MORI, MASUTA

OGAWA, RYOKEI

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Title Osteoplastic Partial Laminectomy for Removing the LumberDisc HerniationAuthor(s)MORI, MASUTA; OGAWA, RYOKEICitation日本外科宝函 (1966), 35(5): 873-878Issue Date1966-09-01URL http://hdl.handle.net/2433/207331RightType Departmental Bulletin PaperTextversionpublisherKyoto University873 臨 床Osteoplastic Partial Laminectomy for Removing the Lumbar Disc Herniation by MASUTA MORI and RYOKEI OGAWA From the Dept. of Orthopedic Surgery, Kansai Medical School Received for Pubilication May 26, 1966 INTRODUCTION In the following, the technique of surgery now being used in our clinic, since its introduction by Prof. Masuta Mori, for the operative removal of lumbar disc herniation in patients presenting the sciatica syndrome will be d白cribed.The characteristics of this surgical procedure is that the large portion of the unilateral vertebral arch at the level of the affected lumbar interspace四nbe restored to its original seat by first undertaking block dissection (removal) of the vertebral arch opposite the lesioned disc in order to secure a wide exposure for the safe removal of the protruded disc. HISTORICAL REVIEW Before describing this surgical procedure in detail, an explanation of the term“Osteかplastic Laminectomy”and its past history will be briefly reviewed.・Osteoplast』cla mi nee-tomy may well be defined as a special kind of laminectomy exclusively available for the surgical treatment of lumbar disc herniation in which treatment block removal of the vertebral arch is followed by its restoration into the original seat on completion of the disc removal. This technique and concept was first introduced in 1949, by Prof. Emeritus E. Kon-do, Orthopaedic Department of Kyoto University Medical School, whereby operative re-moval of the spine involved almost the entire posterior structure of a single lumbar vertebra in so far as the aim of the surgery at one disc space is concerned (Fig. 1). This first technique was soon discarded ~i~~：；；ロ；；＇ ＂＇ ＇山 because of its too extensive surgical interven-tion and was replaced by a similar technique 1951 in which the unilateral half of the spi-????????????Lme of the i"d引°＂s，，同制 pt(l("('o;.<t Lme of ch.,el rut Lomi"3 Spot吋 areaindicates the extent of block remか nousproc田s, the unilateral vertebral arch val of the spine together with the short remaining stump of Fig. 1 Osteoplastic Laminectomy the superior articular process and the unilateral 874 日本外科宝函第35巻第5号L•••m'"'"m fl副首mLme of chisel cut Spinou宍pcoce.s－、Une of chisel cut Line of inc•sion in イ’－the acue<』larcapsule Line of chisel cut S戸）ttedarea indicat田 the町 tentof block removal of the spine Fig. 2 Osteoplastic Hemilaminectomy An.cular ropsule Lone of cluミcl'"' lnte.,pmous l•gameot ＿』 Line of inc.,.on m the acucular capsule Lme of ciusd円日Spotted ar四 indicatesthe extent of block removal of the spine. Fig. 3 Osteoplastic Partial Laminectomy entire articular proc白sare involved. This technique is now ref erred to as Osteoplastic Hemilaminectomy (Fig. 2) and is stil being used in some clini回 inJapan. A further revision of this technique was undertaken by Prof. Kondo himself in 1954 by which he was able to further reduce surgi周回 lintervertion. This revised technique was named as Osteoplastic Partial Laminectomy in which a much smaller area of the spine com-prising only the large portions (about caudal four fifths) of both vertebral arch and of the spinous process and the entire inferior articular process on the side of the lesion are involved to result in an efficient reduction in surgical attack (Fig. 3). Since then, this technique has become popular under the name of Os-teoplastic Partial Laminectomy and is now recognized as one of the best procedures in disc surgery in Japan, because of its having produced many excellent results according to the litrature so far. MODIFIED TECHNIQUE OF OSTEOPLASTIC PARTIAL LAMINECTOMY BY PROF. M. MORI Quite recently (1962) in the Department of Orthopaedic Surgery in Kansai Medical School, Prof. Masuta Mori, once a student of Prof. E. Kondo, was able to minimize the surgical damage associated with Osteoplastic Partial Laminectomy by the introduction of another new technique of similar type, the modified technique of Osteoplastic Partial Laminectomy, which has proved most successful as回nbe supported by the data, availa-ble on inquiry, on the follow up results and the clinical results in more than one hundred cases. In this present paper only the technique itself will be described. Lme of chisel cut －一一』!nte"P'""" hgament l igamentum flavum Ponio mtnarnculans ， ・ Line of chisel C叫Line of chisel cut Spotted area indicates the extent of block removal of the spine. Fig. 4 Modified Methcxl of Osteoplastic Partial Laminectomy (Mori) SURGICAL TECHNIQUE As compared with the previous technique (Fig. 3) the tissue of operative removal en bloc is further reduced in that the surgical attack involves only the caudal four fifths portion of the unilateral vertebral arch and of the spinous process joined only with the nar-row bony band excentrically situated at the medial side of the inferior articular pr町es.