A multilevel posterior tension band–sparing laminectomy for intraspinal lesions: patient series

Ignacio J Barrenechea Departments of Neurosurgery and

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Luis Márquez Departments of Neurosurgery and

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Sabrina Miralles Radiology, Hospital Privado de Rosario, Rosario, Santa Fe, Argentina

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Héctor P Rojas Departments of Neurosurgery and

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Julián Pastore Departments of Neurosurgery and

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Pablo Vincenti Departments of Neurosurgery and

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Telmo Nicola Departments of Neurosurgery and

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BACKGROUND

Minimally invasive spine surgery (MISS) represents a major development in spinal tumor surgery. However, considering that many intradural lesions compromise multiple spinal segments, MISS has certain limitations. Thus, some intraspinal lesions still require traditional approaches. Because laminectomy has been shown to predispose patients to kyphosis, laminoplasty and hemilaminectomy are the most widely used approaches to preserve the posterior tension band (PTB). However, these techniques are not devoid of complications. To overcome these issues, the authors modified a previously described technique to preserve the PTB while removing various types of intradural lesions. This procedure was originally designed to treat lumbar stenosis and was modified to avoid muscle ischemia during long procedures.

OBSERVATIONS

Between 2014 and 2021, the authors found 17 cases of spinal lesions with a minimum of 2 years of follow-up after surgical treatment using their approach. No significant postoperative changes in the paraspinal Goutallier grade or spinal angles were observed. The cross-sectional area of the measured paraspinal muscles decreased 6% postoperatively. By performing certain technical modifications in this PTB-sparing (PBS) laminectomy, the authors avoided ipsilateral muscle ischemia.

LESSONS

In this initial series, PBS laminectomy proved to be a safe, versatile, inexpensive, and reliable technique to remove intraspinal lesions.

ABBREVIATIONS

CSA = cross-sectional area; MISS = minimally invasive spine surgery; MRI = magnetic resonance imaging; PBS = posterior tension band sparing; PTB = posterior tension band

BACKGROUND

Minimally invasive spine surgery (MISS) represents a major development in spinal tumor surgery. However, considering that many intradural lesions compromise multiple spinal segments, MISS has certain limitations. Thus, some intraspinal lesions still require traditional approaches. Because laminectomy has been shown to predispose patients to kyphosis, laminoplasty and hemilaminectomy are the most widely used approaches to preserve the posterior tension band (PTB). However, these techniques are not devoid of complications. To overcome these issues, the authors modified a previously described technique to preserve the PTB while removing various types of intradural lesions. This procedure was originally designed to treat lumbar stenosis and was modified to avoid muscle ischemia during long procedures.

OBSERVATIONS

Between 2014 and 2021, the authors found 17 cases of spinal lesions with a minimum of 2 years of follow-up after surgical treatment using their approach. No significant postoperative changes in the paraspinal Goutallier grade or spinal angles were observed. The cross-sectional area of the measured paraspinal muscles decreased 6% postoperatively. By performing certain technical modifications in this PTB-sparing (PBS) laminectomy, the authors avoided ipsilateral muscle ischemia.

LESSONS

In this initial series, PBS laminectomy proved to be a safe, versatile, inexpensive, and reliable technique to remove intraspinal lesions.

ABBREVIATIONS

CSA = cross-sectional area; MISS = minimally invasive spine surgery; MRI = magnetic resonance imaging; PBS = posterior tension band sparing; PTB = posterior tension band

The advent of minimally invasive spine surgery (MISS) has been a major development in spine surgery. It allows not only smaller incisions and less blood loss but also the sparing of important structures that give stability to the spine. With time, spine surgeons have also adapted these techniques to treat tumors, vascular lesions, and other intradural lesions.1–3 However, given that many intradural spinal lesions compromise more than two spinal segments, MISS still has certain limitations. Hence, to preserve the function of the posterior tension band (PTB) in these cases, laminoplasty is still the most widely used approach.4,5 However, to remove the lamina–spinous process complex in the latter technique, the PTB needs to be cut at one, or sometimes two, levels. In addition, these procedures are not devoid of complications and require bilateral muscular dissection.6,7 Therefore, some surgeons prefer hemilaminectomy because it requires only unilateral muscular detachment and spares the PTB.8 Nevertheless, this technique provides limited exposure and is usually reserved for small or paramedian lesions.

