What is Laminectomy?
The human spine is made up of 33 vertebrae out of which 24 are individual vertebrae divided into cervical, thoracic, lumbar and the remaining are fused forming the sacral and coccygeal part. The cervical and lumbar regions are clinically significant due to their prominent role in loading and flexibility of the spine, and also because these regions are more prone to trauma and degeneration. Along the sagittal axis, the spinal column is composed of comparatively flexible intervertebral discs which are the largest avascular structure of the body, interspersed between semi-rigid vertebrae. Adjacent pairs of vertebrae are interconnected via seven intervertebral ligaments. Each vertebra has two synovial joints known as facets or zygapophyseal joint that enables controlled movements along a three dimensional plane. Primary function of the spinal column is to protect the spinal cord enclosed within it, maintaining dynamic equilibrium of the body, and proportionately transfer loads.Musculoskeletal complaints account for the leading cause of long term disability. A fully instrumental surgical technique known as decompressive laminectomy was first performed by Sir William Arbuthnot Lane in 1893. In laminectomy, the affected part of the intervertebral bone i.e. lamina is removed with or without the disc material beneath the nerve root or spinal cord. This technique eases the pressure impinging on the nerve root hence enlarging the spinal space and aid in rapid healing.
Causes of degenerative spinal disorders
- Cervical spondylosis: Is caused by degenerative fragmentation of the intervertebral discs causing them to lose their water content and consequently collapse. The fragments apply undue stress on the cartilaginous end plates of the vertebral column leading to osteophyte or subperiosteal bone formation. These osteophytes project into the ventral side of the spinal canal and may impinge on the nerve tissues causing central or foraminal stenosis. Solitary spondylotic alterations at the level of cervical spine are seen in 15 to 40% of patients, whereas multiple alterations are seen in 60 to 85% of patients. Most commonly affected cervical region is the third and seventh vertebrae. This mixed group of pathologies can occur as wear and tear degeneration due to aging or as a result of repeated occupational trauma. About 10% of patients exhibit congenital anomalies such as blocked vertebrae and malformed laminae.
- Cervical spinal radiculopathy: Often termed a shard herniation, it is caused by nerve root impingement at the neural foramina. Approximately one third of the neural foramen is occupied by the nerve root along with radicular veins and arteries. The nerve root is bounded by the facet joint in the posterior region and by the immovable joints and disc in the anterior region, which makes it vulnerable to compression due to stenosis. In 21.9% of cervical spinal radiculopathy patients, the etiology is traced to a disc protrusion while 68.4% of the cases were associated with spondylosis.
- Cervical spondylotic myelopathy: It is a prominent cause of spinal cord degeneration in elderly patients. It is a multifactorial disease cause a complex interaction between genetic and environmental factors. Microinstability of the intervertebral disc caused by ossification of the posterior longitudinal ligament, leads to a cascade of reactive hyperostosis and consequent osteophyte formation causing nerve root impingement. It generally develops insidiously and leads to segmental degeneration and kyphosis of the cervical spine in the later stages.
- Cervical disc herniation: It is mostly seen affecting individuals in the fourth and fifth decades of life leading to motion segment degeneration. Primary etiology for disc herniation is aging that causes deteriorative alterations in the intervertebral disc making it susceptible to tearing and fissuring. A ‘soft herniation’ refers to a case of spontaneous resorption subsequent to disc protrusion and sequestration. A combined effect of mechanical deterioration and chemical irritation of the nerve root leads to inflammatory changes and release of growth factors causing pain.
- Lumbar spinal stenosis: Spinal stenosis is defined as any pathological narrowing of the spinal canal, its lateral recess and the intervertebral foramina that occurs predominantly due to degenerative alterations. Congenital cases are seen in association with syndromes such as Achondroplasia. Degenerative stenosis of lumbar spine is frequently encountered in elderly patients after the fifth decade of life. In 90 to 100% of patients degeneration of the intervertebral disc with osteoarthritis of the vertebral joints with or without osteophyte formation is seen. In central spinal stenosis, the yellow ligament undergoes hypertrophy in order to compensate for segmental hypermobility. Lateral recess stenosis occurs due to degenerative reduction in disc height or hypertrophy and protrusion of the articular process.
