Narrowing of the spinal canal, a condition called spinal stenosis can cause chronic pain, numbness, and muscle weakness in your arms or legs (Fig. 1). The condition primarily afflicts elderly people and is caused by degenerative changes that result in enlargement of the facet joints and thickening of the ligaments. Constriction of the spinal cord and nerves may be effectively relieved with a spinal decompression procedure if your symptoms have not improved with physical therapy or medications. This surgery requires a hospital stay from 1 to 3 days and recovery takes between 4 to 6 weeks.
What is spinal decompression?
Spinal decompression can be performed anywhere along the spine from the neck (cervical) to the lower back (lumbar). The procedure is performed through a surgical incision in the back (posterior).The lamina is the bone that forms the backside of the spinal canal and makes a roof over the spinal cord. Removing the lamina and other soft tissues gives more room for the nerves and allows for removal of bone spurs. Depending on the extent of stenosis, one vertebra (single-level) or more (multi-level) may be involved.
There are several types of decompression surgery : -
Laminectomy is the removal of the entire bony lamina, a portion of the enlarged facet joints, and the thickened ligaments overlying the spinal cord and nerves.
Laminotomy is the removal of a small portion of the lamina and ligaments, usually on one side. Using this method the natural support of the lamina is left in place, decreasing the chance of postoperative spinal instability. Sometimes an endoscope may be used, allowing for a smaller, less invasive incision.
Foraminotomy is the removal of bone around the neural foramen - the space between vertebrae where the nerve root exits the spinal canal. This method is used when disc degeneration has caused the height of the foramen to collapse, resulting in a pinched nerve. It can be performed with a laminectomy or laminotomy.
Laminaplasty is the expansion of the spinal canal by cutting the laminae on one side and swinging them open like a door. It is used only in the cervical area.
In some cases, spinal fusion may be done at the same time to help stabilize sections of the spine treated with laminectomy. Fusion uses a combination of bone graft, screws, and rods to connect two separate vertebrae together into one new piece of bone. Fusing the joint prevents the spinal stenosis from recurring and can help eliminate pain from an unstable spine.
Am I a candidate?
You may be a candidate for decompression if you have : -
significant pain, weakness, or numbness in your leg or foot.
leg pain worse than back pain.
not improved with physical therapy or medication.
difficulty walking or standing that affects your quality of life.
diagnostic tests (MRI, CT, myelogram) that show stenosis in the central canal or lateral recess.
The surgical decision
Decompression surgery for spinal stenosis is elective, except in the rare instance of cauda equina syndrome or rapidly progressing neurologic deficits.Your doctor may recommend treatment options, but only you can decide whether surgery is right for you. Be sure to look at all the risks and benefits before making a decision. Decompression does not cure spinal stenosis nor eliminate arthritis; it only relieves some of the symptoms. Unfortunately, the symptoms may recur as the degenerative process that produces stenosis continues.
Who performs the procedure ?
A neurosurgeon or an orthopedic surgeon can perform spine surgery. Many spine surgeons have specialized training in complex spine surgery. Ask your surgeon about their training, especially if your case is complex or you've had more than one spinal surgery.
What happens before surgery ?
You may be scheduled for presurgical tests (e.g., blood test, electrocardiogram, chest X-ray) several days before surgery. In the doctors office you will sign consent forms and fill out paperwork so that the surgeon knows your medical history (allergies, medicines/vitamins, bleeding history, anesthesia reactions, previous surgeries). You may wish to donate blood several weeks before surgery. You should stop taking all non-steroidal anti-inflammatory medicines (Naprosyn, Advil, Motrin, Nuprin, Aleve, etc.) and blood thinners (coumadin, aspirin, etc.) one week before surgery. Additionally, stop smoking, chewing tobacco, and drinking alcohol one week before and 2 weeks after surgery as these activities can cause bleeding problems.
Patients are admitted to the hospital the morning of the procedure. No food or drink is permitted past midnight the night before surgery. An intravenous (IV) line is placed in your arm. An anesthesiologist will explain the effects of anesthesia and its risks.
What happens during surgery?
There are seven steps of the procedure. The operation generally lasts 1 to 3 hours.
Step 1 : - Prepare the patient
You will lie on your back on the operative table and be given anesthesia. Once asleep you will be rolled over onto your stomach with your chest and sides supported by pillows. The area where the surgery is to be performed will be cleansed and prepped. If a fusion is planned and you have decided to use your own bone, the hip area will be cleansed and prepped to obtain a bone graft. If you've decided to use donor bone, a hip incision is unnecessary.
Step 2 : - Incision
A skin incision is made down the middle of your back over the appropriate vertebrae (Fig. 2). The length of the incision depends on how many laminectomies are to be performed. The strong back muscles are split down the middle and moved to either side exposing the lamina of each vertebra.