To overcome these issues, we modified a previously published laminectomy technique to preserve the PTB in various types of intradural lesions.9,10 This technique was originally designed to treat degenerative stenosis in the lumbar spine and was almost abandoned in favor of minimally invasive techniques. However, because we still use this approach in our department for multilevel lumbar laminectomies, we have noticed that to effectively displace the PTB to the contralateral side, the retractors must severely compress the ipsilateral muscles (with the consequent risk of muscle ischemia). Hence, given that operative times are essentially longer in spinal tumor surgery, we had to adapt this approach to protect the ipsilateral muscles. Here, we present our initial experience with this PTB-sparing (PBS) laminectomy in 17 cases and describe the technical nuances we use to avoid muscle ischemia.

Study Description

We retrospectively reviewed all patients with spinal intradural lesions who were treated surgically using PBS laminectomy by our group between January 2014 and January 2021. Medical charts were reviewed for data on demographic characteristics, presenting symptoms, pre- and postoperative images, and perioperative complications. In all cases, spinal radiographs and magnetic resonance imaging (MRI) studies were obtained to evaluate and characterize the lesion (tumor, vascular lesion, etc.). MRI was performed on a 1.5-T system (GE Healthcare) preoperatively and at the final follow-up more than 2 years postoperatively. All images were obtained using a T2-weighted fast spin echo pulse sequence with a matrix size 260 × 192, field of view 180 mm × 180 mm, bandwidth 37.71 Hz/pixel, and echo factor 15. The slice thickness was 3 mm, and the interslice gap was 0 mm. To evaluate the degree of postoperative muscle atrophy, two independent musculoskeletal radiologists used anatomical landmarks and locating lines on sagittal scans to select the most similar preoperative and follow-up axial images for comparison. The cross-sectional area (CSA) of the detached paraspinal muscles was measured pre- and postoperatively. In the thoracic spine, the CSA of the rotatores, multifidus and semispinalis (transversospinalis muscles), and spinalis and longissimus (two of the erector spinae muscles) were measured using the calibrated scale on the MRI scans. In the lumbar spine, the CSA of the multifidus muscle was measured. In addition, fatty infiltration of these muscles was visually graded using the criteria described by Goutallier et al.11,12 Two weeks after the operation, patients rated their pain on a visual analog scale for a quantitative evaluation of early postoperative pain; the same test was administered at the late assessment. Follow-up was conducted in outpatient evaluations at 1, 3, 6, 12, and 24 months. All patients had a minimum follow-up of 24 months; those who had a longer follow-up were evaluated yearly. Angular measurements of the spinal regions involved were assessed before surgery, at 6 months postoperatively, and annually thereafter using standing radiographs and, in some cases, long-cassette radiographs. Spinal angle measurements were performed by two independent radiologists using Centricity RIS-I 5 software (GE Healthcare).

The primary endpoint of this study was the incidence of ipsilateral muscle atrophy with our modified approach. A secondary objective was to investigate the occurrence of progressive spinal deformity following a PBS laminectomy to expose intraspinal lesions. This was defined as progression of kyphotic curves by at least 10° on two subsequent radiographs. Global balance was not assessed, nor was it the focus of this study. Data analysis was performed with IBM SPSS Statistics software version 21.0 (IBM Corp.). The results are given as the mean values and 1 standard deviation. The Mann-Whitney U test was used for statistical analysis as appropriate. A p value less than 0.05 was considered to indicate statistical significance. The institutional review board approved this study.

