Laminotomy

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Laminotomy
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Surgery on Vertebral Column
Specialty neurosurgeon

A laminotomy is an orthopaedic neurosurgical procedure that removes part of the lamina of a vertebral arch in order to relieve pressure in the vertebral canal. [1] A laminotomy is less invasive than conventional vertebral column surgery techniques, such as laminectomy because it leaves more ligaments and muscles attached to the spinous process intact and it requires removing less bone from the vertebra. [1] As a result, laminotomies typically have a faster recovery time and result in fewer postoperative complications. Nevertheless, possible risks can occur during or after the procedure like infection, hematomas, and dural tears. [2] Laminotomies are commonly performed as treatment for lumbar spinal stenosis and herniated disks. [2] MRI and CT scans are often used pre- and post surgery to determine if the procedure was successful. [2]

Contents

Anatomy overview

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Human Vertebral Column
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Vertebra Superior View

The spinal cord is housed in a bony hollow tube called the vertebral column. [3] The vertebral column is composed of many ring-like bones called vertebra (plural: vertebrae) and it spans from the skull to the sacrum. Each vertebra has a hole in the center called the vertebral foramen through which the spinal cord traverses. [3]

Laminae (singular: lamina) are the anatomical structures of primary importance in a laminotomy. Laminae are part of the vertebral arch which is the region of bone on the back side of each vertebra that forms a protective covering for the back side of the spinal cord. [3]

The vertebral arch is composed of several anatomical features in addition to laminae that must be taken into account when performing a laminotomy. In the center of the vertebral arch is a bony projection called the spinous process. [3] The spinous process is located on the posterior or back side of the vertebra and serves as the attachment point for ligaments and muscles which support and stabilize the vertebral column. [3] Each vertebra has two lateral bony projections called the transverse processes which are located on either side of the vertebral arch. Transverse processes come into contact with the ribs and serve as attachment points for muscles and ligaments that stabilize the vertebral column. [3] The lamina is the segment of bone that connects the spinous process to the transverse process. Each vertebra has two lamina, one on each side of the spinous process. [3]

Vertebral Column: Lamina Vertebra Posterolateral-en.svg
Vertebral Column: Lamina

Types

US Navy Cmdr. Kenneth Kubis, director of surgical services aboard the Military Sealift Command hospital ship USNS Mercy uses an operating microscope US Navy 080607-N-9689V-011 Cmdr. Kenneth Kubis, director of surgical services aboard the Military Sealift Command hospital ship USNS Mercy (T-AH 19), uses an operating microscope.jpg
US Navy Cmdr. Kenneth Kubis, director of surgical services aboard the Military Sealift Command hospital ship USNS Mercy uses an operating microscope

Different types of laminotomy are defined by the type of instrument used to visualize the procedure, what vertebra the procedure is performed on, and whether or not both lamina of a vertebra are operated on or just one.G [4]

Common types of laminotomy:

These classifications of laminotomies can be combined to form the most descriptive name for the procedure possible. For example, an endoscopic unilateral lumbar laminotomy is the removal of bone from only one lamina of a lumbar vertebrae using an endoscope. [1]

Procedure

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Featured: Ligamentum Flavum

The procedure of a laminotomy remains largely the same regardless of the instrument used, or the level of vertebrae operated on. Laminotomies require general or spinal anesthesia and frequently require a hospital stay following the procedure—although the duration of the stay depends on the physical condition of the individual and their reason for having a laminotomy. [1] [2] A laminotomy takes about 70–85 minutes depending on the type of procedure used. [1] Unilateral laminotomies typically require less time because bone is removed from only one lamina, whereas bilateral laminotomies usually take more time because bone is removed from both laminae. The level of the vertebrae that the laminotomy is performed on and what instrument is used produce no significant differences in the length of the procedure. [1] Both unilateral and bilateral laminotomies are performed in a shorter time period compared to a conventional laminectomy which takes over 100 minutes on average. [1]

