Laminectomy

What is a lumbar laminectomy and rhizolysis?

A lumbar laminectomy and rhizolysis is an operation on the spine in the lower back. Its purpose is to relieve pressure on the nerve roots that leave the spine and run down to form the nerves in your legs.

The back of the spine has a bony ‘shingle’ on either side of the midline. These angled segments of bone are known as the laminae, and their purpose is to permit muscles to attach to the spine and also to protect the nerve roots. Removal of portions of these laminae is known as a ‘laminectomy’, ‘hemilaminectomy’, or ‘partial hemilaminectomy’.

By simply removing portions of the laminae, the underlying nerve roots may remain somewhat compressed. To adequately decompress the nerve root, it is often necessary to remove part of the facet joint (‘mesial facetectomy’), as well as any thickened ligament. Decompression of a nerve root is known in surgical terms as a ‘rhizolysis’.

Why might I need a lumbar laminectomy and rhizolysis?

xray for laminectomyDecompressive lumbar spine surgery may be needed for a variety of problems. Generally, surgery may be performed for degenerative disorders or disc prolapses.

A lumbar laminectomy (more commonly a partial hemilaminectomy) and rhizolysis is usually performed to treat pressure on one or more spinal nerves in the lower back. Such pressure may be caused by lumbar spondylosis (with lumbar canal, lateral recess or subarticular stenosis), an intervertebral disc prolapse, and/or foraminal stenosis.

Surgery is usually recommended when all reasonable conservative measures (pain medications, nerve sheath injections, physical therapy, hydrotherapy, pilates etc.) have failed. In cases of significant instability or neurological problems, surgery may be the appropriate first option.

What are the goals (potential benefits) of surgery?

The goals of decompressive lumbar spine surgery include the relief of pain, numbness, tingling and weakness.Potential benefits of surgery may therefore include:

  • Relief of neural compression
  • Pain alleviation Medication reduction Prevention of deterioration
  • Stabilisation of the spine (if an interspinous distractor is used)

Generally, the symptom that improves the most reliably after surgery is buttock and leg pain. Back pain may or may not improve (occasionally it can be worse). The next symptom to improve is usually weakness. Your strength may not return completely back to normal, however improvement in strength generally occurs over weeks and months. Numbness or pins and needles may or may not improve with surgery, due to the fact that the nerve fibres transmitting sensation are thinner and more vulnerable to pressure (they are more easily permanently damaged than the other nerve fibres). Numbness can take up to 12 months to improve.

The chance of obtaining a significant benefit from surgery depends upon a wide variety of factors. Your surgeon will give you an indication of the likelihood of success in your specific case.

What are the specific risks of lumbar spine surgery?

Generally, surgery is fairly safe and major complications are uncommon. The chance of a minor complication is around 3 or 4%, and the risk of a major complication is 1 or 2%. Over 90% of patients should come through their surgery without complications.The specific risks of decompressive lumbar spine surgery and interspinous distractor insertion include (but are not limited to):

  • Fail to benefit symptoms or to prevent deterioration
  • Worsening of pain/weakness/numbness
  • Infection
  • Blood clot in wound requiring urgent surgery to relieve pressure Cerebrospinal fluid (CSF) leak: this risk is much higher in revision (re- operation) surgery
  • Surgery at incorrect level (this is rare, as X-rays are used during surgery to confirm the level)
  • Blood transfusion
  • Injury to bowel or abdominal blood vessels
  • Implant failure, movement, or malposition (if an interspinous distractor is used)
  • Recurrent disc prolapse or nerve compression (the risk is around 10%) Nerve damage (weakness, numbness, pain) occurs in less than 1% Quadriplegia (paralysed arms and legs)
  • Incontinence (loss of bowel/bladder control) Impotence (loss of erections)
  • Chronic pain (may require further surgery, usually a fusion) Instability (may require further surgery, usually a fusion) Stroke (loss of movement, speech etc)
  • Blindness (extremely rare)

What are the implications of surgery?

Most patients are admitted on the same day as their surgery; however some patients are admitted the day before. Patients admitted the day before surgery include those who: reside in country regions, interstate, or overseas; have complex medical conditions or who take warfarin; require further investigations before their surgery; are first on the operating list for the day. You will be given instructions about when to stop eating and drinking before your admission.

You will be in hospital for between 1 and 3 days after your surgery. You will be given instructions about any physical restrictions that will apply following surgery, and these are summarised later in this section.