Surgical Technique

Patients were placed prone over two rolls, and both motor evoked potential and somatosensory evoked potential electrodes were placed. A midline incision was made at the appropriate level, from one level above to one level below the target area. Spinal muscles were detached unilaterally, taking care to preserve the supraspinous ligament. Afterward, with a curved oscillating saw (ELAN 4, Aesculap, B. Braun), the spinous processes were cut in the coronal plane at the spinolaminar junction. A continuous piece consisting of the supraspinous ligament, spinous processes, and interspinous ligaments was gently detached from the underlying laminae. This PTB remained attached to the contralateral muscles throughout the procedure. At this point, retraction of the PTB was performed. Instead of using self-retaining retractors (Fig. 1A), the PTB was “pulled away” with a Taylor retractor, allowing the ipsilateral muscles to be retracted independently with two Beckman-Adson or Gelpi retractors (Fig. 1B and C). Subsequently, contralateral multifidus muscles were detached from the contralateral hemilaminae with a Penfield dissector. Then, self-retaining retractors were placed to retract the ipsilateral muscles without exerting too much distraction on the ipsilateral muscle side. Afterward, laminectomy was performed as usual (Fig. 1D). Once full hemostasis was achieved, ultrasound was used to ensure that the laminectomy level was accurate and that the length was sufficient. Subsequently, an operating microscope was used. After the dura mater was opened, complete exposure of the spinal cord anatomy was achieved. Access to both lateral recesses and foramina was achieved, which allowed complete removal of various types of intradural lesions. After addressing the offending pathology, the posterior dural sac was closed with a running 5-0 silk suture under microscopic magnification. DuraSeal (Integra Life Sciences) was placed over the suture line in all cases. Finally, retractors were removed, and the fascia overlying the ipsilateral muscles was sutured back to the supraspinous ligament. Before doing this, the bases of the “floating” spinous processes were thoroughly waxed to avoid extradural hematoma formation. Subcutaneous layers and skin were closed in a routine manner. A round epidural Jackson-Pratt drain was placed in every case and removed after 24 hours.

FIG. 1
FIG. 1

A: Artist’s rendering of the original Ohki approach. In this technique, a lumbar retractor is used to displace the PTB against the ipsilaterally detached muscles. This exerts tremendous pressure on the ipsilateral muscles, ultimately rendering these muscles ischemic (note the difference in the paraspinal muscle colors between sides). B: Spinal process base cut in the coronal plane. Unlike the original approach in which an osteotome was used, we performed the cuts with an oscillating saw. In this way, we avoided hammering over a compressed spinal cord or cauda equina. C: Pulling the PTB with a Taylor retractor, which was fixed at the contralateral facet. The ipsilateral muscles are retracted independently with Gelpi self-retaining retractors. These retractors displace the muscles without exerting too much pressure. D: Final exposure with retractors in place. Unlike hemilaminectomies, this approach allows exposure to both lateral recesses without compromising the facet joint.

Our database contains 24 cases of spinal lesions operated on using our modified approach between January 2014 and January 2021. Of these 24 cases, 17 had at least 2 years of follow-up. There were 7 female and 10 male patients, with a mean age of 49.2 ± 3.8 years (mean ± standard deviation). We operated on five schwannomas, four meningiomas, two filum ependymomas, two spinal dural arteriovenous fistulas, one fifth ventricle, one arachnoid cyst, one cavernoma, and one epidural lymphoma. Four cases were performed in the upper thoracic spine, four cases in the thoracic spine, six in the thoracolumbar junction, and three in the lumbar spine. We cut three spinous processes in 14 cases, two in two cases, and one in one case. The mean operative time was 204 minutes (range 145–270 minutes), and the average blood loss was 212 ml (range 150–400 ml). No neurological deterioration was observed postoperatively. At the upper thoracic and thoracic levels, the CSA was reduced from 408.5 ± 62.8 mm2 preoperatively to 383.8 ± 59.2 mm2 postoperatively (p = 0.002 against the null hypothesis of no differences between groups). The atrophy ratio mean was 0.9 ± 0 (p = 0.0009 against the null hypothesis of a ratio = 1). The area reduction averaged 24.8 ± 6.1 mm2 (p = 0.002 against the null hypothesis of a reduction = 0 mm2), meaning a 6% reduction. In the thoracolumbar and lumbar spine, the CSA was reduced from 1695.3 ± 209.4 mm2 preoperatively to 1599.6 ± 215.2 mm2 postoperatively (p = 0.007). The atrophy ratio mean was similar to that described above, 0.9 ± 0 (p = 0.003). The area reduction averaged 95.8 ± 32.2 mm2 (p = 0.007), meaning a 6.1% reduction compared with the preoperative CSA (Fig. 2). Additionally, in all patients, the pre- and postoperative Goutallier paraspinal degeneration grades (range 0–3) were exactly similar. Comparing the pre- and postoperative radiographs, we found no significant midterm changes in spinal angles (Fig. 3, Table 1).

FIG. 2
FIG. 2

Changes in the paraspinal muscle CSA preoperatively and after 2 years of follow-up. The line at 45° indicates no change between the pre- and postoperative area measurements.

FIG. 3
FIG. 3

Changes in spinal angles with the proposed surgical technique at 2 years. The line at 45° indicates no change between pre- and postoperative values. Values to the left and under 0° indicate patients with lordosis.

