Chang, Victor

Chedid, Mokbel

Lim, Seokchun

English

Henry Ford Health System Scholarly Commons

Henry Ford Health Henry Ford Health Scholarly Commons Neurosurgery Articles Neurosurgery 7-15-2021 Commentary: Lumbar Laminoplasty for Resection of Myxopapillary Ependymoma of the Conus Medullaris: 2-Dimensional Operative Video Seokchun Lim Henry Ford Health, slim2@hfhs.org Mokbel Chedid Henry Ford Health, MCHEDID1@hfhs.org Victor Chang Henry Ford Health, vchang1@hfhs.org Follow this and additional works at: https://scholarlycommons.henryford.com/neurosurgery_articles Recommended Citation Lim S, Chedid M, and Chang V. Commentary: Lumbar Laminoplasty for Resection of Myxopapillary Ependymoma of the Conus Medullaris: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021. This Article is brought to you for free and open access by the Neurosurgery at Henry Ford Health Scholarly Commons. It has been accepted for inclusion in Neurosurgery Articles by an authorized administrator of Henry Ford Health Scholarly Commons. COMMENTARYCommentary: Lumbar Laminoplasty for Resectionof Myxopapillary Ependymoma of the ConusMedullaris: 2-Dimensional Operative VideoSeokchun Lim, MDMokbel Chedid, MDVictor Chang, MDDepartment of Neurosurgery, Henry FordHospital, Detroit, Michigan, USACorrespondence:Victor Chang, MD,Department of Neurosurgery,Henry Ford Hospital,2799 West Grand Blvd,Detroit, MI 48202, USA.Email: vchang1@hfhs.orgReceived, February 24, 2021.Accepted,March 14, 2021.Published Online, June 15, 2021.C© Congress of Neurological Surgeons2021. All rights reserved.For permissions, please e-mail:journals.permissions@oup.comI n this video abstract, the authors1 present acase of intradural, extramedullary myxopap-illary ependymoma resection via lumbarlaminoplasty. While many spine surgeons wouldhave chosen conventional laminectomy as theirsurgical corridor, laminoplasty was utilized inthis case to preserve the posterior elements in aneffort to avoid kyphotic deformity in the future.While the microsurgical aspect of intraduralspine tumor surgery is well known to mostneurosurgeons, the theoretical benefits of lumbarlaminoplasty over laminectomy warrant detaileddiscussion.The significance of posterior tension bandin biomechanical support has been illustratedextensively in the literature. The posteriorligament complex provides tension constraintduring flexion, support for fascia and musclein all body positions, and restraint duringextension.2,3 Spine surgeons have become morecognizant of the role of posterior tensionband and of the unfavorable postoperativeoutcome when its role is ignored. To illus-trate, Kaptain et al4 reported that 21% patientswho underwent multilevel cervical laminectomyeventually developed kyphotic deformity. Forthis reason, the World Federation of Neuro-surgical Society (WFNS) recommends surgeonsto consider laminoplasty or addition of fusioninstead of isolated laminectomy decompressionfor 3+ levels to address cervical spondyloticmyelopathy.5 The comparative advantage oflaminoplasty over laminectomy is also reportedfor intramedullary tumor. A single-institutionreview of 144 laminectomy and 22 lamino-plasty cases for intramedullary spinal cord tumordemonstrated that patients who underwentlaminectomy were 6 times more likely to developkyphosis compared to the laminoplasty cohort(5% vs 30%).6Although there is no formal guideline from anorganized society regarding lumbar laminoplasty,several study findings suggest that posteriortension band in thoracolumbar spine surgeryis also crucial in maintaining biomechanicalstability. Papagelopoulos et al7 reported that 28%of patients under the age of 30 yr developedspinal deformity after multilevel thoracolumbarlaminectomy. Similarly, a study by Mulin et al8demonstrated that 54% of patients had insta-bility as evidenced by the dynamic lateral imageafter laminectomy.To preserve the posterior tension band, variouslumbar laminoplasty techniques have beenhighlighted in spine literature. Kakiuchi et al9,10described a spinous process splitting techniqueto preserve paraspinal muscle attachment andposterior ligament complex with good outcomeat both 8 and 12 yr after surgery. Menkuet al11 presented a laminoplasty techniqueutilizing laminar osteotomy for intraspinalsurgery with subsequent replacement using adrill and miniplates, which is technically