- Scoliosis: It is the most common type of spinal deformity seen in children and young adults and presents as a rotation of the vertebral bodies of at least 10 degrees. Types of scoliosis are idiopathic, neuromuscular, congenital and degenerative. Approximately 2-3% of the adolescent population is affected by idiopathic scoliosis or lordoscoliosis. Asymmetrical growth of the anterior vertebral column along the coronal plane with tethering of the posterior segment predisposes to scoliosis. Neuromuscular scoliosis or kyphoscoliosis is a severe form of scoliosis with progressive spinal deformityalong both the sagittal and coronal planes. Most of the cases of congenital scoliosis are sporadic occurring secondary to a congenital vertebral defect. Degenerative scoliosis exhibits a slow progression and is mostly seen in patients in their sixties.
- Spondylolisthesis: It is a biomechanical disorder of the entire lumbosacral junction. Spine is a two column structure comprised of an anterior segment made up of vertebral bodies and discs, and a posterior segment composed of bones and ligaments which rest on the sacrum. An ideal sacral inclination varies between 40 and 60 degrees. An abnormality in the orientation of the sacrum causes high shear forces at the lumbosacral junction predisposing to an increased risk of disc slippage.
- Juvenile Kyphosis or Scheuermann’s Disease: Classical form of the disease is seen as thoracolumbar hyperkyphosis owing to the wedging of the vertebrae developed during adolescence. The atypical form affects the lumbar region and/or the thoracolumbar junction caused by vertebral growth abnormalities with absence of wedging. Wedge shaped deformities are caused by enhanced growth of the normal parts of the vertebral column subsequent to absence of growth in the pathologic areas.
- Spinal cord malformations or spinal dysraphisms: These malformations occur due to embryological defects occurring at 2-6 weeks of intrauterine life and are generally diagnosed at birth or early infancy. Myelomeningocelewherein the spinal intradural elements protrude outside via a defect in the midline,is the most commonly encountered malformation of this group accounting for 0.6 patients per 1000 live births. Spina bifida i.e. the formation of a bony cleft in the spinousprocesshas been found to affect 17-30 % of the total population.
- Facet joint osteoarthritis: Similar to a diarthrodial joint, the facet joints are composed of a hyaline cartilage on the surface, a synovial membrane and a fibrous capsule. Degenerative changes in the facet joints lead to misalignment and predisposition to osteoarthritis. There can be a complete loss of articular cartilage in the later stages with osteophyte and bone cysts formation and bone sclerosis.
- Fractures: Cervical spine injury is one of the commonly encountered spinal injuries accounting for one third of the cases. Predominantly affected site is the C2, C6 and C7 vertebrae. The impact of motor vehicle collision can injure bone as well as adjacent soft tissues resulting in whiplash injuries. It is estimated that in the US emergency departments, neck sprain accounts for 328 out of every 100000 motor vehicle occupants. Avulsion fractures or pure ligamentous injuries lead to atlantoaxial instability and is commonly seen in rheumatoid arthritis patients.
- Tumors and inflammation: Spinal infections are predominantly seen in elderly and immunocompromised patients and is potentially life- threatening. The rich vascularity of the vertebral bodies and the valveless venous plexus with slow blood flow, increase the risk of spinal infections. Staphylococcus aureus is the frequently associated pathogen in 30-55% of the cases and Pseudomonas aeruginosa in 65% cases of drug abusers.Intradurallipomascomprise 24.1% of all spinal lipomas.The thoracic and thoracolumbar regions of the spineaccount for about 70% of the metastatic lesion whereas the lumbar and sacral regions are involved in 22% of metastses and the cervical spine in 8% of the cases. The tumors most frequently metastasizing to the spine are the tumors of the breast and lungs.
Signs & Symptoms of spinal disorders
- Predominant symptom is pain. Patients suffering from radiculopathy suffer from radicular pain i.e. pain along the dermatome. Sensory disturbances and motor weakness is seen varying on the nerve root affected.
- Patients suffering from myelopathy develop numb, clumsy and painful hands with difficulty in writing. They experience disturbance in fine motor skills and difficulty in walking.