TABLE 1

Clinical and surgical characteristics of patients

Case No.SexAge (yrs)Region; Pathology Levels (Spinous Process Cut)No. Spinous Processes CutDiagnosisBlood Loss (ml)Op Time (mins)Goutallier GradeCSA of Paraspinal Muscles (mm2)CSA Postoperative/Preoperative Ratio% CSA ReductionPreoperative Angle*Postoperative Angle*FU (mos)
PreoperativePostoperativePreoperativePostoperative
1M61 Thoracolumbar; T12–L1 (T11-T12-L1)3 5th ventricle230 226 2 2 1960 1670 0.8514.81.13.6103 
2F49 Upper thoracic; T4 (T3-T4-T5)3 Meningioma210 210 2 2 435 400 0.928.026.028.087 
3M52 Thoracic; T6 (T6-T7-T8)3 dAVF220 193 2 2 447 437 0.982.255.058.083 
4M31 Lumbar; L4 (L4-L5)2 Schwannoma150 197 0 0 2584 2498 0.973.3−45.0−46.071 
5F76 Thoracic; T8–9 (T8-T9)2 Schwannoma160 145 2 2 130 120 0.927.753.056.050 
6F44 Upper thoracic; T4–5 (T3-T4-T5)3 En plaque meningioma380 270 2 2 362 330 0.918.88.07.845 
7M60 Thoracolumbar; T11-T12-L1 (T11-T12-L1)3 Arachnoidal intradural cyst190 190 1 1 1120 1000 0.8910.75.06.041 
8M80 Lumbar; L2 (L1-L2-L3)3 dAVF170 186 2 2 1129 1085 0.963.9−46.0−45.039 
9M24 Lumbar; L5 (L5)1 Schwannoma150 210 2 2 1680 1520 0.909.5−43.0−42.037 
10M45 Upper thoracic; T4 (T3-T4-T5)3 Epidural lymphoma350 203 2 2 497 445 0.9010.520.023.034 
11F56 Thoracic; T5 (T4-T5-T6)3 Meningioma240 218 2 2 228 222 0.972.666.067.033 
12M30 Upper thoracic; T2 (T1-T2-T3)3 Cavernoma220 210 1 1 720 680 0.945.62.01.031 
13M56 Thoracolumbar; L1–2 (T12-L1-L2)3 Schwannoma180 186 2 2 1000 1000 1.000.00.00.031 
14F42 Thoracolumbar; L1 (T12-L1-L2)3 Filum ependymoma190 158 1 1 1100 982 0.890.111.812.030 
15F38 Thoracolumbar; T12 (T11-T12-L1)3 Schwannoma170 231 1 1 1985 1982 0.990.23.03.225 
16F59 Thoracic; T6 (T5-T6-T7)3 Meningioma190 223 1 1 449 436 0.972.954.055.025 
17M33 Thoracolumbar; L1 (T12-L1-L2)3 Filum ependymoma185 208 1 1 2700 2659 0.981.513.413.024 

CSA = cross-sectional area; dAVF = dural arteriovenous fistula; FU = follow-up.

Cervicothoracic junction was measured between C6 and T3; global thoracic kyphosis was measured between T1 and T12; upper thoracic kyphosis was measured between T1 and T5; thoracolumbar junction was measured between T10 and L2; lumbar lordosis was measured between L1 and S1. Negative values correspond to lordotic angles.

Two-week postoperative pain was rated between 1/10 and 3/10. No approach-related pain was reported at the last visit. The versatility of this approach allowed us to thoroughly map the spinal cord (if required) and resect intradural extramedullary tumors without compromising spinal stability. Additionally, given the wide attack angle provided by this approach, bilateral exposure of the lateral recesses and foramina was achieved (see the example case in Fig. 4). Ultimately, this technique allowed us to perform intraoperative ultrasound, an important tool to ensure adequate exposure before opening the dura mater and to document complete removal in intramedullary tumors.

