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Recurrent stenosis after laminectomy


Introduction

Lumbar spinal stenosis is one of the most common diagnoses in the United States and worldwide that predominantly affects the aging population, with reported prevalence estimates up to 47%. Advanced disease results in back pain and neurological compression. Lumbar laminectomy is the gold standard treatment with overall good outcomes and symptom relief. However, up to 33% of patients in some reports can develop symptomatic restenosis that requires a reoperation. Oftentimes, a preexisting spinal malalignment is the culprit, which can be easily overlooked. In this chapter, we utilize a case example to illustrate the clinical presentation, preoperative workup, and surgical management of recurrent stenosis after lumbar laminectomy.

Example case

  • Chief complaint: leg and back pain

  • History of present illness: The patient is a 54-year-old male with history of L4–5 laminectomy a year ago for neurogenic claudication who presents with a 3-month history of back pain that radiates down the posterior aspect of his thighs and legs to his ankles. His symptoms are leg-predominant and worse with Valsalva maneuvers. He also reports imbalance and fear of falling when walking but does not need assistance. Lumbar spine imaging ( Figs. 6.1 and 6.2 ) showed diffuse lumbar spondylosis most prominent at the L3–4 and L4–5 levels with disc desiccation and narrowing, L3–4 canal and neuroforaminal stenosis from herniated intervertebral disc, and ligamentum flavum and facet arthropathy with hypertrophy and joint effusion. Anteroposterior x-rays ( Fig. 6.1A ) showed mild dextrorotatory curvature, and dynamic flexion-extension x-rays showed mild L3–4 retrolisthesis with extension ( Fig. 6.1B and 6.1C ).

    Fig. 6.1, Preoperative standing x-rays. (A) Anteroposterior x-ray demonstrating diffuse lumbar spondylosis, mild dextrorotatory curvature, and coronal wedging on the left L3–4. (B) Lateral flexion and (C) extension lumbosacral x-rays showing diffuse lumbar spondylosis most prominent at the L3–4 and L4–5 levels with disc narrowing and zygapophyseal arthropathy with widened (radiolucent) facet joints predominantly at L4–5. There is also mild L3–4 retrolisthesis with extension.

    Fig. 6.2, Preoperative magnetic resonance images. (A) Axial and (B) sagittal T2 images demonstrating L3–4 canal and neuroforaminal stenosis from herniated intervertebral disc and ligamentum flavum and zygapophyseal arthropathy with hypertrophy and effusion (evidenced by increased T2 signal intensity).

  • Medications: acetaminophen

  • Allergies: no known drug allergies

  • Past medical history: atrial fibrillation, coronary artery disease, deep vein thrombosis

  • Past surgical history: previous L4–5 laminectomy

  • Family history: no history of malignancies

  • Social history: smoking (one pack per day), occasional alcohol

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle and no clonus or Babinski; sensation intact to light touch; negative straight leg raise and hip motion testing

  • Laboratories: all within normal limits

  • Richard Allen, MD, PhD

  • Jakub Sikora, MD

  • Orthopaedic Surgery

  • University of California at San Diego

  • San Diego, California, United States

  • Juan Fernando Ramon, MD

  • Neurosurgery

  • University Hospital Fundacion Santa Fe de Bogata

  • Bogota, Columbia

  • Susana Núñez-Pereira, MD, PhD

  • Orthopaedic Surgery

  • Hospital Universitario Vall d’Hebron,

  • Barcelona, Spain

  • Michael Y. Wang, MD

  • Yingda Li, MBBS

  • Neurosurgery

  • University of Miami

  • Miami, Florida, United States

Preoperative
Additional tests requested Flexion/extension L-spine x-rays

  • Flexion/extension L-spine x-rays

  • Medicine evaluation

Full body AP/lateral x-rays to evaluate sagittal alignment

  • Pain drawing

  • Standing AP/lateral L-spine x-rays

  • Anesthesia evaluation

Surgical approach selected L3–4 bilateral hemilaminal foraminotomies, partial facetectomies L3–4 laminectomy, facetectomy, foraminotomy, L2–5 posterior fusion L3–4 laminectomy and posterior fusion +/- TLIF (based on spinopelvic parameters) L3–4 lateral MIS lumbar interbody fusion
Goal of surgery Decompression of central/subarticular/foraminal stenosis Decompression, stabilization Decompression, stabilization Indirect decompression, stabilization, and fusion to relieve neurogenic claudication and mechanical back pain
Perioperative
Positioning Prone on Jackson table with Wilson frame Prone Prone, on Jackson table Lateral
Surgical equipment

  • Fluoroscopy

  • Osteotomes

  • Fluoroscopy

  • O-arm

Fluoroscopy

  • IOM (MEP, SSEP, EMGs)

