Breaking Down and Understanding:

Laminectomy

Laminotomy,

&Spinal Fusion

Laminotomy, Laminectomy and Spinal Fusion 2

1. The need for a Laminotomy, Laminectomy or Spinal Fusiona. Causative Factorsb. Signs and Symptoms

2. Laminectomya. Descriptionb. Visualizationc. Primary Goal and Aims of Treatmentd. Riskse. Clinical Nursing Considerations

3. Laminotomya. Description

i. Differentiation between a Laminotomy and a Laminectomyb. Visualizationc. Primary Goal and Aims of Treatmentd. Riskse. Clinical Nursing Considerations

4. Fusiona. Description

i. Posterior Fusion, Anterior Fusion, Posterior Interbody Fusion, and Anterior Interbody Fusion

ii. Primary and Secondary Indicationsb. Visualizationc. Primary Goal and Aims of Treatment

i. Primary treatment (Ffracture) vsii. Reinforcement (Laminectomy stabilization)

d. Riskse. Clinical Nursing Considerations

5. Post-Op Rehabilitation and Patient Education

6. EBP Research Articles and Conclusions on the Different Procedures

References

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1. The need for a Laminotomy, Laminectomy or Spinal FusionSpinal Stenosis and a Herniated Disk are the two most common causative factors

leading up to a corrective Laminotomy or Laminectomy procedure.Spinal stenosis is the result of degeneration of the spine, and refers to an abnormal

narrowing of the spinal canal, and this narrowing of the canal compresses the nerves as they pass through the stenosed part of the spine. The common symptoms of stenosis (depending on where the location of stenosis is occurring) are numbness, weakness or stiffness of the extremities, gait abnormalities, neurogenic claudication (symptoms which occur with activity), and pain.

Hypertrophy of the Ligamenta Flava (Latin for yellow ligament) which are ligaments that connect the laminae (the vertebral “roof”) of adjacent vertebrae, can also cause spinal stenosis because it lies inside the posterior portion of the vertebral canal (Fig.1). Each ligament consists of two lateral portions which commence one on either side of the roots of the articular processes (Fig.5), and extend backward to the point where the laminæ meet to form the spinous process (Fig.2). Each consists of yellow elastic tissue, the fibers of which, almost perpendicular in direction, are attached to the anterior surface of the lamina above, some distance from its inferior margin, and to the posterior surface and upper margin of the lamina below. In the cervical region the ligaments are thin, but broad and long; they are thicker in the thoracic region, and thickest in the lumbar region.

Disc herniations often require aggressive surgical repair, however, surgical repair of a herniated disc is usually the last resort after conservative medical treatment fails or the herniation is severe, or significantly impairs the patient’s quality of life. Discs are the soft, gelatinous cushions that function as a shock absorber between the hard, bony vertebrae. Lower back herniations are often caused by trauma such as a fall or lifting something the wrong way, patients typically experience sudden and severe pain when the trauma occurs, which then usually recedes without treatment and then gradually worsens over time. Additional possible causes of disc herniations are disc degeneration, and loss of elasticity, spur formation, spondylosis (degenerative arthritis causing pressure on nerve roots and subsequent pain) and spondylolisthesis (any forward slipping of one vertebra on the one below it). A herniated disk occurs when the nucleus of the disk protrudes out through the disk wall and exerts pressure against a nerve in the spinal canal, which can cause a wide range of symptoms depending on where the herniation occurs and the degree to which the nerves entering the spine, or the spine itself, are affected. In addition to pain around the site of the herniation, many patients also experience significant pain elsewhere in the body other than where the herniation is physically located. This is due to the pressure being exerted on the surrounding nerves that carry impulses from different parts of the body to the spine and then to the brain. Thus, the pain feels as though it is being experienced in the area from where this nerve originates. Symptoms include back pain, aching/cramping of the legs, neurogenic claudication (pain that gets worse with activity), muscle spasms, neurological deficits such as numbness and paraesthesia, reflex loss, motor weakness and muscle atrophy.3

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The two main causative factors requiring a spinal fusion is a vertebra fracture – usually when a transverse process has been broken off, or after severe trauma to the body of one or more vertebrae requiring surgical decompression and fusion, or after having a laminectomy procedure. The most common symptom requiring spinal fusion to correct is the immobilizing pain the patient feels with movement. Even just the movement of breathing may be seen to cause the patient unbearable pain.

