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The word laminectomy literally means - excision of lamina. However in most cases, involves excision of the supraspinous ligament and some or all of the spinous process. A laminectomy is a surgical procedure that removes a portion of a vertebra called the lamina. It is a major spine operation with residual scar tissue and may result in post-laminectomy syndrome. This procedure is performed to decompress the spinal canal. As medical science advances, there are several techniques to accomplish spinal decompression, such as open or minimally invasive laminectomy, hemi-laminectomy (half laminetomy), laminotomy and laminoplasty. Decompression techniques classify as direct and indirect; direct procedures involve those techniques with visualization of the dural sac during the surgery such as laminectomy. On the other hand, indirect decompression takes place without dural sac visualization. Laminectomy alone or associated with fusion is one of the most common procedures performed by a spinal surgeon. The word laminectomy literally means - excision of lamina. However in most cases, involves excision of the supraspinous ligament and some or all of the spinous process. Lamina is rarely removed if utterly required rather, it is done to break the continuity of the rigid ring of the spinal canal to allow the soft tissues within the canal to: 1) expand (decompress); 2) change the contour of the vertebral column; or 3) permit access to deeper tissue inside the spinal canal.
Technique 1: Conventional Laminectomy - The skin was incised horizontally over a length of 8–10 cm in the midline along with lumbodorsal fascia. The paraspinal musculature was detached from the spinous process and laminae in a subperiosteal fashion and bilaterally retracted. Decompression was performed using standard techniques to remove the spinous process, lamina, and ligamentum flavum, along with partial medial facetectomy (limited to one-third of the facet joint) and rhizolysis of the traversing nerve roots (that is, the nerve roots that exit at the vertebral level below the surgical level).
Technique 2: Minimally Invasive ULBD - Minimally Invasive Surgical (MIS) techniques include laminotomy and microendoscopic laminotomy with tubular retractors. Contemporary literature supports these procedures resulting in better preservation of posterior musculature, decreased intraoperative bleeding, and postoperative pain.[1][2]
Relevant Anatomy
lamina and other elements of vertebrae
The lamina is a posterior arch of the vertebral bone lying between the spinous process and the more lateral pedicles and the transverse processes of each vertebra. The lamina, facets and spinous process are major parts of the posterior elements that help guide the movement of the vertebrae and protect the spinal cord. The supraspinous ligament connects the tips of the spinous processes from the seventh cervical vertebra to the sacrum. It runs over the posterior aspect of the vertebrae.
central stenosis- neurogenic claudication, which includes pain, tingling, or cramping sensation in the extremity
lateral recess, foraminal and extraforaminal lumbar stenosis - radiculopathy, patients with central stenosis may experience more symptoms in standing position and during walking and pain is usually relieved with leaning forward or in sitting position.
Hyperextension Test The patient needs to passively mobilise the trunk over the full range of extension, while the knees stay extended. The test indicates that the radiant pain is caused by disc herniation if the pain deteriorates.
Manual Testing and Sensory Testing Look for hypoaesthesia, hypoalgesia, tingling or numbness
The Back Pain Functional Scale (BPFS) is a subjective scale used to measure the patient's physical function after low back pain. This scale was developed by Stratford et al. (2000). It is simple and easy to understand and administer by the patients. This scale is based upon the International Classification of Function (ICF) model proposed by the World Health Organisation. It is used to evaluate the patient's level of physical independence during the initial two weeks of low back pain. However, it is not used for backpain after two weeks. This scale consists of a total score of 60. Moreover, the patient's score can be measured from the responses obtained on the Likert scale (0 to 5), and accordingly, a total score is summed up out of 60. Furthermore, the maximum score obtained indicates the maximum physical abilities of the patients. In addition, this scale also has an 'Adjusted score' ranging from 0 (0%)-unable to perform any activity to 60 (100%)-no difficulty in any activity
Pre-Operative Exercises
1. Instruction in bed mobility, transfers, and body mechanics education with ADLs
3. Focus on local muscle systems (tonic/postural/stabilizing) longus colli before global (phasic/primary movers) such as SCM, PCM. Local muscles are shorter in length and closer to axis or rotation while the global muscles have no direct attachment on the spine.
