Spinal Disorders: Fundamentals of Diagnosis and Treatment Part 55. Spinal disorders are among the most common medical conditions with significant impact on health related quality of life, use of health care resources and socio-economic costs. Spinal surgery is still one of the fastest growing areas in clinical medicine. | 528 Section Degenerative Disorders Figure 6. Surgical decompression of a spinal stenosis a A midline approach exposes the interlaminar windows L3 4 and L4 5 as well as the facet joints to decompress a spinal stenosis at these levels. b The supra-and interspinous ligaments are resected under the preservation of the spinous process. The interlaminar window is opened with a Kerrison rongeur and the compressing bone and hypertrophied flavum are removed. c It is important to realize that the narrowest part of the stenosis is always under the lamina. Therefore the lamina has to be resected laminotomy in the caudal third or half. The remaining part needs to be undercut from the superior and inferior sides respectively. d In some cases the undercutting of the lamina does not suffice for an adequate decompression and the lamina needs to be resected. riorate in longer follow-up 45 49 89 . Clinical results of decompression on open 50-90 6 80 95 or microsurgical 53 96 laminotomy are quite similar to those achieved by laminectomy. Although it is generally assumed that laminectomy may increase or cause vertebral instability 31 35 no difference in clinical outcomes or spondylolisthesis progression between the two treatment methods was seen in two studies 95 96 especially not when the motion segments were Lumbar Spinal Stenosis Chapter 19 529 fully stable preoperatively and were not made unstable by a total laminectomy 29 80 . Decompression and Spinal Fusion The addition of fusion with or without instrumentation to surgical decompression is generally recommended when segmental instability is assumed. However the radiologic assessment of segmental instability remains a matter of debate. Decompression and fusion are considered by many spine surgeons in case of segmental instability degenerative spondylolisthesis and scoliosis concomitant moderate to severe back pain necessity for a wide decompression recurrent spinal stenosis The best fusion technique Case Introduction Case Study 2
