Gagliardi Martin, Guiroy Alfredo, Sícoli Alfredo, Masanés Nicolás Gonzalez, Ciancio Alejandro Morales, Asghar Jahangir
Spine Unit, Department of Orthopedics, Hospital Español, Mendoza, Argentina.
Spine Unit, Department of Orthopedics, Hospital Español, Mendoza, Argentina; The Paley Orthopedic and Spine Institute at Saint Mary's Medical Center, West Palm Beach, Florida, USA.
World Neurosurg. 2022 Mar;159:107. doi: 10.1016/j.wneu.2021.12.088. Epub 2021 Dec 29.
Degenerative lumbar spinal stenosis involves an acquired reduction in the spinal canal diameter due to osteoarthritic changes on the disk, facet joints, and ligaments and may result in spinal cord or cauda equina compression. This process may lead to pain radiating to the legs, neurogenic claudication, and neurologic deficit. First-line treatment includes conservative care such as physical therapy, spinal injections, and lifestyle changes. If this strategy is insufficient to achieve symptom relief, surgical management is recommended. Surgery generally encompasses a decompression procedure through a posterior approach. There are several techniques to accomplish this in the context of severe bilateral stenosis including standard open laminectomy, unilateral laminectomy with bilateral decompression, and a tubular approach with bilateral decompression (e.g., "over-the-top technique"). Among these, the spinous process splitting laminectomy has emerged as a strategy that allows decompressing the spinal canal through a familiar anatomy to the surgeon while respecting paravertebral muscles. This technique involves exposure of the laminae by cutting through the spinous process and then separating both halves and muscles attached at the sides. The main advantage is that the insertion of these paravertebral soft tissues is preserved, the required retraction is reduced and postoperative pain is decreased. Moreover, the learning curve to achieve a successful decompression employing the splitting laminectomy is substantially shorter than with other minimally invasive approaches, such as tubular. This video aims to show the steps to perform this technique (Video 1). We report the case of a 74-year-old male who presented with left sciatica and neurogenic claudication. The images showed multilevel degenerative lumbar spinal stenosis, with severe bilateral compression at L4-5, without signs of instability. Surgical alternatives were discussed with the patient, and it was decided to perform an L4-5 spinous process splitting laminectomy. The patient had a good evolution with an unremarkable postoperative course.
退行性腰椎管狭窄症是指由于椎间盘、小关节和韧带的骨关节炎变化导致椎管直径后天性减小，可能会导致脊髓或马尾神经受压。这个过程可能会导致腿部放射性疼痛、神经源性间歇性跛行和神经功能缺损。一线治疗包括保守治疗，如物理治疗、脊柱注射和生活方式改变。如果这种策略不足以缓解症状，则建议进行手术治疗。手术通常包括通过后路进行减压手术。在严重双侧狭窄的情况下，有几种技术可以实现这一点，包括标准开放椎板切除术、单侧椎板切除术加双侧减压以及双侧减压的管状入路（例如“过头技术”）。其中，棘突劈开椎板切除术已成为一种策略，它允许外科医生通过熟悉的解剖结构对椎管进行减压，同时保留椎旁肌肉。该技术包括通过切开棘突暴露椎板，然后将两半分开并分离附着在两侧的肌肉。主要优点是保留了这些椎旁软组织的附着，减少了所需的牵开，减轻了术后疼痛。此外，与其他微创方法（如管状入路）相比，采用劈开椎板切除术成功进行减压的学习曲线要短得多。本视频旨在展示执行该技术的步骤（视频1）。我们报告了一例74岁男性患者，其表现为左侧坐骨神经痛和神经源性间歇性跛行。影像学检查显示多节段退行性腰椎管狭窄，L4-5节段严重双侧受压，无不稳定迹象。与患者讨论了手术方案，决定进行L4-5棘突劈开椎板切除术。患者术后恢复良好，病程顺利。
