776

20. CONCLUSION
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.

21. 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.

22. CCaassee SSaammpplleess

23. BURAYA VİDEO LİNKİ YAPILACAK

24. PPrree--oopp PPoosstt--oopp 77tthh mmoonntthhss
““RREECCUURRRREENNTT DDIISSCC HHEERRNNIIAATTIIOONN””
11 lleevveell sstteennoossiiss

25. 22 lleevveellss sstteennoossiiss
PPrree--oopp
PPoosstt--oopp 66tthh mmoonntthhss
““FFAARR LLAATTEERRAALL HHNNPP””

26. PPrree--oopp PPoosstt--oopp
PPoosstt--oopp 66tthh mmoonntthhss
DDiiffffeerreenntt lleevveell ““RREECCUURRRREENNCCEE””
33 lleevveellss sstteennoossiiss

27. 11 lleevveell sstteennoossiiss
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28. 11 lleevveell sstteennoossiiss
PPrree--oopp PPoosstt--oopp

29. 11 lleevveell sstteennoossiiss
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30. AADDJJAACCEENNTT SSEEGGMMEENNTT DDIISSEEAASSEE

31. 11 lleevveell sstteennoossiiss
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32. 11 lleevveell sstteennoossiiss
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33. PPrree--oopp
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34. AADDJJAACCEENNTT SSEEGGMMEENNTT DDIISSEEAASSEE
PPrree--oopp PPoosstt--oopp

35. 22 lleevveellss sstteennoossiiss
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36. 22 lleevveellss sstteennoossiiss
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37. 22 lleevveellss sstteennoossiiss
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38. L4-5
PPrree--oopp PPoosstt--oopp
L4-5 L4-5
L5-S1 L5-S1
22 lleevveellss sstteennoossiiss

39. 22 lleevveellss sstteennoossiiss
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40. 22 lleevveellss sstteennoossiiss
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41. 33 lleevveellss
PPrree--oopp PPoosstt--oopp
DDOORRSSAALL ++ LLUUMMBBAARR SSTTEENNOOSSIISS

42. L3-4 L3-4
L4-5 L4-5
PRE-OP. POST-OP.
L5-S1 L5-S1
33 lleevveellss sstteennoossiiss
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43. 33 lleevveellss sstteennoossiiss
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49. L3-4 L3-4
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sstteennoossiiss

50. PPrree--oopp
2 incision
PPoosstt--oopp
33 lleevveellss sstteennoossiiss

51. 33 lleevveellss sstteennoossiiss
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52. PPrree--oopp PPoosstt--oopp
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57. 44 lleevveellss sstteennoossiiss
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58. THANK YOU
Q & A
MEMORIAL ŞİŞLİ HOSPITAL
NEUROSURGERY CLINIC
İSTANBUL, TURKEY
Yunus AYDIN, MD
Halit ÇAVUŞOĞLU, MD
Okan KAHYAOĞLU, MD