Lumbar (low back) Laminectomy and Decompression
This procedure is one of the more common procedures performed by spine surgeons. This procedure is usually performed for patients with a diagnosis of Spinal Stenosis. In simple terms, this means that the canal which transmits the spinal nerves is so small that is placing excessive pressure on these nerves. The MRI image on the right shows this case. Normally the fluid surrounding the nerves shows up as a white structure, and the nerves as a round black structure. The image to top right is an example of a normal MRI. The white area is the fluid surrounding the neural structures. The image below it is an example of a patient with spinal stenosis. The white fluid is not visible and the neural structures are under pressure by the surrounding bony structures as well as the disc from the front. The lower image has been marked for better understanding which shows the canal and the nerves within the canal. Short explanation of the disease process and symptoms is provided here, however for a more complete explanation please refer to the link of Spinal Stenosis. Patients are usually in their 60′s or older when complaining of these symptoms. The symptoms can include pain on standing, or walking for short distances. There may be weakness, pain, or numbness, however the majority of patients complain of inability to walk for more than one or two blocks.
The basic principle of the operation is to remove bone from the back of the spine in order to create more space for the nerves passing by. The creation of room in the spinal canal is referred to as decompression. The word Laminectomy simply means the removal of the area of bone we call the Lamina. Several segments may be compressing the nerves and these areas could be visualized by an MRI or a CT Scan. Your physician may elect to inject a dye in the spinal canal for better visualization of the canal. This procedure is called CT enhanced with a Myelogram. Depending on the clinical scenario, your physician may use one or more studies to confirm the diagnosis and present a treatment plan.
Indications for Surgery:
Patients presenting to our office will be counseled regarding conservative modalities before the suggestion of surgical correction. Several options are presented and a treatment plan is suggested which is appropriate for the specific patient. Most patients will undergo a series of conservative treatment modalities such as medication, physical therapy, and epidural steroid injections. If these modalities fail to provide relief of symptoms, operative considerations will be given and appropriate decisions are made with the patient, and family members. Patients who present with marked neurologic deficiency may elect a faster route of recovery with the appropriate surgical procedure and avoid the conservative modalities. Many other factors are considered and the combinations of all facts will determine the appropriate steps.
Patients are routinely seen by their primary care physician for a pre-operative evaluation and optimized for the surgery. Patients are instructed of details prior to the surgery. No food or drinks should be taken 12 hours prior to the operation. Diabetic patients should not take their insulin dosage if no food is taken. The intake of other medications should be discussed with your primary care physician. The anesthesiology physician will be the first physician to encounter the patients. Patients are taken to the operating room and placed on the operating table. At that time the anesthesiologist may provide medications to relax anxious patients. Once the patient is relaxed few other preparations will be made and patients are completely anesthetized.
Few patients will have many medical problems which may preclude the anesthesiologist from completely anesthetizing the patient. Your surgeon may choose to perform this operation under spinal anesthesia. With this technique, the anesthetic is injected around the spine numbing the body below the chest and waist. This technique is used with patients at medical risk of full anesthesia.
Once the patient is anesthetized, he or she is placed on the table with the back pointing upward. The skin is prepared to decrease the presence of bacteria to minimize the risk of infection. Sterile drapes are placed and skin incision is placed in the appropriate area. The dissection is performed and the muscles surrounding the bones are moved to the side. The bony elements are exposed and X-ray image is utilized to ensure the correct levels are decompressed. The bone surrounding the nerve roots is removed and the spinal canal is decompressed to create more space for the nerves of the spine. Judgment is used to remove the correct amount of bone. If too little bone is removed, the decompression may not be adequate, however, if too much bone is removed, deformity of the spine may develop. This judgment requires knowledge of anatomy, and experience to remove the right amount of bone, and decompress the neural elements to achieve the best results possible.
Cases which have deformity associated with spinal stenosis may require fusion to avoid the development of deformity or spinal curvature. Patients with scoliosis (curvature of the spine) or spondylolisthesis (slippage of one level over the other) may benefit from a fusion of the decompressed levels. Fusion may be performed with instrumentation (Screws, rods, or other implants) or without. Most surgeons tend to used instrumentation to achieve fusion in these cases.
Once the nerves are decompressed, close inspection is performed to ensure “freedom” of the nerves. The surgeon may choose to place a drain to avoid collection of blood within the wound. This drain is usually removed one or two days later. The wound is closed in layers to ensure appropriate wound healing. Skin may be closed with sutures or staples as dictated by the surgeon. Some patients may choose that their wound be closed using plastic surgery techniques for better cosmetic appearance of the wound. We accommodate such requests and hide all sutures under the skin which may result in a more cosmetically acceptable scar. Patients are then awakened and taken to the recovery. Several hours later, the patient is transported to their room. Over the next several days, the patients are seen by the physical therapy team to help rehabilitate the patient for more expedited recovery. Family support is encouraged and guidance is provided to prepare the home setting for the patient. Depending on the preoperative situation, patients may spend a few days or a few weeks in the hospital prior to discharge. Support will be provided to allow smooth transition from the hospital to home.
Once discharged, follow-up appointment should be made to see your surgeon in one or two weeks. Further assessment of progress will be made in the office and appropriate steps taken to expedite maximal recovery.