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LAMINOTOMY

A laminotomy is an orthopaedic neurosurgical procedure that removes part of a lamina of the vertebral arch in order to decompress the corresponding spinal cord and/or spinal nerve root.

This was originally performed as a hemilaminectomy, consisting in the removal of either the left or right half of the lamina, but is now more commonly carried out as the removal of a portion of both sides of the lamina (while retaining the rest to preserve vertebral stability as much as possible). Laminotomy is also often accompanied by facetectomy.

In lumbar spinal stenosis, compression of the spinal nerve roots in the lower back can cause pain. If the symptomatic stenosis area localizes to a few spots, modern minimally invasive spinal surgery techniques can be used to perform a focused decompression of the specific areas of stenosis.

Similar to the process for lumbar discectomy, fluoroscopic guidance can be used to localize the area of stenosis. By use of small retractors, tubular retractors, and magnification, the surgeon can precisely remove the bone spurs and hypertrophic, or enlarged, ligaments causing the stenosis with minimal disruption of other spine structures.

While the longer-term effects of minimizing the soft tissue dissection may not be completely understood, clinicians are hoping the minimal soft tissue disruption will also reduce the chances of developing laminectomy-related spinal instability patterns.

Outpatient lumbar decompression techniques reduce the surgical exposure, while achieving the removal of the spinal stenosis-causing structures. For the carefully selected patient, there is a high level of satisfaction, with minimal added risk with the outpatient process.

Similar to outpatient lumbar discectomy and laminotomy, approaches to a laterally located (to the side) cervical disc herniation or foraminal narrowing utilizes the same technique. Fluoroscopic guidance minimizes the incision, and tissue-splitting techniques reduce the impact to the muscles and ligaments of the spine. Magnification techniques and specialized tools can allow for a precise removal of the offending bone, tissue, or disc.

There are some important differences that should be considered for the cervical versus the lumbar discectomy procedure.

Cervical discectomy considerations:

In the cervical spine, the disc herniation should be located to the side (laterally), or near the foramen (the gap in vertebrae in the back and to the side of the spine). With this location, there is no need for any significant retraction on the spinal cord.

If the disc is more centrally located, meaning it has herniated toward the back of the spine and is impinging on the spinal cord, the risk associated with moving the cord away from the disc is high. Most surgeons would consider another surgical approach that allows greater visualization, rather than risk causing spinal cord injury.

Lumbar discectomy considerations:

As the spinal cord travels down the spine, it branches out into individual nerves and exits the spinal canal, so it does not run through the lumbar spine. The branching allows individual nerves to be retracted in the lumbar spine without concern for any spinal cord damage. Therefore, for most types of disc herniations in the lumbar spine, retraction of the nerve sac is much more acceptable and tolerated in lumbar procedures.

Posterior cervical procedures may have more incision pain following surgery than occurs in the lower back. The neck muscles may be more sensitive to dissection, and it is not uncommon to need some muscle relaxers during the recovery period. Still, outpatient cervical foraminotomy/discectomy is tolerated well by most patients, and there is a high satisfaction with the procedure.

For the properly selected patient, one- or two-level ACDF is a safe and reasonable option to address cervical disc pathology.

At one time, there was significant concern about potential post-operative complications associated with this technique. Several studies have documented the efficacy and safety of ACDF in the outpatient setting, however.

While the ACDF technique has multiple steps, there is minimal dissection of the tissues.

  • The incision is typically 1 to 2 inches long
  • After the incision to the front of the neck, the rest of the dissection is performed bluntly, with no more cutting
  • The muscles and tissues are gently pushed away from the front of the spine bone
  • There is usually minimal blood loss, and the targeted discs are readily identified and visualized

Because the dissection is performed in a tissue-splitting instead of tissue-cutting fashion, the postoperative neck pain is tolerable. With resolution of the pre-operative arm radiculopathy symptoms in the recovery area, many will experience less pain than immediately before the operation. (Radiculopathy is pain caused by irritation of a spinal nerve root.)

As long as the patient can tolerate the pain and there is no concern about breathing issues or with difficulty swallowing (dysphagia), most patients can go home from the recovery area within a few hours of the surgery.

Within the past few years, cervical disc replacement procedures have also been performed on an outpatient basis. Using the same exposure techniques, there is no difference in terms of immediate postoperative pain from the ACDF surgery.

Only in recent years have surgeons offered outpatient lumbar spinal fusions.

By use of modern localization techniques and muscle-splitting dissections, the postoperative incisional pain can be tolerated enough to allow an outpatient process.

In the past 15 years, advances in spine surgery instrumentation have yielded a tremendous selection of percutaneously delivered spine screws, cages, and exposure retractors. These instruments are designed to create a lumbar spine fusion construct that can be delivered using small incisions and muscle-splitting dissections.

The prudent surgeon, however, will be careful to offer outpatient spinal fusion only with the correct indications, overall health, body type, and pain tolerance. While the procedure can be done successfully using these minimally invasive techniques, other factors may determine the appropriateness of an outpatient setting for certain patients.

Specific types of fusion that may be done by an appropriately skilled and experienced surgeon include:

Anterior Lumbar Interbody Fusion (ALIF)

Some surgeons are able to do an ALIF on an outpatient basis. This is largely because an ALIF includes an approach from the front, through the abdomen, so there is minimal tissue disruption.

Lateral Lumbar Interbody Fusion (e.g. a TLIF or XLIF)

Similar to an ALIF, a fusion approach from the side can be done with minimal tissue disruption, allowing the procedure to be done on an outpatient basis in a properly selected patient and with an appropriately experienced surgeon.

As far as lumbar fusions are concerned, at this time, only a small percentage of the patient population will be appropriate candidates for an outpatient experience.