Name: Unilateral Laminotomy for Bilateral Decompression (ULBD) for Spinal Stenosis
Uploaded: 2026-07-08T00:00:00Z
Channel: Arthrex
Description: Mark A. Mahan, MD (Salt Lake City, UT), presents the case of a 73-year-old male patient with multilevel spondylosis and stenosis who he treated with an ultra-minimally invasive endoscopic L4-L5 unilateral laminotomy for bilateral decompression (ULBD).

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Mark A. Mahan, MD (Salt Lake City, UT), presents the case of a 73-year-old male patient with multilevel spondylosis and stenosis who he treated with an ultra-minimally invasive endoscopic L4-L5 unilateral laminotomy for bilateral decompression (ULBD).

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VID1-008532-en-US | A | Unilateral Laminotomy for Bilateral Decompression (ULBD) for Spinal Stenosis

Mark Mahan, MD (Salt Lake City, UT)

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Unilateral Laminotomy for Bilateral Decompression (ULBD) for Spinal Stenosis

Speaker  Hello, I'm Doctor Mark Mahon, a neurosurgeon from Salt Lake City, Utah. Lumbar spine surgery often involves complex surgical decisions. The concurrence of numerous pathologies, various medical disorders, and narcotic dispensation can present uncertainties on multiple levels. I favor a motion preserving, ultra minimally invasive strategy as the upfront treatment when clinically indicated. In this presentation, I will present a common scenario where this strategy is employed, including clinical decision considerations, surgical techniques, and patient outcomes. I'd like to present a case of a patient with severe leg and back pain. He's a 73 year old man who rates his pain as eight out of ten, and both the back as well as bilateral lower extremities. He says that they're equally painful, both his back and his legs, and the pain radiation is seen on the pain diagram radiating the posterior lateral thighs. He describes that his pain is worsened by walking and by standing, and he states that he can only walk a few blocks before he has to stop. His pain is relieved by bending forward either at a kitchen counter or in a grocery cart. However, he also has a complex medical history, significant for cardiac risk factors with a triple bypass and atrial fibrillation on blood thinning medications, as well as an extremely high narcotic consumption with 30mg of oxycodone seven times a day, for a total of 315 morphine milligram equivalents per day. His preoperative imaging, shown here on the MRI on a sagittal T2 to the left in Axials on the right, show multilevel spondylosis with stenosis at L2 three, L3 four and severe stenosis at L4 five with clumping of the nerve roots. Speaker  On the axial images at L4 five, the same degree of stenosis is visualized, but also a small measure of facet gapping in the supine position that measures approximately a millimeter. However, on standing films, there's not a substantial change in the spondylolisthesis at L4 five between the flexion extension and the standing images, especially compared to the MRI suggestive of a stable, Mild spondylolisthesis at L4 five. On physical exam, he demonstrates weakness in ankle dorsiflexion and plantar flexion, as well as his areflexic at the patella and the ankles. He cannot walk on either his heels or his toes, otherwise the rest of his exam is otherwise within the normal range. So our assessment we have a patient with multilevel stenosis which is moderate L1 two, N2 three and severe at L4 five with a small degree of spondylolisthesis between the supine MRI and the standing imaging. He has complaints most consistent with neurogenic claudication as well as bilateral sciatica or L5 S1 radiculopathies, and his physical exam is most consistent with that same of having an L5 and S1 radiculopathy and weakness. Medically, he is moderate to high risk. More importantly, his high narcotic consumption means that we have to put that into our equation on how we're going to treat it. So the plan we presented to the patient was consideration for an endoscopic L4 five interlaminar decompression, or otherwise known as a ULD. We believe in shared decision making. And so we discussed all the surgical options with him and his family, including multilevel decompression and fusion. Speaker  Multilevel decompression would be trying to treat all the areas of stenosis simultaneously, but that would increase our length of surgery, which is particularly important with the cardiac risk factors, as well as more muscle and tissue trauma associated with more surgery and his higher narcotic consumption. Same thing for fusion at L4 five. Whether it's truly necessary and the additional risks and time taken to perform that fusion by having a shared decision making, we can discuss how we're trying to minimize risk for the patient and also describe that we may consider future surgical procedures should they be necessary, such as addressing the other areas of stenosis or the spondylolisthesis. Here we'll show the intraoperative video from that case. There are three steps to the procedure. First is identification of the anatomical landmarks. Second is drilling and third is an en bloc phlebectomy. First, we land on the caudal aspect of the cranial lamina, which is L4 five