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Open Door Laminoplasty: Creation of a New Vertebral Arch

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Open Door Laminoplasty: Creation of a New Vertebral Arch Open Door Laminoplasty: Creation Of A New Vertebral Arch Monica Lara-Almunia and Javier Hernandez-Vicente Int J Spine Surg 2017, 11 (1) doi: https://doi.org/10.14444/4006 http://ijssurgery.com/content/11/1/6 This information is current as of September 26, 2021. Email Alerts Receive free email-alerts when new articles cite this article. Sign up at: http://ijssurgery.com/alerts The International Journal Downloadedof Spine Surgery from http://ijssurgery.com/ by guest on September 26, 2021 2397 Waterbury Circle, Suite 1, Aurora, IL 60504, Phone: +1-630-375-1432 © 2017 ISASS. All Rights Reserved. Open Door Laminoplasty: Creation Of A New Vertebral Arch Monica Lara-Almunia, MD,1 Javier Hernandez-Vicente, MD2 1Department of Neurosurgery, Son Espases University Hospital, Mallorca, Spain, 2Department of Neurosurgery, University Hospital of Salamanca, Sala- manca, Spain Abstract Background We describe the carrying out of our open door laminoplasty technique by reproducing a posterior vertebral arch us- ing a local originating autologous bony graft and titanium plates. Methods We designed a prospective study and present our first 16 patients. The clinical results were evaluated with the JOA score, Nurick scale and the VAS. The functional and radiological evaluation was performed with radiographs, CT and MRI, and the measurements of the dimensions of the spinal canal were carried out with the MIPAV pro- gramme ( Johns Hopkins University). All the variables were statistically analysed by means of SPSS23.0. Results After following up the cases for two years, the clinical evaluation showed, amongst other findings, a 75% improve- ment in the JOA score, while the radiological controls showed an appropriate range of motion (ROM) along with the stability of the construction. The rate of complete arthrodesis of the cervical neo-arch reached was approxi- mately 92%. Conclusions Our results show that the modifications that we performed on the technique originally described have made it into a simpler, more efficacious and safer procedure, without lessening its essential objectives. cervical spine keywords: cervical spine, cervical multilevel mielopathy, laminoplasty, cervical stenosis, spinal cord compression volume 11 issue 1 doi: 10.14444/4006 pages 30 - 40 4,5 Introduction of the neuronal functions. Cervical laminoplasty is a procedure that allows us to In contrast to the cervical laminectomy, the lamino- widen the diameter of the spinal canal and thus, de- plasty makes a minor transgression of the spinal compressing the spinal cord and conserving some or canal with the surgical instruments as the laminas are all of the posterior elements of the bony cervical elevated together as a single unit. In addition, on the case. Oyama et al.1first described the technique in one hand, the partial or total conservation of the ele- Japan in 1973. ments that make up the posterior cervical tension bands, seems to decrease the instability and inci- This surgical methodology has been shown to give dence of postsurgical kyphosis6,7 and, on the other favorable clinical results in those patients with cervi- hand, it helps to prevent the formation of epidural cal multilevel compressive myelopathy due to the os- scarring that could be responsible for persistent post- sification of the posterior longitudinal ligament operative pain and, even, neurological deterioration.8 (OPLL), cervical spondylotic myelopathy (CSM) or developmental canal stenosis,2,3 while not being indi- Since its original description, the initial concept of cated in those patients with a cervical kyphotic de- the cervical laminoplasty evolved during the 1970's formity greater than 13 º, since the spinal cord is in- becoming popular during the 1980's. Two main capable of posteriorly expanding without cervical lor- methodological schools emerged and developed the dosis. As a consequence, there is a limited recovery "open-door" laminoplasty and the "French-door" Downloaded from http://ijssurgery.com/ by guest on September 26, 2021 doi: 10.14444/4006 method, and since then, there have been numerous the head is flexed to obtain a neutral alignment of the variations of these techniques.9,10 cervical column. We present a modified version of the open-door Approach and exposure laminoplasty initially described by Hirabayashi et al. For the vast majority of patients, the most severely in 1981,11 including the two-year clinical and radiolog- compromised levels were between C3 and C6. After ical follow-up of the cases, along with a statistical antisepsis and draping of the surgical field, a cuta- analysis. Our aim is to increase the safety and effec- neous incision was performed in medial line from the tiveness of this surgical strategy, but without losing external occipital protuberance to the C7-T1, fol- sight of the objective of obtaining a sufficient widen- lowed by subperiosteal dissection of the paraspinal ing of the canal, along