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PubMed1998

Laminectomy and functional impairment of the lumbar spine: the importance of muscle forces in flexible and rigid instrumented stabilization--a biomechanical study in vitro.

Laminectomy is the accepted treatment for spinal canal stenosis in cases where conservative treatment has failed. Opinions diverge on the resulting clinical instability and the necessity of instrumented stabilization. The present biomechanical study was performed to determine the functional impairment following laminectomy and the stabilizing effect of flexible and rigid devices. This was the first time that the effects of agonist and antagonist intersegmental lumbar muscle forces acting on intact, unstable and instrumentally stabilized functional spinal units have been investigated. Six human cadaveric lumbar spines were tested in a spine tester. The coactivation of agonist and antagonist muscle forces resulted in increased stability under the load conditions of bending and rotation; a slight increase in the range of motion was noted during flexion. The functional impairment following laminectomy was corrected by ligamentoplasty and by means of muscle forces. Ligamentoplasty appears to be an alternative to decompression with spondylodesis, especially in patients with well-developed muscles.

Biomechanical Phenomena↗
PubMed1983

Late laminectomy in traumatic paraplegia.

Long-term observation in cases of spinal injury with subarachnoid block, treated by laminectomy and removal of compressing elements, shows worthwhile results in a good percentage. Twenty-seven cases of fractures of the spine at the dorsolumbar and lumbar levels with conus and cauda equina injury were treated by laminectomy and decompression from 6 to 12 weeks after the injury, and have been followed for periods of 3-27 years. Surgical intervention was offered only in those cases in which myelography demonstrated a subarachnoid block. Most of the cases were operated on at 6-12 weeks after the injury. Displaced laminae, thickened ligamentum flavum, and arachnoidal adhesions were the common causes of compression. In six cases there was also an arachnoid cyst. Long-term follow-up showed improvement in bladder function in 14 of 27 patients, and in motor function in 8 of 27. In dorsolumbar and lumbar injuries in which there is a subarachnoid block, decompressive laminectomy is a worthwhile procedure.

Adult↗
PubMed1989

Epidural steroids, epidural morphine and epidural steroids combined with morphine in the treatment of post-laminectomy syndrome.

Epidural morphine injection followed by a steroid has been reported to be effective for the post-laminectomy pain ('failed back') syndrome. This double-blind, parallel study was undertaken to evaluate that mode of therapy. Twenty-two patients who had undergone at least one prior laminectomy, who were still symptomatic, were randomized to receive 50 mg of lidocaine epidurally with: (a) 75 mg triamcinolone diacetate (TR); or (b) 8 mg of preservative-free morphine (MP); or (c) both (TR and MP), at 1 month intervals for 3 consecutive months. The spinal interspace identified with the patients' pain complaint was the site of injection. For each treatment, patients were admitted to the Clinical Research Center for 24 h and their condition continuously monitored with a pulse oximeter and apnea monitor. Five to 7 patients in each group had pain relief for less than 1 month. No patient given morphine had pain relief for more than 1 month. Life-threatening ventilatory depression occurred in the group given triamcinolone and morphine. The use of morphine alone or combined with slow release triamcinolone does not appear to be appropriate for the treatment of the post-laminectomy pain syndrome.

Analgesia, Epidural↗
PubMed1992

The role of laminectomy in the combined treatment of metastatic spinal cord compression.

A retrospective analysis of clinical data concerning 140 patients with spinal cord compression is presented. Treatment consisted of a surgical decompressive laminectomy followed by radiation therapy in 127 cases. Primary radiation therapy supported by steroids was applied in only 26 cases. A dose of 30-40 Gy in 15-20 fractions was delivered to all patients. Treatment outcome was analyzed by comparing motor function (categories: no deficit, mild deficit ambulatory, paraparetic not ambulatory, paraplegic), sphincter function, and pain relief before and after treatment in both modalities. Following laminectomy and radiation therapy, 82% of paraparetic patients regained their ability to walk, sphincter function improved in 68%, pain relief was achieved in 88%. Following radiation therapy alone, 64% of paraparetic patients became ambulatory, 33% showed a normalization of sphincter function, and 72% became pain free. Our results indicate that laminectomy should play a major role in the treatment of patients with metastatic spinal cord compression. The decision as to the treatment of choice has to be made individually for each patient taking into consideration his general condition, life expectancy, and origin of the primary.

Adult↗
PubMedDate not supplied

The effect of the prone position on venous pressure and blood loss during lumbar laminectomy.