Several X-rays of your back will be taken during surgery to make sure that the correct spinal level is being fused, and also to optimise the positioning of the interspinous distractor (if this is being done). It is critical that you inform us if you are pregnant or think you could possibly be pregnant, as X-rays may be harmful to the unborn child.

There is significant variability between patients in terms of the outcome from surgery, as well as the time taken to recover. You will be given instructions about physical restrictions, as well as your return to work and resumption of recreational activities. You should not drive a motor vehicle or operate heavy machinery until instructed to do so by your surgeon.

You should not sign or witness legal documents until reviewed by your GP post- operatively, as the anaesthetic can sometimes temporarily muddle your thinking.

What do you need to tell the doctor before surgery?

It is important that you tell your surgeon if you:

  • Have blood clotting or bleeding problems
  • Have ever had blood clots in your legs (DVT or deep venous thrombosis) or lungs (pulmonary emboli)
  • Are taking aspirin, warfarin, or anything else (even some herbal supplements) that might thin your blood
  • Have high blood pressure
  • Have any allergies
  • Have any other health problems

What Can I Expect?

Before Surgery

  • You may not eat anything after midnight, the night before surgery and must cease drinking clear fluids (water, apple juice, black tea excepted) 2 hours prior to your admission time (unless otherwise instructed.) Note: However, you may continue to take your routine medications (for example, heart and blood pressure medications), on the morning of surgery with a sip of water (unless otherwise directed).  Please bring all your regular medications with you to hospital.
  • Consult with your surgeon if you are taking blood-thinning medications, NSAIDs, or Insulin. Examples include Coumadin (Warfarin), Plavix (Clopidogrel), and Aspirin; Nonsteroidal Anti-inflammatory Drugs (NSAIDs) such as Motrin (Ibuprofen), Aleve (Naproxen), Feldene (Piroxicam); or Insulin.
  • Carefully read the hospital admission form, complete it and send it to the mater hospital at least one week before your operation.
  • Have your blood tests done 5-7 days prior to your date of admission
  • Please shower on the morning of admission. Do not use powder, apply perfume, makeup or nail polish and wear cotton underwear if possible.
  • Please be sure to take the following to the hospital admission on the day of the operation;
    • Surgery consent form
    • MRI/Xray/C.T Scans

On arrival at the hospital, inform the receptionist that you are there to have an operation.  You will be taken to the pre-operative area to be prepared for surgery.

After Surgery

  • During your first few hours on the ward, you will be monitored closely by the nursing staff. You will be given fluids by an intravenous drip and may have a drain coming from your wound. This is all normal procedure.  If you have any pain or feel any sickness it is important to inform the nursing staff so they can keep you comfortable and aid your recovery.  The majority of patients are allowed fluids to drink once you are awake, however with some surgery fluids and what you are allowed to eat will be restricted for the first day or so.
  • The vast majority of spinal patients are allowed to walk to the bathroom with the help of the nursing staff from when they are fully awake from surgery.  If you want to use the toilet, you must ask the nursing staff for assistance.
  • Unless specified by your surgeon, you will commence rehabilitation the day following your surgery.  This means all drips, drains and other appendages will be removed and you will be assisted out of bed on day 1 and walked to the bathroom for a shower.
  • You will be sat on the edge of your bed for meals and taken for short walks by the staff. The following day you will increase the amount of walking and may still require some assistance from the staff.  You will sit out in the chair for short periods of time (meals etc.) It is very important that you do make every effort to get up and walk during this early stage of your rehabilitation.
  • Minor discomfort from the incision is common and can be relieved by pain medication.  You will be given regular pain relief but if this does not keep your pain under control, please speak to the nursing staff. Do not just wait till the next pain medication is due.  Some patients experience mild episodes of muscle spasms in their back and legs (after low back surgery) or in their neck and arms (after neck surgery). Ice/heat packs or muscle relaxants can be used to lessen the discomfort.
  • You may continue to experience pain, numbness, and weakness along the path of the nerve that was decompressed by surgery. These symptoms will gradually decrease over time.
  • Speak with your surgeon’s office about the timing of your first post-operative office visit.
  • The majority of patients discharge home after 2-5 days depending on the type of surgery you have had.