During a laminotomy, the individual lies on his or her stomach with the back facing up towards the physician. [1] An initial incision is made down the middle of the back exposing the vertebrae on which the laminotomy will be performed. [1] In this procedure, the spinous process and the ligaments of the vertebral column are kept intact, but the muscles adjacent to the vertebral column known as the paraspinous muscles (example: spinalis muscle) must be separated from the spinous process and vertebral arch. [1] In a unilateral laminotomy, these muscles are detached only from the side on which the laminotomy is being performed. During a bilateral laminotomy, these muscles must be removed on both sides of the vertebrae. [1] The ligaments connecting the lamina of upper and lower vertebrae, known as Ligamenta flava are often removed or remodeled in this procedure to adjust for the small amount of bone lost. [2] Using either a microscope or an endoscope to have a visual of the procedure, a small surgical drill is used to remove a part of bone from one or both laminae of the vertebrae. [1] Laminotomies can be performed on multiple vertebrae during the same surgery; this is known as a multi-level laminotomy. [1]

A slightly different, but commonly used procedure of laminotomy is the unilateral laminotomy for bilateral spinal decompression. [4] This minimally invasive procedure is often used to treat patients with excessive pressure in the vertebral column that must be relieved. [4] In this procedure, the same spinal ligaments are kept intact and the paraspinous muscles must still be detached. [5] A unilateral laminotomy is performed on one lamina of a vertebra. [5] This removal of bone from one lamina provides an opening into the spinal canal. Using a microscope or an endoscope to visualize the procedure, surgical tools are inserted through this opening into the spinal canal. The surgical tools are then navigated underneath the spinous process and across the spinal canal to reach the other lamina on the opposite side of the vertebra to perform a second laminotomy. [5] The incision for this procedure is smaller because doctors need only access one lamina yet can perform a bilateral laminotomy—remove bone from both lamina of a single vertebra. [5] The unilateral laminotomy with bilateral spinal decompression procedure was developed almost 20 years ago and is a common successful surgical treatment for lumbar spinal stenosis. [4]

Reasons for performing a laminotomy

A laminotomy is typically used to relieve pressure from the spinal canal. Excessive pressure in the spinal canal causes the spinal canal and spinal nerves to be compressed which can be very painful and can impair motor control and/or sensation. A common disorder that causes increased pressure in the spinal canal is lumbar spinal stenosis. Lumbar spinal stenosis is formally defined as a decline in diameter length of either the neural foramina, lateral recess, or spinal canal. [1] Stenosis is classified as a decaying disease because it causes the canal to gradually become more and more narrow which can cause pain or loss of function. [1] Common symptoms of lumbar stenosis are pain, fatigue, weakness of the muscle and numbness. [2] Stenosis can be caused by old age or an injury to the vertebral column and usually requires a CT scan or MRI to diagnose. [2] Performing a laminotomy can relieve pressure in the spinal canal caused by lumbar stenosis and therefore alleviate symptoms. [1]

Laminotomies are also performed to create a window into the spinal canal. [2] Laminotomies are frequently used as a way to surgically repair a spinal disc herniation at any level of the vertebral column (cervical, thoracic, lumbar). [1] A herniated disc can compress spinal nerves and cause intense pain and impaired sensation. [4] Removing a portion of the lamina allows physicians to be able to access and repair the herniated disc. Laminotomies may also be used to treat intraspinal lesions such as spinal tumor or problems with the blood vessels supplying the spinal cord. [4] In any scenario where the inside of the spinal canal must be accessed or there is an increase in pressure in the spinal canal, laminotomy may be used to treat the disorder or alleviate symptoms. [1]

Benefits

The laminotomy procedure has many benefits as to why it is a preferred spinal surgery since it is less invasive than other spinal procedures such as a laminectomy or a spinal fusion. [2] Once a laminotomy procedure is done, patients have a great improvement in their pain and mobility. [2] Laminotomies are usually safer than other surgeries that are open or invasive. [2] This surgery usually is shorter than other spinal decompression procedures by having an average duration of 70–85 minutes, whereas other decompression surgeries can have a duration anywhere from 90 to 109 minutes. Laminotomies are usually more cost efficient than other surgical decompression surgeries. In 2007, it was seen that laminotomies were around $10,000, whereas other surgical procedures were around $24,000. [2] Smaller skin incisions and scarring as well as less surgical trauma are also a benefit of laminotomy. [4] With this procedure there is usually a faster recovery time, and a shorter hospital stay if one is necessary at all. [4] During the surgery there is also a benefit of minimizing the injury to muscles, ligaments, and bones in the spine since more invasive surgeries have a greater risk of damaging them. [4] General anesthesia is usually required, but postoperative spinal instability is typically limited. [4]