in this case. And we can identify the spinous process at the midline. We'll then sweep down laterally along the L4 lamina clearing soft tissue to expose the inferior articulating process of L4. The facet capsule is very clear. And once you're at the inferior articulating process of L4, you're at the cranial aspect of L5 and clear off the soft tissue here. Between the spinous process of L5 and the facet joint, the soft tissue can be removed easily, and there's always a ligament that runs between the spinous processes out to the facet joint, which needs to be cleared to visualize the true ligamentum flavum. Speaker  Once that interspinal ligament is removed, we can work to the contralateral side and remove the same soft tissue to adequately expose both sides and be able to drill from ipsilateral to contralateral sides. Once we've moved all the soft tissue dorsal to the ligamentum flavum in the interlaminar window, we can begin drilling. I prefer to use a fluted hooded drill bit that allows aggressive bone removal, but safety around the soft tissues and neural structures of the spine. We start out by drilling the insertion of the ligamentum flavum on the cranial lamina, and then sweep down on the lateral aspect of the cranial lamina to the inferior articulating process. Oftentimes, drilling is by feel and able to remove the ligamentum flavum. Then I will turn to drilling the cranial aspect of the caudal lamina with our goal of drilling out the insertion so that we see the thin blue membrane, which is the periosteal insertion of the ligamentum flavum. Then I'll drill contralaterally to the opposite sap, using the hood to pull off the ligamentum flavum and expose more of the sap for drilling cranially. We'll then switch back to the ipsilateral side and drill out the sap on the ipsilateral side. This gives us our lateral border for ligament flavum resection, because once we've drilled out the medial border of the ipsilateral sap, we know how far we should go up cranially. And so here we're drilling along the medial aspect of the IAP of L4 to detach the lateral aspect of the Ligamentum flavum. Speaker  That cranial detachment of the Ligamentum flavum allows us to drill to the contralateral side and show us at what level we should be drilling. And then once we've drilled the superior insertion of the ligamentum flavum, then when we'll work down alongside the pars and lamina contralaterally, we'll then join the drilling from a cranial approach to the caudal approach to the SAP, and ensure that we've removed as much ligamentum flavum as possible at the medial border of the sap on the opposite side. The drilling has allowed us to detach ligamentum flavum completely at the cranial side and the caudal side. However, there's always ligamentum flavum in the foraminal segment, so we'll have to use a kerosene or a curette to detach the ligamentum flavum on those sides. And I'll show you my technique of pulling the ligamentum flavum away from the bone to maximize our resection. Often I'll start with the contralateral side first removing the ligamentum flavum at the foraminal section Contralaterally biting the ligamentum flavum and pulling the soft tissue to maximize the removal from the bone. Often twisting and pulling. Once fully released, I might use a curette to detach ligamentum flavum, particularly on the ipsilateral side. The curette allows us to pull the tissue away from that periosteal attachment and see the epidural fat beneath. Then on the ipsilateral border, we'll do the exact same step with grabbing the ligamentum flavum and pulling it away from the Foraminal segment. Biting here at the tip of the SAP on our surgical approach side. Speaker  Once we have marched up towards the cranial detachment, it is now completely free and we can use a grasper to pull it out en bloc. Often requiring removing the entirety of the scope and the working cannula to get these fragments out. We'll then come back and visually inspect to make sure that we're at the lateral borders of the traversing nerve roots, both on the ipsilateral and contralateral side, and ensure we're happy that we have been able to expose the disk space beneath the traversing nerve roots on each side. This affords us a panoramic view of the thecal sac and the two traversing nerve roots. At the conclusion of the case, I'll inject a little dexamethasone, and then I'll pull out the endoscope under direct visualization and cauterize any potential bleeding in the paraspinal muscles. The pieces of ligamentum flavum were so large they had to be removed in two pieces to get them through the seven millimetres skin incision at a six week follow up, which is the latest follow up we have for him. He rated his pain as three out of ten versus eight out of ten Preoperatively. He described that he is 70% better and that he's very happy, particularly because he improved in strength in ankle dorsiflexion as well as plantar flexion. Most surprisingly of all, for a man on 210mg of oxycodone a day, he was off all of his narcotic pain medications at the six week appointment. Thank you for your time.

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Unilateral Laminotomy for Bilateral Decompression (ULBD) for Spinal Stenosis

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