Innovative Approach to Unilateral Laminotomy for Bilateral Decompression: Overcoming Challenges with Minimal Resources in Iraq Running title: Unilateral Laminotomy for Bilateral Decompression

Background The minimally invasive lumbar unilateral laminotomy for bilateral decompression has been accepted as a less disruptive yet effective and safe to treat lumbar spinal stenosis. Objective To develop an innovative approach to unilateral laminotomy for bilateral decompression to overcome challenges with minimal resources. Methods A retrospective analysis of 70 patients with lumbar spinal stenosis undergoing bilateral “over the top” decompression of the lumbar spinal canal through unilateral interlaminar fenestration without using fancy and expensive tools was performed. Patient sociodemographics, preoperative details and clinical outcomes were reviewed and analyzed. Results Most patients were females (72.9%), unemployed (77.1%), nonsmokers (88.6%), overweight (48.6%), had involvement in one level (67.1%), had spinal decompression along with discectomy (55.7%), and had had involvement at the L4-L5 level (47.1%) with a mean age of 47.46 ± 10.52 years, a mean BMI of 27.91 ± 4.46 kg/m ² and a mean preoperative VAS of 8.96 ± 1.233. Only two patients (2.9%) showed no improvement after the surgery. Postoperative outcomes showed the mean VAS of 3.03 ± 1.873, 2.33 ± 1.742, and 1.97 ± 1.744 at 1, 3, and 12 months, respectively (p < 0.001). No significant correlations were observed between the procedure type and affected side (p = 0.092) or the levels involved and the patients’ outcome (p = 0.93). Most patients (61.4%) had excellent outcomes, and none of them had worse outcomes. Conclusions The lumbar "over the top" unilateral laminotomy for bilateral decompression is a safe and effective surgical method that demonstrates positive patient results and a low risk of complications.