Bilateral Laminectomy means both sides of the lamina of the affected vertebra are removed with or without widening of the intervertebral foramina and/or removal of adjacent tissue and bone.
Lumbar laminectomy continues to be one of the most common lumbar procedures performed for spinal stenosis. Currently, there are several techniques to accomplish posterior spinal decompression, such as open or minimally invasive laminectomy, hemilaminectomy, laminotomies, and laminoplasty. Decompression techniques classify as direct and indirect; direct procedures involve those techniques with visualization of the dural sac during the surgery such as laminectomy. On the other hand, indirect decompression takes place without dural sac visualization. Laminectomy alone or associated with fusion is one of the most common procedures performed by a spinal surgeon.[rx]
A laminectomy is a surgical procedure that removes a portion of the vertebral bone called the lamina, which is the roof of the spinal canal. It is a major spine operation with residual scar tissue and may result in postlaminectomy syndrome. Depending on the problem, smaller alternatives, e.g., small endoscopic procedures, without bone removal, may be possible.[rx]
Types of Laminectomy
Depending on the amount of lamina removed or the technique used to relieve neural compression, a lumbar laminectomy can be of the following types:
- Bilateral laminectomy – Both sides of the lamina of the affected vertebra are removed with or without widening of the intervertebral foramina and/or removal of adjacent tissue and bone.
- Unilateral laminotomy – A part of or the entire lamina on one side of the affected vertebra is removed with or without adjacent tissues.
- A cervical laminectomy – is the removal of the lamina in the neck area (cervical spine).
- Lumbar laminectomy – is the removal of the lamina in the lower back (lumbar spine).
- Sacral laminectomy – is the removal of the lamina in the back between your pelvic, or hip bones (sacral spine).
- Thoracic laminectomy – is the removal of the lamina in the middle part of the back (thoracic spine).
Anatomy and Physiology
To understand the principles of laminectomy, proper knowledge of the posterior vertebral arch and laminae anatomy are imperative.
The laminae belong to the posterior vertebral arch, extended medially from the base of the spinous process to the junction between the superior and inferior facet joints, acting as a stabilization structure of the spine in association with the facet joint and also as a spinal cord and nerve root protective layer. The laminae general anatomy consists of a superior and inferior border, an anterior surface in contact with the medullary canal and a posterior surface that serves as erector spinae muscles attachment. The shape and thickness of the laminae vary according to the anatomical region. Laminar height tends to decrease from C2 to C4 and then increases towards a peak at T8. From T9 to L4 tends to decrease in height and increases in length having at L5 the lowest lumbar height, on the other hand, from cervical to lumbar, laminae width decreases progressively up to the narrowest at T4 in the thoracic region and then increase steadily to reach the widest at L5.
Regarding the thickness, it increases from cervical to lumbar regions.[rx]
A better understanding of the laminae anatomy in different regions of the spine may improve surgery success and avoid iatrogenic complications such as nerve root or spinal cord injury.
Indications of Bilateral Laminectomy
The main indication for laminectomy is the presence of
- Spinal canal stenosis, narrowing of the spinal canal has multiples etiologies such as congenital, metabolic, traumatic, or tumoral, however, degenerative stenosis is the most common cause. Spinal stenosis can also be classified according to Wiltse in central stenosis, lateral recess, foraminal and extraforaminal stenosis.[rx] Also, Lee et al. classified the lateral region into three zones of nerve root compression: entrance zone (lateral recess), mid zone (foraminal region) and exit zone (extraforaminal region) in order to clarify anatomy and surgical strategy.[rx] Laminectomy is especially effective for the treatment of central and lateral recess stenosis.
- Central stenosis is the most common, and the main symptom is neurogenic claudication, which includes pain, tingling, or cramping sensation in the lower extremity. On the other hand, lateral recess, foraminal and extraforaminal stenosis may cause radiculopathy, patients with central stenosis may experience more symptoms in a standing position and during walking, and pain is usually relieved with leaning forward or in a sitting position. In cases of central stenosis, straight leg raising and femoral nerve stretching test are usually normal.
- When symptoms derived from stenosis do not respond to conservative treatment, surgical management such as decompression with or without fusion is usually a consideration.
