Unilateral partial hemilaminectomy and discectomy decreased surgical time and hospital length of stay for lumbar disc herniated patients

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ОРИГИНАЛЬНЫЕ СТАТЬИ
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UDC: 616. 34−007. 43−031:611. 959
Farid Yudoyono (M.D.)1, Muhammad Zafrullah Arif in (M.D., Ph.D.)1,
Farida Arisanti (M.D.)2, Shin Dong Ah (Prof., M.D.)3
Department of Neurosurgery, Faculty of Medicine Universitas Padjadjaran-Dr Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia1
Department of Physical Medicine and Rehabilitation, Faculty of Medicine Universitas Padjadjaran-Dr Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia2
Yonsei University College of Medicine, Seoul. Korea: Spine and Spinal cord Research Institute, Yonsei University College of Medicine3
UNILATERAL PARTIAL HEMILAMINECTOMY AND DISCECTOMY DECREASED SURGICAL TIME AND HOSPITAL LENGTH OF STAY FOR LUMBAR DISC
HERNIATED PATIENTS
Objective. To present the profiles of discectomy technique of Herniated Lumbar Disc through a unilateral Partial hemilaminectomy (UPHL) and to demonstrate its usefulness for herniated lumbar disc that significantly occupy the foraminal canal. Methods. From April 2012 to June 2012, 24 herniated lumbar disc were approached with unilateral partial hemilaminectomy retrospectively.
Results. A total of 24 consecutive patients who underwent unilateral partial hemilaminectomy comprised male 14 and female 10 (1,4: 1), the mean age was 54 y.o. (21−68 years), with reflects to surgical level 2 patients involved Th 12-L 1, 12 patients involved lumbar 4−5, two patients involved L 3−4, and 6 patients involved L5-S1. In all cases, the herniated disc was removed totally without damaging thecal sac or roots. Neurological status showed improvement in all patients except three whose neurologic deficit slight changed. Surgical time was 179 minutes, hospital length of stay 5 days. Postoperative spinal stability was preserved during the follow-up period (in the mean 6 months) in all cases. Recurrence herniated disc did not develop during the follow-up period. Robinson Clinical outcome assesment good 21, fail 3.
Conclusion. Unilateral Partial hemilaminectomy combined with microsurgical technique provides sufficient space for the removal of foraminal herniated disc. The basic profiles of the herniated lumbar disc which can be removed through the unilateral Partial hemilaminectomy demonstrate its role for the surgery of the herniated lumbar disc in foraminal location, and it can decreased surgical time and hospital length of stay.
Key words: herniated lumbar disc, microsurgical unilateral partial hemilaminectomy
Introduction
Yasargil et al in 1991 first describe the unilateral hemilaminectomy for the spinal cord tumor surgery. Advances in microsurgical technique and modern microsurgical equipment have added its usefulness to herniated lumbar disc surgery. Sporadic results of surgery for spinal cord herniated lumbar disc using a unilateral hemilaminectomy have been reported by many authors. Unilateral hemilaminectomy has more benefits with regard to postoperative spinal stability comparing with a total laminectomy. However, unilateral partial hemilaminectomy has not been a widely accepted surgical option for the removal of herniated lumbar disc. This may be because of surgeons'- concerns about incomplete removal of the herniated disc or inadvertent thecal sac damage with the relatively narrow surgical corridor. [1, 2, 3]
In this study, we retrospectively investigated the profiles of herniated lumbar disc that could be removed through a unilateral partial hemilaminectomy. We would like to illuminate the role of unilateral partial hemilaminectomy for herniated lumbar disc that significantly occupy the foraminal intervertebralis. Some technical tips are also discussed for overcoming the narrow surgical corridor.
Figure 1 — A) MRI lumbar of herniated disc Sagittal View B) Herniated disc at foraminal Axial View (asterixis)
Materials
Patients who presented to Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, between April 2012 and June 2012 with one and two consecutive level of herniated lumbar disc in the foraminal intervertebralis, were removed through a unilateral partial hemilaminectomy between. Medial location that need extensive thecal sac retraction were excluded. The spinal level, location in the spinal canal,
Farid Yudoyono, e-mail: faridspine@gmail. com
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visual analog scale and hospital length of stay, surgical time and robinson clinical outcome assesment was evaluated.
