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|Year : 2022 | Volume
| Issue : 8 | Page : 113-116
Laminectomy with Rib Shears: A Technical Note
Survendra Kumar R Rai, Saswat K Dandapat, Dikpal Jadhav, Neha Jadhav, Abhidha Shah, Ranjit D Rangnekar
Department of Neurosurgery, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai, Maharashtra, India
|Date of Submission||05-Nov-2018|
|Date of Decision||13-Jul-2019|
|Date of Acceptance||04-May-2020|
|Date of Web Publication||11-Nov-2022|
Survendra Kumar R Rai
Department of Neurosurgery, Seth G. S. Medical College and K. E. M. Hospital, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Laminectomy/laminoplasty either free or vascularized pedicle flap is currently performed with a variety of expensive instruments. Use of Tudor Edwards rib shears to perform above procedure is described.
Materials and Methods: Tudor Edwards rib shear was used to cut lamina in 18 cases for a variety of spinal lesions. Depending upon the size of lesion, laminectomy/laminoplasty was required for 2 to 8 levels. Vascularized pedicle laminoplasty or free flap laminoplasty was done with Tudor Edwards rib shears. Ligamentum flavum and interspinous and supraspinous ligaments were preserved in cases of vascularized pedicled laminoplasty, which was carried out in 12 cases. Free flap laminoplasty was carried out in 6 cases.
Results: In all our cases, laminectomy was successfully achieved with rib shears without any injury to the dura or its underlying structures. It was possible to perform vascularized pedicle laminoplasty or free flap laminoplasty in all cases. Laminectomy was easier to perform in the cervical region and dorsal region, while it was difficult in the lumbar region due to the wider, thick lamina and its angulation, especially in adults.
Conclusion: Laminectomy/laminoplasty with Tudor Edwards rib shears is quick, safe, and easy. Beveled cut edges with minimal bony loss prevents sinking of laminoplasty, thereby facilitates lamina fixation. This is an alternative method of performing laminectomy/laminoplasty, especially for those not having accessibility to expensive equipment.
Keywords: Laminectomy, laminoplasty, Tudor Edwards rib shears
Key Message: Laminectomy /laminoplasty using routinely available inexpensive Tudor Edwards rib shears is quick, safe and easy producing beveled cut edges with minimal bony loss preventing sinking of laminoplasty without damaging underlying dura and spinal cord.
|How to cite this article:|
R Rai SK, Dandapat SK, Jadhav D, Jadhav N, Shah A, Rangnekar RD. Laminectomy with Rib Shears: A Technical Note. Neurol India 2022;70, Suppl S2:113-6
In the year 1887, Victor Alexander Haden Horsely first performed laminectomy for removal of spinal tumor. Since then laminectomy has become an armamentarium to deal with various spinal pathologies. Laminectomy or laminoplasty is commonly performed for degenerative cervical spine or spinal tumors. Accessibility to spinal canal is achieved by using multiple instruments like bone rongeurs/nibblers, Kerisson punch, high-speed drills, thread wire saw, and ultrasonic bone shavers., In degenerative spinal disease (e.g., CSM, OPLL), augmented laminoplasty is done to increase the volume of stenosed canal but in case of spinal tumor involving multiple segments, free flap or pedicle laminoplasty is preferred to prevent postoperative spinal instability. In the present study, we have done laminectomy or laminoplasty based on the vascularized pedicle with intact supraspinous, interspinous, and ligamentum flavum in majority of cases, while free independent flap in others.,,,, We report for the first time in literature, the use of rib shears for cutting the lamina for laminectomy or laminoplasty.
| » Materials and Methods|| |
Patients with a variety of spinal pathologies underwent laminectomy with Tudor Edwards rib shears in 18 cases. Vascularized pedicle laminoplasty was done in 12 cases, while free flap laminoplasty was done in 6 cases. Ligamentum flavum and interspinous and supraspinous ligaments were preserved in cases of vascularized pedicled laminoplasty. 10 such cases were done for a variety of pathologies in the cervical spine and the rest 8 cases were of the dorsal/cervicodorsal spine. After the completion of the procedure, free end of lamina was anchored to the adjoining intact lamina with sutures. It was possible to achieve laminoplasty by this technique with minimal blood loss. We did not use any screws or plates for fixation of lamina in this technique. Tudor Edwards rib shears have right-angled anterior cutting portion [Figure 1]a and [Figure 1]b. Due to obliquity of long blades' cutting edge, force of cutting is transmitted tangential to dura and spinal cord which ensures its safety without entering into the spinal canal [Figure 2]a, [Figure 2]b, [Figure 2]c.
|Figure 1: (a) Tudor Edwards rib shears as seen from above. (b) Tudor Edwards rib shears as seen from sideways revealing the angulated anterior most portion|
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|Figure 2: (a) Exposed posterior elements of cervical spine after separating paraspinal muscles undergoing laminectomy with rib shears. (b) Vascularized pedicle laminoplasty is done. Cut edges of lamina are elevated exposing the underlying dura of the spinal cord. (c) Line diagram depicting position of the Tudor Rib shears cutting the lamina in beveled fashion and tangential to the spinal canal|
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| » Results|| |
It was possible to perform laminectomy with this technique in 18 such cases without any difficulty for a variety of spinal pathologies. Out of these, vascularized pedicle laminoplasty was done in 12 and free flap laminoplasty in 6 cases. There was no evidence of dural tears or damage to underlying structures. Age of the patient varied from 17 years to 46 years with 5 cases being female while remaining 13 being males. In every case, this technique was used for performing laminectomy or laminoplasty effortlessly, quickly with minimal blood loss.
