Laminectomy

Original Editor - Shreya Pavaskar

Top Contributors - Shreya Pavaskar, Kim Jackson and Kirenga Bamurange Liliane  

Description[edit | edit source]

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[edit | edit source]

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.

Indication[edit | edit source]

Contraindication[edit | edit source]

  • Spinal instability (is a contraindication for laminectomy without associated fusion technique)
  • Degenerative or isthmic spondylolisthesis (relative contraindication)
  • Severe scoliosis (relative contraindication)
  • Severe kyphosis (relative contraindication)

Clinical Presentation[edit | edit source]

  • 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.

Diagnostic Tests[edit | edit source]

Cervical

  1. Spurling test.
  2. Distraction test.
  3. Upper limb tension test.
  4. Shoulder abduction test.
  5. Tinel's sign
  6. Compression test

Lumbar

  1. The straight leg raise test:
  2. The contralateral (crossed) straight leg raise test
  3. Lasègue’s Test - - see straight leg raise test
  4. Bowstring test
  5. Prone knee bending
  6. Slump test
  7. Muscle Weakness or Paresis
  8. Reflexes
  9. 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.
  10. Manual Testing and Sensory Testing Look for hypoaesthesia, hypoalgesia, tingling or numbness

Spinal canal stenosis

  1. Bicycle Stress Test
  2. Two-Stage Treadmill Test

Pre-Operative Exercises[edit | edit source]

1. Instruction in bed mobility, transfers, and body mechanics education with ADLs

2. Instruction in basic home exercise program:

  • Ankle pumps
  • Gluteal sets
  • Quadriceps sets
  • Hamstring sets
  • Heel slides
  • Long and short arc LE extension
  • Transverse Abdominis isometric contractions
  • Breathing relaxation exercises


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.

Post-Operative Cervical laminectomy [3][edit | edit source]

Phase I: Immediate post Surgical Phase (IPSP) 06 weeks
Cervical Range of motion exercises
Cervical isometrics
  1. Prevent excessive initial mobility or stress on tissues.
  2. Diaphragmatic breathing
  3. Relaxation exercises
  4. Upper extremity extension isometric exercises
  5. Multilevel fusions hard collar for 6 wks; one level fusions wear a collar as needed for a week or two
cervical rotation isometrics


Phase II: 6-9 weeks/2-3 times per week

  • Grade 1 or grade 2 joint mobs for neuromodulation of pain
  • Cervical Range of motion exercises.
  • Cervical Isometric exercises.
  • Cervical flexibility exercises: Decreases stress on cervical spine and makes it easier to maintain neutral spine. (levator scapula, upper trapezius, pectoralis major/minor etc)
  • Initiate Scapular movement reeducation including shoulder shrugs, shoulder rolls, scapular retraction/depression exercises
  • Upper thoracic mobilization exercises: cat/camel exercises, upper thoracic extension, upper thoracic rotation, arm locks
  • 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 weeks
    Cervical sb isometric.png
    Modalities 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.
  • Upper extremity strengthening (Rhythmic stabilization upper extremity, free weight shoulder strengthening)
  • Scapular stabilization/strengthening exercises (shoulder shrugs/rolls, chest press, seated rows, pull downs, incline push ups)
  • Spinal stabilization exercises lumbar and cervical
  • Continue Upper thoracic mobilization exercises
  • Advanced balance training exercises.
  • Progress with ADL and activity simulation with recruitment of longus colli/neutral spine.
  • Cardiovascular training, treadmill, stationary bike

Post-Op lumbar laminectomy [4][edit | edit source]

Phase I (0 to 2 Weeks): Protective Phase

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
bridging
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
Wall squat with stability ball.jpg
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

Progress upper extremity/lower extremity strengthening

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)

Resources[edit | edit source]

Techy F, Bell GR. Laminectomy. InPerioperative Management of Patients with Rheumatic Disease 2013 (pp. 297-302). Springer, New York, NY.

References[edit | edit source]

  1. 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.
  2. Estefan M, GO CW. Laminectomy.
  3. 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. BibTeXEndNoteRefManRefWorks
  4. 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.