  • Fluoroscopy

  • Cell saver

  • Retractor system with light source

  • Allograft

  • BMP

Medications None None None Preoperative bowel prep
Anatomical considerations Spinous process, interspinous ligaments, lamina, inferior articular facets Facets, transverse apophysis, L3 lamina, foramen, dura L3–4 nerve roots Ilioinguinal and iliohypogastric nerves, retroperitoneal viscera, lumbar plexus, anterior longitudinal ligament, abdominal aorta and vena cava
Complications feared with approach chosen Instability CSF leak, nerve root injury Instability Epidural scar, CSF leak, paraspinal musculature compromise, spinal instability
Intraoperative
Anesthesia General General General General
Exposure L3–4 L2–5 L3–4 Lateral L3–4
Levels decompressed L3–4 L3–4 L3–4 L3–4
Levels fused None L2–5 L3–4 L3–4
Surgical narrative Position prone, midline incision over L3–4 down to lamina and spinous process of L3 and L4, place McCullough retractor, lateral x-ray to verify level, Leksell rongeur then matchstick bur to demarcate area of resection, thin lamina down to ligamentum flavum, feel out pars to confirm remaining bone with Epstein curette, decompress and find epidural tissue plane, release leigmaentum flavum, perform bilaterally to expose thecal sac, finalize hemilaminectomy at L3 bilaterally and at L4, go down onto superior articular processes and release any capsule and ligamentum flavum, remove this process and all compressive tissue underneath, walk out each neural foramina and decompress foramens, layered closure Position prone, midline incision from L3-L5, open fascia, muscle dissection from top of incision to locate L3 lamina, L3 laminectomy with high-speed drill, open ligamentum flavum, full facetectomy and foramen decompression with Kerrison rongeur, revise inferior level decompression, place L2–5 pedicle screws with fluoroscopy, decorticate exposed bone surfaces, pack autograft into decorticated areas, layered closure with subfascial drain Position prone, incision planned on bony landmarks and previous scar, subperiosteal dissection until posterior arch of L3 identified, scar tissue below and lack of spinous process of L4 help to confirm level, confirm with fluoroscopy, L3–4 facetectomy with chisel, insert poly axial pedicle screws L3–4 bilaterally with freehand technique and fluoroscopic control, careful dissection of lower limit of L3 lamina and bony removal with small chisel/gouge/Kerrison until reaching ligamentum flavum, minimize drill for arthrodesis, flavectomy and decompression bilaterally until wide decompression fo thecal sac is achieved and nerve roots identified without compression, check L3–4 foramina and decompress further if needed, TLIF symptomatic side, remove superior articular process of L4 with gentle dissection of foramen to isolate nerve root, protect thecal sac and remove L3–4 disc, insert cage filled with autologous bone graft with maximal possible height, insert rods, x-ray to confirm hardware placement, close rod-screw system, layered closure with drain Position lateral with most symptomatic side up, table break at iliac crest, fluoroscopy to confirm orthogonal position, two incision technique, entry into retroperitoneum, sweep away retroperitoneal viscera, guide initial dilator to disc space with finger, intradiscal Kirschner wire and retractor positioning with light source under fluoroscopic visualization, Kittner to dissect psoas off of disc, discectomy avoiding end plate and/or ALL violation, Cobb across contralateral annulus, trial then final implant filled with autograft and BMP under fluoroscopy, antibiotic irrigation, removal of retractors, layered closure
Complication avoidance Feel out pars to confirm remaining bone, remove superior articular processes to access foramens Full facetectomy to open up space, revise inferior level decompression Identify normal anatomy, free-hand technique for pedicle screws, minimize drill for arthrodesis, TLIF symptomatic side, care to protect exposed thecal sac Lateral position, fluoroscopy for localization/placement of dilators and retractor/insertion of graft, maintaining end plates and ALL
Postoperative
Admission Outpatient Floor Floor Floor
Postoperative complications feared Infection, instability Infection, CSF leak, neurological injury Infection, CSF leak, nerve root irritation, residual pain Anterior thigh pain/dysesthesia, hip flexion weakness, lumbar plexopathy, abdominal wall pseudo hernia, visceral or vascular injury, hematoma, instability, subsidence, pseudoarthrosis
Anticipated length of stay Same day 4–5 days 4–5 days 1–2 days
Follow-up testing L-spine x-ray 6 weeks after surgery L-spine x-rays within 24 hours, 1 month, 3 months, 6 months after surgery L-spine standing x-ray after drain removal

  • Standing flexion extension x-rays at 3 months after surgery

  • Physical therapy as needed

Bracing None TLSO for 2 months None Lumbar orthosis
Follow-up visits 2 weeks, 6 weeks, 6 months, 12 months after surgery 10 days, 1 month, 3 months, 6 months after surgery 2 weeks, 6 weeks and then 6 and 12 months after surgery 2 weeks and 3 months after surgery
ALL , Anterior longitudinal ligament; AP , anteroposterior; BMP , bone morphogenic protein; CSF , cerebrospinal fluid; EMG , electromyography; IOM , intraoperative monitoring; MEP , motor evoked potentials; MIS , minimally invasive surgery; SSEP , somatosensory evoked potentials; TLIF , transforaminal lumbar interbody fusion; TLSO, thoracic lumbar sacral orthosis.

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