STUDY OBJECTIVE: To determine the effects of three different prone support systems (Andrews spinal surgery frame, Cloward surgical saddle, and longitudinal bolsters) on inferior vena cava (IVC) and superior vena cava (SVC) pressures; the validity of measuring central venous pressure (CVP) for the determination of ideal positioning of the patient; and the relationship among frame type, blood loss, and hemodynamic measurements. DESIGN: Prospective, randomized study of the hemodynamic effects of the prone position. SETTING: Inpatient surgery at a university hospital (regional spinal cord injury treatment center). PATIENTS: Eighteen patients free of significant coexisting disease (ASA physical status I and II) undergoing elective lumbar laminectomy. INTERVENTIONS: Patients were assigned to one of three support frames and measurement of SVC pressure, IVC pressure, and mean arterial pressures (MAP) were obtained supine, prone, and after repositioning. These pressures and measured blood loss were obtained every 15 minutes during the surgical laminectomy portion of the procedure. MEASUREMENTS AND MAIN RESULTS: Patients positioned on the Andrews frame had decreased mean SVC and IVC pressures from 8.7 mmHg and 8.4 mmHg in the supine position to 3.3 mmHg and 1.8 mmHg in the prone position, respectively (p less than 0.001). Prone position CVP also was significantly lower in the Andrews group compared with that in the other two groups (p less than 0.001). Repositioning efforts did not significantly decrease CVP. Blood loss was higher in the Cloward group (1,150 +/- 989 ml) than in the Andrews (245 +/- 283 ml) and bolsters (262 +/- 188 ml) groups (p less than 0.02). CONCLUSIONS: Increased blood loss was not associated with increased SVC or IVC pressure, nor was there any significant correlation between any demographic or hemodynamic variable and blood loss. There was no evidence that CVP is useful in determining the ideal prone position in patients undergoing lumbar laminectomy.

Blood Loss, Surgical↗
PubMed2005

Titanium mesh implantation--a method to stabilize the spine and protect the spinal cord following a multilevel laminectomy in the adult rat.

The development of clinically relevant larger spinal cord injury models is in part limited by the possibility of a widened or multilevel laminectomy causing a spinal cord injury from an unstable spine or from compression of the spinal cord by adjacent soft tissues. In the adult rat, we have developed a method to protect the spinal cord and stabilize the spinal column using a titanium mesh implant following a bilateral, multilevel lumbar laminectomy. For this purpose, bilateral and expanded L1-4 laminectomies were performed with or without the use of a titanium mesh to protect the spinal cord and stabilize the spine. Without titanium mesh protection, the rats developed a severe paraparesis or paraplegia, urinary retention, gross anatomical signs of cord compression, and motoneuron loss. In the titanium mesh treatment group, the rats typically maintained a normal gait and lower urinary tract function, normal gross anatomical features of the spinal cord, and normal motoneuron counts. We propose that the use of a titanium mesh implant may assist in the development of clinically relevant larger spinal cord injury and repair models.

Animals↗
PubMedDate not supplied

Surgical management of cervical myelopathy: indications and techniques for laminectomy and fusion.

BACKGROUND: Cervical spondylotic myelopathy (CSM) is a commonly encountered surgical disease that may be approached through a variety of operative techniques. Operative goals in the treatment of CSM include effective neural element decompression and maintaining spinal stability to avoid delayed deformity progression and neurologic compromise. Determining the most appropriate operative approach requires careful consideration of the patient's clinical presentation and radiographic imaging. PURPOSE: To review the indications and techniques for multilevel laminectomy and fusion in the treatment of CSM. CONCLUSIONS: When indications permit, a multilevel laminectomy is an effective and safe method of neural element decompression. Recognizing the potential for spinal instability is essential to prevent neurologic compromise and intractable axial neck pain caused by deformity progression. A variety of techniques have been described to supplement the posterior tension band after laminectomy; however, lateral mass fixation has evolved into the preferred stabilization technique. Although clinical success is well documented, a successful outcome is dependent on a comprehensive, individualized evaluation of each patient presenting with CSM.

Cervical Vertebrae↗
PubMed2006

The effects of free fat graft or cellulose membrane implants on laminectomy membrane formation in dogs.