- In case of lumbar disc herniation the patient complains of episodes of low back pain radiating to the leg on one side, numbness and weakening of the lower limbs, and inability to urinate.
- Neurological claudication is seen in cases of spinal stenosis presenting as numbness, weakness and discomfort felt in the legs on prolonged walking or standing which regresses by sitting and resting.
- A discogenic pain arising from the thoracolumbar region of the spine manifests as a low back pain which is aggravated on prolonged sitting or bending in a semi-flexed position. Such patients find sitting as the worst position caused due to disc compression.
- Spinal metastatic tumors cause an insidious, continuous and localized pain in the back which is exaggerated during rest and at night. Instability of the spinal column can cause exacerbation of pain on coughing and sneezing.
- Patients with ankylosing spondylitis experience morning stiffness and pain in the pelvic region which is decreased during movement.
- Radiographs: A reduction in spinal diameter of approximately 10mm indicates a developing spinal myelopathy. Oblique radiographs aid in the assessment of facet joint alignment, osteoarthritis of the facet joint and stenosis of the foramina.
- Magnetic Resonance Imaging (MRI): It provides an excellent tissue contrast image along multiple planes which makes it the perfect choice of non-invasive imaging modality. It has the ability to demonstrate disc herniation in 20-35% of asymptomatic patients and disc bulging in 56% of asymptomatic elderly patients. Endplate or modic changes indicative of symptomatic lumbar disc degeneration are frequently observed in MRI. Prominent MRI findings of spinal stenosis are thickening of ligamentumflavum, facet joint hypertrophy and synovial cysts with an hour glass appearance of the spinal canal.
- CT Myelography: It provides excellent imaging of bony structures such as osteophytes in relation to the nerve root and the spinal cord. Image reformations along the foraminalplane assist in preoperative planning of decompression in case of spinal stenosis. CT myelography is found to be 77.4% accurate in diagnosing disc herniations. Absolute stenosis is observed as midsagittal lumbar canal diameters of less than 10 mm while relative stenosis represents a diameter of less than 13mm.
- Injection studies: Discography and facet joint blocks can be used for the localization of the source of pain. In positive cases of disc protrusion, a nerve block has 100% sensitivity to diagnose the affected nerve root.
- Provocative discography: This technique is used to assess intervertebral disc derangement. It is a pain provocation test used to differentiate between symptomatic and asymptomatic disc degeneration. It is preferably used in patients who are potential candidates for surgery.
- Temporary stabilization: To accurately identify the unstable disc level, it is stabilized temporarily with a pantaloon cast. An external transpedicular fixator can also be used to stabilize the abnormal segements.
- Neurophysiological assessment: It can be used in situations where the clinical picture contradicts the radiological assessment, such as in ulnar nerve syndrome and carpel tunnel syndrome, in order to exclude peripheral nerve damage. Neurophysiological analysis aids surgical decision making in cases of cervical myelopathy, and also to differentiate between peripheral and radicular neural compromise.
- Urologic assessment: It is indicated is suspicious cases of caudaequina lesion presenting with subjective difficulty in voiding the bladder. Ultrasonography may also be indicated in such cases to assess urinary retention.
- Radionuclide studies: It is used to diagnose acute vertebral fractures.Skeletal scintigraphy can be used to screen for fracture in polytraumatized patients. It can be used reliably to exclude bone injuries.
- Preoperative preparation: The operative area is prepared surgically using antiseptics and disinfectants. Following administration of general anesthesia the patient is placed in a prone position.
- Incision placement: A small incision is made in skin overlying the site of the affected vertebral bone, about 1.5cm lateral to the midline. Tubular retractors along with a series of dilators are placed for retraction. Viewing under a microscope, the overlying muscles are split down and the inferior edge of the lamina along with the spinous process is exposed.
- Laminectomy: An ipsilateral laminectomy (removal of bony lamina) is performed using matchstick drill, bayonet and Kerrison punches. Subsequently laminectomy is performed on the contralateral side and the lamina along with the spinous process is removed using drill and roungers. This bilaterally exposes the ligamentumflavum i.e. the connection of laminae to the vetebrae. It functions to protect the dura during surgical intervention. The region of the epidural fat where the two parts of ligamentumflavum meet is approached with a rongeur and the ligamentumflavum is extracted. This approach reduces the risk of inadvertently injuring the dura.