Surgical methods
Patients were placed in the prone position under general anesthesia and the surgeries were performed by one neurospinal surgeon. Unilateral subperiosteal muscle dissection was performed and the lamina was exposed in a way similar to the techniques used for unilateral hemilaminectomy and discectomy. The dural sac was exposed by drilling the lamina, including the base of the spinous process, while preserving the facet joint. To overcome the narrow field of the unilateral hemilaminectomy, we employed several operative technical tips. Combining undercutting of the base of the spinous processes and oblique tilting of the operating table to the controlateral or ipsilateral side provided an adequate view for the extradural procedures. After removed of the flavum ligament, epidural fat and dural sac was expose, applying cottonoid to the upper and lower pole helps to prevent the excessive spread of blood clots into the spinal canal. We can slightly retracted the dural sac and nerve root medially to view the herniated disc. [4, 5]
Result
Twenty-four of foraminal herniated lumbar disc were removed through unilateral partial hemilaminec-
Figure 2 — A, B) Illustration of unilateral partial hemilaminectomy
Figure 3 — A) Surgical view of unilateral partial hemilaminectomy showed Nerve root and dural sac B) Minimal (3 cm) Incision of surgical procedure
tomy (one patient had bilateral location). The characteristics of the herniated disc and its basic profiles are summarized (Table 1).
Table 1
Patients Demographic data
No Age (y.o.) Sex Symptoms VAS pre op VAS post op MRI Pro- ce- dure Surgi- cal time (Min- ute) Hos- pital legth of stay (days) Complication Robinson Outcome scale
1 64 male Myeloradiculopathy 6 2 Herniated disc L3-L4 UPHL 150 5 no Good
2 62 male Myeloradiculopathy 5 1 Herniated disc L3−4 and L4−5 UPHL 200 6 no Good
3 56 male Radiculopathy 4 3 Herniated disc L2−3 UPHL 216 6 skin infection Good
4 52 female radiculopathy 5 2 Herniated disc L5-S1 UPHL 320 5 no Good
5 32 female radiculopathy 6 2 Herniated disc L4−5 UPHL 190 5 no Good
6 36 female radiculopathy 7 2 Herniated disc L5-S1 UPHL 150 5 no Good
7 43 female radiculopathy 6 6 herniated disc L5-S1 UPHL 165 5 no fair
8 21 male Myeloradiculopathy 4 2 Herniated disc L4−5 UPHL 175 6 no Good
9 50 male radiculopathy 5 1 Herniated dsic L4−5 UPHL 165 5 no Good
10 54 female radiculopathy 6 1 Herniated disc L4−5 UPHL 180 6 no Good
11 61 male radiculopathy 8 1 Herniated disc Th12-L1 UPHL 190 6 no Good
12 67 male radiculopathy 4 6 Herniated disc L4−5 UPHL 203 6 no Good
13 56 male Myeloradiculopathy 5 5 Herniated disc L3-L4 UPHL 150 5 no fair
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No Age (y.o.) Sex Symptoms VAS pre op VAS post op MRI Pro- ce- dure Surgi- cal time (Min- ute) Hos- pital legth of stay (days) Complication Robinson Outcome scale
14 62 male Myeloradiculopathy 6 1 Herniated disc L3−4 and L4−5 UPHL 165 6 no Good
15 57 male radiculopathy 6 2 Herniated disc L2−3 UPHL 155 6 no Good
16 54 female radiculopathy 6 2 Herniated disc L5-S1 UPHL 155 5 no Good
17 68 female radiculopathy 6 6 Herniated disc L4−5 UPHL 175 5 no fair
18 55 female radiculopathy 7 2 Herniated disc L5-S1 UPHL 166 5 no Good
19 65 female radiculopathy 7 1 herniated disc L5-S1 UPHL 180 5 no Good
20 54 male Myeloradiculopathy 7 1 Herniated disc L4−5 UPHL 190 6 no Good
21 45 male radiculopathy 8 1 Herniated dsic L4−5 UPHL 150 5 no Good
22 66 female radiculopathy 8 5 Herniated disc L4−5 UPHL 152 6 skin infection Good
23 67 male radiculopathy 8 4 Herniated disc Th12-L1 UPHL 165 6 no Good
24 67 male radiculopathy 9 4 Herniated disc L4−5 UPHL 190 6 no Good
The patients consisted of 14 males and 10 females with a mean age of 54 years old (21−68) with reflects to surgical level 2 patients involved Th 12-L 1, 12 patients involved lumbar 4−5, 2 patients involved L 3−4, and 6 patients involved L5-S1. Postoperative neurological status showed improvement in all patients except three whose neurologic deficit slight changed. Surgical time was 179 minutes, hospital length of stay 5 days. Postoperative spinal stability was preserved during the follow-up period (6 months) in all cases. Recurrence herniated disc did not develop during the follow-up period. Robinson Clinical outcome assesment good 21, fail 3.