Preparing to Go Home

Post operative care and instructions:

  • Keep your dressing dry and clean for 7 days after surgery to prevent infection.
  • Leave dressings intact unless damp or ooze present from wound. (If dressing damp or wound has oozed, get someone to change it for you with the dressings provided to you from the ward.)  Ensure they wash hands carefully first.
  • You may shower if you cover the incision with plastic wrap to keep it dry.  A shower chair can be used if needed, otherwise use a special non-slip mat.
  • It is important if you have a low toilet, to consider loaning a plastic extension, or over the toilet seat. These can be hired from some chemists.
  • Steri-strips® (incision tapes) may have fallen off or be removed 7 – 10 days after surgery. Incision and dressing care may vary from patient to patient. Please make sure you understand your surgeon’s instructions before you leave the hospital.
  • Wear back support provided for you at the hospital as instructed (if supplied).
  • Change position regularly, do not lie in one position for too long (you will get stiff and sore).
  • Take pain medication regularly as prescribed and advised. (Do not keep taking pain medication unless you really need it once the pain of the operation has worn off).
  • No stooping, bending or twisting of your back. Keep your back straight and bend your knees using your thigh muscles.
  • No sitting in soft chairs or sofas that allow your back to curve. Sitting may be uncomfortable, so limit your time sitting in a chair (20-30 minutes).
  • Sit and stand straight, do not sit slouched or leaning over to one side in a chair. No stretching to reach high cupboards or shelves.
  • No jogging. Short, frequent short walks are better than long walks.
  • No lifting, housework or yard work during the first six (6) weeks or until allowed by your doctor.
  • No driving or long car journeys until consulting with your surgeon at the first post- operative visit

Follow the Guidelines for Physical Activity after Surgery

Light activities such as walking may be started on the day of surgery. Your physical activities should progress gradually by alternating activity with rest. Plan for short, regular walks with rest periods.

Each day increase your walking distance on a gradual basis.

Once your sutures have been removed and the wound has completely healed (usually 2-3 weeks post-operation) you may go swimming (mainly just walking in the pool and a little gentle swimming.  (No pool games or diving in.)

Sexual activity is permitted within the bounds of your comfort. Consult with your surgeon.

Discuss returning to work during your doctor’s appointment.

When to Call Your Doctor

Call Your Doctor if You Experience Any of the Following Symptoms

  • If you feel warm or chilled, take your temperature. Call your doctor with a temperature of 38.3 °C or above.
  • Increasing redness and swelling at the incision site.
  • Changes in the amount, appearance, or odour of drainage from your incision.
  • New or increased changes in sensation/presence of numbness in extremities.
  • Severe pain that is not relieved by medication and rest. Increasing leg pain, weakness or numbness. Worsening back pain.
  • Problems passing urine or controlling your bladder or bowels. Problems with your walking or balance.
  • Questions or problems not covered by these instructions.

Will I need further investigations?

Most patients will have had X-rays of their back, as well as a CT scan and MRI. Sometimes ‘dynamic’ X-rays of the lumbar spine are performed, with X-rays taken bending forwards and backwards; this is to determine the presence and site of any instability.

What are the results of surgery?

Overall, 80-90% of patients will obtain a significant benefit from surgery, and this is usually maintained in the long term.

Generally, the symptom that improves the most reliably after surgery is leg pain. Back pain may or may not improve (very occasionally they can be worse). The next symptom to improve is usually weakness. Your strength may not return completely back to normal, however. Improvement in strength generally occurs over weeks and months. Numbness or pins and needles may or may not improve with surgery, due to the fact that the nerve fibres transmitting sensation are thinner and more vulnerable to pressure (they are more easily permanently damaged than the other nerve fibres). Numbness can take up to 12 months to improve.

What are the costs of surgery?

Private patients undergoing surgery will generally have some out-of-pocket expenses.

A quotation for surgery will be issued, however this is an estimate only. The final amount charged may vary with the eventual procedure undertaken, operative findings, technical issues etc. Patients are advised to consult with their Private Health Insurance provider and Medicare to determine the extent of out-of-pocket expenses.

Separate accounts will be rendered by the anaesthetist and sometimes the assistant, and hospital bed excess charges may apply. Medical expenses may be tax deductible (you should ask your accountant).

You should fully understand the costs involved with surgery before going ahead, and should discuss any queries with your surgeon.

What is the consent process?

You will be asked to sign a consent form before surgery. This form confirms that you understand all of the treatment options, as well as the risks and potential benefits of surgery. If you are unsure, you should ask for further information and only sign the form when you are completely satisfied.