Risks and potential complications

Since this procedure is a surgical technique there are many complications that can occur either during or after the surgery. Some major complications that can occur are cerebrospinal fluid leaks, dural tears, infection, or epidural hematomas. [2] Death is also a risk; however, it occurs only once per thousand surgeries. [2] Other potential complications are nerve root damage, which can lead to nerve injury or paraplegia, and a significant amount of blood loss that will lead to blood transfusions. [2]

Laminotomy versus laminectomy

Historically, laminectomies have been the primary way to treat lumbar spinal stenosis. [5] A laminectomy is a more invasive method with the aim to decrease the total amount of pain and numbness associated with lumbar spinal stenosis. [2] It is a surgery that eliminates the entire lamina to allow the nerves around this region to function properly. [2] Laminectomies also often produce a longer recovery time as well as a greater risk for post-operative complications. There is typically more damage to the surrounding muscle tissue accompanied by a laminectomy. [5] Since a laminectomy involves the excision of the entire lamina, a laminectomy will usually cause more spinal instability than a laminotomy. [5] When going with the option of laminotomy, the procedure reduces the total amount of muscle severed. Because a laminotomy does not damage the spinous process and critical ligaments, there is not as much muscle weakness, pain, and lumbar instability seen with laminectomies. [4] Laminotomies are fairly new compared to laminectomies, and it involves using less invasive methods with precise instruments to minimize the risk of tissue damage. [5]

Radiographic imaging

X-Rays

For radiographic imaging, an x-ray is the least effective way to collect information when observing a patient with lumbar spinal stenosis. A CT scan provides a 360-degree compiled view of the vertebrae that is more precise than an x-ray. [2]

MRI

MRI of the lumbar spine showing spinal stenosis SPINAL STENOSIS.JPG
MRI of the lumbar spine showing spinal stenosis

Since an MRI provides excellent imaging of blood vessels and tissues, it is recognized as the best type of imaging to observe signs associated with lumbar compression. The precise measurement of the diameter of the spinal canal is a particularly important component when determining the severity of the stenosis itself. [2] High strength 3-Tesla MRI machines are being utilized due to the increased vascular imaging capabilities. Better resolution capacity allows for more detailed observations by the healthcare provider. The sharp contrast of the high power MRI outlines details in the vertebra that are critical when examining a patient with lumbar spinal stenosis who may need a laminotomy. [1] MRI scanning post invasive surgery is used to see the quality of the surgery itself, yet the appropriate postoperative time elapsed before conducting an MRI is a debated topic. [2]

CT scans

A CT scan is not the most effective imaging technique when observing lumbar abnormalities, however it can supplement an MRI by detecting certain degenerative processes. When determining whether or not a laminotomy will be beneficial for the patient, a healthcare provider must assess the severity of the possible abnormalities. Out of all the potential reasons to have a laminotomy performed, lumbar spinal stenosis is the chief reason. CT scans are used specifically to pinpoint a buckled lumbar ligamentum flavum as well as facet hypertrophy, which are some of the main pathophysiological changes indicative of lumbar spinal stenosis. [2] Even though a CT scan can reveal these pertinent signs of lumbar spinal stenosis, it can sometimes give a cloudy image due to the shadowing of the tissue contrast. When this occurs, an intrathecal myelography contrast is conducted with the CT scan to fix the abnormal contrast. A CT scan can also reveal an increase in the cross sectional area of the L3 vertebrae, which ultimately decreases the cross sectional area of the spinal canal. [2] As an increase in the size of the L3 vertebrae occurs, pressure builds up on the cauda equina, commonly causing pain in the lower back and lower extremities. Cauda equina compression can also be due to stenosis of L4-5 region as well. [1] Even though the CT scan allows for intensive image studying, the fixed nature of the image collection process alone is not enough to reach a definitive diagnosis of lumbar spinal stenosis. The outcome of the CT scan can help compile physiological evidence that the patient has lumbar spinal stenosis, and that the patient may potentially benefit from a laminotomy to improve his or her quality of life. [1]

Other than static imaging processes, a CT scan can also be used for observing changes in spinal canal features before and after a laminotomy. One of the main signs of lumbar spinal stenosis is the thickening of the ligamentum flavum, causing it to expand towards the spinal canal. [2] When observing the cross sectional area of the spinal canal of a human cadaver, it was found that the area had decreased due to ligamentum flavum thickening. The ligamentum flavum did not appear to alter the dynamic alterations in the dimensions of the spinal cord. Even after the intervertebral disc was removed, the ligamentum flavum did not appear to be a factor in the change in the dimensions of the spinal canal. [6] By understanding the magnitude of the role that ligamentum flavum hypertrophy plays in lumbar sacral stenosis, the necessity of an invasive lumbar spinal procedure can be accurately measured.[ citation needed ]

