Clin Orthop Surg.  2019 Mar;11(1):95-102. 10.4055/cios.2019.11.1.95.

Restoration of the Spinous Process Following Muscle-Preserving Posterior Lumbar Decompression via Sagittal Splitting of the Spinous Process

• Wi SM
• Lee HJ
• Chang SY
• Kwon OH
• Lee CK
• Chang BS
• Kim H

• KMID: 2438339
• DOI: http://doi.org/10.4055/cios.2019.11.1.95

Abstract

BACKGROUND
In lumbar spinal stenosis, spinous process-splitting decompression has demonstrated good clinical outcomes with preservation of the posterior ligamentous complex and paraspinal muscles in comparison to conventional laminectomy, but the radiological consequence and clinical impact of the split spinous processes have not been fully understood.
METHODS
Seventy-three patients who underwent spinous process-splitting decompression were included. The bone union rate and pattern were evaluated by computed tomography performed 6-18 months after surgery and compared among subgroups divided according to the number of levels decompressed and the extent of spinous process splitting. The bone union pattern was classified into three categories: complete union, partial union, and nonunion. The visual analog scale (VAS) score, Oswestry disability index (ODI), and walking distance assessed both before and 24-36 months after surgery were compared among subgroups divided according to the union pattern of the split spinous process.
RESULTS
Overall, the rates of complete union, partial union, and nonunion were 51.7%, 43.2%, and 5.1%, respectively. In the subgroup with partial splitting of the spinous process, the rates were 85.7%, 14.3%, and 0%, respectively; those of the subgroup with total splitting of the spinous process were 32.9%, 59.2%, and 7.9%, respectively. With single-level decompression, a higher rate of union was observed compared with multilevel decompression. The VAS, ODI, and walking distance were significantly improved after surgery and did not differ according to the degree of union of the split spinous process.
CONCLUSIONS
We found that the single-level operation and partial splitting of the spinous process were favourable factors for obtaining complete restoration of the posterior bony structure of the lumbar spine in spinous process-splitting decompression.

Keyword

Lumbar spinal stenosis; Decompression; Spinous process splitting; Bony union; Clinical outcomes

MeSH Terms

Decompression*
Humans
Laminectomy
Ligaments
Paraspinal Muscles
Spinal Stenosis
Spine
Visual Analog Scale
Walking

Figure

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  Fig. 1 Intraoperative photographs. (A) The spinous process was divided longitudinally and evenly using an ultrasonic blade. (B) The L4 spinous process was split longitudinally in the midline and then divided at its base from the L4 posterior arch, leaving the bilateral paraspinal muscles attached to the split spinous process. The supra- and interspinous ligaments between L3–4 and L4–5 were also split longitudinally using a scalpel. The split halves of the spinous process were bilaterally retracted with the Gelpi retractor to obtain ample working space in the L3–4 and L4–5 interlaminar spaces. The affected nerve tissues were successfully decompressed.

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  Fig. 2 Clinical outcomes. (A) Visual analog scale (VAS) for back pain. (B) VAS for leg pain. (C) Oswestry disability index (ODI). (D) Walking distance.

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  Fig. 3 Union pattern. (A) Complete union (complete restoration of spinolaminar structure): union observed both in-between split spinous processes and at the spinolaminar junction. (B) Partial union (floated union of spinous process): union observed only in-between split spinous processes and nonunion at the spinolaminar junction. (C) Nonunion: no union observed in-between split spinous processes and at the spinolaminar junction.

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  Fig. 4 T2-weighted axial magnetic resonance imaging. (A) The preoperative image revealed severe central and lateral recess stenosis. (B) After decompression, the spinous process and paraspinal muscles were seen well preserved at the L4–5 level.

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