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Laminectomy

Laminectomy

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Updated September 05, 2013

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

Laminectomy – also known as decompression surgery – is the removal of part of the bony ring that forms the back of the vertebra. A laminectomy is often done when things get too crowded in your spinal canal. Other types of decompression spine surgery include foraminotomy and discectomy.

Removing the lamina frees up space around nervous tissue that is located in the canal. The roominess created by a laminectomy helps prevent contact between the nerves and/or spinal cord, and nearby spinal structures such as bones and ligaments. (As we'll discuss below, this type of contact often translates to pressure on the nerves and/or spinal cord. Such pressure can lead to pain and other unpleasant sensations, especially down your leg.) After a laminectomy, the reduced (or eliminated) contact between structures in the spinal canal may lead to a reduction or elimination of your symptoms.

Laminectomy for Spinal Stenosis

Most of the time, laminectomies are given to help mitigate the symptoms of spinal stenosis.

Stenosis is a general medical term meaning “narrowing”. Spinal stenosis refers to narrowing in the spaces that are created by interconnecting spinal bones. (Although there are other spinal spaces - most notably the foramen, where the nerves exit the spinal cord and begin to make their way to outlying areas of the body - a laminectomy will address the narrowing that is located at the spinal canal.)

Related: Intervertebral Foramen

Stenosis may occur as a result of bone spurs and arthritis, or it may be due to thickened ligaments (or both). Either way, when you have stenosis, your nervous tissue does not have enough room to adapt to the movements of your spine without bumping into something (so to speak). As we've already discussed, this can cause debilitating pain.

Sometimes the most bothersome stenosis symptoms are not back pain, but pain and other sensations in your leg. This is because the nerves in your leg actually start in the spine. When a spinal nerve is compressed by adjacent spinal structures, it can respond by sending signals that your brain interprets as leg or buttock pain.

Many doctors recommend laminectomy to their patients with moderate to severe lumbar spinal stenosis.

But Dr. Ali Bydon, Associate Professor of Neurosurgery and Clinic Director of Spine Surgery at Johns Hopkins Bayview Medical Center says the decision to have a laminectomy should be based on your symptoms, rather than the results of your x-ray, CT scan or MRI. "If a patient has severe lumbar stenosis but little to no symptoms, surgery may not be indicated."

Dr. Neel Anand, Clinical Professor of Surgery and Director of Spine Trauma at Cedars-Sinai in Los Angeles says "the indication for surgery is not the extent of the stenosis but rather the extent of its symptoms, and the effect those symptoms have on quality of life." He adds that surgery is not indicated unless you've first tried non-operative methods, and they haven’t worked.

Bydon informs me that surgery may be appropriate if you have neurogenic claudication (i.e. buttock and leg pain when walking), walking with a forward lean or bend, tingling down your legs and pain down your legs when sleeping and your films show evidence of moderate to severe stenosis or compression of the thecal sac or nerve roots.

Related: Neurogenic Claudication.

While most of the time spinal stenosis arises from age related degenerative changes in bones, joints and ligaments, other causes can include tumors, disease, trauma to the spine and/or a genetically (congenital) small spinal canal.

Other reasons for having a laminectomy, Bydon says, include spinal tumors and cysts requiring resection, spinal trauma, insertion of a spinal cord stimulator and more.

Laminectomy - Will You Have A Fusion With That?

Spinal stenosis tops the list of reasons why seniors and the elderly have surgery, according to a 2010 study published in JAMA entitled “Trends, Major Medical Complications, and Charges Associated with Surgery for Lumbar Spinal Stenosis in Older Adults”.

The study, authored by Deyo and associates, also says that this population (ie advanced age combined with a diagnosis of spinal stenosis) is the one in which the use of lumbar spinal surgery is growing the fastest.

Until recently, a laminectomy, also called simple decompression, was pretty much the only surgical choice for stenosis. While laminectomies are still used extensively to treat spinal stenosis, advances in technology and changes in the business climate have led to the use of fusion to help address the condition.

