Open midline decompression (OMD) is a revolutionary surgical technique designed to optimize neural decompression while preserving critical spinal structures. Traditional methods such as partial laminectomy and unilateral approach bilateral laminectomy (UBL) often require partial resection of the facet joints, leading to complications like postoperative instability and chronic back pain. OMD addresses these issues by utilizing a tunneling approach to remove the ligamentum flavum en bloc, achieving thorough decompression without compromising facet joint integrity. This preservation significantly reduces the risk of postoperative complications and helps maintain spinal stability, offering a clear advantage over conventional techniques. Additionally, OMD creates a wide interlaminar space, providing an ideal surgical field for ligamentoplasty (LP). This synergy between OMD and LP enables simultaneous decompression and stabilization, resulting in improved patient outcomes and reduced recovery times. This chapter explores the principles and surgical methodology of OMD, detailing how its innovative approach minimizes complications and maximizes effectiveness. By emphasizing facet joint preservation and its compatibility with LP, OMD is establishing itself as a preferred method for achieving optimal outcomes in spinal decompression surgeries.