Laminectomy – Types, Indications, Contraindications

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laminectomy is a surgical procedure that removes a portion of the vertebral bone 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, smaller alternatives, e.g., small endoscopic procedures, without bone removal, may be possible.[rx]

Back or neck pain that interferes with normal daily activities may need surgery for treatment. Laminectomy is a type of surgery in which a surgeon removes part or all of the vertebral bone (lamina). This helps ease pressure on the spinal cord or the nerve roots that may be caused by injury, herniated disk, narrowing of the canal (spinal stenosis), or tumors. A laminectomy is considered only after other medical treatments have not worked.

Types of Laminectomy

When laminectomy involves one vertebra, it is called single level. When it involves more than one vertebra, it is called multilevel.

The types of laminectomy procedures include:

  • Cervical laminectomy – is the removal of lamina in the neck area (cervical spine).
  • Lumbar laminectomy – is the removal of lamina in the lower back (lumbar spine).
  • Sacral laminectomy – is the removal of lamina in the back between your pelvic, or hip bones (sacral spine).
  • Thoracic laminectomy is the removal of lamina in the middle part of the back (thoracic spine).

Other procedures that may be performed

Your doctor may perform one or more other procedures in addition to a laminectomy:

  • Discectomy is the surgical removal of part or all of a spinal disc. A discectomy treats degenerated, herniated or ruptured spinal discs.
  • Foraminotomy is the widening of the opening where the nerve roots leave the spinal canal. Your doctor may use this procedure when the opening (foramina) is narrowed causing pressure on the spinal nerves.
  • Spinal fusion is the permanent joining together of two vertebrae. This procedure permanently stops movement between the two vertebrae and limits the motion of your spine. Spinal fusion is usually needed with multilevel laminectomy to stabilize your spine.

Anatomy and Physiology

To understand the principles of laminectomy, proper knowledge of the posterior vertebral arch and laminae anatomy are imperative.

The laminae belong to the posterior vertebral arch, extended medially from the base of the spinous process to the junction between the superior and inferior facet joints, acting as a stabilization structure of the spine in association with the facet joint and also as a spinal cord and nerve root protective layer. The laminae general anatomy consists of a superior and inferior border, an anterior surface in contact with the medullary canal and a posterior surface that serves as erector spinae muscles attachment. The shape and thickness of the laminae vary according to the anatomical region. Laminar height tends to decrease from C2 to C4 and then increases towards a peak at T8. From T9 to L4 tends to decrease in height and increases in length having at L5 the lowest lumbar height, on the other hand, from cervical to lumbar, laminae width decreases progressively up to the narrowest at T4 in the thoracic region and then increase steadily to reach the widest at L5.

Regarding the thickness, it increases from cervical to lumbar regions.

A better understanding of the laminae anatomy in different regions of the spine may improve surgery success and avoid iatrogenic complications such as nerve root or spinal cord injury.

Indications of Laminectomy

The main indication for laminectomy is the presence of spinal canal stenosis, narrowing of the spinal canal has multiples etiologies such as congenital, metabolic, traumatic or tumoral, however, degenerative stenosis is the most common cause. Spinal stenosis can also be classified according to Wiltse in central stenosis, lateral recess, foraminal and extraforaminal stenosis. Also, Lee et al. classified the lateral region into three zones of nerve root compression: entrance zone (lateral recess), mid zone (foraminal region), and exit zone (extraforaminal region) in order to clarify anatomy and surgical strategy. Laminectomy is especially effective for the treatment of central and lateral recess stenosis.

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Central stenosis is the most common, and the main symptom is neurogenic claudication, which includes pain, tingling, or cramping sensation in the lower extremity. On the other hand, lateral recess, foraminal and extraforaminal stenosis may cause radiculopathy, patients with central stenosis may experience more symptoms in a standing position and during walking and pain is usually relieved with leaning forward or in a sitting position. In cases of central stenosis, straight leg raising and femoral nerve stretching test are usually normal.

When symptoms derived from stenosis do not respond to conservative treatment, surgical management such as decompression with or without fusion is usually a consideration.

Fusion techniques are required when stenosis is associated with spinal instability, degenerative or isthmic spondylolisthesis, kyphosis or scoliosis, as laminectomy alone may increase the risk of spinal instability in these conditions. However, in cases of low-grade degenerative spondylolisthesis, the literature exhibits variable results regarding the risk of instability after laminectomy alone, some studies support fusion in cases degenerative spondylolisthesis. On the other hand, Wang et al. in a recent meta-analysis found no increased risk of instability after laminectomy, especially in patients without predominant symptoms of mechanical back pain and after minimally invasive procedures.

Other important indications for laminectomy are primary or secondary tumors, infection (peridural abscesses), trauma (fractures that compromise the spinal canal) and stenosis associated with the deformity.

