Laminectomy is a surgical procedure that entails opening the spinal column to treat nerve compression in the spinal cord.
Purpose
Laminectomy may be performed when an abnormality causes spinal nerve root compression that causes leg or arm pain that limits activity. Numbness or weakness in hands, arms, legs, or feet, and problems controlling bowel movements or urination are indication for surgical consideration.
Precautions
Before surgery, patients should refrain from medications and activities as deemed appropriate by the anesthesiologist and surgeon. These precautions can include avoidance of blood thinners such as Advil or Motrin. After surgery, there can be serious complications. Patients should go to a hospital emergency department if they develop loss of bladder or bowel control (or if they cannot urinate); if they are unable to move their legs (indicates nerve or spinal cord compression); experience sudden shortness of breath (possible blood clot in the lungs causing a condition called pulmonary embolism); or if they develop pneumonia or some other heart/lung problem.
Description
Laminectomy can also be called back surgery, disc surgery, or discectomy. Laminectomy is a surgical procedure used in an attempt to treat back pain. The most common site for back pain is usually the lower back, or lumbar spine. A disc acts like a shock absorber for the spinal cord, which contains nerves that exit from foramina, or holes in a disc. A disc (or vertebral disc) is made up of a tough outer ring of cartilage with an inner sac containing a jellylike substance called the nucleus pulposis. When a disc herniates, the jellylike substance pushes through and causes the harder outer ring (annulus fibrosus) to compress a nerve root in the spinal cord. Herniation of a vertebral disc can cause varying degrees of pain. Approximately 25% of persons who have back pain have a herniated disc, causing a condition called sciatica, causing pain to be felt through the buttocks into one or both legs. The most serious compression disorder in the spinal cord is a condition called the cauda equine syndrome. The cauda equine is an area in the spinal cord where nerve roots of all spinal nerves are located. Cauda equine syndrome is a serious condition that may cause loss of all nerve function below the area of compression, which can cause loss of bladder and bowel control. Such a condition is a surgical emergency and immediate decompression is required without delay.
Typically, conservative medical therapy is attempted for the treatment of a herniated disc. Surgery should be considered when recurrent attacks of pain cause interference with work or daily activities. The decision for surgery is indicated for chronic cases and should be made jointly between the patient and surgeon. Severe deficit can cause patients to have loss of nerve function, causing movement deficits in affected areas. Back pain is more common in men than women and more common in Caucasians than among other racial groups. Back pain results in more lost work than any other medical condition or disability. As a disorder, back pain has been documented through the ages since the first discussions date more than 3,500 years ago in ancient Egyptian writings.
Laminectomy as a procedure is not exclusive to a herniated disc. Laminectomy is used for metastatic tumor invasion of the spinal cord (which causes compression), and for narrowing of the spinal cord (a condition called spinal stenosis.)
In the United States, approximately 450 cases of herniated disc per 100,000 require surgery. Men are two times more likely to have back surgery as women and the average age for surgery is 40–45 years. More than 95% of all laminectomies are performed on the fourth and fifth lumbar vertebrae (lumbar laminectomy). Back pain is ranked second (behind the common cold) among the leading causes of missed workdays. Approximately one in five Americans, typically 45–64 years of age, will experience back pain. Each year, an estimated 13 million people will see their primary care practitioner for chronic back pain. Approximately 2.4 million Americans are chronically disabled from back pain, and another 2.4 million are temporarily disabled.
Description of surgical procedure
Typically, the patient is placed in the kneeling position to reduce abdominal weight on the spine. The surgeon makes a straight incision over the affected vertebrae (can be anywhere in the spinal cord) extending to the bony arches of the vertebrae (lamina.) The surgical goal is to completely expose the involved nerve root. To expose the nerve root(s), the surgeon removes the ligament joining the vertebrae along all or part of the lamina. The nerve root is pulled back toward the center of the spinal column, and all or part of the disc is removed. Muscle is placed to protect the nerve root(s) and the incision is closed.