The purpose of this study was to determine the effect of cellulose membrane or free fat grafts (FFG) on laminectomy membrane (LM) formation. Eighteen dogs were randomly divided into three groups of six dogs. All dogs underwent a modified dorsal laminectomy on T(13)-L(1). The laminectomy defect was left uncovered in the control group but either a FFG or a cellulose membrane implant was provided in the other two groups. The dogs were evaluated through neurological examination, myelography, macroscopic roundness index of spinal cord and histological evaluations of epidural fibrosis and spinal cord. The results showed a significant difference between the control and the FFG group, with the FFG causing neurological deficits and spinal cord compression as assessed by the roundness index of the spinal cord. Both FFG and cellulose membrane were partially effective in preventing LM formation. The use of FFG was associated with a high rate of significant neurological complications and spinal cord lesions.

Adipose Tissue↗
PubMed1984

Chemotherapy as an alternative to laminectomy and radiation in the management of epidural tumor.

Nine children with neuroblastoma and five with Ewing sarcoma were found at diagnosis to have epidural extension of tumor. Five children underwent laminectomy prior to referral, with good neurologic recovery in only one. Management in the other nine children did not include laminectomy. All 14 patients were given chemotherapy without radiotherapy. Rapid regression of tumor with neurologic recovery occurred in response to chemotherapy in all patients with neurologic deficits. The responses observed in these children indicate that for chemotherapy-sensitive tumors, effective chemotherapy is a feasible alternative to laminectomy and radiation therapy in the management of epidural disease.

Adolescent↗
PubMed1997

Local wound infiltration with bupivacaine in lumbar laminectomy.

BACKGROUND: Parenteral administration of narcotics has been the mainstay for postoperative pain relief in patients undergoing lumbar laminectomy. However, this may lead to respiratory depression and nausea, which may be hazardous in these patients. METHODS: We evaluated the efficacy of wound infiltration with bupivacaine in 45 consecutive patients undergoing elective single-level lumbar laminectomy for intervertebral disc prolapse in a prospective, double-blind, randomized controlled trial. Prior to wound closure, the muscle and subcutaneous tissues were infiltrated with bupivacaine 0.375% or sterile physiologic saline. Postoperatively, the patients were assessed hourly for pain and an analgesic administered if the patient had moderate or severe pain. RESULTS: All the 21 placebo recipients required analgesics in the first 9 hours postoperatively, compared to only 11 of 24 patients who received bupivacaine (p < 0.001). The mean (standard deviation) time before administration of the first dose of analgesic postoperatively in the bupivacaine and placebo recipients was 807.7 (567.6) minutes and 181.4 (110.1) minutes, respectively (p < 0.001). No adverse effects of local wound infiltration were noted. CONCLUSIONS: Local wound infiltration with bupivacaine is a safe and effective method for providing postoperative pain relief and reducing narcotic use in patients undergoing lumbar laminectomy.

Adult↗
PubMed2003

Laminectomy for cervical myelopathy.

STUDY DESIGN: Cervical laminectomy with or without fusion, or laminoplasty, successfully address congenital or acquired stenosis, multilevel spondylosis, ossification of the posterior longitudinal ligament (OPLL), and ossification of the yellow ligament (OYL). To optimize surgical results, however, these procedures should be applied to carefully selected patients. OBJECTIVES: To determine the clinical, neurodiagnostic, appropriate posterior cervical approaches to be employed in patients presenting with MR- and CT-documented multilevel cervical disease. To limit perioperative morbidity, dorsal decompressions with or without fusions should be performed utilizing awake intubation and positioning and continuous intraoperative somatosensory-evoked potential monitoring. SETTING: United States of America. METHODS: The clinical, neurodiagnostic, and varied dorsal decompressive techniques employed to address pathology are reviewed. Techniques, including laminectomy, laminoforaminotomy, and laminoplasty are described. Where preoperative dynamic X-rays document instability, simultaneous fusions employing wiring or lateral mass plate/screw or rod/screw techniques may be employed. Nevertheless, careful patient selection remains one of the most critical factors to operative success as older individuals with prohibitive comorbidities or fixed long-term neurological deficits should not undergo these procedures. RESULTS: Short- and long-term outcomes following dorsal decompressions with or without fusions vary. Those with myelopathy over 65 years of age often do well in the short-term, but demonstrate greater long-term deterioration. Factors that correlated with greater susceptibility to deterioration include advanced age (>70 years at the time of the first surgery), severe original myelopathy, and recent trauma. CONCLUSIONS: Success rates of laminectomy with or without fusion, or laminoplasty may be successfully employed to address multilevel cervical pathology in a carefully selected population of patients.

Bone Wires↗
PubMed2006

Transient paraparesis after laminectomy for thoracic ossification of the posterior longitudinal ligament and ossification of the ligamentum flavum.

