Original Article
Long-Term Results and Efficacy of Laminectomy with Fusion Versus Young Laminoplasty
for the Treatment of Degenerative Spinal Stenosis

Ivan Skoro 1
, Marin Stanc ic 2, Marinko Kovac evic 1, Kresimir S. Ðuric 2
- OBJECTIVE: In the treatment of degenerative lumbar
stenosis, facet-sparing laminectomy with instrumented
fusion (FSL) was recently almost totally replaced by less
invasive, allegedly equally effective surgical techniques.
We performed a long-term comparison between outcomes
after Young laminoplasty (YL) as a representative of the
less invasive technique and FSL.
- METHODS: From December 4, 2000, to March 11, 2005, 56
patients with a history of neurogenic claudication and
radiologically verified absolute lumbar stenosis were sur-
gically treated. After applying inclusion and exclusion
criteria, 44 patients were enrolled.
- RESULTS: Using the Oswestry Disability Index scale,
significant improvement on 1-year and 8-year follow-up
examinations was noticed in the FSL and YL groups. The
Oswestry Disability Index was significantly better in the
FSL group compared with the YL group at the 8-year follow-
up (27.82
1.918 vs. 40.74
2.163).
- CONCLUSIONS: FSL is a more invasive and more
expensive surgical technique than YL. In a short-term and
long-term follow-up comparison, FSL is a more successful
operative technique, and the difference increases over
time in favor of FSL.
INTRODUCTION
D egeneration of the intervertebral disc is the first step in
the development of degenerative changes in the spine
and is accompanied by simultaneous hypertrophy of the
ligamentum flavum and subsequent subluxation of the upper
Key words
- Laminectomy
- Minimally invasive surgical procedures
- Spinal fusion and instrumentation
- Spinal stenosis
Abbreviations and Acronyms
FSL: Facet-sparing laminectomy with fusion
MRI: Magnetic resonance imaging
ODI: Oswestry Disability Index
YL: Young laminoplasty
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processus of the small joint. Further hypertrophy of the liga-
mentum flavum develops along with the generation of osteophytes
at the level of the intervertebral disc as well as on the surface of a
small joint, which together additionally narrow the diameter of the
spinal canal (Figure 1).1-6 During the 1950s and 1960s,Verbiest and
others were the first to use the term “spinal stenosis” and connect
it with the pathognomonic clinical picture.7-10 The average inci-
dence of surgery for degenerative lumbar stenosis is 9.7 per
100,000 people.4 Degenerative lumbar stenosis commonly occurs
after the age of 60.
The symptom that is most commonly and most reliably asso-
ciated with lumbar spinal stenosis is neurogenic claudication or
pseudoclaudication. Symptoms worsen when the patient is
standing or walking and decrease when the patient is sitting or
lying. Magnetic resonance imaging (MRI) is the diagnostic
method of choice for patients with spinal stenosis. Relative lum-
bar spinal stenosis is diagnosed when the surface of the spinal
canal on the transverse section is between 75 and 100 mm2, and
absolute stenosis is diagnosed when the size of the spinal canal is
<75 mm2 (Figure 2).11
As the population ages and as the number of elderly people in
the general population increases, more attention is paid to
improving the quality of life of older patients. Over the past 30
years, the superiority of surgery over conservative treatment of
degenerative lumbar stenosis has been proven. In 1992, Turner
et al.7 published a meta-analysis of studies on the performance of
patients with degenerative lumbar stenosis who received surgical
treatment; this meta-analysis showed that good or excellent re-
sults were present in 64% of these patients. Over the last 40 years,
surgical techniques have undergone major changes. One of the
first and most common surgical techniques for patients with
degenerative lumbar stenosis is a wide decompressive lam-
inectomy. In this surgical technique, wide decompression of the
spinal canal has often led to the destruction of the pars inter-
articularis or destruction of the small joints of the spine, resulting
in the instability of the spine. The development of surgically
From the 1Department of Neurosurgery, The University Hospital Centre “Sestre Milosrdnice”;
and 2Department of Neurosurgery, The University Hospital Centre Zagreb, Zagreb, Croatia

To whom correspondence should be addressed: Ivan Skoro, M.D., Ph.D.
[E-mail: iskoro@gmail.com]
Citation: World Neurosurg. (2016) 89:387-392.
http://dx.doi.org/10.1016/j.wneu.2016.01.078
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2016 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org 387
 ORIGINAL ARTICLE

IVAN SKORO ET AL. LAMINECTOMY WITH FUSION VERSUS YOUNG LAMINOPLASTY

results of minimally invasive techniques, but all these studies

had short follow-up periods. To our knowledge, there are no
studies that report the results of a longer period of follow-up of
minimally invasive techniques in the treatment of degenerative
lumbar stenosis. The purpose of this study was to detect a dif-
ference in the quality of life between patients treated by lam-
inectomy with instrumented fusion and patients treated by
minimally invasive Young laminoplasty (YL) after 1 year and after 8
years of postoperative follow-up.

