Laminectomy

Overview and Indications

A lumbar laminectomy is performed for patients with symptomatic, painful lumbar spinal stenosis occurring at multiple (> 3 vertebrae) levels of the spine. It is performed to remove the large, arthritic osteophytes (bone spurs) that are compressing the spinal nerves.

Surgical Technique

The surgery is performed utilizing general anesthesia. A breathing tube (endotracheal tube) is placed and the patient breathes using a ventilator during the surgery. Preoperative intravenous antibiotics are given. Patients are positioned in the prone (lying on the stomach) position, generally using a special operating table/bed with special padding and supports. The surgical region (low back area) is cleansed with a special cleaning solution. Sterile drapes are placed, and the surgical team wears sterile surgical attire such as gowns and gloves to maintain a bacteria-free environment.

A 4-8 centimeter (depending on the number of levels) longitudinal incision is made in the midline of the low back, directly over the area of the spinal stenosis. The fascia and muscle is gently divided in the midline, and retractors are used to allow the surgeon to visualize the posterior (back part) vertebral arches. After the retractor is in place, an x-ray is used to confirm that the appropriate spinal level(s) is identified.

A complete laminectomy (removal of lamina portion of bone) and foraminotomy (removal of bone spurs near where the nerve comes through the hole of the spine bone) is typically performed, allowing the nerves to return to their normal size and shape when the compressive lesions are removed. The nerve roots and neurologic structures are protected and carefully retracted, so that the bone spurs can be visualized and removed. Small dental-type instruments and biting/grasping instruments (such as a pituitary rongeur and kerrison rongeur) are used to remove the arthritic, hypertrophic (overgrown) bone spurs and ligamentum flavum. All surrounding areas are also checked to ensure no compressive spurs or disc fragments are remaining.

The wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer and subcutaneous layers are closed with a few strong sutures. The skin is closed using stitches or surgical staples. A sterile bandage is applied, and is changed daily while in the hospital.

The total surgery time is approximately 1 _ to 3 hours, depending on the number of spinal levels involved.

Post-Operative Care

Most patients are usually able to go home 2-5 days after surgery. Before patients go home, physical therapists and occupational therapists work with patients and instruct them on proper techniques of getting in and out of bed and walking independently. Patients are instructed to avoid bending at the waist, lifting (more than five pounds), and twisting in the early postoperative period (first 2-4 weeks) to avoid a strain injury. Patients can gradually begin to bend, twist, and lift after 2 weeks as the pain subsides and the back muscles get stronger.

Brace

Patients are generally not required or recommended to wear a back brace after surgery. Occasionally, patients may be issued a small, soft lumbar corset that can provide additional lumbar support in the early postoperative period, if necessary.

Wound Care

The wound area should remain covered with a gauze bandage secured in place with tape. The area should be kept clean and dry. The bandage should generally be changed every 1-2 days, especially after showering.

Shower/Bath

Patients can shower immediately after surgery, but should keep the incision area covered with a bandage and tape, and try to avoid the water from water hitting directly over the surgical area. After the shower, patients should change the bandage, and dry off the surgical area. The dressing should otherwise be changed every 2-3 days when at home. Patients should not take a bath until the wound has completely healed, which is usually around 2 weeks after surgery.

Driving

Patients may begin driving when the pain has decreased to a mild level, which usually is between 7-14 days after surgery. Patients should not drive while taking pain medicines (narcotics). When driving for the first time after surgery, patients should make it a short drive only and have someone come with them, in case the pain flares up and they need help driving back home. After patients feel comfortable with a short drive, they can begin driving longer distances alone.

Return to Work and Sports

Patients may return to light work duties as early as 2-3 weeks after surgery, depending on when the surgical pain has subsided. Patients may return to heavy work and sports as early as 6-8 weeks after surgery, if the surgical pain has subsided and the back strength has returned appropriately with physical therapy.

Doctor's Visits and Follow-Up

Patients will return for a follow-up visit to see the doctor approximately 12-14 days after surgery. The incision will be inspected and the stitches or staples will be removed. Patients will be given a prescription to begin physical therapy for back exercises, to start 4-6 weeks after the surgery. Medications will be refilled if necessary.

Results and Outcome Studies

The results of laminectomy surgery in the treatment of symptomatic spinal stenosis are generally excellent. Numerous research studies in medical journals demonstrate greater than 81-95% good or excellent results from laminectomy surgery. Most patients are noted to have a rapid improvement of their pain and return to normal function.

Selected Bibliography

Getty CJ. Lumbar spinal stenosis: the clinical spectrum and the results of operation. J Bone Joint Surg Br 1980;62:481.

Grabias S. The treatment of spinal stenosis. J Bone Joint Surg Am 1980;62:308-13.

Herno A, Airaksinen O, Saari T. Long-term results of surgical treatment of lumbar spinal stenosis. Spine 1993;11:1471.

Herkowitz HN, Kurz LT. Degenerative lumbar spondylolisthesis with spinal stenosis: A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 1991;73:802.

Herron LD, Mangelsdorf C: Lumbar spinal stenosis: results of surgical treatment. J Spinal Disord 1991;4:26.

Johnsson KE, Willner S, Johnsson K. Postoperative instability after decompression for lumbar spinal stenosis. Spine 1986;11:107.

Johnsson KE, Rosen I, Uden A. The natural course of lumbar spinal stenosis. Clin Orthop 1992;279:82.

Katz JN, Lipson SJ, Larson MG, McInnes JM, Fossel AH, Liang MH. The outcome of decompressive laminectomy for degenerative lumbar spinal stenosis. J Bone Joint Surg Am 1991;73:809.

Sanderson PL, Wood PLR. Surgery for lumbar spinal stenosis in old people. J Bone Joint Surg Br 1993;75:393.

Spengler DM. Degenerative stenosis of the lumbar spine. J Bone Joint Surg Am 1987;69:305.

Turner JA, Ersek M, Herron L, Deyo R. Surgery for lumbar spinal stenosis: an attempted meta-analysis of the literature. Spine 1992;17:1.

Verbiest H: Results of surgical treatment of idiopathic developmental stenosis of the lumbar vertebral canal: a review of twenty-seven years' experience. J Bone Joint Surg Br 1977;59:181.