Visual analogue scale was improved in all patients except three, whose neurological deficit slightly changed. Complications, such as cerebrospinal fluid leakage, postoperative instability, and aggravation of neurological status, did not occur. The patient was observed without any surgical intervention, and the symptom was completely resolved during the hospital stay. The conventional bilateral laminectomy has been employed for surgical removal of herniated lumbar disc. It offers some convenience to neurospinal surgeons, such as widened exposure of the surgical fields. However, bilateral laminectomy also has disadvantages that can complicate postoperative outcomes. It produces overt spinal instability, leading to spinal deformity, epidural fibrosis, the absence of osseous protection for the spinal cord and postoperative axial pain. Well-recognized postlaminectomy kyphosis, especially in children, is commonly associated with instability.
Discussion
Various operative techniques were developed to reduce postlaminectomy complications. Some authors presented advantages of laminoplasty in maintaining postoperative stability. However, the advantage of laminoplasty in maintaining postoperative stability is not considered because laminoplasty can still disrupt the posterior ligamentous structures on the dorsal spine.
The integrity of ligament flavum, supraspinous, and interspinous ligaments is known to be crucial for the dynamic stability of the spine. Unilateral partial hemilaminectomy avoids damage to the supraspinous and interspinous ligaments, and the paravertebral muscle of the opposite side. For this reason, unilateral partial hemilaminectomy results in less injury to the dynamic dorsal structures of the vertebral column compared with total laminectomy or even laminoplasty. Disadvantage of unilateral partial hemilaminectomy is a narrow surgical corridor formed by the spinous process and ipsilateral facet joint. This is the main reason that this procedure is still not widely accepted. [4, 6]
Our experience indicates that unilateral partial hemilaminectomy is useful for the removal of herniated lumbar disc in the intervertebral foraminal. All but three patient showed slightly neurological improvement. Most of the patients presented radiating pain symptoms. Analyses of data from the 24 cases revealed that however, there was ultimately no case of conversion to a total laminectomy. Since we adopted the unilateral partial hemilaminectomy for the removal of herniated lumbar disc, all consecutive cases of herniated lumbar disc have been removed with a unilateral partial hemilaminectomy. The distribution of the herniated lumbar disc was variable. [2, 6, 7]
Figure 4 — A) Post operative Lumbar CT scan showed unilateral partial hemilaminectomy (asterixis)
B) Lumbar 3D CT showed bone worked (asterixis)
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Rehabilitation programs post unilateral partial hemilaminectomy of lumbar disk herniated could be delivered as early as possible due to preserve stability of the spine and faster recovery compared to other surgery approach. [8,9] Previous studies revealed that short term intensive rehabilitation programs could be started 4−6 weeks with range duration 6−12 weeks after spine surgery in lumbar disk herniated patients and shown functional status, faster decrease of pain, disability and return to work. [9, 10, 11]
Return to work times is depending on previous condition of the patient and physical requirement of the job. Higher functional disability, more intensive
pain, and poor motivation at 2 months after lumbar disk operation are risk factors for future loss of working time [13]. Early return to work is 3,3 days in preliminary study following an agressive rehabilitation program initiated 1 day post spine surgery. [12]
Conclusion
Unilateral partial hemilaminectomy combined with several microsurgical technique provides sufficient coridor for the removal of herniated lumbar disc. We recommend unilateral partial hemilaminectomy as a suitable surgical option for the removal of herniated disc in the foraminal intervertebralis.
REFERENCES
1. Cai-xing, Shang-nao Xie, Yang Yu, Hong-jian Yang, Bin Wu. Unilateral hemilaminectomy for patients with intradural extramedullary tumors. Journal of Zhejiang University-Science B (Biomedicine & amp- Biotechnology) 2011- 12: 575−81.
2. Mony Benifla, Igor Melamed, Revital Barrelly, An-drey AloushinbAnd Ilan Shelef,. Unilateral partial hemilaminectomy for disc removal in a 1-year-old child Case report. J Neurosurg Pediatrics 2008−2: 133−5.
3. Yasargil MG, Tranmer, B.I., Adamson, T.E., Roth, P. Unilateral Partial Hemilaminectomy for the Removal of Extra- and Intramedullary Tumors and AVMs. Advances and Technical Standards in Neurosurgery 1991: 113−32.
4. Dong Kyu Yeo. Soo Bin Im, Kwan Woong Park, Dong Seong Shin, Bum Tae Kim, Won Han Shin, Department of Neurosurgery, Soonchunhyang University Hospital, Bucheon, Korea. Profiles of Spinal Cord Tumors Removed through a Unilateral Hemilaminectomy. J Korean Neurosurg Society 2011−50 195−200.
