J Korean Orthop Assoc.  2020 Feb;55(1):71-77. 10.4055/jkoa.2020.55.1.71.

Preservation of the Posterior Ligaments for Preventing Postoperative Spinal Instability in Posterior Decompression of Lumbar Spinal Stenosis: Comparative Study between Port-Hole Decompression and Subtotal Laminectomy

• Jung YH
• Na HY
• Choe S
• Kim J
• Lee JH

• KMID: 2470771
• DOI: http://doi.org/10.4055/jkoa.2020.55.1.71

Abstract

PURPOSE
To determine if sparing the interspinous and supraspinous ligaments during posterior decompression for lumbar spinal stenosis is significant in preventing postoperative spinal instability.
MATERIALS AND METHODS
A total of 83 patients who underwent posterior decompression for lumbar spinal stenosis between March 2014 and March 2017 with a minimum one-year follow-up period, were studied retrospectively. The subjects were divided into two groups according to the type of surgery. Fifty-six patients who underwent posterior decompression by the port-hole technique were grouped as A, while 27 patients who underwent posterior decompression by a subtotal laminectomy grouped as B. To evaluate the clinical results, the Oswestry disability index (ODI), visual analogue scale (VAS) for both back pain (VAS-B) and radiating pain (VAS-R), and the walking distance of neurogenic intermittent claudication (NIC) were checked pre- and postoperatively, while simple radiographs of the lateral and flexion-extension view in the standing position were taken preoperatively and then every six months after to measure anteroposterior slippage (slip percentage), the difference in anteroposterior slippage between flexion and extension (dynamic slip percentage), angular displacement, and the difference in angular displacement between flexion and extension (dynamic angular displacement) to evaluate the radiological results.
RESULTS
The ODI (from 28.1 to 12.8 in group A, from 27.3 to 12.3 in group B), VAS-B (from 7.0 to 2.6 in group A, from 7.7 to 3.2 in group B), VAS-R (from 8.5 to 2.8 in group A, from 8.7 to 2.9 in group B), and walking distance of NIC (from 118.4 m to 1,496.2 m in group A, from 127.6 m to 1,481.6 m in group B) were improved in both groups. On the other hand, while the other radiologic results showed no differences, the dynamic angular displacement between both groups showed a significant difference postoperatively (group A from 6.2° to 6.7°, group B from 6.5° to 8.4°, p-value=0.019).
CONCLUSION
Removal of the posterior ligaments, including the interspinous and supraspinous ligaments, during posterior decompression of lumbar spinal stenosis can cause a postoperative increase in dynamic angular displacement, which can be prevented by the port-hole technique, which spares these posterior ligaments.

Keyword

port-hole; laminectomy; spinal stenosis; decompression; posterior ligaments

MeSH Terms

Back Pain
Decompression*
Follow-Up Studies
Hand
Humans
Intermittent Claudication
Laminectomy*
Ligaments*
Posture
Retrospective Studies
Spinal Stenosis*
Walking

Figure

• 

  Figure 1 Port-hole decompression is different from a conventional laminectomy. (A) The figure shows spinal stenosis with a thickened ligamentum flavum and hypertrophied facet joints. (B) The figure shows resected posterior ligaments and medial facets in a conventional laminectomy. (C) The figure shows the port-hole decompression preserving posterior ligaments and facet joints, which are important for segmental stability. Cited from Song et al. J Korean Orthop Assoc. 2018;53:44-50.11)

• 

  Figure 2 Preoperative flexion (A) and extension (B), and one-year postoperative flexion (C) and extension (D) simple radiographs of a 68-year-old patient who underwent port-hole decompression at L4-5. Note the dynamic angular displacement between the preoperative (14°–9°=5°) and one-year postoperative (16°–10°=6°) radiographs showing little difference (1°).

• 

  Figure 3 Preoperative flexion (A) and extension (B), and one-year postoperative flexion (C) and extension (D) simple radiographs of a 69-year-old patient who underwent a conventional subtotal laminectomy at L4-5. Note the dynamic angular displacement between the preoperative (14°–12°=2°) and one-year postoperative (17°–2°=15°) radiographs showing a significant difference (13°).

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