FIG. 4
FIG. 4

Case 6. A 44-year-old patient was referred to our neurosurgery department after being diagnosed with a T4–5 spinal extradural mass. Her chief complaint was bilateral upper abdominal pain for the past 11 months. Two months before her office appointment, she developed urinary symptoms and frequent falls. Her physical exam showed bilateral hypesthesia with a T4 level and 4/5 leg weakness, with upper motor nerve signs in both lower extremities. Previous contrast-enhanced MRI, performed at an outside facility, showed a T4–5 extradural mass. This tumor severely compressed the thoracic spinal cord 360°. With the diagnosis of extradural metastasis in mind, surgery was performed in May 2019. A three-level thoracic spinous process cut and PBS laminectomy were performed (T3, T4, and T5). This wide three-level exposure allowed us to access the tumor from both sides. After a neat closure, the patient was transferred to the postanesthesia care unit and discharged home after 3 days. A: Preoperative sagittal T1-weighted, contrast-enhanced MRI. A T4–5 extradural mass is clearly visualized. B: Axial T2-weighted MRI; the CSA of the rotatores, multifidus and semispinalis (transversospinalis muscles), and spinalis and longissimus (two of the erector spinae muscles) were measured (preoperative CSA = 362 mm2). C: Intraoperative photograph showing the initial exposure of the T3, T4, and T5 spinous processes from the left side. D: Cutting the spinous process bases with an oscillating saw (black arrow). E: Exposure of the spinous process bases with the retractors in place. After this initial step, laminectomy was performed in the usual manner. F: Postoperative sagittal T2-weighted MRI showing complete spinal cord decompression. G: Postoperative axial T2-weighted MRI. Note the bilateral laminectomy with the floating spinous process (yellow arrow). No signs of severe ipsilateral muscle atrophy were observed (postoperative CSA = 330 mm2). H and I: Preoperative and postoperative long-cassette radiographs. No angular kyphosis developed at the operated level (preoperative upper thoracic kyphosis: 8°/postoperative: 7.8°). The final diagnosis was a completely extradural “en plaque” World Health Organization grade I meningioma.

Finally, we have not had any short- or long-term complications associated with this technique. Only one patient with a previous diagnosis of type 2 diabetes (case 15) had a noninfected partial wound dehiscence 1 month after the procedure, which required primary closure in the operating room. This patient already had a history of wound-healing problems. Although we have always been afraid of epidural hematomas (considering the vascularized bone marrow of the preserved spinous processes), no patient in this initial series developed this complication.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Approach-related morbidity resulting from iatrogenic muscle injury has become an increasing concern for spinal surgeons when treating multilevel spinal tumors. Long incisions, extensive detachment of muscles, and subsequently prolonged wide retraction can result in ischemic necrosis and denervation of the paraspinal musculature.13,14 To overcome the described complications and avoid postoperative kyphosis, we have been using this type of multilevel laminectomy, modified from the original report. The main technical difference is the method employed to retract the PTB. In their original report, authors used a self-retaining retractor.9,10 By doing so, the detached muscles must counterbalance the tremendous pressure exerted by the intact PTB. Therefore, postoperative muscle pain and ischemia are likely to develop, especially in long procedures (in the original report, the average operative time was 1.3 hours). To avoid this, we “pulled” the PTB separately with a Taylor retractor, which can be left in place for hours without any concerns. By performing this maneuver, we enabled the detached ipsilateral muscles to be retracted independently with low pressure. Hence, no patient in our study developed muscle ischemia or severe atrophy (we found only a 6% reduction in the CSA in the detached muscles), even when most procedures lasted more than 3 hours. In fact, other authors have compared CSA reduction following open surgery versus MISS. In a study conducted by Fan et al.,15 59 patients were examined to determine whether a minimally invasive approach for one-level instrumented posterior lumbar interbody fusion reduced undesirable changes in the multifidus muscle compared with a conventional open approach. Interestingly, the authors found a 36.8% ± 12.3% reduction in the multifidus CSA after open surgery.

Another technical detail we introduced was the use of an oscillating saw, which allowed us to avoid hammering over a compressed spinal cord when we cut the spinous processes. Notably, although the original technique was tested in the lumbar spine with one- or two-level spinous process cuts, we have shown that this technique is also useful to remove various intraspinal lesions in the thoracic spine and thoracolumbar junction, where we performed a three-level spinous process cut in 82% of our cases. Although we did not include cases performed in the cervical spine in our series, this approach could also be used in this region as well as in the cervicothoracic junction. However, although not described in this initial report, we operated on a patient with an extensive cervicothoracic spinal cord ependymoma using this technique. This patient also had chronic lymphocytic leukemia, which led to the patient’s death 7 months after the procedure. Notwithstanding this, the patient did not show any complications related to the technique or signs of cervicothoracic kyphosis during this period. In fact, a similar technique combined with bilateral open-door expansive laminoplasty was reported in 2011 to treat cervical spondylotic myelopathy.21 In that series, all patients maintained their cervical alignment after 2 years.