similarto the surgery described in this video manuscript.The comparative clinical benefit of lumbarlaminoplasty over conventional laminectomywas also demonstrated in a small randomizedcontrolled trial by Watanabe et al,12 whichutilized a spinous process splitting technique.Although this randomized study showed thatpatients who underwent laminoplasty hadless pain, the authors did not present a radio-graphical assessment of kyphotic progressionin both cohorts. Also, despite the seeminglyfavorable outcome from laminoplasty reportedin literature, it is important to note the potentialauthor bias in these studies as surgeons who havea great deal of experience and familiarity withlumbar laminoplasty are likely to publish thesestudies, and the result may not be generalizableto most surgeons.Two important technical points to beconsidered in this video manuscript are completedissection of the entire paraspinal muscleattachment and the disruption of posteriortension band at the T12-L1 and L2-L3 levels.OPERATIVE NEUROSURGERY VOLUME 21 | NUMBER 2 | AUGUST 2021 | 157Downloaded from https://academic.oup.com/ons/article/21/2/E157/6299899 by Henry Ford Hospital - Sladen Library user on 22 July 2021LIM ET ALFIGURE. A 42-yr-old female referred to our clinic for progressive lower back pain with magnetic resonance imaging (MRI) illustratedby A, sagittal T2, B, sagittal DWI, and C, axial post contrast T1 MRI. Left-sided T12 and L1 hemilaminectomy with undercutting ofspinous process was performed to obtain an adequate surgical corridor for gross-total resection. Postoperative MRI demonstrated gross-totalresection as shown by D, sagittal T2 and E, axial postcontrast T1 MRI images.Unlike the spinous process splitting technique, completeparaspinal muscle dissection is unavoidable for creating anadequate operative window for intradural tumor removal. Also,there is probably additional structural support compared toisolated laminectomy as the L1-L2 posterior complex wasnot disrupted, but the detachment of the T12-L1 and L2-3ligamentous complex from the rest of the thoracolumbar spineis not addressed in this manuscript. Menku et al11 solved thisproblem by repairing the interspinous ligament with PDS 1.0suture following laminoplasty, although there is no way to objec-tively assess the additional benefit of repairing the interspinousligament.One easy solution to provide strong structural support forthe posterior complex is utilizing posterolateral fusion. However,we believe that the authors made the correct choice of avoidingfusion in a young male patient who has a high chance of devel-oping adjacent segment disease with a small fusion constructat the thoracolumbar junctional zone. However, laminoplastydoes not fully circumvent this pathology. A review of 73lumbar laminoplasties with 2- to 13-yr follow-up demon-strated that 11% of patients developed adjacent segmentdisease.13Another way to address intradural, extramedullary spinalcord tumor while preserving the posterior ligament complexis with unilateral hemilaminectomy. Basheer et al14 presenteda case where multifocal thoracic ventral pilocytic astrocytomawas addressed via unilateral hemilaminectomy combined withundercutting the base of spinous process for additional exposure.This technique obviates resecting the interspinous ligamentand therefore minimizes the disruption of physiologic posteriortension band. As an example, we have an illustrative case ofextramedullary epidermoid resection in a young female at theconus medullaris level utilizing unilateral hemilaminectomy witha spinous process undercutting technique (Figure). However, aunilateral approach is arguably more challenging compared towide laminectomy in obtaining a sufficient operative window158 | VOLUME 21 | NUMBER 2 | AUGUST 2021 www.operativeneurosurgery-online.comDownloaded from https://academic.oup.com/ons/article/21/2/E157/6299899 by Henry Ford Hospital - Sladen Library user on 22 July 2021COMMENTARYdespite the additional space gained by undercutting of spinousprocess.In addition to biomechanical support, lamina flap offerspotential advantages over traditional laminectomy, includingrestoration of bony protection, better cosmetic results, avoidanceof postlaminectomy epidural scarring, decreased incidence ofepidural hematoma, and decreased risk of pseudomeningoceleformation.6,12 However, there