STUDY DESIGN: Case report. OBJECTIVES: To report a case with thoracic myelopathy caused by ossification of the posterior longitudinal ligament (OPLL) and ossification of the ligamentum flavum (OLF), in which postoperative paralysis occurred after laminectomy and was reversed after an additional posterior instrumented fusion. SETTING: A University Hospital in Japan. CASE REPORT: A 71-year-old woman, with a spastic palsy of both lower extremities, had OPLL and OLF at T10-T11, which pinched the spinal cord anteriorly and posteriorly. She underwent a laminectomy at T10-T11, and no further neurological deterioration was seen immediately after surgery. Over the next 18 h, however, myelopathy worsened, showing severe paraparesis. An additional posterior instrumented fusion at T7-L1 was performed without correction of the kyphosis. After fusion, neurological deficits gradually recovered, despite the presence of residual anterior impingement of spinal cord by the OPLL. CONCLUSIONS: The present case provides evidence for the possibility that laminectomy alone produces postoperative paralysis for combined thoracic OPLL and OLF, and we recommend that a posterior instrumented fusion should be added when posterior decompression is performed for this disorder.

Female↗
PubMedDate not supplied

[Results of extensive cervical laminectomy].

39 patients were studied for late effects of cervical laminectomy. With a mean follow-up of 51 months and mean extent of laminectomy of 4.15 levels, analysis of pre- and postoperative radiographs showed changes in cervical spine curvature type in 72% and in 44% extreme spinal deformity. In addition, postoperative effects on pain and neurological symptoms are evaluated. Close follow-up during rehabilitation in essential for the prevention of clinical deterioration after laminectomy.

Adolescent↗
PubMed2003

Follow-up after cervical laminectomy, with special reference to instability and deformity.

Misalignment and instability after cervical laminectomy, performed to treat spondylotic myelopathy, has been described as possible adverse effects. Forty-six consecutively patients on whom laminectomy had been performed in a 4-year period were identified; 7.7 +/- 0.6 years after operation, 11 patients had died and 27 patients were available for follow-up. Postoperative static subluxation was observed in 26% of the patients with an average slip of 3.7 +/- 3.1 mm; 7% had abnormal intervertebral movement displaying 1-2 mm movement from full flexion to full extension. Seventy-four per cent of the patients showed abnormal spinal curvature as judged from radiographs. However, no correlation with outcome was observed. Seventy-four per cent of the patients thought of the result of the operation as either good or fair; objectively, the best long-term effect of the operation was upon arm function. Although some patients develop postural anomaly, laminectomy remains, in terms of instability, a justifiable procedure in the elderly patient with spondylosis.

Adult↗
PubMed1999

Surgical-site complications associated with a morphine nerve paste used for postoperative pain control after laminectomy.

OBJECTIVE: To identify risk factors that might explain a sudden increase in the rate of surgical-site complications following laminectomy. DESIGN: Retrospective cohort study. PATIENTS AND SETTING: Patients who underwent laminectomy at a 120-bed hospital from August 1 through October 15, 1996 (the epidemic period). A case-patient was defined as a patient with postoperative surgical-site complications (surgical-site drainage, edema, or swelling) requiring surgical debridement. RESULTS: Of the 148 patients who underwent a laminectomy during the epidemic period, 17 (11%) met our case definition. The rate of postoperative surgical debridement was 7.6-fold higher during the epidemic period than the preceding 19-month period (17/148 vs 15/995, P<.001). Development of surgical-site complications was associated with intraoperative receipt of morphine nerve paste (relative risk [RR], 11; P<.001), preoperative shaving by nurses rather than surgeons (RR, 6.6; P=.006), procedures done by a certain surgeon (RR, 3.1; P=.022), or receipt of iodine rather than povidone-iodine for preoperative skin antisepsis (RR, 5.1; P=.002). In multivariate analysis, only receipt of morphine nerve paste remained as a risk factor (RR, 18; P=.011). The paste was used to control postoperative pain and was applied directly to exposed dura and surrounding tissues. At the time of surgical debridement (median, 24 days postsurgery), the original surgical sites showed residual paste and a lack of healing. Ten of 16 cultures from surgical sites were positive; all but three grew skin commensals. Histological examination of surgical specimens showed a foreign-body reaction, but no marked acute inflammation. CONCLUSIONS: The intraoperative use of morphine nerve paste may delay wound healing and increase postoperative morbidity. When new products are introduced, standardized protocols should be developed for their use, and systematic surveillance should be done to monitor for potential adverse outcomes.

