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Spine Surgeries


Laminectomy for Lumbar Spine

A laminectomy is a surgical procedure in which the surgeon removes a portion of the bony arch, or lamina, on the dorsal surface of a vertebra, which is one of the bones that make up the human spinal column. It is done to relieve back pain that has not been helped by more conservative treatments. In most cases a laminectomy is an elective procedure rather than emergency surgery . A laminectomy for relief of pain in the lower back is called a lumbar laminectomy or an open decompression.

Purpose

Structure of the spine

In order to understand why removal of a piece of bone from the arch of a vertebra relieves pain, it is helpful to have a brief description of the structure of the spinal column and the vertebrae themselves. In humans, the spine comprises 33 vertebrae, some of which are fused together. There are seven vertebrae in the cervical (neck) part of the spine; 12 vertebrae in the thoracic (chest) region; five in the lumbar (lower back) region; five vertebrae that are fused to form the sacrum; and four vertebrae that are fused to form the coccyx, or tail-bone. It is the vertebrae in the lumbar portion of the spine that are most likely to be affected by the disorders that cause back pain.

The 24 vertebrae that are not fused are stacked vertically in an S-shaped column that extends from the tail-bone below the waist up to the back of the head. This column is held in alignment by ligaments, cartilage, and muscles. About half the weight of a person's body is carried by the spinal column itself and the other half by the muscles and ligaments that hold the spine in alignment. The bony arches of the laminae on each vertebra form a canal that contains and protects the spinal cord. The spinal cord extends from the base of the brain to the upper part of the lumbar spine, where it ends in a collection of nerve fibers known as the cauda equina, which is a Latin phrase meaning "horse's tail." Other nerves branching out from the spinal cord pass through openings formed by adjoining vertebrae. These openings are known as foramina (singular, foramen).

Between each vertebra is a disk that serves to cushion the vertebrae when a person bends, stretches, or twists the spinal column. The disks also keep the foramina between the vertebrae open so that the spinal nerves can pass through without being pinched or damaged. As people age, the intervertebral disks begin to lose moisture and break down, which reduces the size of the foramina between the vertebrae. In addition, bone spurs may form inside the vertebrae and cause the spinal canal itself to become narrower. Either of these processes can compress the spinal nerves, leading to pain, tingling sensations, or weakness in the lower back and legs. A lumbar laminectomy relieves pressure on the spinal nerves by removing the disk, piece of bone, tumor, or other structure that is causing the compression.

 Causes of lower back pain

The disks and vertebrae in the lower back are particularly vulnerable to the effects of aging and daily wear and tear because they bear the full weight of the upper body, even when one is sitting quietly in a chair. When a person bends forward, 50% of the motion occurs at the hips, but the remaining 50% involves the lumbar spine. The force exerted in bending is not evenly divided among the five lumbar vertebrae; the segments between the third and fourth lumbar vertebrae (L3-L4) and the fourth and fifth (L4-L5) are most likely to break down over time. More than 95% of spinal disk operations are performed on the fourth and fifth lumbar vertebrae.

Specific symptoms and disorders that affect the lower back include:

