Lumbar Spinous Process–Splitting Technique for Ligamentum Flavum Cyst Removal

Abstract

Background Laminotomy for lumbar stenosis is a well-defined procedure and represents a routine in every neurosurgical department. It is a common experience that the uni- or bilateral paraspinal muscle detachment, together with injury of the supra- and interspinous ligaments, can lead to postoperative pain. In the literature, the application of a minimally invasive technique, the lumbar spinous process–splitting (LSPS) technique, has been reported.

Methods In this study, we present a case series of 12 patients who underwent LSPS from September 2019 to April 2020. Two patients had a cyst of the ligamentum flavum, eight a single-level lumbar canal stenosis (LCS), and two a two-level LCS. Moreover, we propose a novel morphological classification of postoperative muscle atrophy and present volumetric analysis of the decompression achieved.

Results There were no complications related to this technique. In all patients, the vertebral canal area was more than doubled by the procedure. The muscle sparing showed grade A, according to our classification.

Conclusion To our knowledge, this is the first description of this surgical technique and the first LSPSL case series in Europe. Furthermore, cases of ligamentum flavum cyst removal using this safe and effective technique have not yet been reported.

Keywords

lumbar stenosis - laminectomy - laminotomy - flavectomy back pain - lumbar muscles sparing - ligamentum flavum cyst removal

• References

• 1 Shiraishi T. A new technique for exposure of the cervical spine laminae. Technical note. J Neurosurg 2002; 96 (1, Suppl): 122-126
• 2 Sihvonen T, Herno A, Paljärvi L, Airaksinen O, Partanen J, Tapaninaho A. Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine 1993; 18 (05) 575-581
• 3 Watanabe K, Hosoya T, Shiraishi T, Matsumoto M, Chiba K, Toyama Y. Lumbar spinous process-splitting laminectomy for lumbar canal stenosis. Technical note. J Neurosurg Spine 2005; 3 (05) 405-408
• 4 Shiraishi T. Skip laminectomy: a new treatment for cervical spondylotic myelopathy, preserving bilateral muscular attachments to the spinous processes: a preliminary report. Spine J 2002; 2 (02) 108-115
• 5 Baghdadi YM, Moussallem CD, Shuaib MA, Clarke MJ, Dekutoski MB, Nassr AN. Lumbar spinous process-splitting laminoplasty: a novel technique for minimally invasive lumbar decompression. Orthopedics 2016; 39 (05) e950-e956
• 6 Kakiuchi M, Fukushima W. Impact of spinous process integrity on ten to twelve-year outcomes after posterior decompression for lumbar spinal stenosis: study of open-door laminoplasty using a spinous process-splitting approach. J Bone Joint Surg Am 2015; 97 (20) 1667-1677
• 7 Kakiuchi M, Wada E, Harada T, Ito K, Fukushima W. Expansive suspension laminoplasty using a spinous process-splitting approach for lumbar spinal stenosis: surgical technique and outcomes over 8 years of follow-up. J Am Acad Orthop Surg Glob Res Rev 2018; 2 (10) e008
• 8 Kanbara S, Yukawa Y, Ito K, Machino M, Kato F. Surgical outcomes of modified lumbar spinous process-splitting laminectomy for lumbar spinal stenosis. J Neurosurg Spine 2015; 22 (04) 353-357
• 9 Lee GW, Ahn MW. Comparative study of two spinous process (SP) osteotomy techniques for posterior decompression surgery in lumbar spinal stenosis: SP base versus splitting osteotomy. Eur Spine J 2018; 27 (07) 1644-1652
• 10 Lee S, Srikantha U. Spinous process splitting laminectomy: clinical outcome and radiological analysis of extent of decompression. Int J Spine Surg 2015; 9: 20
• 11 Lee YS, Kim YB, Park SW. Spinous process-splitting hemilaminoplasty for intradural and extradural lesions. J Korean Neurosurg Soc 2015; 58 (05) 494-498
• 12 Maruo K, Tachibana T, Inoue S, Arizumi F, Yoshiya S. Prognostic factors of surgical outcome after spinous process-splitting laminectomy for lumbar spinal stenosis. Asian Spine J 2015; 9 (05) 705-712
• 13 Nomura H, Yanagisawa Y, Arima J, Oga M. Clinical outcome of microscopic lumbar spinous process-splitting laminectomy: clinical article. J Neurosurg Spine 2014; 21 (02) 187-194
• 14 Rajasekaran S, Thomas A, Kanna RM, Prasad Shetty A. Lumbar spinous process splitting decompression provides equivalent outcomes to conventional midline decompression in degenerative lumbar canal stenosis: a prospective, randomized controlled study of 51 patients. Spine 2013; 38 (20) 1737-1743
• 15 Uehara M, Takahashi J, Hashidate H. et al. Comparison of spinous process-splitting laminectomy versus conventional laminectomy for lumbar spinal stenosis. Asian Spine J 2014; 8 (06) 768-776
• 16 Watanabe K, Matsumoto M, Ikegami T. et al. Reduced postoperative wound pain after lumbar spinous process-splitting laminectomy for lumbar canal stenosis: a randomized controlled study. J Neurosurg Spine 2011; 14 (01) 51-58
• 17 Wi SM, Lee HJ, Chang SY. et al. Restoration of the spinous process following muscle-preserving posterior lumbar decompression via sagittal splitting of the spinous process. Clin Orthop Surg 2019; 11 (01) 95-102
• 18 DiMaio S, Marmor E, Albrecht S, Mohr G. Ligamentum flavum cysts causing incapacitating lumbar spinal stenosis. Can J Neurol Sci 2005; 32 (02) 237-242
• 19 Shah K, Segui D, Gonzalez-Arias S. Midline ligamentum flavum cyst of lumbar spine. World Neurosurg 2018; 110: 284-287