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Table of Contents    
LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 2  |  Page : 226-227

Modified French door laminoplasty using autologous spinous process as interlaminar spacer


Department of Neurosurgery, Shri Ramachandra Bhanj Medical College and Hospital, Cuttack, Odisha, India

Date of Submission01-Aug-2013
Date of Decision04-Aug-2013
Date of Acceptance06-Apr-2014
Date of Web Publication14-May-2014

Correspondence Address:
Sanjay K. Behera
Department of Neurosurgery, Shri Ramachandra Bhanj Medical College and Hospital, Cuttack, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.132449

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How to cite this article:
Mishra SS, Das S, Behera SK, Senapati SB, Das D. Modified French door laminoplasty using autologous spinous process as interlaminar spacer. Neurol India 2014;62:226-7

How to cite this URL:
Mishra SS, Das S, Behera SK, Senapati SB, Das D. Modified French door laminoplasty using autologous spinous process as interlaminar spacer. Neurol India [serial online] 2014 [cited 2021 Mar 4];62:226-7. Available from: https://www.neurologyindia.com/text.asp?2014/62/2/226/132449


Sir,

Laminoplasty is one surgical option to treat multilevel cervical spondylotic myelopathy, especially when associated with ossified posterior longitudinal ligament (OPLL) and spinal canal stenosis. [1] Posterior approaches to decompress multilevel cervical spinal cord compression include laminectomy, laminectomy with fusion, and laminoplasty. Laminectomy safely brings adequate decompression of the cervical spinal cord; nevertheless, it can have the adverse outcomes of epidural scar formation (post-laminectomy membrane) after cervical laminectomy and of post-laminectomy kyphosis secondary to iatrogenic destabilization of the cervical spine. [2] Laminoplasty allows the spinal cord and the neuro-foramen to be decompressed without directly removing anterior pathology. By preserving the dorsal elements of the spine, laminoplasty preserves spine stability and alignment and decreases the risk of post-laminectomy kyphosis and instability. [1]

A 42-year-old male with insidious onset of neck pain radiating to both hands and weakness of both upper and lower limb for last eight month complained of progressive difficulty in walking with spasticity of lower limbs and became bedridden since last one month with a pre-op Nurick grade 5. He had atrophy of the small muscles of hand, spastic gait and 4/5 weakness of the muscles of upper limb and 3/5 over lower limb and grip weakness bilaterally. Deep tendon reflexes were exaggerated. The plantar reflexes were extensor bilaterally, and there were sustained clonus at the ankles. Magnetic resonance imaging (MRI) of the cervical spine and computed tomography (CT) scan demonstrated circumferential stenotic levels at C3-C4, C4-C5, and C6-C7 due to disc herniation and OPLL. Through posterior approach, following midline dissection along the avascular subperiosteal plane, paraspinal muscles are retracted laterally and the spinous processes, lamina, and medial aspect of the facets were completely denuded of soft tissue. The spinous processes and laminae are exposed from C2-C7 laterally as far as lateral border of facet joints. Gutters are made bilaterally with a high-speed drill at the lamina-lateral mass junction from C3 to C6, just medial to the pedicle. The spinous process excised and are cleared off from soft tissues and preserved. The midline opening is created using a fine Kerrisonrongeur and high-speed drill. We find that a 6 mm diamond burr is useful to cut the outer cortex in the process and 2 or 3 mm Kerrison punch for removing the thin rim of remnant lamina and associated ligamentum flavum from caudal to rostral. Split lamina opened in midline using lamina spreader. French door laminoplasty was done using excised spinous processes as interlaminar spacer and were secured with titanium wire [Figure 1]. The canal diameter was increased significantly, and cord pulsation was visible intra-operatively. Post-operatively, patient improved, spasticity of limbs decreased, and patient could walk with support. Comparing pre-operative CT scan cervical spine with that of post-operative one also show significant increase in canal diameter [Figure 2] and [Figure 3].
Figure 1: Intra-operative picture showing: Gutter on each side of the lamina-facet junction and midline liminotomy after excision of spinous process (a). Excised spinous processes used as interlaminar spacer and were secured with titanium wire (b)

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Figure 2: Comparing pre- and post-operative CT scan cervical spine sagittal view showing: Significant increase in canal diameter