Contraindications of Laminectomy

  • Spinal instability (is a contraindication for laminectomy without associated fusion technique)
  • Degenerative or isthmic spondylolisthesis (relative contraindication)
  • Severe scoliosis (relative contraindication)
  • Severe kyphosis (relative contraindication)

Equipment

  • Standard radiolucent table with spinal frames and foams pads
  • C-arm to localize level and minimize skin size incision
  • Laminectomy instrument set (bone cutting rongeurs, high-speed burr, Kerrison rongeurs, forceps, ball tip, angled spatula spreader, bayonet-shaped curettes, hollow probes, tubular retractors and dilators for MIS approaches)

Personnel

  • No additional Staff OR personnel is required; usually, one or two spinal surgeons, registered nurse staff, and anesthesiologist.
  • Neuromonitoring is usually a recommendation in cervical or dorsal laminectomies, and lumbar cases when there is an increased risk of nerve injury.

Preparation

Laminectomy is performed with the patient in the prone position on a support frame with foam pads for nipples and ASIS (anterior superior iliac crest spine) leaving the abdomen free, avoiding abdominal pressure decreases epidural venous pressure and therefore, surgical site bleeding.

Arms are positioned at 90 degrees abduction and flexion to prevent axillary nerve injury.

How do I get ready for a laminectomy?

  • Your healthcare provider will explain the surgery to you and offer you the chance to ask any questions that you might have about the procedure.
  • You will be asked to sign a consent form that gives your permission to do the surgery. Read the form carefully and ask questions if something is not clear.
  • In addition to a complete health history, your healthcare provider may do a physical exam to make sure that you are in good health before undergoing the procedure. You may have blood tests or other diagnostic tests.
  • Tell your healthcare provider if you are sensitive to or are allergic to any medicines, latex, tape, and anesthesia medicines (local and general).
  • Tell your healthcare provider of all prescribed and over-the-counter medicines and herbal supplements that you are taking.
  • Tell your healthcare provider if you have a history of bleeding disorders or if you are taking any blood-thinning (anticoagulant) medicines, aspirin, or other medicines that affect blood clotting. You may be told to stop these medicines before the procedure.
  • If you are pregnant or think you could be, tell your healthcare provider.
  • Follow any directions you are given for not eating or drinking before the surgery.
  • You may get a sedative before the surgery to help you relax.
  • You may meet with a physical therapist before your surgery to discuss rehabilitation.
  • Certain activities may be limited after your surgery. Arrange for someone to help you for a few days with the household activities and driving.
  • Based on your health condition, your healthcare provider may have other instructions for you.

Technique

Laminectomy can be performed through a traditional open approach or with a minimally invasive technique.

The traditional open approach requires a posterior midline incision (3 to 4 cm in length for single level), subperiosteal dissection along spinous processes to detach and retract paraspinous muscles from the spinous processes medially to the lateral laminar border avoiding damage of the facet joint. Spinous processes may be resected along with dorsal laminae to expose ligamentum flavum with bone cutting rongeur or a burr, resection of ligamentum flavum is possible with Woodson elevator and spatula, medial facetectomies can be performed to decompress the lateral recess, and foraminal region can is reachable with Kerrison rongeurs. Use of a ball tip or angled probe help to assess foraminal size. Great care is necessary to avoid damage to pars interarticularis and more than 50% of the facet joint to decrease the risk of instability. The decompression procedure is usually complete upon confirmation of the dural sac, exiting, and descending nerve roots.

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Minimally Invasive Surgical (MIS) techniques include laminotomy and microendoscopic laminotomy with tubular retractors. Contemporary literature supports these procedures resulting in better preservation of posterior musculature, decreased intraoperative bleeding, and postoperative pain.

Even though MIS approaches may have some early outcome advantages over open procedures, the economic value and cost-effectiveness of MIS require further investigation.

A recent systematic review compared conventional laminectomy with three different techniques that avoid the removal of the spinous process (unilateral laminotomy, bilateral laminotomy and split spinous process laminotomy). A decreased postoperative back pain for bilateral laminotomy and split spinous laminotomy was found, however, there were no observable clinically significant differences. Further, there was no difference in terms of hospital length of stay, operative time, and complications of these techniques compared to conventional laminectomy.

Before Your Laminectomy

Before your laminectomy, you should receive detailed instructions on how to prepare from your surgeon’s staff during one of your office visits. Here’s what you should do and plan for before the surgery:

  • Don’t eat or drink anything after midnight the night before your laminectomy.
  • Wear loose, comfortable clothing. Don’t wear jewelry, especially necklaces or bracelets.
  • Bring your insurance information and your pocketbook for any co-payments or required paperwork.
  • If your doctor thinks you might be able to go home the same day, bring someone to drive you home and help take care of you.
  • Plan for being slow for a while. Stock up on groceries and take care of all the errands and housekeeping you can.
  • Let friends and family know you’ll be having surgery; you’ll be able to use extra help during your recovery.

