Lumbar Canal Spinal Stenosis—Novel Surgical Approach, or Not?
The patient is a 74-year-old female with neurogenic claudication. She is unable to walk more than a block. Her VAS is 7.
She has obesity, which may contribute to her slightly waddling gait.
- 5/5 strength
- 1+ reflexes
- No clonus
Figure 1. Sagittal MRI
- Physical therapy
- Epidural injections
- Oral steroids
L4-L5 spinal canal stenosis
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A L4-L5 split spinous process laminectomy (SPSL) was performed. Experience with this procedure has yielded clinical results similar to open laminectomy, but with less postoperative pain.
- Tissue disruption is reduced by staying within the periosteum boundaries.
- Visualization into both lateral recesses is better than a MIS technique.
- The structural integrity of the ligament is better preserved than with an open technique.
- This procedure allows the surgeon to avoid the facets.
Video 1 (below) shows bone removal with the Kerrison punch
Video 2 (below) shows ligamental removal with the Kerrison punch
Figure 4. Viewing the lateral recess
Figure 5. Central decompression
Video 3 (below) shows inspection of the lateral recesses with the Woodson elevator
Figure 6. Initial inspection
Video 4 (below) shows rostal and caudal inspection with a longer Murphy ball
Figure 7. Final inspection
The patient tolerated the surgical procedure well. She was discharged home the same day as surgery.
There exist a multitude of nonfusion, surgical options for the management of neurogenic claudication secondary to lumbar spinal stenosis. These range from traditional open wide laminectomy to minimally invasive tubular techniques. While the minimally invasive techniques have been demonstrated to have some advantages over the traditional open techniques in terms of blood loss, infection rate and postoperative pain; they can be associated with a steep learning curve and require access to significant capital equipment, not necessarily available in all facilities.
The spinous process splitting laminectomy/decompression procedure, beautifully employed in this case, offers some of the benefits of a minimally invasive technique (decreased muscle stripping and therefore, reduced blood loss and postoperative pain as well as preservation of some of the midline structures) while giving the surgeon a more traditional operative view through the midline corridor. As such, techniques such as this one can permit “open” surgeons to offer their patients less invasive treatment options. I commend the authors on their application of this innovative technique to a common spinal condition.