Compared with laminoplasty,16,17 PBS laminectomy has many advantages, such as unilateral muscle detachment, complete supraspinous and interspinous ligament preservation, and avoidance of hardware use. Moreover, laminoplasty is not devoid of complications7,18 and has not consistently been shown to have a decreased incidence of postoperative kyphosis compared with laminectomy in the treatment of spinal cord tumors.6,18 For instance, in an attempt to determine whether the use of laminoplasty versus laminectomy reduced the incidence of subsequent spinal deformity following intradural tumor resection, McGirt et al.19 retrospectively reviewed the records of 238 consecutive patients undergoing resection of intradural tumors at a single institution. They concluded that laminoplasty was not associated with a decreased incidence of short-term (14 months) progressive spinal deformity or improved neurological function.

Many of the advantages of our approach are shared by hemilaminectomy. However, this latter technique exposes the spinal canal from a unilateral window, leaving a blind area in the ipsilateral lateral recess and foramina. Additionally, larger-volume tumors are difficult to remove through hemilaminectomy, as shown by Goodarzi et al.20 In a retrospective review of 52 patients undergoing intradural spinal tumor resection over a 6-year period, these authors compared the outcomes of laminectomy versus hemilaminectomy. In their study, they achieved gross-total resection in 100% of patients in the hemilaminectomy group compared with 79% in the laminectomy group. However, the mean tumor size in the hemilaminectomy group was 1.25 cm3 compared with 7.02 cm3 in the laminectomy group. Thus, the authors suggested that hemilaminectomy is a viable option for smaller tumors (less than 3 cm3) that provides adequate visibility and access, whereas laminectomy continues to be the preferred method for the resection of large tumors with a complex morphology.

Observations

To our knowledge, this is the first report of a series of different intraspinal lesions treated with this modified approach. We believe this technique could be especially useful in treating spinal filum ependymomas because exposure must sometimes be extended to cut an infiltrated filum beyond the initial exposure (based on frozen sections). Additionally, PBS laminectomy could be indicated for multilevel epidural metastases or empyemas, considering that this technique can be performed without instrumentation. Finally, we refrained from correlating muscle atrophy with the (actual) functional outcome because of the inappropriateness of such an analysis, given the limitations posed by our small sample size and the methodological nature of our series. Moreover, our study design did not allow a direct comparison between the surgical characteristics of the current technique and those of a traditional bilateral approach (control group).

Lessons

In this initial series, PBS laminectomy proved to be a safe, versatile, inexpensive, and reliable technique to remove various intraspinal lesions. This technique has been shown to avoid ipsilateral muscle damage and postoperative kyphosis in the midterm. It could be added to the surgeon’s armamentarium to expose the spinal canal at multiple levels, especially in larger tumors. This study was limited by the single-center, retrospective nature of the data review. These types of studies are limited by both selection and institutional biases. Hence, no definite conclusions should be drawn when comparing our approach with hemilaminectomies and laminoplasties. In addition, considering the limited number of cases included, it is possible that other complications could arise with a larger sample. Notwithstanding that, this initial series showed that this technical modification is feasible and safe for patients. Further prospective studies comparing this technique to hemilaminectomies and laminoplasties are required to compare the rate of short- and long-term complications, postoperative pain, costs, and long-term outcomes.

Acknowledgments

The authors express their gratitude to Marta Alarcon for her invaluable assistance in preparing the manuscript.

Author Contributions

Conception and design: Barrenechea, Márquez, Pastore, Vincenti. Acquisition of data: Barrenechea, Márquez, Miralles, Rojas, Nicola. Analysis and interpretation of data: Barrenechea, Pastore, Nicola. Drafting the article: Barrenechea, Pastore, Vincenti, Nicola. Critically revising the article: Barrenechea, Rojas, Pastore, Vincenti, Nicola. Reviewed submitted version of manuscript: Barrenechea. Approved the final version of the manuscript on behalf of all authors: Barrenechea. Administrative/technical/material support: Barrenechea. Study supervision: Barrenechea.

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    Hirabayashi K, Toyama Y, Chiba K. Expansive laminoplasty for myelopathy in ossification of the longitudinal ligament. Clin Orthop Relat Res. 1999;(359):3548.

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    • Export Citation
  • 18

    Raab P, Juergen K, Gloger H, Soerensen N, Wild A. Spinal deformity after multilevel osteoplastic laminotomy. Int Orthop. 2008; 32(3):355359.