Alternative minimally invasive procedures

Minimally invasive procedures are a more common alternative due to the decreased risk of damaging significant muscle tissue. The difference between invasive and minimally invasive spinal surgeries is that minimally invasive procedures involves a series of small incisions. Minimally invasive procedures can be performed anywhere along the spine, and have been used to treat various abnormalities. [2] The percutaneous pedicle screw fixation technique allows for a procedure that presents minimal risk to the patient. Fluoroscopic image guided navigation through these portals allows for surgeons to perform more efficient procedures. Minimally invasive procedures often yield a much faster recovery time than fully invasive surgeries, making them more appealing to patients. Laminectomies have always been the gold standard when treating lumbar spinal stenosis, but recently, less invasive surgeries have emerged as a safer alternative treatment that helps maintain the postoperative structural integrity of the spine. [4]

Spinal microsurgery

Spinal microsurgery is a minimally invasive unilateral laminotomy used to correct bilateral lumbar spinal compression. Spinal microsurgery is the most common and effective microsurgical decompression treatment for patients who present with moderate to severe spinal stenosis. [4] Spinal microsurgeries are performed with high magnification 3-D imaging of the fixated area of the spine, reducing the potential risk of harming the architecture of the spine itself.

Endoscopic spine surgery

Endoscopic spine surgeries can be used to treat thoracic lesions, and have been proven to be a much safer option than a thoracotomy. However, an endoscopic spine surgery can be performed to treat other spinal conditions, such as a herniated lumbar disc. [4] Recovery time from this type of surgical treatment is often very quick, with patients ambulating within a few hours of the procedure. [2]

Spinal fusion

Spinal fusion involves fusing two vertebrae together using a spacer, and is intended to prohibit movement at that particular segment. Screws are typically inserted to assure that the spacer is held in place. The most common lumbar spinal fusion occurs between L4 and L5. [4] A lumbar spinal fusion may be recommended when non-surgical treatment options for severe degenerative disc disease are ineffective. A laminotomy would not be effective in this case, since this procedure is concerning a degenerated disc that needs to be removed in order to relieve certain symptoms. [2]

See also

Related Research Articles

<span class="mw-page-title-main">Lumbar vertebrae</span> Five bones of the spine in the lower back

The lumbar vertebrae are located between the thoracic vertebrae and pelvis. They form the lower part of the human back in humans, and the tail end of the back in quadrupeds. In humans, there are five lumbar vertebrae. The term is used to describe the anatomy of humans and quadrupeds, such as horses, pigs, or cattle. These bones are found in particular cuts of meat, including tenderloin or sirloin steak.

<span class="mw-page-title-main">Discectomy</span> Surgical removal of an intervertebral disc

A discectomy is the surgical removal of abnormal disc material that presses on a nerve root or the spinal cord. The procedure involves removing a portion of an intervertebral disc, which causes pain, weakness or numbness by stressing the spinal cord or radiating nerves. The traditional open discectomy, or Love's technique, was published by Ross and Love in 1971. Advances have produced visualization improvements to traditional discectomy procedures, or endoscopic discectomy. In conjunction with the traditional discectomy or microdiscectomy, a laminotomy is often involved to permit access to the intervertebral disc. Laminotomy means a significant amount of typically normal bone is removed from the vertebra, allowing the surgeon to better see and access the area of disc herniation.

<span class="mw-page-title-main">Lumbar spinal stenosis</span> Narrowing of the lower spinal canal

Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the nerves and blood vessels at the level of the lumbar vertebrae. Spinal stenosis may also affect the cervical or thoracic region, in which case it is known as cervical spinal stenosis or thoracic spinal stenosis. Lumbar spinal stenosis can cause pain in the low back or buttocks, abnormal sensations, and the absence of sensation (numbness) in the legs, thighs, feet, or buttocks, or loss of bladder and bowel control.

<span class="mw-page-title-main">Laminectomy</span> Surgical removal of a lamina

A laminectomy is a surgical procedure that removes a portion of a vertebra called the lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postlaminectomy syndrome. Depending on the problem, more conservative treatments may be viable.

