Laminotomy

• Decompression through a microdisectomy-like approach to target the

stenotic levels either unilaterally or bilaterally.
• Caudal aspect of superior lamina and the cephalad portion of the
inferior lamina at the stenotic level are resected

• Approach:
• Unilateral  Unilateral pathology, bilateral decompression
• Bilateral  Bilateral stenosis
• Advocates: Leaving the midline structures intact  Decrease the chance of
iatrogenic instability and back pain
• Multiple laminotomies  Additional stability provided by intervertebral disc
and the facet-joint capsule complex
• Gurelik and colleagues  Laminectomy resulted in a significantly larger
increase in dural sac area than laminotomy but postoperative instability are
not found in laminotomy patients
• Thome and colleagues  Bilateral laminotomy demonstrated the best
overall outcomes compared to unilateral laminotomy for bilateral
decompression, and laminectomy for lumbar stenosis. Dural tear was the
most common compliaction
• Celik and colleageuse 
• Laminectomy  More perioperative complications and postoperative
instability.
• Laminotomy  No significant trend toward superior walking distance, pain
control, and disability
• Fu and colleaguse  Laminotomy resulting in good long term result
with few complications
• Bilateral laminotomy  Better perceived recovery at final follow-up &
less severe postoperative low back pain
• Unilateral laminotomy for bilateral decompression and bilateral
laminectomy  lower rates of iatrogenic instability
• Less invasive unilateral or bilateral laminoforaminotomy  One or
two-level lateral recess stenosis without significant central stenosis
Fenestration
• Treat stenosis with variability surgical techniques similar to traditional
laminotomy.
• Aim to preserve the midline structures and minimize soft tissue and
bony resection while addressing sites of neurologic compression
• Decompression through a 5-mm drill hole in the pars
interarticularis below the superior facet exposing
inerior aspect of the pedicle and the nerve root in the
foramen Drilling the inferior aspect of the superior
pedicle through 2-mm diamond drill bit and operating
microscope Dorsal aspect of the nerve root is
decompressed by undercutting the lamina and
hypertrophied facet

• Preserve spinal stability and allows early mobilization

and shortening hospital length of stay
Laminoplasty
• Distraction laminoplasty by O’Leary and colleagues
• Expansive lumbar laminoplasty by Tsuji and colleagues
Distraction Laminoplasty
• Distraction laminoplasty is a technique for decompression of central
and lateral recess stenosis with minimal bony resection. I
• This technique involves mechanical distraction of the stenotic
interspace to facilitate spinal canal access.
• Begins with removal of the inferior half as the
cephalad vertebra’s spinous process and lamina as
well as the superior edge of the caudal vertebra
• Distraction across the spinous processes of the
segments opening the interlaminar working
space by mobilizing the cephalad lamina
proximally and the caudad lamina distally
• Motion improved visualization
• Removal of ligamentum flavum  Decompression
of the lateral recesses by removing 10-20% of the
facet joint
Laminar spreader between the spinous process  Easier neural
decompression and decreasing the chance of dural violation
Caution in patient with osteoporosis  May cause fracture of the
spinous process or laminar edge
Expansive lumbar laminoplasty
• Expansive lumbar laminoplasty is a technique that aims to provide
osteoplastic enlargement of the spinal canal while retaining spinal
stability in the treatment of spinal stenosis
• Analogous to cervical laminoplasty and involves opening one side of
the lamina by using the contralateral side as hinge
• Spinous process is removed Using a high-speed burr to make a groove in
either side of the lamina One groove extends completely, while the other is
incomplete
• The lamina is hinged open through the site of the incomplete groove and held
open with autograft from the excised spinous process Fixed with braided
wire or nylon suture
• Additional bone graft is packed dorsally over the osteotomy sites
• Higher intraoperative blood loss and longer operative time
• Post operative Japenese Orthopaedic Association (JOA) score
improved significantly. Patients >56 years had significantly less
improvement
• The best indications : Young and active patients with isolated central
spinal stenosis