is no objective evidence behindthese theoretical benefits, and more studies are needed.Wewould like to commend the authors1 for sharing the lumbarlaminoplasty techniques in addressing intradural tumor. Thisvideo and narrative description is informative to spine surgeonswho are unfamiliar with lumbar laminoplasty. While lumbarlaminoplasty is becoming increasingly more popular amongselect surgeons, its superiority over conventional laminectomyis not generalizable based on current evidence. Also, unlike thesurgery for degenerative disease, surgeons should choose the mostcomfortable approach to them in gaining a wide enough windowto facilitate maximal, safe resection for intradural tumor.FundingThis study did not receive any funding or financial support.DisclosuresThe authors have no personal, financial, or institutional interest in any of thedrugs, materials, or devices described in this article. Dr Chang receives researchfunding from Medtronic, who was not involved in this project, specifically. He isa consultant for Globus Medical, K2M, and SpineGuard.REFERENCES1. Strong MJ, Yee TJ, Khalsa SSS, Saadeh YS, North R, Oppenlander ME. Lumbarlaminoplasty for resection of myxopapillary ependymoma of the conus medullaris.Oper Neurosurg. 2021;20(5):E352.2. Hotta H. An experimental study on stability of human spine, especially the role ofthe lumbar ligaments. J Jpn Orthop Assoc.1976;50:1-14.3. Newman PH. Sprung back. J Bone Joint Surg Br. 1952;34-B(1):30-37.4. Kaptain GJ, Simmons NE, Replogle RE, Pobereskin L. Incidence and outcome ofkyphotic deformity following laminectomy for cervical spondylotic myelopathy. JNeurosurg. 2000;93(2 Suppl):199-204.5. Bajamal AH, Kim SH, ArifiantoMR, et al. Posterior surgical techniques for cervicalspondylotic myelopathy:WFNS Spine Committee Recommendations.Neurospine.2019;16(3):421-434.6. McGirt MJ, Chaichana KL, Atiba A, et al. Incidence of spinal deformity afterresection of intramedullary spinal cord tumors in children who underwentlaminectomy compared with laminoplasty. J Neurosurg Pediatr. 2008;1(1):57-62.7. Papagelopoulos PJ, Peterson HA, Ebersold MJ, Emmanuel PR, Choudhury SN,Quast LM . Spinal column deformity and instability after lumbar or thoracolumbarlaminectomy for intraspinal tumors in children and young adults. Spine (Phila Pa1976). 1997;22(4):442-451.8. Mullin BB, Rea GL, Irsik R, CattomM,MinerME. The effect of postlaminectomyspinal instability on the outcome of lumbar spinal stenosis. J Spinal Disord.1996;9(2):107-116.9. Kakiuchi M, Fukushima W. Impact of spinous process integrity on ten to twelve-year outcomes after posterior decompression for lumbar spinal stenosis: study ofopen-door laminoplasty using a spinous process-splitting approach. J Bone JointSurg Am. 2015;97(20):1667-1677.10. Kakiuchi M, Wada E, Harada T, Ito K, Fukushim W. Expansive suspensionlaminoplasty using a spinous process-splitting approach for lumbar spinal stenosis:surgical technique and outcomes over 8 years of follow-up. J Am Acad Orthop SurgGlob Res Rev. 2018;2(10):e008.11. Menku A., Koc RK, Oktem IS, Tucer B, Kurtsoy A. Laminoplasty with miniplatesfor posterior approach in thoracic and lumbar intraspinal surgery. Turk Neurosurg.2010;20(1):27-32.12. Watanabe K, Matsumoto M, Ikegami T, et al. Reduced postoperative woundpain after lumbar spinous process-splitting laminectomy for lumbar canalstenosis: a randomized controlled study. J Neurosurg Spine. 2011;14(1):51-58.13. Kawaguchi Y, Ishihara H, Kanamori M, et al. Adjacent segment disease followingexpansive lumbar laminoplasty. Spine J. 2007;7(3):273-279.14. Basheer A, Rammo R, Kalkanis S, Felicella MM, Chedid M. Multifocal intraduralextramedullary pilocytic astrocytomas of the spinal cord: a case report and reviewof the literature. Neurosurgery. 2017;80(2):E178-E184.OPERATIVE NEUROSURGERY VOLUME 21 | NUMBER 2 | AUGUST 2021 | 159Downloaded from https://academic.oup.com/ons/article/21/2/E157/6299899 by Henry Ford Hospital - Sladen Library user on 22 July 2021

Commentary: Lumbar Laminoplasty for Resection of Myxopapillary Ependymoma of the Conus Medullaris: 2-Dimensional Operative Video

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Commentary: Lumbar Laminoplasty for Resection of Myxopapillary Ependymoma of the Conus Medullaris: 2-Dimensional Operative Video

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