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A personal view of the role of laminectomy in lumbar disk herniation is presented. The phenomena of the true herniated nucleus pulposus and the asymptomatic bulging degenerative disk are discussed in relation to clinical presentation, neuroradiologic studies, and surgical findings. Microscopic technique and so-called less invasive procedures are also evaluated.
Minilaminotomy as an alternative to microdiskectomy or standard laminectomy has been performed at two community hospitals on 1000 patients over a period of 10 years. The operative technique, employing simple prone positioning, a 4-cm incision, standard instruments, X-ray guidance, a fiberoptic head light, and 4.5 x binocular loupes, has not changed since 1986, when the initial series of 200 cases was published. The overall results in 800 additional patients continued to compare favorably to all reported series of microdiskectomy: minimal blood loss, less narcotic requirement, fewer days in the hospital, earlier return to normal activity, no wound infection, and low rate of second surgery.
Pseudo-meningocele post-laminectomy is a non-frequent complication of this surgical technique. It is usually diagnosed by myelography; the CT scan has helped to detect more cases. We present a case studied by CT and RMN and there are no existing previous publications on the case confirmed by RMN. The relation between the findings and the clinic as well as the therapy still on discussion.
Arachnoid cysts of the spinal canal are relatively common lesions that may be either intra- or extradural. These cysts are usually asymptomatic but may produce symptoms by compressing the spinal cord or nerve roots. We report a case in which an intradural thoracic arachnoid cyst became symptomatic after a routine decompressive lumbar laminectomy for spinal stenosis. Myelography revealed no abnormality, although magnetic resonance imaging and computed tomography after myelography demonstrated a mass within the posterior aspect of the thoracic spinal canal associated with anterior displacement and compression of the spinal cord. A change in the flow dynamics of the cerebrospinal fluid probably allowed the development of spinal cord compression due to one of the following: expansion of the cyst, decreased cerebrospinal fluid buffer between the cord and the cyst, or epidural venous engorgement. A concomitant and more cephalad lesion such as an arachnoid cyst should be considered when myelopathic complications arise after lumbar surgery. Magnetic resonance imaging and computed tomography after myelography are useful to demonstrate the additional pathological processes.
Over recent years attempts have been made to prevent scar formation after laminectomy by placing biological and non-biological material between the dura mater and nervous structures and the paravertebral muscles. The author discusses his personal use of and preference for fat graft, and reports the surgical and histological findings in a patient submitted to surgery for a herniated disc 3 months previously.
Two hundred seventy-four patients were reviewed 1-5 years after laminectomy for spinal stenosis or herniated disks. All patients were treated according to the Pennsylvania Plan Algorithm for Degenerative Disk Disease. Ninety to ninety-five percent of the patients noted good to excellent relief of their leg pain, whereas only 80% noted low-back pain relief. The majority returned to work within 4 months. This review demonstrates that by following an algorithm for the treatment of back and leg pain from degenerative disk disease, the surgical results can be extremely gratifying, assuming the goals are relief of leg pain, the operative findings are definite, and the preoperative surgical indications and patient selection are well developed.
Back pain is one of the most common disorders seen in general practice. Patients with chronic low back pain form a large proportion of the work of any pain relief unit. The aetiology of low back pain and the post-laminectomy pain syndrome are briefly presented and treatment of the 'failed back surgery patient' and the patient with arachnoiditis are discussed.
The authors describe a 28-year-old patient with cervical intraspinal tumour in whom permanent apnoea developed after decompression laminectomy and plastic operation of the dura. The patient was artificially ventilated and received intensive therapy but died 2 months after the operation for septic complications.
One hundred twenty-nine patients who were treated by lumbar laminectomy for discogenic disease were evaluated preoperation by means of the Millon Clinical Multiaxial Inventory (MCMI) and the Minnesota Multiphasic Personality Inventory (MMPI). At follow-up evaluation, there were 71% good, 18% fair, and 11% poor surgical results. Patients with fair or poor outcomes scored significantly higher in the hypochondriasis, depression, hysteria, and psychasthenia scales in preoperative MMPI testing. These patients also showed significant differences on the MCMI asocial, gregarious, and neurotic depression scales. The MMPI profiles had a higher correlation with successful treatment than did those of the MCMI. The MMPI can help identify patients whose pain syndrome has a significant psychosocial component, and it can easily be used by orthopedic surgeons to facilitate referral and treatment planning.