  • 19

    McGirt MJ, Garcés-Ambrossi GL, Parker SL, et al. Short-term progressive spinal deformity following laminoplasty versus laminectomy for resection of intradural spinal tumors: analysis of 238 patients. Neurosurgery. 2010;66(5):10051012.

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    • Search Google Scholar
    • Export Citation
  • 20

    Goodarzi A, Clouse J, Capizzano T, Kim KD, Panchal R. The optimal surgical approach to intradural spinal tumors: laminectomy or hemilaminectomy? Cureus. 2020;12(2):e7084.

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    • Search Google Scholar
    • Export Citation
  • 21

    Sinha S, Jagetia A. Bilateral open-door expansive laminoplasty using unilateral posterior midline approach with preservation of posterior supporting elements for management of cervical myelopathy and radiculomyelopathy--analysis of clinical and radiological outcome and surgical technique. Acta Neurochir (Wien). 2011;153(5):975984.

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  • FIG. 1

    A: Artist’s rendering of the original Ohki approach. In this technique, a lumbar retractor is used to displace the PTB against the ipsilaterally detached muscles. This exerts tremendous pressure on the ipsilateral muscles, ultimately rendering these muscles ischemic (note the difference in the paraspinal muscle colors between sides). B: Spinal process base cut in the coronal plane. Unlike the original approach in which an osteotome was used, we performed the cuts with an oscillating saw. In this way, we avoided hammering over a compressed spinal cord or cauda equina. C: Pulling the PTB with a Taylor retractor, which was fixed at the contralateral facet. The ipsilateral muscles are retracted independently with Gelpi self-retaining retractors. These retractors displace the muscles without exerting too much pressure. D: Final exposure with retractors in place. Unlike hemilaminectomies, this approach allows exposure to both lateral recesses without compromising the facet joint.

  • FIG. 2

    Changes in the paraspinal muscle CSA preoperatively and after 2 years of follow-up. The line at 45° indicates no change between the pre- and postoperative area measurements.

  • FIG. 3

    Changes in spinal angles with the proposed surgical technique at 2 years. The line at 45° indicates no change between pre- and postoperative values. Values to the left and under 0° indicate patients with lordosis.

  • FIG. 4

    Case 6. A 44-year-old patient was referred to our neurosurgery department after being diagnosed with a T4–5 spinal extradural mass. Her chief complaint was bilateral upper abdominal pain for the past 11 months. Two months before her office appointment, she developed urinary symptoms and frequent falls. Her physical exam showed bilateral hypesthesia with a T4 level and 4/5 leg weakness, with upper motor nerve signs in both lower extremities. Previous contrast-enhanced MRI, performed at an outside facility, showed a T4–5 extradural mass. This tumor severely compressed the thoracic spinal cord 360°. With the diagnosis of extradural metastasis in mind, surgery was performed in May 2019. A three-level thoracic spinous process cut and PBS laminectomy were performed (T3, T4, and T5). This wide three-level exposure allowed us to access the tumor from both sides. After a neat closure, the patient was transferred to the postanesthesia care unit and discharged home after 3 days. A: Preoperative sagittal T1-weighted, contrast-enhanced MRI. A T4–5 extradural mass is clearly visualized. B: Axial T2-weighted MRI; the CSA of the rotatores, multifidus and semispinalis (transversospinalis muscles), and spinalis and longissimus (two of the erector spinae muscles) were measured (preoperative CSA = 362 mm2). C: Intraoperative photograph showing the initial exposure of the T3, T4, and T5 spinous processes from the left side. D: Cutting the spinous process bases with an oscillating saw (black arrow). E: Exposure of the spinous process bases with the retractors in place. After this initial step, laminectomy was performed in the usual manner. F: Postoperative sagittal T2-weighted MRI showing complete spinal cord decompression. G: Postoperative axial T2-weighted MRI. Note the bilateral laminectomy with the floating spinous process (yellow arrow). No signs of severe ipsilateral muscle atrophy were observed (postoperative CSA = 330 mm2). H and I: Preoperative and postoperative long-cassette radiographs. No angular kyphosis developed at the operated level (preoperative upper thoracic kyphosis: 8°/postoperative: 7.8°). The final diagnosis was a completely extradural “en plaque” World Health Organization grade I meningioma.