MATERIALS AND METHODS

Figure 1. Transverse section through the intervertebral disc showing the
loss of water and demarcation of the nucleus pulposus and anulus
fibrosus. (A) Intervertebral disc in an adolescent. (B) Intervertebral disc in
a 28-year-old man.
precise but less destructive procedures came with the introduction
of the operating microscope, MRI, and the high-speed drill. In
1988, Young et al.12 described a microscopic technique
characterized by a unilateral approach with decompression of
the ipsilateral and contralateral dural sac and spinal roots, while
preserving the spinous process and supraspinous and
interspinous ligament. This procedure was later modified by
McCulloch.13 Numerous published scientific works showed good
This study was carried out in accordance with the Code of Ethics of
the World Medical Association. Informed consent was obtained
from all patients, and privacy rights of all patients were respected. In
the period from December 4, 2000, to March 11, 2005, 44 patients
with degenerative lumbar stenosis on 2 levels underwent. The
diagnosis was based on typical anamnesis, physical examination,
and lumbar spine MRI. All participants completed standardized
questionnaires for depression assessment (Beck Depression
Inventory) and for quality-of-life assessment in regard to the spinal
degenerative disease (Oswestry Disability Index [ODI]).
Inclusion criteria for patient enrollment were degenerative
lumbar disease of 2 levels causing neurogenic claudication with
unilateral or bilateral radiculopathy, shortened walking distance of
<100 m, and the inability to stand still for >5 minutes; MRI
confirmation of absolute lumbar spinal stenosis measured as the
surface of the dural sac at the most compressed level 75 mm2 in
at least 1 level; and symptom duration for a minimum of 6 months
with no improvement with conservative therapy. Exclusion criteria
were scoliosis >20 ; anterolisthesis >16%; retrolisthesis >12%;

Figure 2. Magnetic resonance imaging of the lumbosacral spine in the sagittal plane shows the L4-L5 spinal canal
stenosis with protrusion of the intervertebral disc. Transverse images show a narrowing of the diameter of the dural
sac, hypertrophy of the small joints, and hypertrophy of the ligamentum flavum.