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2. LaminectomyThe term laminectomy is derived from the Latin words lamina (thin plate, sheet or layer), and -ectomy (removal). The older, more radical version of this type of surgery is the laminectomy. This is where the lamina, (posterior aspect of the spinal canal) is removed entirely. A laminectomy is used to remove the lamina (roof) of the vertebrae

to provide access to a herniated disk for a discectomy, or used to “trim” the lamina to create more space for the nerves leaving the spine with spinal stenosis. Discectomy is the surgical removal of herniated disc material that presses on a nerve root or the spinal cord. The procedure involves removing the central portion of an intervertebral disc, the nucleus pulposus, which causes pain by stressing the spinal cord or radiating nerves.

A laminectomy is a spinal surgery that involves removing bone to relieve excess pressure on the spinal nerve(s). Conventional laminectomy, as opposed to a laminotomy, remains the gold standard of treatment for disc herniation and spinal stenosis. A laminectomy treating a disc herniation involves removing the vertebral roof (which involves removing the spinous process and removing lamina), pulling aside the neuro components (dura) and locating the herniated disk, discectomy of the disk material and then a spinal fusion. A laminectomy treating spinal stenosis involves removing the vertebral roof over the stenosed area of the spine in order to decompress the narrowed areas exerting painful pressure on the nerves.

Problems with these procedures occur due to the extensive soft tissue dissection and the risk of spinal instability, thus the need for spinal fusion and stabilization. This current surgical treatment is not entirely satisfactory.

Mahadewa (2010) explained how a Laminectomy with Fusion is used to treat spinal stenosis; the decompressive procedure consists of removal of the spinous process, bilateral laminectomy (explained in the next section), partial bilateral facetectomy (surgical removal, excision of the articular facet/s), and foraminotomy (removal of the roof of the intervertebral foramen), followed by a spinal fusion using the current pedicle screw and rod system and implanting the harvesting bone graft material, usually harvested from the iliac crest.

The primary goal and aim of treatment is to restore quality of life and

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the elimination of the pain and the other signs and symptoms the patient experienced prior to the procedure6.

There are always risks even if the surgery is done correctly and effectively, such as significant blood loss, postoperative wound pain, prolonged hospital stay and impaired spinal stability requiring fusion or stabilization.

There is always the risk of infection whenever there is an opening in the skin’s integrity. There’s a risk that the nerves could be damaged, especially in the area where a herniated disk is removed, which could cause numbness or pain along a nerve path. There’s a significant risk of instability of the spine due to the significant amount of bone removal of the procedure; thus, concurrent spinal fusion or another surgery later may be required to fuse that part of the spine. Graft rejection resulting in a failed fusion always carries significant risk associated with a laminectomy as well.

Complications for nurses to watch for:The dura (tough tissue surrounding the spinal cord) may be torn, causing cerebral

spinal fluid to leak out of the spinal cord. The nurse should look at the drainage and the drain system in place and watch for worsening headaches that worsen upon sitting/standing up. If a CSF leak is suspected instruct the patient to lie flat in bed for a time and collect a sample of the fluid to test it in order to determine if it is CSF. Insertion of a lumbar drain is one method of treatment for a CSF leak. Some patients with CSF leaks need an additional surgery to repair the nicked dura in the spinal canal.

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3. LaminotomyThe term laminotomy is derived from the Latin word lamina (thin plate, sheet or

layer), and the Greek word -tome (incision; division of one of the vertebral laminae). In a laminotomy (or lumbar microdiscectomy) only a small part of the lamina directly over the affected area is removed. For example, to correct a herniated disc, in this procedure, a small piece of bone (lamina) is removed from the affected vertebra, allowing the surgeon to better see and access the area of disc herniation for a discectomy without compromising the integrity and stability of the spine or requiring spinal fusion, which is often the result of a laminectomy

procedure. Discectomy is the surgical

removal of herniated disc material that presses on a nerve root or the spinal cord. The procedure involves removing the central portion of an intervertebral disc, the nucleus pulposus, which causes pain by stressing the spinal cord or radiating nerves. A. a small incision is made B. portions of the lamina

are removed C. neural elements exposed D. all herniated disc material is removed.

Mahadewa (2010) explained how a Laminotomy is used to also treat spinal stenosis, instead of completely removing the vertebral arches and then using spinal fusion as in a Laminectomy. The spinous processes are removed at their insertion into the posterior arch, flavectomy (removal of the ligamentum flavum) is done leaving a narrow channel exposing the

spinal canal. The lamina is undercut at the stenotic levels, then laterally to undercut the medial facets on each side to decompress the nerve roots (and visualize the dura - tough tissue surrounding the spinal cord) while leaving most of the facets intact. The decompression is advanced to the lateral recesses and foraminal areas (Fig.8) until all hypertrophic flavum ligaments and

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hypertrophic and stenosed (narrowed, constricted) facet joints compressing the roots have been completely removed.

The primary goal of the treatment procedure is to restore quality of life and eliminate the pain and other signs and symptoms the patient was experiencing.