”A fusion is done to fix unstable or diseased joints in the back, or when the joints are thought to be generating the pain,” Bydon says.

Deyo’s study divided stenosis surgery into 3 main categories and measured several outcomes associated with each. The 3 categories were: Decompression alone, a "simple" fusion and a "complex" fusion.

A simple fusion involves only 1 or 2 disc levels and requires only one incision, according to the study.

A complex fusion surgery is back surgery that addresses more than 2 disc levels and/or where the surgeon cuts into the spine both from the front of your body as well as from the from the back.

The study found that complex fusion surgery is risky – about three times more for life threatening complications.

According to the study, in the first 30 days following the procedure about twice as many complex fusion surgery patients had to be readmitted to the hospital than those who underwent a simple decompression procedure.

And the complex spinal fusion was almost 4 times as expensive, the study found.

While Bydon does not encourage distinguishing between "simple" and "complex" fusions, he does provide some insight as to when fusions are added to laminectomies.

In general, he says, "a decompressive laminectomy is performed if one has little to no back pain but predominantly buttock and leg pain."

”Fusion is added if one has significant back pain (in addition to buttock and leg pain), significant instability, malalignment of vertebrae (spondylolisthesis), underlying pars defect (spondylolysis), or if the planned decompression will be wide enough to destabilize the patient afterwards.”

Bydon says that fusions are also added in cases of disc herniation.

The Deyo study reports that for surgery done to relieve pain, spine experts really don't agree on which procedure does the best job. This is so even though some high quality studies looking at outcomes for specific surgical procedure-spine condition combinations have been done.

Deyo comments that the surgeons' preferences for one procedure over another can override patient selection factors such as age, medical status and patient preference – not necessarily a good thing for the patient.

But both Bydon and Anand say that age does not have to be a barrier to pain relief for stenois.

Bydon runs a spinal outcomes laboratory at Johns Hopkins. Researchers there are currently looking at a large national database to find out how 80-year-olds do when they are fused – as compared to other age groups. The preliminary data, he says, is very interesting: "There is no increased mortality or morbidity in patients who undergo fusion in their 80s compared to other age groups."

"Chronological age is not as much a factor as physiological age," Anand comments. In other words, a healthy 80 year old may make a better candidate for a laminectomy than a sick 60 year old.”

Sources:

Dr. Neel Anand, clinical professor of surgery and director of spine trauma at Cedars-Sinai Spine Center in Los Angeles

Bydon, A., MD, Associate Professor of Neurosurgery, Director of Neurosurgical Medical Student Education, Director of Neurosurgical Undergraduate Education, the director of Spinal Biomechanics and Spinal Outcomes Laboratory and the Clinic Director of Spine Surgery at Johns Hopkins Bayview Medical Center.

Richard A. Deyo, MD, MPH; Sohail K. Mirza, MD, MPH; Brook I. Martin, MPH; William Kreuter, MPA; David C. Goodman, MD, MS; Jeffrey G. Jarvik, MD, MPH. Trends, Major Medical Complications, and Charges Associated With Surgery for Lumbar Spinal Stenosis in Older Adults. April 7, 2010, Vol 303, No. 13.

Weinstein JN, Tosteson TD, Lurie JD, et al. Surgical versus nonsurgical therapy for lumbar spinal stenosis. N Engl J Med. 2008;358:794-810.

Diagnosis and treatment of degenerative lumbar spinal stenosis: technical report. Burr Ridge, IL: North American Spine Society, 2011. 184 p. Electronic copies: Available in Portable Document Format (PDF) from the North American Spine Society (NASS)

Hormuzdiyar H. Dasenbrock, M.D.,1 Stephen P. Juraschek, B.A. Lonni R. Schultz, Ph.D.,5 Timothy F. Witham, M.D. The efficacy of minimally invasive discectomy compared with open discectomy: a meta-analysis of prospective randomized controlled trials. Daniel M. Sciubba, M.D. J Neurosurg Spine 16:452–462, 2012.

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