- Fusion techniques are required when stenosis is associated with spinal instability, degenerative or isthmic spondylolisthesis, kyphosis, or scoliosis, as laminectomy alone may increase the risk of spinal instability in these conditions.[rx] However, in cases of low-grade degenerative spondylolisthesis, the literature exhibits variable results regarding the risk of instability after laminectomy alone, some studies support fusion in cases of degenerative spondylolisthesis.[rx] On the other hand, Wang et al. in a recent meta-analysis found no increased risk of instability after laminectomy, especially in patients without predominant symptoms of mechanical back pain and after minimally invasive procedures.[rx]
- Other important indications for laminectomy are primary or secondary tumors, infection (peridural abscesses), trauma (fractures that compromise the spinal canal), and stenosis associated with the deformity.
- Bone spurs, abnormal growths of bone on a vertebra, which can lead to compression of the spinal cord and nerves
- Degenerative disc disease, a breakdown of the cushioning discs between the vertebrae, which can lead to compression of the spinal cord and nerves
- Herniated spinal disc, displacement of the cushioning disc between the vertebrae
- Sciatica, pain that runs down the buttock and leg due to compression of a nerve in the lower back
- Spinal stenosis, a narrowing of the spinal column causing pressure on the spinal cord and nerves
- Spondylosis also called spinal osteoarthritis, is caused by wear and tear on the discs in your spine
Contraindications of Bilateral Laminectomy
Spinal instability (is a contraindication for laminectomy without associated fusion technique)
Degenerative or isthmic spondylolisthesis (relative contraindication)
Severe scoliosis (relative contraindication)
Severe kyphosis (relative contraindication)
Standard radiolucent table with spinal frames and foams pads
C-arm to localize level and minimize skin size incision
Laminectomy instrument set (bone cutting rongeurs, high-speed burr, Kerrison rongeurs, forceps, ball tip, angled spatula spreader, bayonet-shaped curettes, hollow probes, tubular retractors and dilators for MIS approaches)
No additional Staff OR personnel is required; usually, one or two spinal surgeons, registered nurse staff, and anesthesiologist.
Neuromonitoring is usually a recommendation in cervical or dorsal laminectomies, and lumbar cases when there is an increased risk of nerve injury.
Laminectomy is performed with the patient in the prone position on a support frame with foam pads for nipples and ASIS (anterior superior iliac crest spine) leaving the abdomen free, avoiding abdominal pressure decreases epidural venous pressure and therefore, surgical site bleeding.
Arms are positioned at 90 degrees abduction and flexion to prevent axillary nerve injury
Laminectomy can be performed through a traditional open approach or with a minimally invasive technique.
The traditional open approach requires a posterior midline incision (3 to 4 cm in length for single level), subperiosteal dissection along spinous processes to detach and retract paraspinous muscles from the spinous processes medially to the lateral laminar border avoiding damage of the facet joint. Spinous processes may be resected along with dorsal laminae to expose ligamentum flavum with bone cutting rongeur or a burr, resection of ligamentum flavum is possible with Woodson elevator and spatula, medial facetectomies can be performed to decompress the lateral recess, and foraminal region can is reachable with Kerrison rongeurs. Use of a ball tip or angled probe help to assess foraminal size. Great care is necessary to avoid damage to pars interarticularis and more than 50% of the facet joint to decrease the risk of instability. The decompression procedure is usually complete upon confirmation of the dural sac, exiting and descending nerve roots.
Minimally Invasive Surgical (MIS) techniques include laminotomy and microendoscopic laminotomy with tubular retractors. Contemporary literature supports these procedures resulting in better preservation of posterior musculature, decreased intraoperative bleeding, and postoperative pain.[rx][rx]
Even though MIS approaches may have some early outcome advantages over open procedures, the economic value and cost-effectiveness of MIS require further investigation.
A recent systematic review compared conventional laminectomy with three different techniques that avoid the removal of the spinous process (unilateral laminotomy, bilateral laminotomy and split spinous process laminotomy). A decreased postoperative back pain for bilateral laminotomy and split spinous laminotomy was found, however, there were no observable clinically significant differences. Further, there was no difference in terms of hospital length of stay, operative time, and complications of these techniques compared to conventional laminectomy.[rx]
How do I get ready for a laminectomy?
- Your healthcare provider will explain the surgery to you and offer you the chance to ask any questions that you might have about the procedure.
- You will be asked to sign a consent form that gives your permission to do the surgery. Read the form carefully and ask questions if something is not clear.
- In addition to complete health history, your healthcare provider may do a physical exam to make sure that you are in good health before undergoing the procedure. You may have blood tests or other diagnostic tests.
- Tell your healthcare provider if you are sensitive to or are allergic to any medicines, latex, tape, and anesthesia medicines (local and general).