  • Sciatica. Sciatica refers to sudden pain felt as radiating from the lower back through the buttocks and down the back of one leg. The pain, which may be experienced as weakness in the leg, a tingling feeling, or a "pins and needles" sensation, runs along the course of the sciatic nerve. Sciatica is a common symptom of a herniated disk.
  • Spinal stenosis. Spinal stenosis is a disorder that results from the narrowing of the spinal canal surrounding the spinal cord and eventually compressing the cord. It may result from hereditary factors, from the effects of aging, or from changes in the pattern of blood flow to the lower back. Spinal stenosis is sometimes difficult to diagnose because its early symptoms can be caused by a number of other conditions and because the patient usually has no history of back problems or recent injuries. Imaging studies may be necessary for accurate diagnosis.
  • Cauda equina syndrome (CES). Cauda equina syndrome is a rare disorder caused when a ruptured disk, bone fracture, or spinal stenosis put intense pressure on the cauda equina, the collection of spinal nerve roots at the lower end of the spinal cord. CES may be triggered by a fall, automobile accident, or penetrating gunshot injury. It is characterized by loss of sensation or altered sensation in the legs, buttocks, or feet; pain, numbness, or weakness in one or both legs; difficulty walking; or loss of control over bladder and bowel functions. Cauda equina syndrome is a medical emergency requiring immediate treatment . If the pressure on the nerves in the cauda equina is not relieved quickly, permanent paralysis and loss of bladder or bowel control may result.
  • Herniated disk. The disks between the vertebrae in the spine consist of a fibrous outer part called the annulus and a softer inner nucleus. A disk is said to herniate when the nucleus ruptures and is forced through the outer annulus into the spaces between the vertebrae. The material that is forced out may put pressure on the nerve roots or compress the spinal cord itself. In other cases, the chemicals leaking from the ruptured nucleus may irritate or inflame the spinal nerves. More than 80% of herniated disks affect the spinal nerves associated with the L5 vertebra or the first sacral vertebra.
  • Osteoarthritis (OA). OA is a disorder in which the cartilage in the hips, knees, and other joints gradually breaks down, allowing the surfaces of the bones to rub directly against each other. In the spine, OA may result in thickening of the ligaments surrounding the spinal column. As the ligaments increase in size, they may begin to compress the spinal cord.

Factors that increase a person's risk of developing pain in the lower back include:

  • Hereditary factors. Some people are born with relatively narrow spinal canals and may develop spinal stenosis fairly early in life.
  • Sex. Men are at greater risk of lower back problems than women, in part because they carry a greater proportion of their total body weight in the upper body.
  • Age. The intervertebral disks tend to lose their moisture content and become thinner as people get older.
  • Occupation. Jobs that require long periods of driving (long-distance trucking; bus, taxi, or limousine operation) are hard on the lower back because of vibrations from the road surface transmitted upward to the spine. Occupations that require heavy lifting (nursing, child care, construction work, airplane maintenance) put extra stress on the lumbar vertebrae. Other high-risk occupations include professional sports, professional dance, assembly line work, foundry work, mining, and mail or package delivery.
  • Lifestyle. Wearing high-heeled shoes, carrying heavy briefcases or shoulder bags on one side of the body, or sitting for long periods of time in one position can all throw the spine out of alignment.
  • Obesity. Being overweight, particularly if the extra pounds are concentrated in the abdomen, adds to the strain on the muscles and ligaments that support the spinal column.

Trauma. Injuries to the back from contact sports, falls, criminal assaults, or automobile accidents may lead to misalignment of the vertebrae or a ruptured disk. Traumatic injuries may also trigger the onset of cauda equina syndrome.

Description

A laminectomy is performed with the patient under general anesthesia, usually positioned lying on the side or stomach. The surgeon begins by making a small straight incision over the damaged vertebra.

The surgeon next uses a retractor to spread apart the muscles and fatty tissue overlying the spine. When the laminae have been reached, the surgeon cuts away part of the bony arch in order to expose the ligamentum flavum, which is a band of yellow tissue attached to the vertebra that helps to support the spinal column and closes in the spaces between the vertebral arches. The surgeon then cuts an opening in the ligamentum flavum in order to reach the spinal canal and expose the compressed nerve. At this point the cause of the compression (herniated disk, tumor, bone spur, or a fragment of the disk that has separated from the remainder) will be visible.

Bone spurs, if any, are removed in order to enlarge the foramina and the spinal canal. If the disk is herniated, the surgeon uses the retractor to move the compressed nerve aside and removes as much of the disk as necessary to relieve pressure on the nerve. The space that was occupied by the disk will be filled eventually by new connective tissue.

If necessary, a spinal fusion is performed to stabilize the patient's lower back. A small piece of bone taken from the hip is grafted onto the spine and attached with metal screws or plates to support the lumbar vertebrae.

Following completion of the spinal fusion, the surgeon closes the incision in layers, using different types of sutures for the muscles, connective tissues, and skin. The entire procedure takes one to three hours.