with the best possible preser- musculature following medial raphe by means of vation of cervical movement. As observed in our lit- monopolar electrocautery until reaching an adequate erature review, our complete surgical technique has exposure, from the inferior edge of the laminas of the never been published before. C2 to the inferior edge of the C7 laminas, of the spin- ous processess, laminas and articular processes, and always avoiding damaging the articular facets since Methods this could cause unforeseen fusions. Once the expo- Patient and data collection sure has finished, two retractors are placed, one at Our team has carried out a prospective study of the each end of the surgical wound. first 16 patients with cervical multilevel compressive myelopathy submitted to a modified technique of the Laminotomy and green stick fracture open-door laminoplasty, presenting the two- year Next, the spinous processes from C3 to C6 (a total of follow-up. four) are removed from their base by using a Still´s - Horsley bone cutter forceps or an oscillating saw, and A total of 34 variables referring to the demographic are conserved for later use. The hemostasia in this and clinical characteristics of the patient, radiological step is assured with bone wax. characteristics of the vertebral process and peculiari- ties of the surgical technique were analyzed in each Then, and to open the vertebral arches, we firstly of the cases for the configuration of the data base. create the “open side” of the laminoplasty. For this, The information was obtained by means of a detailed a 2mm Kerrison punch is used to perform a lamino- revision of the clinical histories and imaging tests. tomy in the longitudinal axis along with the resection of the yellow ligament, in the union between the lam- Surgical technique ina and the articular processes. The small fragments All the surgical techniques were performed by the of bone obtained during this manoeuvre are con- same surgeon, senior author ( JHV), using the same served in totality. method. In the same way, and to carry out the “hinged side” Positioning of the laminoplasty, a groove is made in the external Under general anaesthesia, the patient is positioned cortical in the union between the laminas and the ar- on the surgical table in a prone position on small ticular processes, using a 5mm diamond burr. This rolling cushions situated appropriately to alleviate diameter facilitates, on the one hand, the posterior the pressure on the chest. The head and neck are sta- green stick fracture, and on the other hand, that the bilized using a Mayfield skull clamp, the shoulders walls of the groove created do not collide when the are taped down to obtain a complete radiographic vi- laminas are elevated, and, consequently they do not sualization of the lower cervical spine and table is sit- limit the canal expansion. Special interest should be uated in reverse Trendelenburg approximately some paid to this side of the laminoplasty during the 20 – 30 degrees to minimize the venous bleeding. drilling of the upper and lower edges of each lamina Using intraoperative radiological control (C-Arm), because they are the areas with the most concentra- Downloaded from http://ijssurgery.com/ by guest on September 26, 2021 International Journal of Spine Surgery 2 / 10 doi: 10.14444/4006 tion of cortical bone and that could make the eleva- plasty. In more detail, it is necessary to obtain from tion of the laminas difficult if the drilling is not the spinous processses, bony grafts similar to struts enough. or columns with the greatest proportion of non- cortical bone in the extremes that will contact with Lastly, a 2 mm Kerrison is used to section the yellow the edges of the laminotomy regarding shape, and ap- ligament transversally and in this way free the verte- proximately 10-12 mm in length regarding size. bral laminas that correspond with the upper and low- er limits of the laminoplasty. Then, four straight titanium plates with six orifices and 2mm thick are used. Each one of them is molded In this way, and after the described manoeuvres, we like an italic “S”, always bearing in mind the size of have created three free edges and a hinged edge on the bony graft. The plates are generally situated: two those that articulate the widening of the canal. orifices in contact with the articular processes, two orifices in contact with the laminas and the rest es- The opening of the laminas together as a single unit, tablishing the bridge between the articular masses is obtained by applying a Penfield dissector on the and the laminas. longitudinal free edge of the laminoplasty, whose ex- treme is situated in the medullar bone between the Next, the cut bony struts are situated at the open external and internal surface of the laminas, prevent- side of the laminoplasty in contact with the both ing with this manoeuvre the entrance of the distal ex- edges of the laminotomy, and are joined to the titani- treme of the instrument accidentally in an already um plates with two non reabsorbable silk ligatures to compressed spinal canal.
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