Unilateral Laminectomy bilateral decompression of the spine: technique lecture

1. ULBD: Unilateral
Laminectomy Bilateral
Decompression
 December 1, 2017
 Upper Chesapeake Medical Center

2. 72 woman with R buttock pain
LBP

8. Normal?
 Boden article: JBJS Vol. 72-A,
No. 8, Sept 1990
<40 years
N=167
<40 years >40 years
N=97
>40 years
MAJOR MINOR
Herniated
disc
3% 4% 1% 4%
Bulging disc 0 5% 1% 5%
Foraminal
stenosis
3% 4% 9% 14%
Disc space
narrowing
2% 11% 16% 22%
Degenerative
disc
8% 37%
Spurs 3% 14% 6% 34%
Abnormal
cord
9% 9% 1% 18%

12. xter and Barr JBJS 1934
s the first description of
rniated discs causing
atica with surgery as a
ccessful treatment

13. Henk Verbiest
1909-1997
Dutch neurosurgeon
introduced the
concept of a
developmental spinal
stenosis 1940 due to
a small AP diameter
spinal canal

19. Red flag
 Nocturnal pain
 Pain at rest
 Progressive
neurological
deficit
 Suspicious for
cancer or
infection

20. High index of
suspicion
 H/O cancer
 Osteoporosis/steroids
/immunosuppression
 AS
 10/10
 Weight loss
 IVDA
 UTI/sepsis

28. Kleeman, T.J., Hiscoe, A.C., Berg, E.E.: “Patient Outcomes
Following Minimally Destabilizing
Lumbar Stenosis Decompression: The ‘Port Hole’ Technique”,
Spine, April 2000.

30. Toyoda et al. Clinical Outcome of Microsurgical Bilateral Decompression via Unilateral Approach
for Lumbar Canal Stenosis. Spine 2011; 36:410-415
Poletti CE. Central Lumbar Stenosis caused by ligamentum flavum unilateral laminectomy for
bilateral ligamentectomy. Neurosurgery 1995; 37: 343-347

32. Prone Position

33. OSI Jackson Table 2bends, rotates, secure

39. Slide a
Ligamentum
flavum

40. Optimal anatomy

41. L5S1

42. L4L5

43. L3L4

44. L2L3

45. L1L2

46. T12L1

47. T11T12

48. 144 single level, korea, Trefoil canal stenosis patients were more difficult to
decompression due to angle of approach and patients had worse outcomes

51.  J Neurosurg Spine. 2014 Aug;21(2):179-86. doi: 10.3171/2014.4.SPINE13420. Epub
2014 May 30.
 Outcomes after decompressive laminectomy for lumbar spinal stenosis: comparison
between minimally invasive unilateral laminectomy for bilateral decompression and
open laminectomy: clinical article.
 Mobbs RJ1, Li J, Sivabalan P, Raley D, Rao PJ.
79 patients prospective 1:1 ULBD v. open laminectomy, oswestry disability and
Patient satisfaction were similar, ULBD had shorter stay 55 h v 100 h, shorter
time
To mobilize 15h v 33 h and more people not requiring opiates 51% v 15%

52. Neurosurgery. 2006 Dec;59(6):1264-9; discussion 1269-70.
Long-term results of microsurgical treatment of lumbar spinal stenosis by unilateral
laminotomy for bilateral decompression.
Oertel MF1, Ryang YM, Korinth MC, Gilsbach JM, Rohde V.
 133 patients mean fu 5.6 years up to 10
years
 Reoperation 11%, 2 instability, 7
restenosis
 85% excellent to fair long term results
Dr M F Oertel Department of Neurosurgery, University Hospital, School of
Medicine, Aachen University, Pauwelsstrasse 30, 52057 Aachen, Germany

53. ULBD pitfalls complications
 Restenosis( contralateral side)
 Dural tear
 Nerve injury
 Instability
 Persistent pain from facet
 Pars fracture
 Inadequate decompression
 Persistent foramenal stenosis

55. Working window
Wax
Down to lamina

58. Keep pars intact
Dura is 23 mm wide
Need 11 mm from midline
No more than 3 burr diameters

59. Start lateral to know your pars
Stay medial to facet
Go above facet and yellow lig

61. Connect two areas

63. Lig flavum protects dura
Keep it on as long as possible

64. Start on top to find dura
Remove bone first
Keep ligament intact to protect dura

65. You should be looking at yellow ligament at this point

66. lift ligament with curette and remove
With kerrison
Shave lateral border with curved currette

67. Dura exposed

68. Undermine lamina opposite side

74. Which side to approach?

76. THANKS