Spinal Stenosis Laminectomy

Spinal stenosis surgery by way of decompressive laminectomy is the most common surgery performed in order to correct spinal stenosis in the lumbar spine. The goal of this operation is to create more room for the nerve root that has been encroached upon by the facet joints of the vertebra. Because the LSS symptoms are created by the compression of the nerve root, decompressing the nerve root relieves the symptoms.

The procedure begins with a small incision of three to five inches length in the lower back of the patient. The surgeon then removes the lamina (the roof of the vertebrae) and makes an incision in the ligamentum flavum in order to visualize the compressed nerve. The surgeon then looks for the cause of the compressed nerve, which is normally already identified during spinal stenosis diagnosis. The cause could be:

• Hypertrophic facet capsules
• Osteophytes
• Uncinate spurs
• Protruding disc materials

Once all of the compressing materials have been removed, the remaining muscles and ligaments are sutured in order to promote faster healing after the operation.

Following the operation, the patient stays in the hospital for one to three days. Normally it takes several weeks to recover from this operation enough to perform physical activities, but the length of time to recover is mostly based on the patient’s age and physical condition prior to surgery.

Indications for Laminectomy

The indications for surgical decompression of LSS are not clearly defined.^23,24  Most agree that surgery is elective, except in the rare instance of cauda equina syndrome or rapidly progressing neurologic deficits.  Surgery is performed to improve the quality of life for individuals who have disabling back and leg pain, and significant limitations in walking tolerance.^{14,22,30,31,32,} Variations in reported decompressive surgery rates across geographic regions in the United States suggest that there still exits considerable uncertainty among physicians regarding the appropriate indications for decompressive laminectomy.^24,25,26,27, Generally, surgery is pursued once conservative treatments for spinal stenosis have failed.

Larequi-Lauber and associates³³ evaluated the appropriateness of surgical indications in 328 consecutive patients undergoing laminectomy for lumbar spinal stenosis or disc herniation. The authors used the consensus of a panel of experts to determine the appropriateness criteria and concluded that 38% of patients had inappropriate indications for surgery. The most common reason for a classification of inappropriate was insufficient preoperative duration of conservative treatment.

Surgery is clearly indicated in cases of acute cauda equina syndrome or with rapidly deteriorating neurologic status, but these cases are rare.^34,35,36 Cauda equina syndrome is in fact the only absolute indication for decompressive laminectomy.³⁷

Laminectomy Risks

Decompressive laminectomy is considered a relatively invasive surgical procedure, especially when accompanied by a fusion. Deyo et al used the ICD-9-CM codes to compile complications from lumbar spine procedures including decompressive laminectomy.^38,39,40 These included:

• Death
• Operative hemorrhage
• Hematoma
• Gastrointestinal problems
• Urinary tract problems
• Respiratory complications
• Cardiac problems
• Postoperative infections
• Central nervous system problems
• Wound dehiscence
• Peripheral vascular problems
• Transfusion problems

Other authors in defining complications for decompressive laminectomy procedures have cited one or more of the following: ^{7, 10, 11, 28, 29, 30, 33, 38, 39, 40}
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• Pain
• Infection
• Dural tears
• Bleeding
• Neurological deficit
• Re-operations
• Functional Disability

Laminectomy Success Rates

With success rates reported between 26% and 100% (the mean being 64%)⁷, surgery for degenerative lumbar spinal stenosis is generally performed electively to improve quality of life, except in rare cases of cauda equina syndrome or rapidly progressing neurologic deficits.²²,²³

Further, while patient satisfaction is an important outcome for elective surgeries, patient satisfaction after surgery for spinal stenosis has received little study. One retrospective study with an average of 4.6 years of follow-up showed that 31% of patients were dissatisfied with their operation.²⁸,²⁹

There has been limited prospective study of outcomes of surgery for spinal stenosis, and to date there is no published information on the clinical and sociodemographic factors associated with patient satisfaction after surgery for spinal stenosis, nor has there been a study comparing surgery of any type to conservative care.⁷

Unfortunately, the symptoms of LSS may reoccur as early as seven years after the operation because the surgery does not stop degeneration of the spine. It only fixes what’s happened due to previous degeneration at the time of the surgery, and more degeneration after the surgery is possible.

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