Step 3 : - Laminectomy or laminotomy
Once the bone is exposed, an X-ray is taken to verify the correct vertebra.
Laminectomy : - The surgeon removes the bony spinous process. Next, the bony lamina is removed with a drill or bone-biting tools. The thickened ligamentum flavum that connects the laminae of the vertebra below with the vertebra above is removed (Fig. 3). This is repeated for each affected vertebrae.
Laminotomy : - In some cases, the surgeon may not want to remove the entire protective bony lamina. A small opening of the lamina above and below the spinal nerve may be enough to relieve compression (Fig. 4). Laminotomy can be done on one side (unilateral) or both sides (bilateral) and on multiple vertebrae levels.
Step 4 : - Decompress the spinal cord
Once the lamina and ligamentum flavum are removed the protective covering of the spinal cord (dura mater) is visible. The surgeon can gently retract the protective sac of the spinal cord and nerve root to remove bone spurs and thickened ligament.
Step 5 : - Decompress the spinal nerve
The facet joints, which are directly over the nerve roots, may be undercut (trimmed) to give the nerve roots more room (Fig 5). Called a foraminotomy, this maneuver enlarges the neural foramen (where the spinal nerves exit the spinal canal). If a herniated disc is causing compression the surgeon will perform a discectomy.
Step 6 : - Fusion (if necessary)
If you have spinal instability or have laminectomies to multiple vertebrae, a fusion may be performed. Fusion is the joining of two vertebrae with a bone graft held together with hardware such as plates, rods, hooks, pedicle screws, or cages. The goal of the bone graft is to join the vertebrae above and below to form one solid piece of bone.There are several ways to create a fusion. The right one for you depends on your own choice and your doctor's recommendation.
The most common type of fusion is called the posterolateral fusion. The topmost layer of bone on the transverse processes is removed with a drill to create a bed for the bone graft to grow. Bone graft, taken from the top of your hip, is placed along the posterolateral bed. The surgeon may reinforce the fusion with metal rods and screws inserted into the vertebrae. The back muscles are laid over the bone graft to hold it in place.
Step 7 : - Closure
The muscle and skin incisions are sewn together with sutures or staples.
What happens after surgery ?
You will wake up in the postoperative recovery area, called the PACU. Your blood pressure, heart rate, and respiration will be monitored, and yourpain will be addressed. Once awake you will be moved to a regular roomwhere you'll increase your activity level (sitting in a chair, walking).If you've had a fusion, a brace may need to be worn. In 1 to 2 days you'll be released from the hospital and given discharge instructions.
Discharge instructions : -
Discomfort
After surgery, pain is managed with narcotic medication. Because narcotic pain pills are addictive, they are used for a limited period (4 to 8 weeks). Their regular use may also cause constipation, so drink lots of water and eat high fiber foods. Laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) can be bought without a prescription. Thereafter, pain is managed with acetaminophen (e.g., Tylenol).
Restrictions
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 drive for 2 to 4 weeks after surgery or until discussed with your surgeon.
Avoid sitting for long periods of time.
Do not lift anything heavier than 10 pounds (e.g., gallon of milk). Do not bend or twist at the waist.
Housework and yard-work are not permitted until the first follow-up office visit. This includes gardening, mowing, vacuuming, ironing, and loading/unloading the dishwasher, washer, or dryer.
Postpone sexual activity until your follow-up appointment unless your surgeon specifies otherwise.
Do not smoke. Smoking delays healing by increasing the risk of complications (e.g., infection) and inhibits the bones' ability to fuse.
Activity
You may need help with daily activities (e.g., dressing, bathing) for the first few weeks. Fatigue is common. Let pain be your guide.
Gradually return to your normal activities. Walking is encouraged; start with a short distance and gradually increase to 1 to 2 miles daily. A physical therapy program may be recommended.
If applicable, know how to wear the brace before you leave the hospital. Wear for daily activities (excluding sleep) unless instructed otherwise.
Bathing/Incision Care
You may shower 4 days after surgery unless instructed otherwise.
Staples or stitches, which remain in place when you go home, will need to be removed. Ask your surgeon or call the office to find out when.
When to Call Your Doctor
If your temperature exceeds 101° F or if the incision begins to separate or show signs of infection, such as redness, swelling, pain, or drainage.
What are the results ?
Decompressive laminectomy is successful in relieving leg pain in 70% of patients allowing significant improvement in function (ability to perform normal daily activities) and markedly reduced level of pain and discomfort [1]. However, back pain may not be relieved and 17% of older adults need another operation Symptoms may return after a few years.
Decompressive laminotomy is successful in relieving back pain (72%) and leg pain (86%), and in improving walking ability (88%). Endoscopic laminotomy results in less blood loss, shorter hospital stay, and less postoperative pain medication than an open laminotomy.