Preparation
Weeks before surgery, the surgeon (a neurosurgeon or orthopedic spine surgeon) will make a general medical assessment and establish fitness for surgery. Days before the procedure, an assessment with the anesthesiologist is necessary to discuss anesthetic options during surgery: whether to use general or spinal anesthesia. A careful history should include information about all prescription and over-the-counter (OTC) medications. Anti-inflammatory agents such as aspirin or ibuprofen (Advil, Motrin) should be stopped several days before surgery. If the patient smokes, smoking should stop at least several days before surgery. Typically, imaging studies such as x rays or magnetic resonance imaging (MRI), heart tracing studies (ECG), and routine blood work are performed before surgery. No food is permitted after midnight before surgery.
Anyone undergoing surgery that lasts more than two hours may be at risk of developing a blood clot, and administering heparin (an anticoagulant) may reduce the possibility of this complication. If heparin is administered to a patient receiving laminectomy, careful monitoring and blood tests are necessary to ensure that the blood is not excessively thinned, which can cause bleeding.
Aftercare
During recovery, patients will lie on a side or supine (back). There may be pain and patients will typically wear compression stockings to avoid blood-clot formation, a complication that can occur after surgery. There may be a catheter placed in the bladder to collect and measure urine output. Pain medications will be administered, and sometimes the surgeon will allow patient-controlled analgesia (PCA) with a pump that enables patients to self-deliver pain medications. Walking is encouraged hours after surgery and breathing exercises may be performed to avoid loss of air in a lung or pneumonia. It is advised to bend at the hip, not at the waist, and to avoid twisting at the shoulders or hips. The first few days after surgery may pose problems with sleeping, especially if therapeutic positions are different from normal sleeping positions. Different types of pillow positioning may be helpful (especially under the neck and knees.) To make getting out of bed easier, the patient should move the body as a unit, tighten the abdominal muscles, and roll to the side or edge of the bed and press down with arms on the bed to help raise the body while concurrently and carefully swinging legs to the floor. Typically, the surgeon will schedule an appointment with postoperative patients about one week after the procedure. At about seven days, the surgeon will remove any sutures (stitches) or staples that were placed during operation. Follow-up with the personal primary care practitioner occurs within the first month after operation.
In-home recovery
Recovery can be easier at home if patients have someone to drive for them for one or two weeks after surgery. Short, frequent walks each day may help speed recovery. Return to work is possible within one to two weeks for sedentary work, but may take more time (two to four months) if employment is strenuous with physical demands. Driving is usually not advised for one to two weeks after surgery, since postoperative medications for pain may cause drowsiness as a side effect, which can impair driving ability.
Risks
After laminectomy (postoperative), there is a risk of developing complications that can include blood clots, infection, excessive bleeding, worsening of back pain, nerve damage, or spinal fluid leak. It is possible to experience drainage at the incision site, redness at the incision area, fever (over 100.4° F), or increasing pain and numbness in arms, legs, back, or buttocks. Additionally, patients may experience inability to urinate, loss of bladder or bowel control, a severe headache, or redness, swelling, or pain in one extremity. If any of these signs or symptoms appears, patients are advised to immediately call the surgeon. If the sutures or staples come out, or if the bandage becomes soaked with blood, a call to the surgeon is necessary without delay.
Normal results
Some studies indicate that surgery provides better results than observation alone after one follow-up visit to the physician. However, other studies reveal that there is no statistical difference between conservative medical treatment or surgery 10 years after surgery.
BOOKS
Townsend, Courtney M. Sabiston Textbook of Surgery, 16th ed. New York: W. B. Saunders Co., 2001.
PERIODICALS
Petrozza, Patricia H. "Major Spine Surgery." Anesthesiology Clinics of North America 20, no. 2 (June 2002).
Spivak, Jeffery M. "Degenerative Lumbar Spinal Stenosis." The Journal of Bone and Joint Surgery 80-A: 7 (July 1998).
ORGANIZATIONS
The American Back Society. 2647 International Boulevard, Suite 401, Oakland, CA 94601. (510) 536-9929; Fax: (510) 536-1812. info@americanbacksoc.org. <http://www.americanbacksoc.org>.