(Fig. 4) (so that most of the process should remain intact.) OSTEOPLASTIC PARTIAL LAMINECTOMY FOR THE LUMBAR DISC HERNIATION 875 4th Lamina Yelow Ligament Fig. 5 Unilateral Dorsal Approach . : 可制骨骨Gross appearanαof the 4th vertebral arch toge・ther with spinous pr叩e日 wichare removed en bloc. Fig. 6 The incision of the soft subcutneous tissue, fascia, ligaments, etc. related to the surgical approach to the lumbosacral support-ing structure (Fig 5), and nec白saryto reach both the 4th and 5th intervertebral spaces may be neglected here be伺 usethey are identi-cal in almost every surgical technique in dorsal removal of the disc. The subperiosteal detachment of the dorsal muscles from the posterior structure of the affected lumbosacral structure from 4th and 5th lumbar and first sacral laminae with the yellow ligaments in between them are completely carried out on the side of the lesion. Then the self retaining retractor is fixed to secure a satisfactory surgical exposure to admit easy removal of the superficial layer of the yellow ligament at each level of the 4th and 5th interlaminar spaces by use of a small scalpel, forceps, and sometimes, Kocher’s hemostat sharply and bluntly. For the removal of the spinal bony block a thin bladed chisel 5 mm in breadth is pre-f erable. At first the point corresponding to about 3 mm caudal to the line of insertion of yellow ligament on the cranial margin of the vertebral arch and 3 mm medial to the outer border of the interarticular portion (portio interarticularis) of the spine should be defined from where the bony cut by the chisel in the sagittal plane is made so as to descend verti田I-ly and caudal-wards from the cranial until the caudal end of the inferior articular process is reached. This descending bony cut should correspond to 1 mm lateral to the medial margin of the superior articular facet of the 5th vertebra hidden by the inferior articular process of 4th spine. A horizontal 加ny cut is then made transversely toward midline into the spinous process beginning from the previous starting point for about 10 to 15 mm by using two or three different type of chisel. After that, the spinous process of the 4th spine is exposed 876 日本外科宝函第35巻第5号at its entire dorsal apex, where the bony cut along the midline of the apex is employe:l at its caudal four fifths area, as if the process were exactly divided into two halves. As soon as this midline cut of the spinous process fuses completely with the transverse cut of the vertebral arch, the spinal bony block, comprising approximately four fifths portion of both spinal proc回sand of the vertebral arch joined with small bridge-like bony tissue of the inferior articular proc自ら becomessuddenly removable en bloc without difficulty by use of boneforceps or scissors or both (Fig. 6). The above is the most important and characterizing part of this operative procedure. Then, the deep layer of yellow ligament and the remnant of its superficial layer together with al the bony tissues into which every deep layer of the ligament is firmly inserted is to be removed. All such bony tissues with the yellow ligament inserted into them are chiselled off from the neighbouring spinal bone and completely removed. 4th Lamina Spinal Du a Now, the spinal dura with the overlying fat tissue together with the lesioned root be-come visible. By removing fat and driving the compressed root away from its original place toward the midline with one or two spatulas, a wide scope for the protruded disc can satisfactorily be obtained. At the same ・ time, to secure hemostasis, two small strips of gauze should be packed into each of the slits resulting from dissection of the posterior longitudinal ligament anteriorly, the bony side wall of the spinal canal laterally and the spinal dura joined with the narve root at its caudal part posteriorly (Fig. 7) . The ability to ob-tain a satisfactory wide exposure for every fourth lumbar disc is characteristic. Fig. 7 Operntive Exposure An incision with a short bladed knife is made in an encircling fashion into the disc to