<span class="mw-page-title-main">Spondylosis</span> Degeneration of the vertebral column

Spondylosis is the degeneration of the vertebral column from any cause. In the more narrow sense it refers to spinal osteoarthritis, the age-related degeneration of the spinal column, which is the most common cause of spondylosis. The degenerative process in osteoarthritis chiefly affects the vertebral bodies, the neural foramina and the facet joints. If severe, it may cause pressure on the spinal cord or nerve roots with subsequent sensory or motor disturbances, such as pain, paresthesia, imbalance, and muscle weakness in the limbs.

<span class="mw-page-title-main">Degenerative disc disease</span> Loss of function in the spines intervertebral discs

Degenerative disc disease (DDD) is a medical condition typically brought on by the aging process in which there are anatomic changes and possibly a loss of function of one or more intervertebral discs of the spine. DDD can take place with or without symptoms, but is typically identified once symptoms arise. The root cause is thought to be loss of soluble proteins within the fluid contained in the disc with resultant reduction of the oncotic pressure, which in turn causes loss of fluid volume. Normal downward forces cause the affected disc to lose height, and the distance between vertebrae is reduced. The anulus fibrosus, the tough outer layers of a disc, also weakens. This loss of height causes laxity of the longitudinal ligaments, which may allow anterior, posterior, or lateral shifting of the vertebral bodies, causing facet joint malalignment and arthritis; scoliosis; cervical hyperlordosis; thoracic hyperkyphosis; lumbar hyperlordosis; narrowing of the space available for the spinal tract within the vertebra ; or narrowing of the space through which a spinal nerve exits with resultant inflammation and impingement of a spinal nerve, causing a radiculopathy.

<span class="mw-page-title-main">Cauda equina syndrome</span> Nerve damage at the end of the spinal cord

Cauda equina syndrome (CES) is a condition that occurs when the bundle of nerves below the end of the spinal cord known as the cauda equina is damaged. Signs and symptoms include low back pain, pain that radiates down the leg, numbness around the anus, and loss of bowel or bladder control. Onset may be rapid or gradual.

<span class="mw-page-title-main">Spinal fusion</span> Immobilization or ankylosis of two or more vertebrae by fusion of the vertebral bodies

Spinal fusion, also called spondylodesis or spondylosyndesis, is a surgery performed by orthopaedic surgeons or neurosurgeons that joins two or more vertebrae. This procedure can be performed at any level in the spine and prevents any movement between the fused vertebrae. There are many types of spinal fusion and each technique involves using bone grafting—either from the patient (autograft), donor (allograft), or artificial bone substitutes—to help the bones heal together. Additional hardware is often used to hold the bones in place while the graft fuses the two vertebrae together. The placement of hardware can be guided by fluoroscopy, navigation systems, or robotics.

<span class="mw-page-title-main">Spondylolysis</span> Defect or fracture in the pars interarticularis of the vertebral arch

Spondylolysis is a defect or stress fracture in the pars interarticularis of the vertebral arch. The vast majority of cases occur in the lower lumbar vertebrae (L5), but spondylolysis may also occur in the cervical vertebrae.

<span class="mw-page-title-main">Ligamenta flava</span> Ligaments connecting the laminae of adjacent vertebrae

The ligamenta flava are a series of ligaments that connect the ventral parts of the laminae of adjacent vertebrae. They help to preserve upright posture, preventing hyperflexion, and ensuring that the vertebral column straightens after flexion. Hypertrophy can cause spinal stenosis.

Microsurgical lumbar laminoplasty is a minimally invasive technique for decompressing pinched nerves in the lumbar spine. Pinched or compressed nerves may result from herniated discs, lumbar spinal stenosis, or spondylolisthesis.

<span class="mw-page-title-main">Cervical spinal stenosis</span> Narrowing of the upper spinal canal

Cervical spinal stenosis is a bone disease involving the narrowing of the spinal canal at the level of the neck. It is frequently due to chronic degeneration, but may also be congenital. Treatment is frequently surgical.