5. A Cetin Sanoglu, H Bozkus. Unilateral hemilaminectomy for the removal of the spinal space-occupying lesions. Minimally Invasive Neurosurg 1997−40: 74−7.
6. Amit Agrawa, Bhushan Wani. Modified posterior unilateral laminectomy for a complex dumbbell
schwannoma of the thoracolumbar junction. Acta Orthop Traumatol Turc 2009−43: 535−9.
7. Balak N. Unilateral partial hemilaminectomy in the removal of a large spinal ependymoma: case report and technical review. Spine Journal 2008. -8:1030−6.
8. Snyder, L.A., O'-Toole, John., Eichholz, KM., Perez-Cruet, M.J., Fessler, Richard., The technological development of minimally invasive spine surgery. BioMed Research International 2014: 1−9
9. Ostelo, JG. et al. Rehabilitation following first-time lumbar disc surgery: A systematic review within the framework of the Cochrane collaboration 2003−28: 209−18.
10. Canbulat, Nazat et al. A rehabilitation protoocol for patients with lumbar degenerative disk disease treated with lumbar total disc replacement. Archives of Physical Medicine and Rehabilitation 2011: 92: 670−6
11. Oosterhuis, T. et al. Rehabilitation after lumbar disc surgery. Cochrane data based system review 2008: 4- CD003007.
12. Sjoliner, PO., Nota, DF. Early return to work after following an aggressive rehabilitation program initiated one day after spine surgery. Journal of Occupational Rehabilitation 1996: 4(4) — 211−28.
13. Puolakka, K., Ylinen, J., Hakkinen, A. Risk factors for back pain-related loss of working time after surgery for lumbar disc herniation- a 5 years follow-up study. European spine journal 2008: 17(3) — 386−92.
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Т? ЙІНДЕМЕ
Farid Yudoyono (M.D.)1, Muhammad Zafrullah Arifin (M.D., Ph.D.)1, Farida Arisanti (M.D.)2,
Shin Dong Ah (Prof., M.D.)3
Department of Neurosurgery, Faculty of Medicine Universitas Padjadjaran-Dr Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia1
Department of Physical Medicine and Rehabilitation, Faculty of Medicine Universitas Padjadjaran-Dr Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia2
Yonsei University College of Medicine, Seoul. Korea: Spine and Spinal cord Research Institute, Yonsei University College of Medicine3
БІРЖА?ТАМАЛЫ? ІШІНАРА ГИМЕЛАМИНЕКТОМИЯ Ж? НЕ ДИСКЭКТОМИЯ КЕЗІНДЕ ОМЫРТ? АНЫ? БЕЛ АУМА? ЫНЫ? ДИСК ЖАРЫ? Ы БАР ПАЦИЕНТТЕРДІ? АУРУХАНАДА ЖАТУ? ЗА?ТЫ?Ы МЕН
ОПЕРАЦИЯ УА? ЫТЫН АЗАЙТУ
Ма? саты. Омырт? аны? бел аума? ыны? диск жары? ы кезінде біржа?тамалы? ішінара гемиламинэктомия (UPHL) ар? ылы дискэктомия техникасыны? м? мкіндігін ?сыну ж? не фораминалды локализациялы омырт? аны? бел аума? ыны? диск жары? ы кезіндегі тиімділігін к? рсету.
?дістері. 2012 жылды? с? уірі мен маусымы аралы? ында біржа?тамалы? ішінара гемиламинэктомия? дісімен омырт? аны? бел аума? ы дискісіні? 24 жары? ына операция жасалды.
Н? тижелері. Біржа?тамалы? ішінара гемиламинэктомия ал? ан 24 пациентті? 14-і ер кісі, 10-ы ?йел (1,4: 1), орта жас 54 жасты?? рады (21−68 жас), за? ымдалу де? гейіне ?атысты — 2 пациентте Th 12 L 1 де? гейінде, 12 пациентте L 4−5 де? гейінде, 2 пациентте L 3−4 ж? не 6 пациентте L5-S1. Бар-лы? жа? дайларда дуральды? апшы? немесе т? бір-шіктерді? за? ымдалуынсыз омырт? ааралы? диск жары? ы толы? ымен алынып тасталынды. Невроло-гиялы? статуста барлы? топтарда жа? сару бай? алды, тек неврологиялы? статусы болмашы? ана ?згерген ?ш пациенттен? зге. Операция? за?ты?ы орта есеппен 179 минутты?? рады, емделуге жат? ызу
к? ніні? ?за?ты?ы 5 к? н. Барлы? топтарда орта есеппен 6 ай ба? ылау мерзімінде операциядан кейінгі кезе? де омырт? аны ?оз?аушы сегменттерді? т? ра?сызды?ы белгілері аны? талмады. Кейінгі кезе? дердегі ба? ылауды? барлы? уа? ытында диск жары? ыны? ?айталану бай? алмады.