  • 1

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    Balasubramanian SC, Nair AR, Saphiya NN, Madan A, Mathews SS. Minimally invasive resection of spinal tumors with tubular retractor: case series, surgical technique, and outcome. World Neurosurg. 2021;149:e612e621.

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  • 3

    Haji FA, Cenic A, Crevier L, Murty N, Reddy K. Minimally invasive approach for the resection of spinal neoplasm. Spine (Phila Pa 1976). 2011;36(15):E1018E1026.

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  • 4

    Sun S, Li Y, Wang X, et al. Safety and efficacy of laminoplasty versus laminectomy in the treatment of spinal cord tumors: a systematic review and meta-analysis. World Neurosurg. 2019;125:136145.

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    Ruggeri A, Pichierri A, Marotta N, Tarantino R, Delfini R. Laminotomy in adults: technique and results. Eur Spine J. 2012;21(2):364372.

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    Amhaz HH, Fox BD, Johnson KK, et al. Postlaminoplasty kyphotic deformity in the thoracic spine: case report and review of the literature. Pediatr Neurosurg. 2009;45(2):151154.

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    Hosono N, Yonenobu K, Ono K. Neck and shoulder pain after laminoplasty. A noticeable complication. Spine (Phila Pa 1976). 1996; 21(17):19691973.

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    Lee JH, Jang JW, Kim SH, Moon HS, Lee JK, Kim SH. Surgical results after unilateral laminectomy for the removal of spinal cord tumors. Korean J Spine. 2012;9(3):232238.

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  • 9

    Ohki I. Our surgical approach for “laminotomy.” In: Pitfalls and Knack in Orthopaedic Treatments, Spine and Pelvis. Nakayama-shoten; 1997:220221. In Japanese.

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  • 10

    Kinoshita T, Ohki I, Roth KR, Amano K, Moriya H. Results of degenerative spondylolisthesis treated with posterior decompression alone via a new surgical approach. J Neurosurg. 2001;95(1 suppl):1116.

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    Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;(304):7883.

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    Tamai K, Chen J, Stone M, et al. The evaluation of lumbar paraspinal muscle quantity and quality using the Goutallier classification and lumbar indentation value. Eur Spine J. 2018;27(5):10051012.

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  • 13

    Stevens KJ, Spenciner DB, Griffiths KL, et al. Comparison of minimally invasive and conventional open posterolateral lumbar fusion using magnetic resonance imaging and retraction pressure studies. J Spinal Disord Tech. 2006;19(2):7786.

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  • 14

    Taylor H, McGregor AH, Medhi-Zadeh S, et al. The impact of self-retaining retractors on the paraspinal muscles during posterior spinal surgery. Spine (Phila Pa 1976). 2002;27(24):27582762.

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  • 15

    Fan S, Hu Z, Zhao F, Zhao X, Huang Y, Fang X. Multifidus muscle changes and clinical effects of one-level posterior lumbar interbody fusion: minimally invasive procedure versus conventional open approach. Eur Spine J. 2010;19(2):316324.

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    • Export Citation
  • 16

    Steinmetz MP, Resnick DK. Cervical laminoplasty. Spine J. 2006; 6(6)(suppl):274S281S.

  • 17

    Hirabayashi K, Toyama Y, Chiba K. Expansive laminoplasty for myelopathy in ossification of the longitudinal ligament. Clin Orthop Relat Res. 1999;(359):3548.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Raab P, Juergen K, Gloger H, Soerensen N, Wild A. Spinal deformity after multilevel osteoplastic laminotomy. Int Orthop. 2008; 32(3):355359.

  • 19

    McGirt MJ, Garcés-Ambrossi GL, Parker SL, et al. Short-term progressive spinal deformity following laminoplasty versus laminectomy for resection of intradural spinal tumors: analysis of 238 patients. Neurosurgery. 2010;66(5):10051012.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Goodarzi A, Clouse J, Capizzano T, Kim KD, Panchal R. The optimal surgical approach to intradural spinal tumors: laminectomy or hemilaminectomy? Cureus. 2020;12(2):e7084.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Sinha S, Jagetia A. Bilateral open-door expansive laminoplasty using unilateral posterior midline approach with preservation of posterior supporting elements for management of cervical myelopathy and radiculomyelopathy--analysis of clinical and radiological outcome and surgical technique. Acta Neurochir (Wien). 2011;153(5):975984.

    • PubMed
    • Search Google Scholar
    • Export Citation

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