What is a lumbar laminectomy?
A lumbar laminectomy is a procedure to remove bone as well as thickened ligaments between those bones to decompress the nerves running through the lumbar spinal canal. This a common neurosurgical operation.
What are the parts of the lumbar spine?
What are the indications for lumbar laminectomy?
The most common indication for a lumbar laminectomy is narrowing of the spinal canal, that is, lumbar canal stenosis. Stenosis occurs most commonly due to a combination of degenerative changes, such as the disc bulging and over-growth of the ligaments in the lumbar spine, and arthritis of the facet joints. Some people have a congenitally narrow spinal canal, which means that they are born with a narrow spinal canal. They are therefore more likely to develop spinal stenosis due to degenerative change. A laminectomy may also be performed to access the spinal canal to remove a large disc, a tumour, or other pathologies.
The most common symptom of lumbar spinal stenosis is termed neurogenic claudication. This means pain, pins and needles, or numbness that occurs in one or both leg. This typically occurs from standing in the one spot, or walking for a distance. The distance may become shorter and shorter over time, until the symptoms occur even at rest; which is a concerning sign. The symptoms of neurogenic claudication are usually relieved by sitting for a period before the person can stand or walk for a similar distance again. This responds very well to surgery.
In some cases, spinal stenosis affects only one nerve in particular, in which case it causes a ‘pinched nerve’ or radiculopathy. This type of pain is commonly referred to as sciatica.
If lumbar stenosis is more severe, it may cause a condition known as cauda equina syndrome which is where multiple nerve roots in the lumbar spine are compressed so as to cause weakness of the lower limbs, numbness in the areas around the perineum, (that is the anus and genitals), as well as bladder and bowel dysfunction and incontinence. If this occurs it requires urgent neurosurgical treatment.
How is a lumbar laminectomy performed?
The operation is performed under a general anaesthetic with the patient positioned face down on a specialised operating table. An x-ray is performed to ensure the incision is made directly above the level of the disc protrusion. The incision is marked and the skin prepared with antimicrobial solution.
An incision is made and the muscle dissected off the back of the spine so as to expose the lamina. The lamina at the appropriate level or levels is removed along with any overgrown ligaments that may also be compressing the nerves. The facet joints on each side are preserved but the area underneath the edge of these joints, a common side for nerve impingement is also cleared. Once the nerve roots are satisfactorily decompressed then wound is irrigated. A drain may be left in the wound particularly is multiple levels are involved. The wound is then sutured closed with dissolving sutures.
When the operation is complete the patient will be woken from the anaesthetic and taken to the recovery room. After a short period of observation, the patient is taken to the normal ward for the remainder of their hospital stay. A wound drain is not normally used but patients will have an intravenous cannula (‘a drip’) for 24 hours through which they will receive fluids and antibiotics. Patients are mobilised with the physiotherapists following the surgery.
What are the risks of surgery?
While lumbar laminectomy is a safe and common spinal operation performed, all surgery caries risk. There are risks common to all surgeries such as infection, bleeding, deep vein thrombosis (DVT), pulmonary embolism and those associated with a general anaesthetic.
The spinal cord is normally well clear of the site of the surgery. In the lower lumbar spine, the spinal cord has changed into a group of nerve roots called the cauda equina. While patients commonly worry about complications such as paraplegia and incontinence, such problems would be extremely rare. More common is the chance of injuring one nerve root at the site of the surgery and the risk of this is less than 1% and may result in numbness or weakness of the leg which may be permanent.
The covering of the nerve roots called the dura not only contains the nerves but also spinal fluid. Occasionally the dura can be torn, particularly if the stenosis is tight or if there is any pre-existing scar tissue. This can result in a CSF leak. The tear is normally repaired and a drain is more commonly left in the wound for some extra time. Very rarely, is a leak continues then more sutures may be required.
Occasionally patients will experience persistent back pain after surgery. This is usually due to existing arthritis and other degenerative changes. It can sometimes be treated with further surgery but that is unusual.