Three hundred thirty-five patients with herniated lumbar intervertebral discs were injected with chymopapain. The overall success rate was 76%. The success rate was higher for private insurance patients (89%) than for Worker's Compensation patients (66%). There were no serious complications and patients spent fewer days in the hospital and returned to work faster than patients with laminectomies. Chemonucleolysis is an excellent alternative to open surgery for treatment of a herniated lumbar disc, especially if patients are selected carefully and good technique is strictly followed.
Malalignment of the atlas and axis was seen in 4 horses with an idiopathic form of atlantoaxial subluxation characterized by spinal cord compression on extension. The bone structure and density of the atlas and axis were radiographically normal in 3 of the 4 horses. Clinical signs appeared when the horses were 6 to 30 months old, and 3 of the 4 horses had a history of trauma. Although a congenital anomaly could not be ruled out, the cause was thought to be trauma. The horses were moderately to severely ataxic at the time of examination. Myelography revealed compression of the spinal cord at the atlantoaxial junction on extension. Flexion completely relieved the compression. In each horse, subtotal laminectomy of the caudal two thirds of the dorsal arch of the atlas was used to relieve the spinal cord compression. Two horses recovered fully, one had residual grade-1 neurologic deficits, and a fourth was euthanatized after it fractured a limb 6 weeks after surgery.
The reach of the lumbar vertebral column in the dog should be preferred in operations on the spinal marrow after own experiments. A better survey during the operation and a smaller risk of contusion of the spinal marrow by surgical instruments passed through there by reason a wider spinal canal a more voluminous spinal marrow. This method is more expensive, however more advantageous than a laminectomy in the reach of the thoracic spine because there exist some differences in the form of the bodies of the vertebra in humans and dogs.
The authors have recently reviewed the results of their consecutive cases of decompressive thoracic or lumbar laminectomy for spinal cord compression from epidural metastatic neoplasia at the City of Hope National Medical Center over the 15-year period, 1960-1974. This limited series tends to demonstrate the effect of case selection on results, as well as contrast the type of patient with paraparesis seen at a cancer treatment center with that seen at a community or county hospital.
A 16-year-old spayed female Siamese cat was presented with a history of paraparesis and obstipation. The cat's impaired function was attributed to malalignment of the L7-S1 spine (cauda equina syndrome) and to traumatic fracture of the left femoral neck, with severe degenerative arthritis. Laminectomy resolved the cauda equina problem, and the hip joint was not treated.
The feasibility of intraoperative sonography during lumbar laminectomy was demonstrated in six cases. The most obvious advantage was the ability to image the spinal canal anterior to the spinal cord or cauda equina, which cannot be seen directly from the posterior operative approach. A water bath of warm saline serves as an ideal acoustic window. This technique has the potential to be a significant contribution to intraoperative exploration and localization.
In a double-blind study of fifty patients that was done to test the ability of epidural morphine to decrease the discomfort after lumbar laminectomy, we found that during the first postoperative day the patient's pain was lessened appreciably but that the total dose of morphine received postoperatively was not diminished. We used a three-milligram dose of epidural morphine, and there were no problems with respiratory depression. The addition of epinephrine to the morphine solution had no beneficial effect.
The authors report on spinal posterior synthesis using Knodt 's instrumentation in compression. This technic has been applied in case of spinal instability , when a laminectomy has been achieved in emergency for epidural medullary compression. The technic is reported and qualities are discussed on the bases of the first ten cases.
The patient is lying on his left side. Paravertebral muscles of the right side are separated from the spinous processes and from the right laminae. Spinous processes are then cut at their base, and hold with a strong retractor Laminectomies are then feasible, as wide as necessary. Reconstruction is particularly strong. Our 3 years experiences of 200 cases, with clinical and radiologically very good late results, is underlined.