Робинсон ауруларыны? н? тижесі шкаласы бойынша: жа? сы — 21, с? тсіз — 3.
Т? жырым. Біржа?тамалы? ішінара гемиламинэктомия микрохирургиялы? техникамен бірлесе отырып, бел б? лігіні? фораминальды диск жары? ын алып тастау? шін ?ажетті ке?істікті ?амтамасыз етеді. Омырт? аны? бел б? лігі фораминальды диск жары? тары біржа?тамалы? ішінара гемиламинэктомия ар? ылы алынып тасталыну м? мкін, б? л омырт? аны? бел б? лігіні? диск жары? ыны? хирургиясында? ы оны? алатын орнын к? рсетеді ж? не б? л операция уа? ыты мен емделуге жату мерзімін азайту? а м? мкіндік береді.
Негізгі с? здер: омырт? аны? бел аума? ыны? диск жары? ы, микрохирургиялы? біржа?тамалы? ішінара гемиламинэктомия.
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РЕЗЮМЕ
Farid Yudoyono (M.D.)1, Muhammad Zafrullah Arifin (M.D., Ph.D.)1, Farida Arisanti (M.D.)2,
Shin Dong Ah (Prof., M.D.)3
Department of Neurosurgery, Faculty of Medicine Universitas Padjadjaran-Dr Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia1
Department of Physical Medicine and Rehabilitation, Faculty of Medicine Universitas Padjadjaran-Dr Hasan Sadikin General Hospital, Bandung, Jawa Barat, Indonesia2
Yonsei University College of Medicine, Seoul. Korea: Spine and Spinal cord Research Institute, Yonsei University College of Medicine3
уменьшение продолжительности операции и койко дней на
ФОНЕ ОДНОСТОРОННЕЙ ЧАСТИЧНОЙ ГЕМИЛАМИНЕКТОМИИ И ДИСКЭКТОМИИ У ПАЦИЕНТОВ С ГРЫЖЕЙ ДИСКА ПОЯСНИЧНОГО ОТДЕЛА ПОЗВОНОЧНИКА
Цель. Представить возможности техники дискэктомии при грыже диска поясничного отдела позвоночника через односторонную частичную гемиламинэктомию (UPHL) и продемонстрировать эффективность при грыжах диска поясничного отдела позвоночника с фораминальной локализацией.
Методы. С апреля 2012 года по июнь 2012 года, были прооперированы методом односторонней частичной гемиламинэктомии 24 грыжи диска поясничного отдела позвоночника.
Результаты. Из 24 пациентов, перенесших односторонную частичную гемиламинэктомию -мужчин — 14, женщин — 10 (1,4: 1), средний возраст составил 54 года (21−68 лет), относительно уровня поражения — у 2-х пациентов на уровне Th 12 L 1, у 12 пациентов на уровне L 4−5, у 2-х пациентов L 3−4, и у 6-и пациентов L5-S1. Во всех случаях, грыжа межпозвоночного диска была удалена полностью, без повреждений дурального мешка или корешков. В неврологическом статусе отмечалось улучшение во всех группах, кроме трех пациентов у которых неврологический статус изменился незначительно. Средняя длительность операции составила
179 минут, длительность госпитализации 5 дней. В послеоперационном периоде не было выявлено признаков нестабильности позвоночнодвигательных сегментов в период наблюдения в среднем 6 месяцев во всех группах. Рецидивов грыжи диска не отмечалось за все время последующего наблюдения. По шкале исхода заболевания Робинсона: удачно — 21, неудачно — 3.
Заключение. Односторонняя частичная гемиламинэктомия в сочетании с микрохирургической техникой обеспечивает достаточное пространство для удаления фораминальной грыжи диска поясничного отдела. Фораминальные грыжи диска поясничного отдела позвоночника могут быть удалены путем односторонней частичной гемиламинэктомии, что демонстрирует ее роль в хирургии грыжи диска поясничного отдела позвоночника, и это может уменьшить операционное время и пребывание в больнице.
Ключевые слова: грыжа диска поясничного отдела позвоночника, микрохирургическая одно-сторонная частичная гемиламинэктомия.

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