be followed by adequate removal of its contents. It must be mentioned that every disc in the spinal canal回nbe removed under direct vision by the operator and to any extent he wishes. By the use of curett田， pituitaryforceps etc., the disc伺 nnow be completely removed at the 4th inter-vertebral space, and then the exploration should always be made at t上e5th space according to the interlaminar approach. On exploration, where the protruded disc causing the first sacral root compression is found, it must be removed in due course. After completing these procedur田， themaneuver to restore the spinal bony block to its original seat is done without difficulty by fastening the once divided counterpart to the side of the remaining spinous process by the ordinary suture technique: Two silk strings are drawn through two corresponding holes drilled side by side at a level of about 5 to 10 mm distant from the apex of the spinous process removed. For the remaining counterpart of the spinous process, these two strings are made to pass through a single dril hole, the entrance to which is situated on the medial cut sur-face of the process more deeply than the corresponding two dril holes mentioned above OSTEOPLASTIC PARTIAL LAMINECTOMY FOR THE LUMBAR DISC HERNIATION 877 with its outlet on the dorso-lateral surface at the central part of the remaining apex. By tying these two strings, a suture firm enough to secure a normal anatomical condition, not only of the spinous proc田sbut also the entire bony structure of the affected vertebra, m 伺sily be brought about. And thus, through such simple suture devices, the spinal bony block四nbe stabilized at the place of reduction into the original s回 t.Finally, the suture of al soft tissue including supra-and interspinous ligament or fascia lumbo-dorsalis and the skin etc.四 nbe done and the total procedure of disc removal四 nbe said to have been completed. Plaster jacket immobilization of the surgical site for from 3rd to 6th week followed by the use of a simple supporting appliance to the lumbar region for the following four weeks is al that need to be done postoperatively. Patients 四 n usually return to work from the beginning of the 4th postoperative month and 回 neven be able to do manual labour before the elapse of the 6 months following this surgery. SUMMARY Precise descrヤtionof our new technique called as Osteoplastic Partial Laminectomy for the operative removal of the lumbar disc herniation is given together with the brief history of its developmental background. And the advantageous feature characterizing this operative procedure is also reviewed. REFERENCE I) Hirsch, C.: Exposure of Ruptured LumbJr Discs. A Technical Discussion, Act. Orth. Scand., 28 : 7, 1958目2) Kondo, E. : Improvement of Osteoplastic Hemilaminectomy in Cases of Hernintion of Lumbar Intervertebral Di路.J. B. J. S., 37-A : 1309, 1955. 3) Kondo, E. : New Technique of The Surgery in Protrude3 Lumbar Disc Herniation. J. Jap. Orthop. Ass .24 : 13,1950. (Japanese) 4) Kondo, E. : The Revi盟dTechnique of Osteoplastic Hemilaminectomy. J. Jap. Orthop. A出， 28: 419. 1954. (Japanese) 5) Leikkonen, 0. : Low Back Pain & Sciatica. Act. Orthop. S臼nd.Suppl. : 1959. 6) Love, J. G目， CampJ. D. : Intraspinal Protrusion of lntervertebral Dis田， J.B. J. S., 19 : 776. 1937. 7) Love, J. G., Walsch M. N. : Protruded Intervertebral Di路； Reportof I 00Ca悶 inwhich Operation Was Performed. J. A. M. A., 111 : 396. 1938. 8）しJVe,J. G. : Protrusion of Discs. J. A. M. A., 113 : 2029, 1939. 9) Mori, M. : A Clinical Study of Osteoplastic Hemilaminectomy in ]_,umbago-Sciati田.J. B. J. S. 37-A : 1308, 1955. 10) O’conel, J. E. A. : Protrusions of The Lumbar Intervertebral D回目 J. B. J. S., 33-B : 8,1951. 1) Spurling, R. G. : Hypertrophy of The Ligamenta Flava as A Cause of Low Back Pain. J. A. M. A., 109: 928, 1937. 12) Spurling, R. G., Bradford K. F. : Neurological Aspect of Herniated Nucleus Pulposus At The IVth & Vth Lumbar Spaces. J. A. M. A . 113 : 2019, 1939. 878 和文抄録日本外科宝函第35巻第5号腰部椎間板ヘルニヤに対するOsteoplastic Partial Laminectomy 関西医科大学整形外科学教室森 益太・小川亮 盲’.，、我々が1962年秋以来実施している腰部椎間板ヘルニ 来の OsteoplasticPartial Laminectomyに対する変法ア摘出術 OsteoplasticPartial Laminectomy （骨形成的 modified methodと云い得るものであって，偏側椎弓部分的椎弓切除術）の詳細な術式を紹介し， 併せて と同側二分のー赫突起の各々局側略4/5を一塊として1949年以後本邦整形外科学会に於いて独自の発展と成 摘出し且つ還納し，従来手術の対象となっていた偏側長をとげた所謂 OsteoplasticLamineccomyなる術式の の下関節突起の大部分は手術の対象とならないという概念と歴史的考察とを試みた．本文記載の新術式は従 利点を有するものである．

腰部椎間板ヘル二ヤに対するOsteoplastic Partial Laminectomy

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腰部椎間板ヘル二ヤに対するOsteoplastic Partial Laminectomy

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