Laminectomy

Diagnosis/Preparation

Diagnosis

The differential diagnosis of lower back pain is complicated by the number of possible causes and the patient's reaction to the discomfort. In many cases the patient's perception of back pain is influenced by poor-quality sleep or emotional issues related to occupation or family matters. A primary care doctor will begin by taking a careful medical and occupational history, asking about the onset of the pain as well as its location and other characteristics. Back pain associated with the lumbar spine very often affects the patient's ability to move, and the muscles overlying the affected vertebrae may feel sore or tight. Pain resulting from heavy lifting usually begins within 24 hours of the overexertion. Most patients who do not have a history of chronic pain in the lower back feel better after 48 hours of bed rest with pain medication and either a heating pad or ice pack to relax muscle spasms.

If the patient's pain is not helped by rest and other conservative treatments, he or she will be referred to an orthopedic surgeon for a more detailed evaluation. An orthopedic evaluation includes a physical examination , neurological workup, and imaging studies. In the physical examination, the doctor will ask the patient to sit, stand, or walk in order to see how these functions are affected by the pain. The patient may be asked to cough or to lie on a table and lift each leg in turn without bending the knee, as these maneuvers can help to diagnose nerve root disorders. The doctor will also palpate (feel) the patient's spinal column and the overlying muscles and ligaments to determine the external location of any tender spots, bruises, thickening of the ligaments, or other structural abnormalities. The neurological workup will focus on the patient's reflexes and the spinal nerves that affect the functioning of the legs. Imaging studies for lower back pain typically include an x ray study and CT scan of the lower spine, which will reveal bone deformities, narrowing of the intervertebral disks, and loss of cartilage. An MRI may be ordered if spinal stenosis is suspected. In some cases the doctor may order a myelogram, which is an x ray or CT scan of the lumbar spine performed after a special dye has been injected into the spinal fluid.

Lower back pain is one of several common general medical conditions that require the doctor to assess the possibility that the patient has a concurrent psychiatric disorder. Such diagnoses as somatization disorder or pain disorder do not mean that the patient's physical symptoms are imaginary or that they should not receive surgical or medical treatment. Rather, a psychiatric diagnosis indicates that the patient is allowing the back pain to become the central focus of life or responding to it in other problematic ways. Some researchers in Europe as well as North America think that the frequency of lower back problems in workers' disability claims reflect emotional dissatisfaction with work as well as physical stresses related to specific jobs.

Preparation

Most hospitals require patients to have the following tests before a laminectomy: a complete physical examination; complete blood count (CBC) ; an electrocardiogram (EKG); a urine test; and tests that measure the speed of blood clotting.

Aspirin and arthritis medications should be discontinued seven to 10 days before a laminectomy because they thin the blood and affect clotting time. Patients should provide the surgeon and anesthesiologist with a complete list of all medications, including over-the-counter and herbal preparations, that they take on a regular basis.

The patient is asked to stop smoking at least a week before surgery and to take nothing by mouth after midnight before the procedure.

Aftercare following a laminectomy begins in the hospital. Most patients will remain in the hospital for one to three days after the procedure. During this period the patient will be given fluids and antibiotic medications intravenously to prevent infection. Medications for pain will be given every three to four hours, or through a device known as a PCA (patient-controlled anesthesia). The PCA is a small pump that delivers a dose of medication into the IV when the patient pushes a button. To get the lungs back to normal functioning, a respiratory therapist will ask the patient to do some simple breathing exercises and begin walking within several hours of surgery.

Aftercare during the hospital stay is also intended to lower the risk of a venous thromboembolism (VTE), or blood clot in the deep veins of the leg. Prevention of VTE involves medications to thin the blood and wearing compression stockings or boots.

Most surgeons prefer to see patients one week after surgery to remove stitches and check for any postoperative complications. Patients should not drive or return to work before their checkup. A second follow-up examination is usually done four to eight weeks after the laminectomy.

Patients can help speed their recovery by taking short walks on a daily basis; avoiding sitting or standing in the same position for long periods of time; taking brief naps during the day; and sleeping on the stomach or the side. They may take a daily bath or shower without needing to cover the incision. The incision should be carefully patted dry, however, rather than rubbed.



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