SpineNovember2005 10/14/05 2:09 PM Page 405

J Neurosurg Spine 3:405–408, 2005

Lumbar spinous process–splitting laminectomy for lumbar

canal stenosis

Technical note

KOTA WATANABE, M.D., TOSHIHIKO HOSOYA, M.D., TATERU SHIRAISHI, M.D.,

MORIO MATSUMOTO, M.D., KAZUHIRO CHIBA, M.D., AND YOSHIAKI TOYAMA, M.D.
Department of Orthopaedic Surgery, Ohta General Hospital; Department of Orthopaedic Surgery,
Keio University School of Medicine; and Department of Orthopaedic Surgery,
Saiseikai Utsunomiya Hospital, Tokyo, Japan

U In conventional laminectomy for lumbar canal stenosis (LCS), intraoperative damage of posterior supporting struc-
tures can lead to irreversible atrophy of paraspinal muscles. In 2001, the authors developed a new procedure for lum-
bar laminectomy, the lumbar spinous process–splitting laminectomy (LSPSL).
In this new procedure, the spinous process is split longitudinally in the middle and then divided at its base from the
posterior arch, leaving the bilateral paraspinal muscles attached to the lateral aspects. Ample working space for
laminectomy is obtained by retracting the split spinous process laterally together with its attached paraspinal muscles.
After successfully decompressing nerve tissues, each half of the split spinous process is reapproximated using a strong
suture. Thus, the supra- and interspinous ligaments are preserved, as is the spinous process, and damage to the para-
spinal muscles is minimal.
Eighteen patients with LCS underwent surgery in which this new technique was used. Twenty patients in whom
conventional laminectomy was undertaken were chosen as controls. At 2 years, the clinical outcomes (as determined
using the Japanese Orthopaedic Association [JOA] scores and recovery rate) and the rate of measured magnetic reso-
nance imaging–documented paravertebral muscle atrophy were evaluated and compared between the two groups. The
mean JOA score recovery rates were 67.6 and 59.2%, respectively, for patients treated with LSPSL and conventional
laminectomy; the mean rates of paravertebral muscle atrophy were 5.3 and 23.9%, respectively (p = 0.0005).
Preservation of posterior supporting structures and satisfactory recovery rate after 2 years indicated that this tech-
nique can be a useful alternative to conventional decompression surgery for lumbar canal stenosis.

KEY WORDS • decompression surgery • laminectomy • lumbar spine •

spinal canal stenosis • spinous process

conventional laminectomy for LCS, bilateral para-
I
N
spinal muscles are dissected and detached extensively
from the spinous process and laminae. Furthermore,
the posterior midline ligaments such as the supra- and
interspinous ligaments lose their original attachments
when the spinous processes are removed. Such intraoper-
ative damage to these posterior lumbar supporting struc-
tures can lead to atrophy of paraspinal muscles, which
causes trunk extensor weakness2 and possibly failed–back
surgery syndrome.7
Various authors have developed decompression proce-
dures for LCS that preserve the posterior supporting struc-
Abbreviations used in this paper: JOA = Japanese Orthopaedic
Association; LCS = lumbar canal stenosis; LSPSL = lumbar spi-
nous process–splitting laminectomy; MR = magnetic resonance.
tures of the lumbar spine. Some authors have performed
laminectomy in which the midline osteoligamentous
structure is preserved.10,11 Some authors have achieved
bilateral decompression via hemilaminectomy.8 In these
procedures, however, bi- or unilateral paraspinal muscles
are detached from the spinous process, and this may cause
postoperative atrophy of paraspinal muscles.
In 2001, we first performed a new lumbar laminectomy
procedure9 for LCS in which we modified the exposure
technique that was designed for cervical canal decom-
pression reported by Shiraishi.5,6 The new procedure,
LSPSL, involves exposure of the lamina by longitudinal-
ly splitting the spinous process into two halves, leaving its
muscular and ligamentous attachments undisturbed, and
followed by laminectomy with minimal muscle dissection
from the lamina. This procedure allows for better expo-
sure of intraspinal nerve tissues comparable with conven-

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K. Watanabe, et al.

