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What is a laminectomy

Surgical spinal decompression : Laminectomy

Key words: Back pain, slipped disc, spinal pain, cervical pain, lumbar pain, disc prolapsed, spondylosis, spondylolysthesis, spondylitis, lordosis, kyphosis, radicular pain, sciatic pain, numbness, reflexes, epidural injection, spinal injection, laminectomy, micro-discectomy, McKenzie technique, MRI scan, orthopaedics surgery, orthopaedic surgeon, neurosurgery.
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Laminectomy
Surgical decompression of the spine, spinal cord or spinal nerve root is a combination of procedures designed to provide surgical access to the spinal cord or relieve pressure on the cord or spinal nerve roots. Most commonly the pressure on the cord or nerve roots is caused by a prolapsed inter-vertebral disc. Traditionally an essential part of gaining access to the spinal canal involved removing the posterior element of a vertebral bone on one side (the lamina) by means of a laminectomy. This was then combined with excision of the prolapsed fragment of inter-vertebral disc or decompression of a bulging or degenerative disc.

Laminectomy is a dated and largely disused procedure. Over the course of time access was gained by smaller and smaller openings. The lamina was only partially resected and then not resected at all. This was facilitated by use of magnification or microscopes in the course of surgery with special instruments. This minimal access surgery to the spinal canal is known as micro-discectomy (see Microdiscectomy information sheet) and has largely superseded laminectomy for most standard spinal nerve decompression and for the removal of intervertebral discs. The minimal access causes minimal disruption to the surrounding structures and muscles and is associated with smaller scars but also less postoperative pain and stiffness. This commonly results in rapid mobilisation, a shorted hospital stay and faster mobilisation, return of function and return to work.

Anatomy
The anatomy of the spine and the way it works is a very complicated subject beyond the scope of this guidance.

The vertebrae are the bones which make up the spinal column. The spine is made up of seven cervical or neck vertebrae, twelve thoracic vertebrae, five lumbar vertebrae, five sacral vertebrae and four coccygeal bones.
Whilst the bones of the sacrum and coccyx are largely fused together from birth there is usually a joint between the sacrum and coccyx which may to some degree be mobile. The bones of the cervical vertebrae have the greatest degree of mobility between them and the bones can move in forward flexion and extension as well as rotation. The bones of the lumbar spine are larger and flatter in order to carry the weight of the body to the sacrum and through the hips to the legs. The movement between the lumbar vertebrae is more restricted. Rotation is limited leaving only a variable degree of forward flexion and extension. The Motion between the thoracic vertebrae is commonly thought to be very restricted but most of the rotation of the spine occurs in the thoracic region, whilst the ribs prevent a significant degree of forward flexion or extension.

The inter-vertebral discs lie between the vertebral bodies and provide some cushioning between the bones and allow for a limited degree of motion between the bones. The central area of the inter-vertebral disc is a gelatinous substance known as the nucleus pulposus. It is this which bulges or prolapses through the fibrous outer annulus fibrosus of the disc to produce a disc bulge or disc prolapse. The posterior elements of each vertebrae form a hollow ring through which the spinal cord and nerve run from the brain. The spinal cord gives off the spinal nerves which exit from the spinal canal as spinal nerve roots and emerge as peripheral nerves. The large sciatic nerve is a collection of these nerves which is the principal motor nerve supply to the legs.

At the back of the posterior elements are the small facet joints between the posterior elements of adjacent vertebrae, the posterior arch called the lamina on both sides and the dorsal spinal process. Between the lamina of adjacent vertebrae lies the elastic ligamentum flavum. Between the dorsal processes of each vertebrae lies the strong interspinus ligament and posteriorly the supraspinus ligament.

Surgical laminectomy
The operation is performed under general anaesthetic (so you are fully asleep). If the operation is performed on the neck (a cervical laminectomy), it is usually performed through a vertical cut, three or four inches long, along the middle of the neck at the back. The surgeon exposes the bones of the neck beneath the skin and a small amount of bone is clipped away, which relieves the pressure on the nerves. The operation is often combined with a closely related operation called a ‘foraminotomy’. During this operation, the bony canal through which the nerves pass as they leave the spinal cord is widened, which again relieves the pressure on the nerves. The skin is closed at the end of the operation, usually with metal clips but sometimes with stitches. An adhesive dressing is applied over the wound. Sometimes, a plastic drain is left in the wound for a few days after the operation to drain any blood that may have collected under the wound.

In the cervical spine surgery may also be undertaken through an anterior approach particularly where a spinal fusion is also undertaken. This involves a cut to the side of the neck and careful dissection down to the anterior-lateral aspect of the cervical spine.

When the procedure is performed on the neck it is most often performed for a trapped nerve. This may result from a disc prolapse from a cervical disc or result from arthritis affecting the cervical spine. When the procedure is performed on the lower back it is a lumbar laminectomy. This procedure is often performed for disk protrusions, which may occur after a major accident but also sometimes occur after a quite minor twisting injury of the lower back.

The hospital procedure
No food or drink should be consumed for six to eight hours before the procedure. A ‘pre-med’ injection may be given a few hours before the operation; this may make you drowsy and cause a dry mouth.

On arriving at the hospital, you are seen by a nurse, your surgeon and the anaethetist, who will explain the procedure to you and obtain your written consent for the operation. The anaesthetist will see you to ensure that you are medically fit for the operation. A number of tests may be performed before the operation, which may include blood tests, urine analysis and sometimes an electrical recording of the heart (electrocardiogram, ECG) and a chest X-ray.

On recovering from the anaesthetic you will feel drowsy. The aching and stiffness of the neck or back you will feel for several days is controlled with pain killing injections at first and tablets later. Usually, after cervical laminectomy you are nursed up-right in bed for the first day and not allowed to lie flat to prevent excessive build-up of fluid under the wound. If a drain has been inserted into the wound, this is usually removed after a day or two. You may be allowed out of bed one or two days after a cervical laminectomy. The period of bed rest may be less than a day if microdiscectomy was undertaken but may be a few days longer for a lumbar laminectomy. The details of the procedure may vary depending on the trating doctors and medical advice.

The average length of stay in hospital is two to three days, but this can vary somewhat, according to whether your operation was on the neck or back and on the size and exact nature of the operation performed.

The surgical wound clips or stitches may be removed while in hospital just before going home, but on occasion they will be removed after discharge from hospital by a GP or a nurse.

Neck ache, pain and stiffness often persist for several weeks after the operation, but gradually improve with time. On leaving hospital, a person may be given a supply of pain-killing tablets to take. Most people need to be off work for between one and three weeks after leaving hospital, depending on the nature of their work. Work that is physically demanding or that involves lifting heavy objects may require a longer time off.

Complications
Some degree of neck or back pain is common after this operation, but relief can be achieved with pain-killing injections or tablets. Some oozing from the wound is also common, but is not usually serious and settles spontaneously after a few days. Infection of the wound is very uncommon and can usually be treated with antibiotics. Some surgeons routinely give antibiotics before the operation to help prevent this complication from occurring. More significant complications may occur in certain circumstances and your treating doctors should advise you about this. They may on occasion include damage to the motor or sensory nerves to the limbs. This may on occasion affect the function of organs such as the diaphragm, bowel, urinary or sexual function. Chronic pain may also be a factor in certain cases. Occasionally as with other types of surgery other more general complications may occur including cardio-vascular events, strokes, heart attacks, thrombosis or other conditions. Once again you treating doctors will advise you of the risks of surgery.

© OrthopaedicsOpinionOnline 2011 www.OrthopaedicOpinionOnline.co.uk
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