4. Avoid preloading the spine with overhead arm movements too early in rehab. No pain no gain axiom usually does not apply to the spine
5. Focus on low load high repetitions to improve endurance rather than high load low repetition for strength.
6. Focus on pain relief with Neck Disability Index of 50+, with scores of 3050 focus on decreasing pain, muscle reeducation, gradual strengthening, and flexibility and improve cardiovascular endurance, with scores less than 30 focus on work simulation and progressive strengthening.
Neuromuscular reeducation of longus colli with pressure biofeedback (include arm and leg movements in varying positions).
Restricted (to 5 lbs) arm exercises. Progress to overhead after 6 weekscervical isometrics with neck rotationModalities for symptom modulation if needed
Phase III: 9-12 weeks/2-3 times per week
Posture emphasis with exercises, posture training
Work/activity specific training
Soft tissue mobilization to decrease guarding
Joint mobilizations over restricted joints (around fusion) to increase contribution to overall movement (OA/AA and upper thoracic). Protect fusion.
Nerve mobilization (nerve glides). Do not reproduce symptoms.
Avoid bending and twisting, lifting, pushing and pulling 5kgs or more for two weeks.
Limit sitting, including the car, to no more than 30 minutes at a time (standing/walk breaks).
No extension range of motion or rotation exercises for eight weeks
Educate regarding posture and body mechanics
Light Stretching: Hip flexors, quadriceps, hamstrings, calf
Gluteal, multifidus and transverse abdominus (without pelvic tilt) bracing/isometrics
Walk for 10 mins twice daily
Phase II (2 to 6 Weeks): Initial Strengthening Phase
Frequency - One to two times a week, for four or more weeks
Lifting Restrictions: Begin at 5kgs
Keep spine neutral with focus on proper neuromuscular control
Walking Progression: At least 30 minutes or more • Stationary Bike Recumbent: Can initiate at two weeks
Transverse Abdominis/Multifidi Progression (maintain neutral spine) - start with isometrics and progress to SLR, marches, superman etc.
Continue with Proper Glute Activation Exercises Eg.: prone hip extensions, bridges, side lying clams, side lying 90/90 leg lifts, side lying abduction, quadruped hip extension, bird dog
modified squats with swiss ball
Upper Extremity/Lower Extremity Strength Training - Step ups, leg press, wall squats, squats, etc. Balance (with Transverse Abdominis bracing): single leg stance, tandem, foam, etc. Upper extremity light resistive exercises (machines, theraband, free weights)
Continue stretching exercises
Phase III (6 to 8 Weeks): Progression to Advanced Strengthening
Advanced core strength and stabilization exercises: Progress to weight bearing, balance, Swiss Ball, Reformer, etc.
Progress to multi-planar exercises with upper extremity/lower extremity
Begin running, agility and plyometrics for return to sport after 8 to 12 weeks (if symptoms stable and cleared)
Lumbar Spine: More than eight weeks to improve lumbar extension range of motion, but avoid end-range Eg.: prone lying, prone on elbows, press-ups, and/or standing extensions (if no periphalization)
↑Mobbs RJ, Li J, Sivabalan P, Raley D, Rao PJ. Outcomes after decompressive laminectomy for lumbar spinal stenosis: comparison between minimally invasive unilateral laminectomy for bilateral decompression and open laminectomy. Journal of Neurosurgery: Spine. 2014 Aug 1;21(2):179-86.
↑Low M, Burgess LC, Wainwright TW. A critical analysis of the exercise prescription and return to activity advice that is provided in patient information leaflets following lumbar spine surgery. Medicina. 2019 Jul;55(7):347.
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↑Hebert JJ, Marcus RL, Koppenhaver SL, Fritz JM. Postoperative rehabilitation following lumbar discectomy with quantification of trunk muscle morphology and function: a case report and review of the literature. journal of orthopaedic & sports physical therapy. 2010 Jul;40(7):402-12.