On the day of your laminectomy

  • You’ll be provided a private area to change into a loose-fitting medical gown.
  • You’ll wait in a “pre-op” area on a stretcher or bed. Your surgeon, your anesthesiologist, or the anesthesiologist’s assistant will visit you and examine you.
  • When everyone is ready, you’ll be transported to the operating room.

During Your Laminectomy

Most laminectomies are performed with general anesthesia and mechanical ventilation. Here’s what will happen:

  • The anesthesiologist or an assistant will place a mask over your face, delivering a mix of oxygen and anesthetic gas. You may also be given medicines through your veins to help you relax. Within a few breaths, you’ll be unconscious. This is general anesthesia.
  • The anesthesiology professional will then insert a plastic tube through your mouth and vocal cords, into your windpipe, or trachea. This is called intubation.
  • During the surgery, a ventilator, or breathing machine, will pump air in and out of your lungs. Your vital signs will be continuously monitored throughout the operation.
  • You’ll be rolled over into the face-down position to provide access to your back.
Next, the surgeon will perform the laminectomy
  • The surgeon will make an incision in the skin of your back over the affected area. The muscles and soft tissues around the spine will be pulled to the side, exposing the spine.
  • The surgeon will then cut away bone, bone spurs, and ligaments that are compressing nerves. This is referred to as decompression. The surgeon may remove a small part or a large portion of several spinal bones, depending on your reason for the operation.
  • Some people may also undergo spinal fusion to stabilize the spine, receive a special implant that will help stabilize the bones in the lower back but not restrict motion in the same way a fusion does, have a disc removed, or have additional removal of bone to widen the passageway where nerves leave the spinal canal.

At the end of the surgery, the wound will be stitched, you’ll be turned back over, the anesthesia will be turned off, and the breathing tube will be removed.

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After Your Laminectomy

Here’s what will happen in the hospital or surgical center after the laminectomy:

  • You’ll be transported to a “post-op” area for observation and continued monitoring of your vital signs. Most people are awake but groggy for several hours after a laminectomy.
  • Although some people go home the same day, most are admitted to the hospital for at least one day.
  • You will feel pain in your lower back. You’ll be provided pain medication.
  • Depending on the extent of your surgery, you may need help getting out of bed and walking for up to a few days after the laminectomy.

Here’s what you can expect at home after your laminectomy

  • Expect some significant pain that may require strong pain medication. You shouldn’t drive while taking these drugs. Most people can return to driving in one to two weeks; your surgeon will let you know when it is safe to get back on the road.
  • You’ll need to limit your activities that include bending, stooping, or lifting for several weeks after your laminectomy.
  • You’ll also need to keep the incision site clean and dry. Ask your doctor for instructions on showering and bathing.
  • Your doctor will remove your stitches or staples after about two weeks.
  • You should avoid long plane flights or car rides — they can lead to blood clots in your legs. If you do travel, stand and walk around once an hour or so.
Your recovery time will depend on the extent of your surgery and your own personal situation. In general, here’s what to expect:
  • After a minor (decompressive) laminectomy, you are usually able to return to light activity (desk work and light housekeeping) within a few days to a few weeks.
  • If you also had spinal fusion with your laminectomy, your recovery time will likely be longer — from two to four months.
  • Your doctor may not advise a return to full activities involving lifting and bending for two to three months.
  • You should start light walking for exercise and physical therapy exercises as soon as your doctor says you’re ready. This will help speed your recovery.

How will you know the results of your laminectomy? The majority of people who undergo laminectomy do experience a reduction in their back pain symptoms. You may not know if the surgery reduced your back pain until about six weeks or more after the laminectomy.

Complications

Laminectomy is a relatively safe procedure, with a low complication rate. Related-technique complications are associated with the underlying structures covered by the laminae, being the dural sac tear and nerve roots injury the most commons. These complications occur more often in elderly patients due to the fragility of the dural sac. Also, the severity of compression could be a factor that increases the rate of a dural tear; the most common risk factor for dural tear is the reoperation due to the presence of scar tissue.

Cerebrospinal fluid (CSF) leak from dural sac tear may cause dizziness, painful orthostatic headache, or thunderclap headache. Nonsurgical management of CSF leaks includes bed rest, caffeine, or acetazolamide to alleviate symptoms. Surgical intervention with direct dura mater repair or dural patching can be performed in cases of tear injury when it is feasible.

Reports exist of surgically induced spinal instability, especially when laminectomy was compared with unilateral laminotomy and in cases of extensive posterior laminectomy. This complication is avoidable by preserving the pars interarticularis and at least two-thirds of lumbar or fifty percent of cervical facet joints.

Postoperative wound infection and wound dehiscence are other complications to consider, the presence of wound erythema, increased pain or swelling may raise the suspicion of wound infection.

References

 laminectomy, Laminectomy – Types, Indications, Contraindications,