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IVAN SKORO ET AL.
sagittal kyphosis >12 ; previous surgery of the lumbar spine;
lumbar spine trauma; and the presence of lumbar spinal tumors,
infections, and cauda equina syndrome.
Patients were randomly assigned into 2 groups: patients who
were surgically treated by facet-sparing laminectomy with instru-
mented fusion (FSL) comprised one group and patients who un-
derwent minimally invasive YL comprised the second group. After
initial randomization, some patients refused to be operated on
using minimally invasive YL, and those patients were enrolled in
the FSL group. This resulted in 26 patients being enrolled in the
FSL group and 18 patients being enrolled in the YL group. Thus,
the conducted study was a partly randomized and partly obser-
vational cohort.
Surgical Technique
YL. The patient is placed in prone position on the operating table.
Using intraoperative fluoroscopy, the target level is identified. A
midline skin and thoracolumbar fascia incision is made, and
paravertebral muscles are detached from spinous processes and
laminae on the symptomatic side. After placing the retractor, the
ipsilateral interlaminar space is visualized. Interlaminectomy is
performed until the beginning grip of the ligamentum flavum is
verified. In the microsurgical technique, the ipsilateral liga-
mentum flavum is removed, and, if needed, undercutting of the
ipsilateral facet joint and foraminotomy are carried out, decom-
pressing the exiting and transverse spinal root and the dura mater.
The patient is then tilted with the operating table on the contra-
lateral side, making visualization of the contralateral side possible.
The procedure is repeated on the contralateral side until decom-
pression of the upper and lower spinal roots to their entry into the
intervertebral foramen is achieved (Figure 3). A bilateral
decompression of exiting and traversing spinal roots and dural
Figure 3. Schematic representation of Young
laminoplasty. After ipsilateral decompression of the
spinal root, contralateral decompression of the spinal
root is achieved.
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ORIGINAL ARTICLE
LAMINECTOMY WITH FUSION VERSUS YOUNG LAMINOPLASTY
sac is achieved via a unilateral approach, maximally preserving
the osseous and ligamentous structures of a spinal functional unit.
FSL. The patient is placed prone on the operating table, and the
target level is identified using fluoroscopy. A midline skin and
thoracolumbar fascia incision is made, and the paravertebral
musculature is detached bilaterally exposing the spinous pro-
cesses, laminae, and facet joints. Transpedicular screws are placed
freehand with fluoroscopic verification of position. A laminectomy
is done in the usual manner, and lateral decompression is ach-
ieved by a bilateral facet-sparing technique, facet undercutting. In
this manner, the appropriate dural sac and traversing and exiting
spinal roots are decompressed. Transpedicular screws are con-
nected with the longitudinal rod that was previously bent for
lumbar lordosis alignment. The rod is securely locked. The
transverse connecting rod is placed and locked. Osseous debris
collected after the laminectomy is packed in the soft tissue below
the longitudinal rod. In this manner, appropriate dural sac and
spinal root decompression as well as lumbar lordosis realignment
is achieved (Figure 4).
Follow-Up
Patients were scheduled for follow-up examinations 3, 6, 12, and
96 months after the surgical procedure. The ODI score was
assessed 1 and 8 years after the surgical procedure. Patients un-
derwent a complete neurologic examination, and plain static ra-
diographs were analyzed by the radiologist and the operating
surgeon. Static and dynamic x-ray images were obtained as a
follow-up assessment. Static anteroposterior and left lateral x-ray
images were obtained to validate sagittal balance and to exclude
any pathologic condition in the coronal plane postoperatively. X-
rays were also performed to check the position of implanted
materials (screws and bars) and to determine if they were viable.
Statistical Analysis
The data were statistically analyzed using SPSS for Windows
version 17 (SPSS, Inc, Chicago, Illinois, USA) and MedCalc Soft-
ware 12.2.1 (MedCalc Software bvba, Mariakerke, Belgium). The
sample size was calculated from the preliminary results using
medium values and SD. The normal distribution of continuous
variables was considered irreducible, and curvature distribution
was <1. Also, the regularity of distribution was checked with the
Kolmogorov-Smirnoff test. Medium values of continuous vari-
ables are expressed in the median and range for variables that are
not normally distributed. Nominal data are presented by share
and frequency distribution in groups. To determine the difference
between 2 independent samples, Student t test was used, with a
logarithmic transformation. To determine the difference between
the proportions between the 2 samples, c2 test was used. To
determine the correlation between the samples, Kendall tau and
Spearman rho test were used for nonparametric analysis, and
Spearman rank correlation test was used for parametric analysis
of continuous variables. A P value < 0.05 was considered
statistically significant.
RESULTS
The study included 44 patients who underwent surgery during the
period 2000e2005 for treatment of degenerative lumbar stenosis.
www.WORLDNEUROSURGERY.org 389
 ORIGINAL ARTICLE

IVAN SKORO ET AL. LAMINECTOMY WITH FUSION VERSUS YOUNG LAMINOPLASTY

blood loss for the FSL group was 546.15 mL
161.32 and for the
YL group was 446.15 mL
106.97. The duration of postoperative
hospitalization for the FSL group was 5.77 days
1.54 and for the
YL group was 3.46 days
0.88.
There was no statistically significant difference in the preoper-
ative ODI score in the FSL group versus the YL group (54.47

14.48 vs. 56.79
12.48; t ¼ 0.552, P ¼ 0.584). A statistically sig-
nificant difference was found in the ODI score after 1 year in the
FSL group versus the YL group (24.22
1.892 vs. 28.01
1.945;
t ¼ 9.868, P < 0.001). After 8 years, the ODI score was 27.82

1.918 in the FSL group and 40.74
2.163 in the YL group. This
was a statistically significant difference (t ¼ 20.852, P < 0.001)
(Figures 5e7). All patients were operated on by the same senior
surgeon (M.S.).
Both surgical techniques lead to a significant improvement, and
this improvement changes over time in favor of the FSL group.
The relative ratio of ODI expressed as a percentage between the 2
groups after 8 years of follow-up shows a difference of 26.02% in
favor of the FSL group. In all 26 patients in the FSL group, fusion
was achieved. All patients were treated by noninstrumented as
well as instrumented fusion. Complications occurred in 2 patients.
In 1 patient in the YL group, there was a dural tear that was pri-
marily repaired with sutures and fibrin glue. In 1 patient in the FSL
group, a subdermal infection developed (no deep structures were
involved) and was successfully treated with antibiotics.