tional laminectomy, while minimizing damage to posteri- TABLE 1

or supporting structures.9 Summary of clinical data obtained in 38 patients with LCS
In the present study, we describe the LSPSL technique
and report clinical outcome data obtained during a mini- Value
mum follow-up period of 2 years. We compare outcomes Conventional
observed in LSPSL-treated patients with those of conven- Factor LSPSL Laminectomy
tional laminectomy–treated control patients.
sex
male 8 10
Clinical Material and Methods female
age (yrs)*
10
67.3 6 8.9
10
70.0 6 5.7
Patient Population follow up (mos)* 29.0 6 2.9 38.7 6 14.3
op level
Thirty-eight patients with symptomatic LCS underwent 1 10 10
sugery for relief of symptoms (Table 1). Since January 2 8 10
2001, the LSPSL procedure was performed in 18 patients JOA score*
preop 12.9 6 4.7 12.5 6 4.1
(eight men and 10 women), whose mean age at the time of postop 24.2 6 2.9 22.2 6 4.1
operation was 67.3 years (range 51–79 years). The mean recovery rate (%) 67.6 6 19.2 59.2 6 20.9
follow-up period was 29 months (range 26–33 months). grade
Since January 1998, a conventional laminectomy was per- excellent 7 6
formed in 20 patients (10 men and 10 women), whose good 9 9
mean age at the time of operation was 70 years (range fair 2 3
poor 0 2
57–76 years). The mean overall follow-up period was 38.7 paraspinal muscle atrophy rate (%)† 5.3 6 6.6 23.9 6 17.5
months (range 24–70 months). Patients with degenerative
spondylolisthesis and spinal instability were excluded from * Difference not significant. Values presented as the means 6 standard
deviations.
the study. In the LSPSL group, decompression was per- † Statistically significant difference (p = 0.0005). Values presented as the
formed at single level in 10 cases and at two levels in eight. means 6 standard deviations.
In the conventional laminectomy group, decompression
was performed at single level in 10 cases and at two lev-
els in 10 (Table 1). In all patients surgery was performed compressed, each half of the split L-4 spinous process is
by the senior author (T.H.). reapproximated using a strong nonabsorbable suture (Fig.
1C and D). Thus, a one-level posterior L4–5 decompres-
Surgical Technique. We describe the technique for one- sion is accomplished by removing the L-4 lamina and pre-
level L4–5 decompression performed via spinous process serving the supra- and interspinous ligaments of L3–4 and
splitting. L4–5, as well as the L-4 spinous process, with minimal
Operative Exposure. The patient is placed in the prone damage to the paraspinal muscles (Fig. 1E and F).
position on a Hall frame. A posterior midline skin incision The patient is allowed to sit up and walk on the 1st post-
is made between the L-3 and L-5 spinous processes to operative day with a soft lumbar support.
expose the tip of L-4 spinous process. The L-4 spinous
process is split longitudinally in the middle using a high- Quantitative Analysis of the Paraspinal Muscles
speed drill running a fine 2-mm diamond-tipped burr; the To evaluate the magnitude of surgical damage to the
structure is then divided at its base from the L-4 lamina, back muscles, the cross-sectional area of the paraspinal
leaving the bilateral paraspinal muscles attached to the lat- muscles was measured on pre- and 2-year postoperative
eral aspect of the split spinous process. The supra- and in- T2-weighted axial MR images obtained using the MCID
terspinous ligaments between L3–4 and L4–5 are also imaging system (Imaging Research, Inc., St. Catharines,
split longitudinally using a scalpel. The muscles attached ON, Canada). The axial images were obtained at the inter-
to the L-4 lamina are gently dissected using an elevator. vertebral level. The rate of muscle atrophy was calculated
Ample working space for laminectomy is obtained by using the following formula: atrophy rate (%) = (1 2 total
retracting the split spinous process laterally together with postoperative area/total preoperative area) 3 100.
its attached paraspinal muscles (Fig. 1A and B).
Decompressive Procedure. The L-4 lamina and the ce- Recovery Rate
phalad half of the L-5 lamina are removed using a high- All patients were examined postoperatively by indepen-
speed drill; the L4–5 ligamentum flavum is then excised dent orthopedic surgeons, and low-back pain JOA scores
in the L4–5 interspace. The ligamentum flavum beneath were recorded.1 The highest JOA score was 29. The 2-
the anterior aspect of the L-5 lamina is removed using a year recovery rate was calculated using the following for-
small curved curette or a fine oblique Kerrison rongeur. If mula: recovery rate (%) = (2-year postoperative JOA
the working space and visualization for decompression score 2 preoperative JOA score)/(29 2 preoperative JOA
are inadequate, the medial one third of the L4–5 facet joint score) 3 100. A recovery rate of 75% or greater was re-
is removed to widen the operative space. Thus, good ac- garded as excellent, 50 to 74.9% as good, 25 to 49.9% as
cess to the lateral recesses and the entry zone of the inter- fair, and less than 25% as poor.
vertebral foramina is obtained. In obese patients the surgi-
cal microscope is used as it is when adhesion between the
nerve tissues and surrounding tissues exists. After the af- Results
fected nerve roots and the thecal sac are successfully de- In the LSPSL group, the mean preoperative JOA score