| » Discussion|| |
Performing laminoplasty requires precise cutting of lamina at the lamina-facet junction. This precise cutting of lamina can be performed by use of Kerisson punch, high-speed drills, and ultrasonic bone shavers. However, ideal laminectomy method should involve cutting lamina with no bone loss and avoiding introduction of any instruments underneath the lamina. Preservation of structures attached to the spinous process and lamina as much as possible, viz., supraspinous process, interspinous ligaments, and ligamentum flavum, should be done which enhances the stability of laminoplasty flap. Pedicle-based vascularized laminoplasty is good strategy to avoid post laminectomy sequel.,, All tissue preservation strategies are superior in terms of postoperative outcome. Laminectomy with rib shears is a step in this direction. All the techniques and instruments used for achieving laminectomy have advantages and disadvantage.
Bone loss during the laminectomy procedure is another issue and always understressed unlike in craniotomy. Use of bone rongeurs, Kerisson punch, high-speed drill, and ultrasonic bone shavers can achieve laminectomy, but by sacrificing the bony tissue to a varying extent. Use of bone rongeurs leads to more bone loss. However, use of Kerisson punch of small sizes leads to relatively narrow bony defect and similar problem exists with ultrasonic bone shavers as well. Use of high-speed drills leads to bony loss to varying extent., With use of rib shears and technique described here, there is always minimal loss of bony tissue.
Laminectomy with bone rongeurs involves removal of lamina into multiple small pieces and also involves exerting some amount of pressure over the lamina in consideration for its removal. The danger of dura tear is also imminent. Use of high-speed drill for laminectomy creates bony defect at the cut edges due to loss of bony tissue.,, Inadvertent injury to the dura, exiting nerve roots, and spinal cord is a possibility with the use of any powered instrument. Laminectomy with Kerisson punch requires insertion of footplate underneath the lamina which is not advisable in cases with severe spinal stenosis. Ultrasonic bone shavers can sharply cut bone without damaging the underlying structures as the cutting probes stop automatically when coming in contact with the underlying soft tissue. This also involves bone loss to some extent as well as these are very expensive equipment.
Rib shears, especially Tudor Edwards have typical physical construct. Its anterior cutting end is angulated. Thick blades of the rib shears need to engage upper and lower border of the lamina for its cutting action. Adjacent intact lamina allows only just engaging the laminar bone with pressure and prevents it from entering into the spinal canal due to large size blade which is obstructed by adjoining lamina. The angle of the rib shear maintains obliquity over lamina which is almost tangential to the underlying dura mater, thereby minimizing chances of dural breach and producing beveled cut during laminectomy. In addition, layer of ligamentum flavum provides additional protection. Blades have right angle bend in its anterior portion giving it obliquity to the cut edges of the lamina [Figure 1]a and [Figure 1]b. This oblique cut edges of the lamina prevent laminar edges from sinking into the spinal canal during laminoplasty. Pressure and force exerted during cutting action of lamina is transmitted tangential to dura of spinal cord by virtue of its angled blades. Always an attempt is made not to breach the layer of ligamentum flavum. Applying too much pressure while doing laminectomy directly over the spine carries danger of damaging the spinal cord or the underlying structures. Rib shears have longer and thicker blade and, hence, entering into the spinal canal is less likely. Long grasping handles with long lever arms enable cutting of lamina with minimal effort. Cutting of lamina is possible with minimal effort and negligible blood loss in quick time making it easier to perform laminectomies required for exposure of spinal canal without damaging underlying dura or cord for addressing a variety of pathologies [Figure 2]a, [Figure 2]b, [Figure 2]c. Use of additional cut by kerrison rongeur may be required at times in some situation to complete laminectomy.
Laminectomy is easier with this instrument in the cervical and dorsal region. However, in lumbar region, laminectomy is possible in young patients but not in adults because of the very wide and typical slant of lamina, which prevents the edges of lamina from coming in between the cutting zone of the rib shear blades. The ligaments attached to the lamina and spinous process are preserved in all cases [Figure 2] and [Figure 2]b. In case of very obese patients, doing laminectomy by this method may be difficult due to large amount of subcutaneous fat, excessive depth and difficulty in positioning the instrument for the laminectomy.
The angle of the rib shear maintains obliquity over lamina producing beveled cut during laminectomy. There is little bone loss which results in good outcome. This also prevents laminoplasty from sinking within the spinal canal [Figure 2]c and [Figure 3]a, [Figure 3]b. This technique is an alternative to those not having access to expensive tools for laminectomy.
|Figure 3: (a) Preoperative sagittal image showing contrast-enhancing intramedullary lesion. (b) Postoperative sagittal image showing radical excision of the lesion with well-placed vascularized pedicle laminoplasty|
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| » Conclusion|| |
Laminectomy/laminoplasty with Tudor Edwards rib shears is quick, safe, and easy. Beveled cut edges with minimal bone loss prevents sinking of laminoplasty, thereby facilitates lamina fixation. This is an alternative method of performing laminectomy/laminoplasty, especially for those not having accessibility to expensive equipment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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