DISCUSSION
Figure 4. Laminectomy with spondylodesis done at the level of L1-L4, Improved standard of living and overall extended life span of
which shows a good position of the transpedicular screws. people are increasing a portion of the older population with
degenerative spinal disorders, which are dramatically reducing the
quality of their lives. For patients with severe symptoms whose
All patients included in the study had clinically and radiologically
quality of life is significantly compromised, surgical treatment is a
verified lumbar stenosis. Predominant symptoms were neurogenic
primary option.
claudications, unilateral or bilateral radiculopathy, shortened
After decompressive laminectomy with or without spondylodesis,
walking distance of <100 m, and the inability to stand still for >5
the likelihood of the development of restenosis is increased. In a
minutes. Postoperatively, all patients experienced a partial
neurologic improvement. There was no additional neurologic
deterioration postoperatively in any patient compared with pre-
operative status.
Subjects were followed from diagnosis to 8 years after surgery.
There were 26 patients in the FSL group and 18 patients in the YL
group; there were 28 men and 16 women. Both surgical groups
were epidemiologically very similar. The average age of patients
was 64.15 years
14.25 in the FSL group and 65.75 years
8.84 in
the YL group.
Surgery was performed in 44 patients on a total of 130 levels.
Surgery was performed on 2 levels in 15 patients, on 3 levels in 19
patients, on 4 levels in 7 patients, and on 5 levels in 3 patients. The
average number of operated levels per patient was 2.95. There
were no statistically significant differences on the surface of the
dural sac in the FSL group versus the YL group (53.6 mm2
8.39
vs. 54.1 mm2
10.11; t ¼ 0.179, P ¼ 0.859).
To estimate the degree of invasiveness of each surgical tech-
nique, the duration of the surgery in minutes, the amount of blood
loss in milliliters, and the duration of postoperative hospitaliza- Figure 5. Preoperative values of Oswestry Disability Index compared
tion in days were measured for all patients. The average duration with values at 1-year and 8-years follow-up show a statistically significant
difference between groups in favor of the facet-sparing laminectomy
of surgery for the FSL group was 60.77 minutes per level
10.17, with fusion (FSL) group. YL, Young laminoplasty.
and for the YL group was 46.46 minutes per level
9.22. Average

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 ORIGINAL ARTICLE

IVAN SKORO ET AL. LAMINECTOMY WITH FUSION VERSUS YOUNG LAMINOPLASTY

patients. One of the main advantages of YL is that it reduces surgical

60
trauma and avoids the development of postoperative instability. To
56.79 the best of our knowledge, the outcome of patients with degenerative
54.47
50
lumbar spinal stenosis who were treated with YL is described only by
Young et al.12 and McCulloch13 with a 9-month follow-up period.
The aim of this study was to determine whether YL is as
Oswestry Disablity Indeks

