Comparison of bilateral decompression via unilateral laminotomy and conventional laminectomy for single-level degenerative lumbar spinal stenosis regarding low back pain, functional outcome, and quality of life - A Randomized Controlled, Prospective Trial

In the absence of any improvement or deterioration following diverse conservative treatments or in the presence of neurological deficit, surgical treatment is warranted for degenerative lumbar spinal stenosis (DLSS). Typically, surgery is performed using a posterior approach for adequate decompression of the stenotic site. Conventional laminectomy (CL) is usually performed for adequate decompression, but it can damage the posterior structures that provide lumbar stability during flexion. In addition, excessive intraoperative resection of the facet joints could result in postoperative segmental instability, which could necessitate additional fusion surgery [1]. Moreover, conventional posterior open lumbar surgery is associated with considerable trauma to the paraspinal muscles. Even without substantial damage to the facet joints, severe damage to the paraspinal muscles could cause low back pain (LBP), resulting in poor functional outcomes. Some recent studies have suggested a correlation of atrophy of the multifidus muscle and chronic LBP with poor circulation of arterial blood, excessive muscle stripping, and damage to the posterior branches of dorsal rami following prolonged intraoperative muscle traction [2‐11].

Thus, several studies have proposed numerous surgical techniques that can minimize damage to the paraspinal muscles, particularly unilateral laminotomy for bilateral decompression [12, 13]. In addition, these studies have assumed that bilateral decompression via unilateral laminotomy (BDUL) can postoperatively decrease damage to soft tissues and the degree of LBP compared with CL. These findings suggest that postoperative functional outcome and quality of life of patients is enhanced following BDUL.

Hence, this study aimed to compare the degree of postoperative LBP, functional outcome, and quality of life of patients between BDUL (group U) and CL (group C), which were randomly performed by a spine surgeon in patients with single-level DLSS requiring surgery.

In DLSS, the compression of a nerve (cauda equina and nerve root) by degenerated and hypertrophied bony structure and surrounding soft tissue causes symptoms such as LBP, referred buttock pain, radiating lower leg pain, and intermittent neurogenic claudication. The primary surgical treatment for this condition involves adequate decompression of the nerve, and the leading treatment failure in decompression surgery is inadequate decompression. Of note, segmental fusion should be performed if the posterior stabilizing structures are damaged and followed by the occurrence of segmental instability [15]. To date, several studies have reported adequate decompression to be the most successful surgical option for DLSS alone. Reportedly, the incidence of complications increases with the use of combined decompression and fusion surgery, and there is no evidence that the outcomes are superior to decompression alone [16, 17]. In addition, CL for central DLSS is a method that involves dissection of the posterior paraspinal muscles of bilateral sides as well as of the spinous process and supraspinous and interspinous ligaments. However, this posterior structure plays a crucial role in lumbar stability during lumbar flexion, and its excessive resection might cause LBP; therefore, it is essential to minimize its damage as much as possible. CL and decompression can attain satisfactory neurological recovery, but it is inevitable that the multifidus is stripped during surgery and damaged during prolonged traction. While performing these procedures with the bilateral approach, muscle damage is severer than that with the unilateral approach [12]. Lie et al. [18] reported that lumbar spinous process-splitting laminectomy decreased muscle damage and multifidus atrophy, leading to decreased LBP. Furthermore, several studies have reported BDUL to be a good treatment method in terms of morphological evaluation and postoperative spinal instability as well as symptom recovery [12, 19].

Nevertheless, Lie et al. [11] questioned the impact of LBP reduction because BDUL could damage the multifidus muscle in one lamina and the spinous process. Arai et al. [20] reported better results by unilateral approach than that by the bilateral approach but observed no difference between the two groups at a single level. However, multilevel LSS revealed a large difference in terms of back pain and functional outcome. The lack of statistical significance for LBP, functional outcome, and quality of life in both groups could be attributed to the fact that we performed single-segmental decompression using a microscope.

In this study, we observed no differences in terms of LBP, referred buttock pain, functional outcome, and quality of life between the groups after 6, 12, and 24 months because of short muscle traction time during surgery. Gejo et al. [21] reported that the traction of the paraspinal muscles for > 80 min (40–125 min) is only approximately 50% of the total muscle strength at 6 months postoperatively and that weakness of these muscles could cause LBP. We believe that although the total operation time of groups C and U was 83 and 119 min, respectively, from skin incision to skin closure, the muscle retraction time in both groups was < 80 min. Moreover, we thought that the use of intermittent Gelpi retractor instead of continuous Beckman retractor could decrease damage to the posterior muscle structures. On postoperative day 7, the trained back muscle isokinetic exercise was performed by the medical staff to help decrease LBP and recover the trunk muscle performance gradually [21]. In a study on adolescents, Remes et al. [22] reported that LBP was severe at 3–6 months postoperatively and did not markedly differ after 1 year of surgery and that motion preservation possibly plays a vital role in the maintenance of back muscle integrity, besides initial surgical trauma.

To date, few comparative studies have been conducted on single-level DLSS requiring decompression surgery. Fan et al. [23] reported a decline in postoperative LBP after a minimal level of multifidus and functional outcome in a minimal approach using a tubular system in single-level posterolateral interbody fusion surgery. This study comprised patients with lumbar spinal stenosis accompanied by instability and those who underwent fixation rather than decompression. The average operation time was 200 min, and retractor time was longer. In addition, Fan et al. [23] suggested that after 6 months of spinal surgery, the VAS score of LBP improved and ODI improved by the recovery process of the back muscle. Hong et al. [19] reported BDUL reduced the risk of late instability when compared with a conventional laminotomy. Although not a comparative study of the two surgical methods, Oertel et al. [13] reported that BDUL is an adequate technique for decompression of LSS in experienced hand. Dohzono et al. [24] reported microscopic BDUL prevents postoperative spinal instability. All of these studies included studies involving more than two levels, and no studies have analyzed only one level.

The present study has some limitations. One limitation is the lack of imaging findings, such as intramuscular pressure, paraspinal muscle edema in muscle damage, and pelvic parameter [25]; laboratory tests, such as serum creatine phosphokinase and inflammatory cytokine levels; and blood loss and transfusion volume during surgery. In addition, no radiological instability or increased severity of the LBP occurred at a mean of 24 months; however, the follow-up period was shorter to detect radiological changes and LBP. Despite the RCT study design, I could not register on http://​www.​clinicaltrials.​gov.

In a randomized, controlled, prospective trial comparing CL and BDUL in patients with DLSS, CL exhibited shorter operation time. In addition, we observed no significant differences in terms of three spine-related pains (LBP, referred buttock pain, and radiating lower leg pain) over time and in terms of functional outcomes (ODI and RMDQ) and SF-36 between the two groups. In single-level decompression of DLSS, group U had the advantages of shorter operation time than group C, but not in terms of back pain, functional outcome, and quality of life.