<span class="mw-page-title-main">Neurogenic claudication</span> Discomfort in the legs during walking due to nerve impingement

Neurogenic claudication (NC), also known as pseudoclaudication, is the most common symptom of lumbar spinal stenosis (LSS) and describes intermittent leg pain from impingement of the nerves emanating from the spinal cord. Neurogenic means that the problem originates within the nervous system. Claudication, from Latin claudicare 'to limp', refers to painful cramping or weakness in the legs. NC should therefore be distinguished from vascular claudication, which stems from a circulatory problem rather than a neural one.

<span class="mw-page-title-main">Laminoplasty</span>

Laminoplasty is an orthopaedic/neurosurgical surgical procedure for treating spinal stenosis by relieving pressure on the spinal cord. The main purpose of this procedure is to provide relief to patients who may have symptoms of numbness, pain, or weakness in arm movement. The procedure involves cutting the lamina on both sides of the affected vertebrae and then "swinging" the freed flap of bone open thus relieving the pressure on the spinal cord. The spinous process may be removed to allow the lamina bone flap to be swung open. The bone flap is then propped open using small wedges or pieces of bone such that the enlarged spinal canal will remain in place.

<span class="mw-page-title-main">Spinal cord</span> Long, tubular central nervous system structure in the vertebral column

The spinal cord is a long, thin, tubular structure made up of nervous tissue that extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column (backbone) of vertebrate animals. The center of the spinal cord is hollow and contains a structure called the central canal, which contains cerebrospinal fluid. The spinal cord is also covered by meninges and enclosed by the neural arches. Together, the brain and spinal cord make up the central nervous system.

<span class="mw-page-title-main">Spinal disease</span> Disease involving the vertebral column

Spinal disease refers to a condition impairing the backbone. These include various diseases of the back or spine ("dorso-"), such as kyphosis. Dorsalgia refers to back pain. Some other spinal diseases include spinal muscular atrophy, ankylosing spondylitis, scoliosis, lumbar spinal stenosis, spina bifida, spinal tumors, osteoporosis and cauda equina syndrome.

<span class="mw-page-title-main">Spinal decompression</span> Relief of pressure on the spinal cord or compressed nerve roots

Spinal decompression is the relief of pressure on the spinal cord or on one or more compressed nerve roots passing through or exiting the spinal column. Decompression of the spinal neural elements is a key component in treating spinal radiculopathy, myelopathy and claudication.

<span class="mw-page-title-main">Spinal stenosis</span> Disease of the bony spine that results in narrowing of the spinal canal

Spinal stenosis is an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots. Symptoms may include pain, numbness, or weakness in the arms or legs. Symptoms are typically gradual in onset and improve with leaning forward. Severe symptoms may include loss of bladder control, loss of bowel control, or sexual dysfunction.

<span class="mw-page-title-main">Vertebral column</span> Bony structure found in vertebrates

The vertebral column, also known as the spinal column, spine or backbone, is the core part of the axial skeleton in vertebrate animals. The vertebral column is the defining and eponymous characteristic of the vertebrate endoskeleton, where the notochord found in all chordates has been replaced by a segmented series of mineralized irregular bones called vertebrae, separated by fibrocartilaginous intervertebral discs. The dorsal portion of the vertebral column houses the spinal canal, an elongated cavity formed by alignment of the vertebral neural arches that encloses and protects the spinal cord, with spinal nerves exiting via the intervertebral foramina to innervate each body segments.

<span class="mw-page-title-main">Vertebra</span> Bone in the vertebral column

Each vertebra is an irregular bone with a complex structure composed of bone and some hyaline cartilage, that make up the vertebral column or spine, of vertebrates. The proportions of the vertebrae differ according to their spinal segment and the particular species.

References

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  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Costandi S, Chopko B, Mekhail M, Dews T, Mekhail N (January 2015). "Lumbar spinal stenosis: therapeutic options review". Pain Pract. 15 (1): 68–81. doi:10.1111/papr.12188. PMID   24725422.
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  5. 1 2 3 4 5 6 7 8 Levy RM, Deer TR (December 2012). "Systematic safety review and meta-analysis of procedural experience using percutaneous access to treat symptomatic lumbar spinal stenosis". Pain Med. 13 (12): 1554–61. doi:10.1111/j.1526-4637.2012.01504.x. PMID   23136978.
  6. ↑ Maus TP (July 2012). "Imaging of spinal stenosis: neurogenic intermittent claudication and cervical spondylotic myelopathy". Radiol Clin North Am. 50 (4): 651–679. doi:10.1016/j.rcl.2012.04.007. PMID   22643390.
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