Lumbar Laminectomy

Back pain can grow progressively worse and more disabling, depending on the cause. At some point, your doctor may suggest surgery. The lumbar laminectomy may be one procedure. Despite medical breakthroughs, back pain has been a common problem through the centuries with no simple solutions.

• Facts about back pain
  
  
  • Back pain results in more lost work productivity than any other medical condition. It is the second leading cause of missed workdays (behind the common cold).
    
    
  • In their lifetime, 70% of people in the United States will have some kind of back pain. Each year 1 person in 5 will have it.
    
    
  • Back pain is more common in men than women.
    
    
  • Back pain is more common among whites than among other racial groups.
    
    
  • Most back pain occurs among people aged 45–64 years.
    
    
  • Each year 13 million people go to the doctor for chronic back pain. It is estimated that the condition leaves 2.4 million Americans chronically disabled and another 2.4 million temporarily disabled.
    
    
  • Discussion of back pain has been found on Egyptian papyrus dating 3500 years ago. As the centuries went by, thousands of physicians have discussed it and recommended treatments for it.
  
  
• Back pain that can lead to surgery
  
  
  • The most common site of back pain is in the lower back. The National Center for Health Statistics states 14% of all new visits to doctors are for low back pain.
    
    
  • About 25% of people who have back pain have a herniated disk, called sciatica, because the problem once was believed to stem from pressure on the sciatic nerve. Sciatica causes pain to radiate through your buttocks into 1 or both legs.
    
    
  • A disk acts as a shock absorber for your spine. It is made up of a tough outer ring of cartilage with an inner sac filled with a jellylike substance. When a disk herniates, the jellylike nucleus pushes through the harder outer ring (annulus), putting pressure on the nerve root.
    
    
  • A herniated disk can cause varying degrees of pain. The most serious problem is cauda equina syndrome, compression at the point where roots of all the spinal nerves are located.
    
    
    • People may lose all nerve function below the area of compression, including loss of bowel and bladder control.
      
      
    • This condition is a true surgical emergency requiring immediate decompression if you are to preserve bowel and bladder function. The longer the delay, the less recovery can be expected.
  
  
• Surgery for back pain
  
  
  • As with other back pain, doctors first attempt conservative medical treatment for a herniated disc. But surgery often produces gratifying relief.
    
    
  • Surgery may be considered for anyone with frequently recurring sciatica, usually if the pain interferes with your ability to work or do daily activities.
    
    
  • Doctors decide to perform surgery, however, only after they have tried a variety of treatments. Doctors usually reserve surgery for chronic sciatica. In general, most medical sources do not recommend considering surgery in acute sciatica. The decision to have surgery should be a joint decision you make with your doctor.
    
    
  • Another indication for surgery is a progressive loss of nerve function. For example, you may lose a certain reflex and later begin to lose strength gradually.
    
    • Far more commonly, people go to a doctor with an acute lack of nerve function.
      
      
    • Usually these function losses are minor and may come and go. They respond well to medical treatment.
      
      
    • If the deficit is severe—you cannot bend a knee or move a foot—surgery is an option.
      
      
    • Many people may not regain full nerve function, however.
  
  
• In the US, some 450 cases of herniated disk per 100,000 require surgery.
  
  
  • The average age for surgery is 40-45 years.
    
    
  • Men are twice as likely to need surgery as women.
    
    
  • More than 95% of disk operations are performed on the fourth and fifth lumbar vertebrae.
  
  
• Types of surgery: Doctors perform 3 common surgeries on your back to relieve nerve root compression. They often are done in combination with each other.
  
  
  • Laminotomy - Removal of part of the lamina above and below an affected nerve
    
    
  • Laminectomy - Removal of most of the bony arch, or lamina, of a vertebra (Laminectomy is most often done when back pain fails to improve with more conservative medical treatment.)
    
    
  • Discectomy – Removal or partial removal of a spinal disk

All operations have risks. Complications occur rarely, but include the following:

• Nerve damage



• Blood clots



• Spinal fluid leak



• Bleeding



• Infection



• Worsening of the back pain

• Weeks before your surgery is scheduled, both your doctor and a neurosurgeon or orthopedic surgeon will examine you to make sure you are healthy enough for the surgery.
  
  
• A few days before the surgery, you will meet with the anesthesiologist to discuss your options. Usually you will have either a general anesthesia or spinal anesthesia.
  
  
  • You should give the surgeon and anesthesiologist a list of all prescriptions and over-the-counter medications you are taking.
    
    
  • The doctor may instruct you to stop taking anti-inflammatories such as aspirin and ibuprofen (Advil, Motrin) before surgery.
    
    
  • If you smoke, you should stop or at least cut down before surgery.
  
  
• Imaging tests such as x-rays and MRIs will be done. Many hospitals and surgeons require other tests such as ECGs (a heart tracing) and routine blood work before surgery.
  
  
• On the day of surgery, take no food or drink by mouth after midnight. Most surgeons do allow you to brush your teeth and take medicine.
  
  
• You should arrive at the hospital about 2 hours early to do paperwork, last-minute tests, and prepare for the surgery.

• Usually you will be placed in a kneeling position to reduce the weight of your abdomen on your spine.
  
  
  • The surgeon will make a straight incision over the desired vertebrae and down to the lamina, the bony arches of your vertebrae.
    
    
  • The doctor removes the ligament joining the vertebrae along with all or part of the lamina. The goal is to see the involved nerve root.
    
    
  • The doctor pulls the nerve root back toward the center of your spinal column and removes the disk or part of the disk.
    