There are numerous other very rare complications that may also occur including those associated with a general anaesthetic such as reactions to medication, visual loss, discitis, i.e., a deep-seated infection of the disc space.
How long is the hospital stay?
The hospital stay is normally around 3-4 days in total, but varies depending on the patient and their underlying condition. During the hospital stay, the patient receives daily physiotherapy. Patients will receive prophylactic subcutaneous heparin injections and are required to wear stockings to prevent DVTs.
After surgery, there is normally some discomfort and analgesia is provided. However, the amount of analgesia required is usually small. Constipation is a common complaint after surgery and is usually due to analgesics. You should inform staff if this becomes an issue.
How do I care for the wound after surgery?
The wound is normally cleaned and the dressing changed each day. After discharge no dressing is required. You may shower and then pat the wound dry with a clean towel afterwards. While the wound may get wet, do not soak it in the bath or in a pool for at least 2 weeks after the surgery. Do not rub the wound. If there are any concerns such as excessive redness, pain or ooze then you should have your GP review the wound as the first step.
What should I do at home after surgery?
After discharge, it is advisable to rest for 2 weeks which should consist of normal daily activities. One should maintain a good posture as advised by the physiotherapists, for example, you should not slouch in a chair. You should not spend too long in any one position. Once you feel more confident then activities such as driving can resume. Normally one can drive after 2 weeks from the date of surgery. A return to work depends on the work environment. Those with sedentary jobs can usually begin to go back to work after 2-4 weeks. Those with more physical jobs should wait at least 6 weeks but it should be discussed with Prof Owler.
What are the physical restrictions after lumbar laminectomy?
The main physical restriction relates to lifting. For the first 2 weeks, there should be no lifting but this can be slowly increased after that period to weights <5Kg for another 4 weeks. Patients are then able to lift weights <10Kg until 3 months post-operatively. Generally, no-one should be lifting weights >20Kg even after 3 months but this needs to be balanced against the patients’ occupation and normal activities.
Patients are encouraged to walk and undertake gentle exercise from around 2 weeks after surgery. This is gradually increased after surgery depending on how the patient feels. Exercise should be non-impact for the first 3 months. Therefore, activities such as running should not be undertaken until after that time.
When do I follow-up with Prof Owler after surgery?
We will normally make an appointment for you to see Prof Owler 6 weeks from the date of surgery or thereabouts. At that visit any concerns can be discussed and the wound will be checked. If there are any significant problems, then you should contact our office earlier.
What are the expected outcomes from lumbar laminectomy?
Leg pain in the form of radiculopathy or neurogenic claudication is usually the first symptom to improve; often immediately after the surgery. Pins and needles may take longer but tend to improve quickly.
Numbness takes the longest period to recover, perhaps even over 12 months and some patients may not experience full recovery of numbness.
Weakness has variable recovery depending on severity and duration before surgery. Some patients will experience recovery immediately while others may have persistent weakness despite the surgery. Normally physiotherapy is required to treat weakness.
Overall, about 90% of patients will experience significant improvement in pre-operative symptoms while a further 10% will not improve as much as is hoped and 1-2% percentage will be worse off in relation pain or some other problem. No guarantees can be given in relation to the surgery.
What on-going care do I need for my spine after surgery?
Prof Owler’s philosophy is to attempt to return the patient to a normal active life rather than place onerous restrictions on the patient. However, there are two aspects of spinal care that are important to patients that have undergone surgery.
The first, and somewhat obvious, advice is to avoid activities that may reinjure the spine. In the simplest form this includes not lifting heavy or awkward objects. As a general rule, no-one should generally be lifting weights above 20Kg. In the short term the lifting restrictions are much less (see above). When lifting, good technique should be used such as keeping the knees bent and back straight while keeping the object being lifted close to the body.
People should avoid simultaneous lifting and twisting. Lifting and twisting is the most common mechanism of injury to lumbar discs. Those who are golf enthusiasts should wait 3 months after surgery before resuming golf.
The second aspect to long-term care is maintaining spinal fitness. This includes weight loss, core strengthening and on-going exercise. The best exercises are those which are non-impact such as swimming and cycling.