The results of the surgery are largely up to you. It is important to keep a positive attitude and diligently perform your physical therapy exercises. Maintaining a weight that is appropriate for your height can significantly reduce pain. Do not expect your back to be as good as new. You need to be mindful that you'll always have a bad back and will need to use correct posture and lifting techniques to avoid re-injury.
What are the risks?
Spine surgery is a serious procedure and should be treated as such. If spinal fusion is done at the same time as a laminectomy, you will have a greater risk of complications, because fusion is a lengthy procedure.
The following are risks that should be considered : -
Vertebrae failing to fuse : -
There are many reasons why vertebrae fail to fuse. These include smoking, osteoporosis, obesity, and malnutrition. Smoking is by far the greatest factor that can keep a fusion from occurring, and it is the factor most under your control. Nicotine is a toxin that inhibits bone-growing cells. Smoking after the surgery can undermine the fusion process.
Anesthesia : -
A very small number of people experience complications with the anesthesia medication that puts them to sleep.
Deep vein thrombosis : -
Deep vein thrombosis (DVT) is a potentially serious condition in which blood clots form inside the veins of your legs because your body is trying to stop the bleeding after surgery. The clots may break free and travel to your lungs, causing collapse or even death.
There are several ways to treat or prevent DVT. If your blood is moving it is less likely to clot, so an effective treatment is getting you out of bed as soon as possible. Support hose and pulsatile stockings keep the blood from pooling in the veins. Drugs such as aspirin, Heparin, Lovenox, or Coumadin are also commonly used.
Lung problems : -
Your lungs need to be working their best after surgery to provide your tissues with enough oxygen to heal. If they have collapsed areas, then mucus and bacteria can build up providing an environment for pneumonia to develop. Your nurse will encourage you to breath deeply and cough often.
Nerve damage : -
Any operation on the spine comes with the risk of damaging the nerves or spinal cord. Damage can cause numbness or even paralysis.
Infection : -
Tell your doctor if the wound becomes red, swollen or painful so that it can be treated with antibiotics.
Hardware fracture : -
The metal screws, rods and plates used to stabilize your spine are called "hardware." The hardware may move or break before your vertebrae are completely fused.
Implant migration : -
This is similar to a hardware fracture, but occurs when the metal frame that is stabilizing your spine moves from the correct position soon after surgery. If this happens, your doctor may need to perform a second operation.
Persistent pain : -
Be sure to go into surgery with realistic expectations about your pain. Surgery doesn't fix your pain, but allows you to return to some function. Discuss your expectations with your doctor.
Transitional syndrome : -
The vertebrae above and below a fusion take on extra stress, and they may eventually degenerate and cause pain.
Pseudo arthrosis : -
Literally means "false joint." This occurs when a fractured bone hasn't healed or when a fusion is unsuccessful. The motion between the unhealed segments can cause pain.
Figure 1. : - (top view of vertebra) The difference between a normal spinal canal (above) and one with stenosis (below). Spinal stenosis is a degenerative disease that causes narrowing of the spinal canal, enlargement of the facet joints, stiffening of the ligaments, and bony overgrowth. As the spinal canal narrows, it presses on the spinal cord and nerves, causing them to become swollen and inflamed.
Figure 2. : - A skin incision is made down the middle of your back and the muscles overlying the vertebrae are dissected off the bone and moved to the side.
Figure 3.: - A laminectomy involves removal of the entire lamina and ligament. Multiple laminae can be removed.
Figure 4.: - A laminotomy makes a small window by removing bone of the lamina above and below. The spinous process is not removed.
Figure 5.: - The enlarged facet joints are trimmed to relieve pressure on the spinal nerves.
The list of of world class Spine hospitals in India is as follows : -
For more information, medical assessment and medical quote
send your detailed medical history and medical reports
as email attachment to
Email : - info@wecareindia.com
Call: +91 9029304141 (10 am. To 8 pm. IST)
(Only for international patients seeking treatment in India)
For a detailed evaluation send patient’s medical reports / X rays / doctors notes to info@wecareindia.com
Patient Storys
Successful heart surgery at We Care India partner hospital allows Robert Clarke to live a normal life despite a rare genetic disorder We Care india helped Robert find best super specialised surgeon for his rare conditions.
Decompressive Laminectomy, Spinal Stenosis, Decompressive, Decompressive Laminectomy For, Spinal Stenosis, Laminectomy, Decompressive For, India Hospital Tour, Lumbar Spinal Stenosis, Lumbar Decompression, Decompression, Spine, Spinal Fusion, Spinal Decompression India, Decompress India, Spinal Cord India, Nerve India, Laminaplasty India, Laminectomy Removes Bone India, Decompressive Laminectomy Surgery India India, Decompressive Lumbar Laminectomy