- Tell your healthcare provider of all prescribed and over-the-counter medicines and herbal supplements that you are taking.
- Tell your healthcare provider if you have a history of bleeding disorders or if you are taking any blood-thinning (anticoagulant) medicines, aspirin, or other medicines that affect blood clotting. You may be told to stop these medicines before the procedure.
- If you are pregnant or think you could be, tell your healthcare provider.
- Follow any directions you are given for not eating or drinking before the surgery.
- You may get a sedative before the surgery to help you relax.
- You may meet with a physical therapist before your surgery to discuss rehabilitation.
- Certain activities may be limited after your surgery. Arrange for someone to help you for a few days with the household activities and driving.
- Based on your health condition, your healthcare provider may have other instructions for you.
Before Your Laminectomy
Before your laminectomy, you should receive detailed instructions on how to prepare from your surgeon’s staff during one of your office visits. Here’s what you should do and plan for before the surgery:
- Don’t eat or drink anything after midnight the night before your laminectomy.
- Wear loose, comfortable clothing. Don’t wear jewelry, especially necklaces or bracelets.
- Bring your insurance information and your pocketbook for any co-payments or required paperwork.
- If your doctor thinks you might be able to go home the same day, bring someone to drive you home and help take care of you.
- Plan for being slow for a while. Stock up on groceries and take care of all the errands and housekeeping you can.
- Let friends and family know you’ll be having surgery; you’ll be able to use extra help during your recovery.
What happens during a laminectomy?
A laminectomy usually requires a stay in a hospital. Procedures may vary depending on your condition and your doctor’s practices.
A laminectomy may be done while you are asleep under general anesthesia. Or it may be done while you are awake under spinal anesthesia. If spinal anesthesia is used, you will have no feeling from your waist down. Newer techniques are being developed that may allow a laminectomy to be done under local anesthesia as an outpatient. Your doctor will discuss this with you in advance.
Generally, a laminectomy follows this process:
- You’ll be provided a private area to change into a loose-fitting medical gown.
- You’ll wait in a “pre-op” area on a stretcher or bed. Your surgeon, your anesthesiologist, or the anesthesiologist’s assistant will visit you and examine you.
- When everyone is ready, you’ll be transported to the operating room.
- You will be asked to remove clothing and will be given a gown to wear.
- An IV (intravenous) line may be started in your arm or hand.
- Once you are under anesthesia, a urinary drainage catheter may be inserted.
- If the surgical site is covered with extra hair, the hair may be clipped off.
- You will be positioned either on your side or belly on the operating table.
- The anesthesiologist will continuously watch your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
- The healthcare staff will clean the skin over the surgical site with an antiseptic solution.
- The surgeon will make a cut (incision) over the selected vertebra.
- The surgeon will spread the muscles apart.
- The surgeon removes the bony arch of the posterior part of the vertebra (lamina) to ease the pressure on the nerves in the area. This may involve removing bone spurs or growths, or removing all or part of a disk.
- In some cases, spinal fusion may be done at the same time. During a spinal fusion, the surgeon will connect 2 or more bones in your spine.
- The incision will be closed with stitches or surgical staples.
- A sterile bandage or dressing will be applied.
What happens after a laminectomy?
In the hospital
After the surgery, you will be taken to the recovery room for observation. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room. Laminectomy usually requires that you stay in the hospital one or more days.
You will most likely start getting out of bed and walking the evening of your surgery. Your pain will be controlled with medicines so that you can take part in the exercise. You may be given an exercise plan to follow both in the hospital and after discharge.
Once you are at home, it’s important to keep the surgical incision area clean and dry. Your healthcare provider will give you specific bathing instructions. The surgical staples or stitches are removed during a follow-up office visit.
Take a pain reliever for soreness as recommended by your healthcare provider. Aspirin or certain other pain medicines may increase the chance of bleeding. Be sure to take only recommended medicines.
Tell your healthcare provider about any of the following:
- Redness, swelling, bleeding, or another drainage from the incision site
- Increased pain around the incision site
- Numbness in your legs, back, or buttocks
- Trouble urinating or loss of control of your bladder or bowel
Don’t drive until your healthcare provider tells you it’s OK. Don’t bend over to pick up objects or arch your back. Your provider may tell you to limit other activities.
Your healthcare provider may give you other instructions after the procedure, depending on your particular situation.
- Take pain medication as directed by your surgeon. Narcotics can be addictive and are used for a limited period of time.