Administration, Cutaneous↗
PubMed1995

Postoperative analgesia after lumbar laminectomy: epidural fentanyl infusion versus patient-controlled intravenous morphine.

We compared the efficacy and safety of continuous epidural fentanyl infusion with intravenous morphine via a patient-controlled analgesia system (IV-PCA) in the management of postoperative pain after lumbar laminectomy. Twenty patients undergoing elective lumbar laminectomy were randomly allocated to one of two groups. The epidural group (n = 10) received an epidural fentanyl infusion (2 micrograms/mL at 4-10 mL/h) while the IV-PCA group (n = 10) received IV morphine through a PCA system. The general anesthetic technique was standardized. Visual analog pain scores were recorded at 12, 24, and 48 h after the operation. The amount of morphine (or its equivalent in fentanyl) used over the 48-h postoperative period was documented. The postoperative pain scores were significantly lower in the epidural group than in the IV-PCA group throughout the study period. The total consumption of morphine (or its fentanyl equivalent) over the 48-h period was significantly lower (P < 0.001) in the epidural group compared to the IV-PCA group. Although more patients in the IV-PCA group required urinary catheterization and had somnolence than the epidural group, there was no difference in the incidence of vomiting or pruritus. No patient developed respiratory depression or wound infection. We conclude that continuous epidural infusion of fentanyl is superior to IV-PCA morphine in the management of pain after lumbar laminectomy.

Analgesia, Patient-Controlled↗
PubMed1997

Preemptive epidural morphine for postoperative pain relief after lumbar laminectomy.

This study was designed to evaluate the efficacy of preemptive epidural morphine for postoperative analgesia after lumbar laminectomy. Thirty ASA physical status I adults undergoing elective lumbar laminectomy under general anesthesia were randomly allocated to one of two groups. Group 1 (study group) received 3 mg epidural morphine preemptively 60 min before surgery, followed by epidural placebo at the end of surgery. Group 2 (control group) received epidural placebo at the same time preoperatively as the study group, followed by 3 mg epidural morphine at the conclusion of surgery. Pain was assessed using visual analog scales (VAS), and sedation was graded on a 4-point rank drowsiness score. Time to first postoperative analgesic (TFA), the supplementary analgesia, and the amount of morphine used over the 24-h period were noted for the groups. VAS pain scores were significantly less in Group 1 (preemptive group) than in Group 2 8 h after surgery (P < 0.05). TFA in the study group (19.9 +/- 2.3 h) was significantly prolonged compared with the control group (8.5 +/- 1.0 h, P < 0.05). The demand for supplementary analgesia and postoperative morphine consumption in the preemptive group was significantly lower than that in control group (P < 0.05). Patients in the control group were significantly sedated after 12 h and had a high incidence of nausea and vomiting (P < 0.05). The study shows that preemptive epidural morphine is superior to epidural morphine given postoperatively for pain relief after lumbar laminectomy.

Adult↗
PubMed1999

Statistical approaches in the development of clinical practice guidelines from expert panels: the case of laminectomy in sciatica patients.

BACKGROUND: Variation in expert opinion and lack of a systematic methodology hinder the development of reliable clinical practice guidelines. However standardized protocols have been defined to quantify, combine, and summarize expert judgments. In addition, statistical methods may help to outline guidelines based on simplified models of these judgments. METHODS: To test this hypothesis, stepwise logistic regression (SLR) and classification tree pruning (CTP) were used to predict the results of two expert panels (USA 1992 and Switzerland 1995) on laminectomy in sciatica conditions. Both panels, using the RAND-UCLA explicit method, assessed whether the procedure would be inappropriate or of potential use in 720 case scenarios combining 7 relevant factors. RESULTS: Laminectomy was rated as inappropriate in 60% and 70% of the scenarios by the US and Swiss panels, respectively. Either statistical method, in both panels, based its simplest model on the same 4 factors, as follows: imaging test results; disability; neurological findings; and conservative treatment trials (in decreasing order); the influence of 2 other factors, duration of pain and nerve root irritation, were only marginal. The correct classification rates of the models were 89% and 93% for SLR and 93% and 85% for CTP. Adopting the CTP US algorithm as a guideline would lead to consider performing laminectomy only in patients with imaging evidence of hernia, relatively severe disability, reflex abnormalities, and previous nonsurgical treatment. Adherence to the corresponding CTP Swiss algorithm would result in less restrictive conditions. CONCLUSION: The statistical techniques proved as useful instruments to structure and simplify appropriateness criteria developed by expert panels and to outline parsimonious decision models for clinical practice.

Algorithms↗