Bilateral decompression of lumbar spinal stenosis involving a unilateral approach with microscope and tubular retractor system

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Object. The authors studied a consecutive series of patients with spinal stenosis in whom surgery was performed by a single surgeon who used a microscopic tubular retractor system (METRx-MD); patients underwent prospective evaluation involving radiography and magnetic resonance (MR) imaging.

The objective was to assess the feasibility and surgery-related efficacy of performing unilateral-approach bilateral decompression and utilization of METRx-MD instrumentation in patients with spinal stenosis.

Methods. Seventeen consecutive patients with spinal stenosis underwent bilateral decompression; surgery was performed via a unilateral approach using METRx-MD instrumentation. The procedures were performed on an outpatient basis after induction of general anesthesia. Preoperative and 3-month follow-up plain radiographs with flexion—extension views were obtained. Preoperative and postoperative MR imaging was also performed. All studies were assessed by a single radiologist blinded to the clinical results.

Twenty-two levels were surgically decompressed. The mean operative time was 90 minutes and the mean blood loss was 28 ml per level. Preoperatively stenosis was severe at 13 levels, moderate/severe at eight, and moderate at one. Postoperatively stenosis was absent at 13 levels, mild at seven, mild/moderate at one, and moderate at one. Preoperatively degenerative spondylolisthesis was documented in eight patients, with flexion—extension radiography revealing motion in three cases. On early (3-month) postoperative x-ray films there was no evidence of progression in any case. Grade I spondylolisthesis developed postoperatively in one patient, who remained asymptomatic.

Conclusions. Minimally invasive bilateral decompression and instrumentation-assisted fusion can be successfully performed via a unilateral approach in patients with acquired spinal stenosis; the procedure can be undertaken on an outpatient basis, with reasonable operative times, minimal blood loss, and acceptable morbidity rates.

Article Information

Address reprint requests to: Sylvain Palmer, M.D., 26732 Crown Valley Parkway, Suite 561, Mission Viejo, California 92651. email: sylvainpalmer@home.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Various T2-weighted MR images revealing pre- (a) and postoperative (b) sagittal images, and pre- (c) and postoperative (d) axial images.

  • View in gallery

    Illustration showing the tubular retractor in a vertical position and in a medially angulated position to access contralateral side.

  • View in gallery

    Intraoperative photographs. a: Ipsilateral decompression exposing an ipsilateral synovial cyst. b: Excision of the contralateral ligamentum flavum by using a Kerrison punch. c: Blunt nerve hook on the contralateral pedicle. d: Bilaterally decompressed dural sac.

  • View in gallery

    Bar graph depicting changes in degrees of stenosis. Numbers along the horizontal bar represent the lumbar (or lumbosacral, in one case) intervertebral disc space affected by stenosis.

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