- Narcotics can also cause constipation. Drink lots of water and eat high-fiber foods. Laxatives and stool softeners such as Dulcolax, Senokot, Colace, and Milk of Magnesia are available without a prescription.
- Ice your incision 3-4 times per day for 15-20 minutes to reduce pain and swelling.
- Avoid bending, lifting or twisting your back for the next 2 weeks.
- Do not lift anything heavier than 5 pounds for 2 weeks after surgery.
- No strenuous activity for the next 2 weeks including yard work, housework and sex.
- Do not drive for 2 weeks after surgery or until discussed with your surgeon.
- Do not drink alcohol for 2 weeks after surgery or while you are taking narcotic medication.
- If you have had a fusion, do not use non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve) for six months after surgery. NSAIDs may cause bleeding and interfere with bone healing.
- Do not smoke, vape, dip, chew or use nicotine products. It delays healing and prevents new bone growth.
- You may need help with daily activities (dressing, bathing) for the first few weeks. Fatigue is common. Let pain be your guide.
- Get up and walk 5-10 minutes every 3-4 hours. Gradually increase your walking time, as you are able.
- If you were given a brace, where it at all times unless you are sleeping or showering.
- Wash your hands thoroughly before and after cleaning your incision to prevent infection.
- If you have Dermabond (skin glue) covering the incision, you may shower the day after surgery. Gently wash with soap and water. Pat dry.
- If you have staples or steri-strips, you may shower 2 days after surgery. Remove the dressing and gently wash with soap and water. Pat dry. Replace dressing if there is drainage.
- Do not submerge or soak the incision in water (bath, pool or tub).
- Do not apply lotions or ointments to incision.
- Some drainage from the incision is normal. A large amount of drainage, foul smelling drainage, or drainage that is yellow or green should be reported to your surgeon’s office.
- Staples or steri-strips will be removed at your follow-up appointment.
Before you agree to the test or the procedure make sure you know:
- The name of the test or procedure>/li>
- The reason you are having the test or procedure
- What results to expect and what they mean
- The risks and benefits of the test or procedure
- What the possible side effects or complications are
- When and where you are to have the test or procedure
- Who will do the test or procedure and what that person’s qualifications are
- What would happen if you did not have the test or procedure
- Any alternative tests or procedures to think about
- When and how will you get the results
- Who to call after the test or procedure if you have questions or problems
- How much will you have to pay for the test or procedure
Laminectomy is a relatively safe procedure, with a low complication rate. Related-technique complications are associated with the underlying structures covered by the laminae, being the dural sac tear and nerve roots injury the most commons. These complications occur more often in elderly patients due to the fragility of the dural sac. Also, the severity of compression could be a factor that increases the rate of a dural tear; the most common risk factor for dural tear is the reoperation due to the presence of scar tissue.[rx]
Cerebrospinal fluid (CSF) leak from dural sac tear may cause dizziness, painful orthostatic headache, or thunderclap headache. Nonsurgical management of CSF leaks includes bed rest, caffeine, or acetazolamide to alleviate symptoms. Surgical intervention with direct dura mater repair or dural patching can be performed in cases of tear injury when it is feasible.
Reports exist of surgically induced spinal instability, especially when laminectomy was compared with unilateral laminotomy and in cases of extensive posterior laminectomy.[rx][rx] This complication is avoidable by preserving the pars interarticularis and at least two-thirds of lumbar or fifty percent of cervical facet joints.[rx]
Postoperative wound infection and wound dehiscence are other complications to consider, the presence of wound erythema, increased pain or swelling may raise the suspicion of wound infection.
THE SPECIFIC RISKS INCLUDE (BUT ARE NOT LIMITED TO):
- Fail to benefit symptoms or to prevent deterioration
- Worsening of pain/weakness/numbness
- A blood clot in wound requiring urgent surgery to relieve pressure
- Cerebrospinal fluid (CSF) leak
- Surgery at the incorrect level (this is rare, as X-rays are used during surgery to confirm the level)
- Blood transfusion
- Implant failure, movement, or malposition (when a fusion is also done)
- Recurrent disc prolapse or nerve compression
- Nerve damage (weakness, numbness, pain) occurs in less than 1%
- Quadriplegia (paralyzed arms and legs)
- Incontinence (loss of bowel/bladder control)
- Impotence (loss of erections)
- Chronic pain
- Instability or forward collapse of the neck (kyphosis) (may require further surgery)
- Stroke (loss of movement, speech etc)
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