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Figure 3: Comparing pre- and post-operative CT scan cervical spine axial view showing: Significant increase in canal diameter

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Oyama et al. first described cervical laminoplasty in Japanese in 1973 as a treatment for OPLL. In this initial expansive laminoplasty procedure, the "Z-plasty" of the cervical spine, the spinous processes are removed, the lamina is thinned to the lamina-facet junction, and a Z-shaped cut is made between the laminae, which are opened and fixed with suture or wire. [3] Hirabayashi et al. simplified the Z-plasty described by Oyama in the early 1980s with his unilateral expansive open-door laminoplasty. In this technique, a hinge is created on one side of the lamina-spinous process-ligamentum flavum complex. This allows the roof of the canal to be opened on the contra-lateral side leading to an expansion of the spinal canal. [4],[5] In Hirabayashi's expansive open-door laminoplasty, the spinal cord is decompressed asymmetrically since the door opens on one side and hinges on the other. In contrast, in the double-door or French door laminoplasty, described by Kurokawa in 1982, the door is opened along the midline and thus creates a symmetric opening of the canal. Bilateral troughs are created similarly to the open door technique. This procedure is applied with a high-speed drill, and care is taken not to drill completely through the laminae. The midline opening is created using a fine Kerrisonrongeur and high-speed drill. The split laminae are opened in sequence, similar to French doors, to create an opening approximately 15-20 mm wide, using a modified laminar spreader. [2],[6] Various materials have been used as interlaminar spacer in the French door technique. These include ceramic spacers, iliac crest bone graft, autologous ribs, and allografts. Pieces of the resected spinous processes may be secured with wire between the lamina as done in our case. [2] We used titanium wire to secure spinous processes as it induces fewer artefacts than the ferromagnetic materials. [7] High strength sutures work as well until bony union occurs and have the advantage of not causing artifacts on MR imaging. Bone grafts should be placed in the lateral gutters to bring about a bony union and keep the laminoplasty doors away from each other. Otherwise, if the intervening spinous process resorption occurs, the laminoplasty flaps will collapse and the wire will loosen. Furthermore, fracture of the hinged side of the laminoplasty may encroach on the spinal cord and lead to spinal cord injury. This complication may be disclosed on computed tomographic scanning. Laminectomy may be required if this complication occurs. Careful surgical technique will decrease the incidence of fracture of the hinge.

Laminoplasty is becoming an increasingly popular treatment for multilevel cervical stenosis due to cervical spondylotic myelopathy, OPLL, and other causes. In the appropriate patient and with proper surgical technique, laminoplasty can be an excellent option for patients with multilevel cervical stenosis and myeloradiculopathy. Using autologous spinous process as interlaminar spacer is a cost-effective method and can easily be performed.

 
  References Top

1.Steinmetz MP, Resnick DK. Cervical laminoplasty. Spine J 2006;6 Suppl 6:274S-81S.  Back to cited text no. 1
    
2.Kaner T, Sasani M, Oktenoðlu T, Ozer AF. Clinical outcomes following cervical laminoplastyfor 19 patients withcervical spondylotic myelopathy. Turk Neurosurg 2009;19:121-6.  Back to cited text no. 2
    
3.Oyama M, Hattori S, Moriwaki N. A New method of cervical laminoplasty. The (Cent Jpn J Orthop Surg Traumatol).1973;16:792-4.  Back to cited text no. 3
    
4.Vitarbo E, Sheth RN, Levi AD. Open-door expansile cervical laminoplasty. Neurosurgery 2007;60 1 Suppl 1:S154-9.  Back to cited text no. 4
    
5.Hirabayashi K, Watanabe K, Wakano K, Suzuki N, Satomi K, Ishii Y. Expansive open-door laminoplasty for cervical spinal stenotic myelopathy. Spine (Phila Pa 1976) 1983;8:693-9.  Back to cited text no. 5
    
6.Patel CK, Cunningham BJ, Herkowitz HN. Techniques in cervical laminoplasty. Spine J 2002;2:450-5.  Back to cited text no. 6
    
7.Leclet H. Artifacts in magnetic resonance imaging of the spine after surgery with or without implant. Eur Spine J 1994;3:240-5.  Back to cited text no. 7
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