    
  • The doctor closes the incision. Your large back muscle now protects your spine or nerve roots.
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• The surgery takes 1-3 hours. You lose very little blood.

• Recovery: You will be moved to a recovery area until you are fully awake, and then you will return to your hospital room.
  
  
  • Normally you will lie on your side or back.
    
    
  • You may have a catheter in your bladder.
    
    
  • You should expect to have some pain at first. Nurses will provide pain medicine as needed.
    
    
  • You likely will wear compression stockings or compression boots to reduce the chance of blood clots.
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• Hospital room: Once you return to your hospital room, nurses will check your vital signs and help with pain control.
  
  
  • Depending on the surgeon’s preferences and your needs, you may be given pain medicine orally or by IV injection.
    
    
  • The medication will not make you pain free, but it should make the pain tolerable.
    
    
  • Sometimes the surgeon will give you a machine that allows you to provide pain medicine as needed, within certain limits. Patient controlled analgesia (PCA) pumps allow you a little more control over managing your pain.
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• Walking: Normally you will begin to walk within hours of the surgery. To avoid loss of air in a lung or pneumonia, you may be asked to do a variety of breathing exercises.
  
  
• Protection while moving: A few simple techniques will help reduce post-surgical pain and injury. The goal is to protect your back.
  
  
  • Tighten your abdominal muscles to help support your spine. Stand up straight, keeping your ears, shoulders, and hips in a straight line.
    
    
  • Always bend at the hip and not at the waist. Move your body as a unit and do not twist at the hips or shoulders.
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• Sleeping and getting in and out of bed: You may have difficulty sleeping for the first few nights, especially if the recommended positions are different from your normal sleeping positions. Some options include the following:
  
  
  • Sleep on your back with pillows under your neck and your knees.
    
    
  • Lie on your side with your knees slightly bent and a pillow between your knees.
    
    
  • Getting out of bed also can be tricky initially, but with some simple techniques you can minimize possible injury or pain.
    
    
  • Tighten your abdominal muscles and roll on to your side, making sure to move your body as a unit.
    
    
  • Scoot to the edge of the bed and press down with your arms to raise your body. As you raise your body, gently swing your legs to the floor.
    
    
  • Place one foot behind the other, tighten your abdominal muscles, and raise your body with your legs.
    
    
  • To get into bed, back up to the edge of the bed, tighten your abdominal muscles, and lower yourself into bed with your legs.
    
    
  • Once sitting on the bed, use your arms to lower your body onto the bed while you lift your feet into bed.
    
    
  • Roll your body as one unit onto your back.

• Most surgeons prefer to see you about 1 week after your operation to make sure the incision is healing well and that you are not having any postoperative complications.
  
  
• If stitches or staples were used, the doctor usually will take them out at this time.
  
  
• Most surgeons like to do a more comprehensive follow up in 4-8 weeks.
  
  
• Often, your personal doctor also wants to see you during the first month after surgery.

• Call your surgeon or doctor if you have any of these symptoms:
  
  
  • Drainage from the incision
    
    
  • Redness at the incision
    
    
  • If stitches or staples come out
    
    
  • The bandage becomes soaked with blood
    
    
  • Fever over 100.4°F
    
    
  • Increasing pain or numbness in your legs, back, or buttocks
    
    
  • Inability to urinate
    
    
  • Loss of control of bladder or bowels, with loss of urine or stool, or both
    
    
  • Pain, swelling, or redness in one of your legs
    
    
  • A severe headache
    
    
  • If you have any other questions about the way you are recovering
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• Go to the hospital's emergency department immediately if you develop any of these conditions:
  
  
  • Sudden shortness of breath, which may or may not be accompanied by pain in the chest. This could be a sign of pulmonary embolism (blood clot in lungs), pneumonia, or other heart and lung problems.
    
    
  • If you lose control of your bowel or bladder, or if you are unable to urinate
    
    
  • If you are unable to move your legs (This is a serious sign of spinal cord or nerve compression.)

• You can do several things to make your recovery at home easier.
  
  
  • Move groceries, toiletries, and other supplies to places between the level of your hip and shoulder where you can reach them without bending over.
    
    
  • Make sure someone can drive you around for 1-2 weeks after surgery and to help with chores and errands.
    
    
  • Buy a pair of slip-on shoes with closed backs to make dressing easier and to minimize bending over.
    
    
  • Short frequent walks each day may reduce your pain as well as speed your recovery.
  
  
• Normally, if you have a sedentary job, you may return to work in 1-2 weeks. A person with a more strenuous job may have to remain off work for 2-4 months.
  
  
• As your back heals, you may feel ready to have sex. This is normally fine. Choose a position that puts as little pressure on your back as possible.
  
  
  • Side positions or lying on your back are generally acceptable.
    
    
  • Avoid putting pressure on your back or arching your back during sex.
  
  
• Do not drive a car for 1-2 weeks, or as long as you are taking any medication that makes you drowsy.

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Author: Bryan Sleigh, MD, Assistant Professor of Emergency Medicine, Medical College of Georgia; Consulting Staff, Department of Emergency Medicine, Dwight David Eisenhower Army Medical Center.

Coauthor(s): Ibrahim El Nihum, MD, Chief, Section of Pediatric Neurosurgery, Assistant Professor, Department of Surgery, Division of Neurological Surgery, Texas A&M University College of Medicine.

Editors: Joseph A Salomone III, MD, Associate Professor, Department of Emergency Medicine, Truman Medical Center, University of Missouri at Kansas City School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Richard Harrigan, MD, Associate Professor, Department of Emergency Medicine, Temple University Hospital, Temple University School of Medicine.