- Decompression: The dura is carefully retracted and any bone spurs and osteophytes present are removed. Corresponding facet joints are reduced to provide more space to the neural structures. Adequate decompression is confirmed by clear identification of the thecal sac and the nerve root.
- Supplemental procedures: Accessory procedures can be selectively preformed such as, foraminotomy i.e. shaping the neural foramen to enlarge it and relieve the pressure on the nerve root, discectomy i.e. sectioning of the herniated disc. Adjacent vertebrae may be fused using bone grafts in case of treating for spinal instability or multiple laminectomies. Bone grafts are held in place via screws, rods or plates.
- Incision closure: The back muscles are carefully placed over the bone graft to hold it in place. The skin incision is closed with sutures or staples.
Complications associated with Laminectomy
- Dysphagia: 50% of patients may present with dysphagia in the immediate postoperative period following an anterior cervical surgery but tends to decreases to 13% at twelve months postoperatively.
- Neurologic deterioration: It can be observed in surgical interventions of the cases of thoracic disc herniations. Nerve root damage is extremely rare as surgical intervention is done well below the spinal cord termination.
- Infections: Deep wound infections are quite rare having an incidence rate of 0.6-1.1%.
- Failure of fusion: Is influenced by smoking, obesity and chronic diseases.
Risk factors associated with spinal diseases
- Frequent heavy lifting, bending and twisting
- Exposure to vibration
- Sedentary lifestyle
Am I a Good Candidate for Laminectomy?
Surgical intervention is indicated in patient who suffers from one or more of the following:persistent pain which is not relieved by non-surgical treatment for at least 6–12 weeks, a narrow spinal canal, caudaequina syndrome with severe paresis, moderate to severe claudication symptoms that significantly interference with lifestyle, severe structural alterations, one or two level disease.
Recovery time and aftercare
Patient is advised not to rotate the spine and avoid strenuous lifting for at least 10 to 15 days following surgery. Guided functional activities are advised for the initial period of 1 to 2 weeks. Patient is guided to perform light exercises such as walking for at least a few minutes daily. In case of fusion, use of non-steroidal anti-inflammatory drugs for relief of pain is prohibited as it may interfere with the healing process.
Success Rate of Laminectomy
Patient satisfaction post laminectomy has shown to vary from 57% to 81% with regard to excellent to good results. Relief of pain was recorded in 72% of cases for leg pain and 70% of cases for back pain. Walking ability was enhanced in 88% of patients.
Benefits of Laminectomy
- Relief of pain
- Arrest progression of the spinal disease
- Functional improvement in activities
- Better posture
Laminectomy may cost approximately $77000 in the US, while in India it may be performed at around half of the cost or even less depending on the number of vertebrae involved by the disease process and the complexity of the case.
Why Choose MedcureIndia?
Spinal disorders are chronic debilitating conditions causing inconvenience in the daily activities. We at MedcureIndia provide surgical relief from these diseases at cost effective rates. We offer an advanced diagnostic workup preoperatively and also assist in the postoperative rehabilitation. Our surgeons are proficient in painless and effective surgical interventions providing instant relief from pain and enabling you to resume work efficiently.
• How many days do I need to be in the hospital?
The surgical procedure may take approximately 2 to 5 hours depending on the complexity of the case. The patient might be discharged the same day or placed under observation for a day or two.
• Will I be able to resume work normally?
During the first 2 to 3 weeks the patient is advised to perform light activities and not over exert. Yet some activity is advised to prevent non-functionality of the spine. Patient is advised against any longs periods of travel, walking, bending, and lifting. Physical therapy is to be continued for several months. Complete recovery might take 4 to 5 months.
• Will I be awake during the procedure?
No, the patient is given general anesthesia and won’t feel a thing. Following the procedure there might be some pain and weakness at the operative site. Analgesics will be given to relieve the pain and the weakness will subside gradually over the weeks with improvement in functional activity.