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Mini-invasive fenestrationMini-invasive fenestrationof the lumbar spine of the lumbar spine through a transspinous through a transspinous approachapproach
Pr Olivier GILLEPr Olivier GILLESpinal UnitSpinal UnitUniversity Hospital University Hospital Bordeaux FranceBordeaux France
Central stenosisCentral stenosis
The laminaThe lamina– Its proximal partIts proximal part
lateral recess stenosislateral recess stenosis
foraminal stenosis foraminal stenosis
Lumbar fenestration Lumbar fenestration described by Pr Senegas 1976described by Pr Senegas 1976
Alterations of erector spinae muscles following a posterior lumbar surgery
Assessment of erector Assessment of erector spinae musclesspinae muscles
Measurement of muscular strength with force Measurement of muscular strength with force measuring devices measuring devices
Measurement of the electromyographic Measurement of the electromyographic signalsignal
Measurement of the cross-sectional area Measurement of the cross-sectional area (CSA) of the muscles(CSA) of the muscles– Ultrasound studiesUltrasound studies– CT scansCT scans– MRIMRI
Measurement of signal density (CT scans) or Measurement of signal density (CT scans) or signal intensity (MRI)signal intensity (MRI)
Assessment of muscles using Assessment of muscles using MRIMRI
Measurement of muscle area on axial Measurement of muscle area on axial slidesslides
– Barker Spine. 2004Barker Spine. 2004– Parkkola Spine. 1993 Parkkola Spine. 1993 – Dangaria. Spine. 1998Dangaria. Spine. 1998
muscle signal intensitymuscle signal intensity– Visual assessment Visual assessment
– Salminen. J Spinal Disord. 1993; Parkkola R, Spine. Salminen. J Spinal Disord. 1993; Parkkola R, Spine. 19931993
– Region of interest (ROI) in the muscleRegion of interest (ROI) in the muscle– Gejo Spine 1999Gejo Spine 1999 – Kim Spine 2005Kim Spine 2005
Measurement of the muscle Measurement of the muscle contractile component cross-contractile component cross-section area (CCSA)section area (CCSA)
Area measurement by surrounding the Area measurement by surrounding the musclemuscle
signal intensity determination of the signal intensity determination of the contractile tissuecontractile tissue– Using 4 ROI in plain muscular zone Using 4 ROI in plain muscular zone
In collaboration with the biomechanics Laboratory of ENSAM, Paris
Measurement of the muscle Measurement of the muscle contractile component cross-contractile component cross-section area (CCSA)section area (CCSA)
CCSA
CCSA NCCSA
NCCSA
Pre operative MRI
Post operative MRI
Alterations of erector spinae Alterations of erector spinae muscles following a posterior muscles following a posterior lumbar surgerylumbar surgery
Following a posterior Following a posterior lumbar surgerylumbar surgery
the contractile component of the the contractile component of the erector spinae muscles decreases erector spinae muscles decreases of 25%of 25%
O.Gille, JM Vital. Erector spinae muscle changes on MRI following lumbar surgery through a posterior approach. Spine, 2008
LUMBAR SPINOUS PROCESS-SPLITING LAMINECTOMY
WATANABE , 2006
CHIMNEY SUBLAMINAR
DECOMPRESSION
LIN , 2006
CHO : « Marmot technique » , J. Neurosurgery Spine 2007
No high rate of improvementLong time surgeryTechnically difficultLong learning curve“Blind” surgeryHigh risk of nerve root or dural tear
Step 1: Length spinous process measurement on preop MRI
•Step 2: Spinous process osteotomy using a straight osteotom (3 mm security)
•Step 3: Osteotomy at the base of the spinous process performing with a curved osteotom.
•Step 5: The decompressive procedure can be continue as usual
•Step 4: Osteotomy of the distal part of the lamina using a curved osteotom
L4
L5
OpticalOptical magnification magnification Head lightHead light Operative time < 30 mnOperative time < 30 mn No blood lossNo blood loss
15 15 patientspatients Lumbar canal stenosisLumbar canal stenosis
– One levelOne level preop and 3 months postop preop and 3 months postop
MRIMRI– Quality of decompressionQuality of decompression– Assessment of muscle changesAssessment of muscle changes
Measurement of the cross-sectional Measurement of the cross-sectional area of the spinal canal (T2 area of the spinal canal (T2 sequence)sequence)
Preop Postop
Preop Postop
ResultsResults
Preop spinal canal area : 0.8 cm²Preop spinal canal area : 0.8 cm²
Postop spinal canal area : 2.1 cm²Postop spinal canal area : 2.1 cm²
Measurement of the Measurement of the MULTIFIDUS AND LONGISSIMUS MULTIFIDUS AND LONGISSIMUS contractile component cross-contractile component cross-section area (CCSA) section area (CCSA) (T1 (T1 sequence)sequence)
Preop Postop
MeasurementMeasurement of the of the MULTIFIDUS AND LONGISSIMUS MULTIFIDUS AND LONGISSIMUS contractile component cross-contractile component cross-section area (CCSA) section area (CCSA) (T1 (T1 sequence)sequence)
Preop Postop
ResultsResults
Following a transspinous approachFollowing a transspinous approach::– the contractile component of the the contractile component of the
erector spinae muscles decrease erector spinae muscles decrease less than 5% (Mean 4.8)less than 5% (Mean 4.8)
ConclusionConclusion
Advantages of fenestration through Advantages of fenestration through transspinous approach:transspinous approach:
Technically simpleTechnically simple Minimal soft tissues injuryMinimal soft tissues injury Short time surgery (< 30 mn)Short time surgery (< 30 mn) Excellent working space and visualizationExcellent working space and visualization Less bleedingLess bleeding Less postoperative pain ?Less postoperative pain ?
LimitsLimits:: Difficulties for repairing a dural tearDifficulties for repairing a dural tear