406 J. Neurosurg: Spine / Volume 3 / November, 2005

SpineNovember2005 10/14/05 2:09 PM Page 407
Lumbar spinous process–splitting laminectomy
FIG. 1. Illustrations, intraoperative photographs, and radi-
ographs depicting the technique for one-level L4–5 decompression
after L-4 spinous process splitting. A and B: The L-4 spinous
process is split longitudinally in the midline and then divided at its
base from the L-4 posterior arch, leaving the bilateral paraspinal
muscles attached to the lateral aspects of the split spinous process.
The supra- and interspinous ligaments between L3–4 and L4–5 are
also split longitudinally using a scalpel. The muscles attached to
the L-4 lamina are gently dissected. The full exposure of the L-4
lamina is now obtained by retracting the split spinous process lat-
erally together with its attached paraspinal muscles. C and D: After
the affected nerve tissues are successfully decompressed, each half
of the split L-4 spinous process is reapproximated using a strong
suture. The intraoperative photographs (B and D) show the split
spinous process (s) and the exposed dura (d) after decompression.
E and F: Postoperative anteroposterior (E) and lateral (F) radi-
ographs revealing the split and preserved spinous processes.
J. Neurosurg: Spine / Volume 3 / November, 2005
FIG. 2. Axial computerized tomography scan obtained 6 months
postoperatively revealing union of the split spinous process.
was 12.9 (range 7–20) and the mean 2-year-postoperative
JOA score was 24.2 (range 18–28); thus, the mean recov-
ery rate was 67.6% (range 30–94.4%); the recovery rate
was excellent in seven, good in nine, and fair in two pa-
tients (Table 1). In the conventional laminectomy group,
the mean preoperative JOA score was 12.5 (range 7–19)
and the mean 2-year-postoperative JOA score was 22.2
(range 11–26), yielding a mean recovery rate of 59.2%
(range 10–81.8%); the recovery rate was excellent in six,
good in nine, fair in three, and poor in two patients (Table
1). There was no significant intergroup difference. In no pa-
tient did MR imaging demonstrate recurrence of stenosis at
the 2-year follow-up examination. Furthermore, postoper-
ative computerized tomography scanning revealed success-
ful union of the split spinous processes in all LSPSL-treat-
ed patients (Fig. 2).
In the LSPSL group, MR images acquired 2 years post-
operatively (Fig. 3A) revealed more optimal preservation
of the paraspinal muscles than that obtained in the conven-
tional laminectomy group (Fig. 3B). The mean atrophy
rates of the paraspinal muscles 2 years after surgery were
5.3% (range 26 to 18%) in the LSPSL group, and 23.9%
(range 6.4–67.7%) in the conventional laminectomy
group (p = 0.0005).
Discussion
The LSPSL procedure offers the advantages of a wider
surgical working space and optimized visualization while
producing less muscular damage.
In the LSPSL procedure, wide visualization of the central
canal and lateral recess can be obtained by retracting split
spinous processes and attached ligaments bilaterally, allow-
ing unimpeded access to the nerves. The preserved midline
osteoligamentous structures sometimes limit access to the
nerve tissues, disturbing visualization and decompression of
the nerve roots in fenestration and laminotomy.
407

Fig. 3. Magnetic resonance images, obtained 2 years postoperatively in the LSPSL group (A) and the conventional
laminectomy group (B), demonstrating that the paraspinal muscles were well preserved in the former compared with
the latter.
In conventional laminectomy wide dissection and
re­traction of the paraspinal muscles are sometimes
re­quired; this manipulation can irreversibly damage the
paraspinal muscles and result in atrophy. Analysis of
our results demonstrated that the muscle atrophy rate
was significantly lower in the LSPSL group than in
the conventional laminectomy group, which underscores
the LSPSL’s less invasive treatment of the paraspinal
muscles. Several au­thors reported abnormal imaging
and/or electromyographic study findings when assessing
the paraspinal muscles in patients who have undergone
laminectomy.3,4 Sihvonen, et al.,7 correlated the aforemen-
tioned abnormalities with the development of failed–back
surgery syndrome. In LSPSL, the muscular attachments to
the spinous process are preserved, and the medial rami of
dorsal ramus, which are very vulnerable to traction, may
be preserved because less paraspinal muscle manipula-
tion is required. Additionally, the interposition of the split
spinous processes and supra- and interspinous ligaments
acts as a mechanical buffer to reduce retraction pressure
against the paraspinal muscles. Taken together, these
advantages may lead to minimal injury of the paraspinal
muscles.
Conclusions
The LSPSL procedure for LCS allows for better visu-
alization and a wider working space while minimizing
damage to posterior lumbar supporting structures. In our
study, the short-term outcomes were satisfactory at 2
years. Standardized comparative studies in which LSPSL
is com­pared with other decompression procedures are
necessary to verify the advantages of this procedure.
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Manuscript received October 1, 2004.
Accepted in final form August 25, 2005.
Address reprint requests to: Kota Watanabe, M.D., 35 Shina­no­
machi, Shinjyuku-ku, Tokyo 160-8582, Japan. email: kw197251@
sc.itc.keio.ac.jp.
J. Neurosurg: Spine / Volume 3 / November, 2005