40
30
28.01
24.22
20
10
0
preoperaƟve aŌer 1 year
Figure 6. Preoperative values of Oswestry Disability Index and values
after 1 and 8 years of monitoring show a significant statistical difference
between groups in favor of the facet-sparing laminectomy with fusion
(FSL) group after 1 year of follow-up, which increases after 8 years of
follow-up. YL, Young laminoplasty.
study that followed 40 patients treated for lumbar stenosis over an
average period of 8.6 years, Postacchini and Cinotti14 showed that
88% of them developed some form of restenosis. This study
showed that most patients experience bone remodeling, which
can be significant if it leads to repeated clinical worsening.
However, in patients with spondylodesis, the chances of clinically
significant restenosis were lower. Furthermore, it was concluded
that bone remodeling was more prominent in patients who
showed signs of instability either before or after the operation
than in patients who did not show signs of instability.
In the study by Chen et al.,15 which prospectively followed a
group of patients who underwent laminectomy for 4.5 years,
44% of the patients were observed with a new moderate to high
bone formation occurrence. The authors stated that all the
patients showed some form of bone formation and that new
bone formation could develop at any place where the bone was
removed during the previous surgery.
As the representative of a minimally invasive surgical technique, YL
is increasingly being used to decompress the vertebral canal in elderly
RaƟo FSL/YL
0% 0.00%
preoperaƟve aŌer 1 year
-5% -5.25%
-10%
-15%
-20%
-25%
-30%
Figure 7. Relative ratio of Oswestry Disability Index scores expressed in
percentages between the 2 groups throughout the follow-up period. FSL,
facet-sparing laminectomy with fusion; YL, Young laminoplasty.
40.74
effective as FSL and whether YL is less invasive than FSL during an
8-year follow-up period. The quality of the study would be
FSL
27.82 enhanced if postoperative images for all patients operated on
YL
using different techniques were obtained and could be compared.
Surgical outcome was evaluated using the ODI. MRI for direct
comparison between the 2 surgical techniques are lacking because
MRI was not performed postoperatively in all the patients. We are
not claiming that our patients in the FSL group did not develop
aŌer 8 years
“adjacent level disease” or restenosis. We are aware that restenosis
and adjacent disc disease occurs in many patients after surgery. All
26 patients operated on using FSL experienced partial or complete
neurologic improvement. Only control X-rays were done, and MRI
was not routinely performed, only in cases with complications or
unsatisfactory recovery. Some patients likely developed adjacent
disc disease, but it was not clinically significant and so post-
operative MRI was not performed. Our study design did not
include routine postoperative MRI; however, postoperative MRI in
all operated patients would provide important information and
would increase the value of the study.
A logical question concerning our study is why some of the
patients who refused randomization decided to subject themselves
to the more invasive surgical technique. The average age of pa-
tients in both groups was 65 years. After all patients were offered
randomization, some of them refused to be randomly enrolled in
the YL group and asked to undergo the surgically more aggressive
technique. It is possible that when patients were introduced to the
surgical techniques, they were told that larger and wider decom-
pression would be done in the FSL group and that the senior
surgeon had greater experience with spondylodesis and decom-
pression. Thus, the FSL technique possibly was presented as the
gold standard. Also, given the fact that the average age of patients
was high, they may have opted for a more lasting solution.
One of the limitations of this study is that all the patients in the
study were not randomized. The study was designed as a double-
blind randomized study, but at the beginning of the study 26 of 44
patients consented to randomization, and 18 patients refused
randomization. Of the 26 patients randomly assigned, 13 were
assigned to the FSL group, and 13 were assigned to the YL group. Of
the 18 patients who refused the randomization, 13 elected to be in
the FSL group, and 5 elected to be in the YL group. The FSL group
aŌer 8 years
had 26 patients, and the YL group had 18 patients, and the con-
ducted study was partly randomized and partly observational cohort.
The study would have had only 26 patients if only the patients who
were randomly assigned were considered, and that is not enough to
draw a proper conclusion. Regarding the statistical parameters of
the study, the 44 patients included in the study constituted a rela-
-26.02%
tively small sample, and the study is at the lower limit of the
allowable statistical significance. The smaller number of patients in
the study leads to the conclusion that the outcome of the study may
not be accurate. We recognize that the number of patients included
in the study should be larger to enhance the credibility of the pre-
sented conclusions. All patients were operated on by only 1 senior

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IVAN SKORO ET AL. LAMINECTOMY WITH FUSION VERSUS YOUNG LAMINOPLASTY

surgeon. The study was initially designed to involve a minimum of
150 operated patients, but there had been a reorganization of the
hospital, and the senior surgeon left the hospital.
CONCLUSIONS
Tracking the ODI score before surgery and 1 year and 8 years after
surgery makes it clear that both surgical techniques are successful
in treating patients with degenerative lumbar stenosis. Post-
operative results after the first year are similar. However, in the
long-term, FSL has better results than YL. Long-term follow-up
showed YL is not as effective as FSL. Our results show that in
young patients with severe degenerative lumbar stenosis with
multiple levels involved and sagittal imbalance, classic lam-
inectomy with instrumentation is recommended.

7. Turner JA, Ersek M, Herron L, Deyo R. Surgery for 13. McCulloch JA. Microdecompression and unin-
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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 8 October 2015; accepted 27 January 2016
Citation: World Neurosurg. (2016) 89:387-392.
http://dx.doi.org/10.1016/j.wneu.2016.01.078
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2016 Elsevier Inc. All
rights reserved.

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