There are always risks even if the surgery is done correctly and effectively, such as significant blood loss and postoperative wound pain, the risk of infection and the nerves may be damaged, especially in the area where the disk is removed, which could cause numbness or pain along a nerve path.

Possible complications for nurses to consider:The dura (tough tissue surrounding the spinal cord) may be torn, causing cerebral

spinal fluid to leak out of the spinal cord. The nurse should look at the drainage and the drain system in place and watch for worsening headaches that worsen upon sitting/standing up. If a CSF leak is suspected, instruct the patient to lie flat in bed for some time and collect a sample of the fluid in order to test and determine if it is CSF. Another surgery to correct this is highly likely, if the leak is not closed, this condition predisposes the patient to infection of the spinal column (meningitis).

Although some doctors still prefer the older more radical surgery, there is growing evidence that the Laminotomy, the newer, less invasive procedure, is superior to the Laminectomy with fusion.

A review of several professional journals and research articles revealed that Laminotomy and Laminectomy with fusion are equally effective over the short time the follow ups were conducted (all patients underwent serial clinical fallow-up evaluations for periods ranging from 3-36 months). 4,3,1

Compared to a Laminectomy without Fusion, a Laminotomy procedure may in fact better preserve a person’s quality of life by not requiring the spinal fusion often found to be needed at a later time with a Laminectomy without fusion. The reason is simple: the more bone that is removed, the less strong and stabile the remaining structure is. While removing more lamina often does better relieve symptoms initially, there is a far greater rate of postoperative complications resulting from the spinal instability that are often worse than the original problem. These complications often require subsequent spinal fusion and additional surgeries to treat the postoperative complications caused by the spinal instability resulting from the Laminectomy without Fusion.

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4. Fusion (fig 9)

This is a surgical immobilization where two or more adjacent vertebrae are joined together through the placement of posterior pedicle screw-rod constructs, the application of an osteoinductive material along, and bone grafts or implants. Spinal Fusion is used to correct stability problems and to promote bone growth between the vertebral bodies; the graft material acts as a binding medium – as the body heals, the vertebral bone and bone graft eventually grow together to join the vertebrae and stabilize the spine5.

Posterior Spinal Fusion: This procedure involves accessing the posterior aspect of the spine by making an incision in the patient’s back thus allowing direct access to the posterior aspect of the spinal column, and involves the lateral placement of posterior pedicle screws through the transverse

processes and rod constructs and harvested autogeneous bone grafts.

There are 3 types of Interbody Spinal Fusions (fig 12), with 2 Lateral variations: There are two lateral-interbody variations of the three primary interbody spinal fusion techniques: Transforaminal and Posterior Later-Interbody Spinal Fusions (fig 11).

These procedures both involve accessing the posterior aspect of the spinal column by going through an incision made in the patient’s back, thus allowing access to both the posterior aspect of the vertebral column, lateral access to the anterior aspect of the vertebral column, and the lamina of the transverse processes which are necessary for a screw-rod construct for a posterior lateral bone graft fusion/stabilization. Then a Postero-lateral Spinal Fusion is performed.

Transforaminal Interbody: A unilateral laminotomy and a partial facetectomy (surgical removal of the articular facet (Fig.5)) are performed on the side consistent with the patient’s symptoms or anatomical abnormalities. This procedure preserves spinal integrity by minimizing lamina facet, and pars dissection and places the graft in the middle and anterior section of the vertebral disc space.2 Then a Posterior Spinal Fusion is performed.

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Posterior Interbody: Posterior spinal elements are removed to expose the traversing nerve roots and lateral extent of the disc space. The dura matter is retracted to the midline and the interbody space is exposed and discectomy is performed. This procedure places the graft in the posterior section of the vertebral disc space.2 Then a Posterior Spinal Fusion is performed, “after the interbody construct is placed, pedicle screw/rod are attached. The transverse processes are then decorticated [shaved and bleeding, to make the body’s natural repair system think that one large bone has broken], and the bone graft material is placed over them for a posterolateral fusion.”

(Domagoj, C., 1997, p.121)Anterior Interbody Spinal Fusion:

This procedure involves accessing the anterior aspect of the spinal column by going through the abdominal cavity and usually involves the placement of a fusion cage that is in the form of an artificial disc which uses hollow threaded cylinders filled with bone graft and osteoinductive material to fuse two adjacent vertebrae into one long bone.2

Primary Indications include stabilization & fusion of adult spinal deformity, such as symptomatic spondylolisthesis, degenerative scoliosis,

and spinal stenosis associated with instability. For those with stenosis, but without deformity, surgical management has traditionally involved posterior decompressive procedures, including laminectomy & laminotomy. In patients with spinal instability, fusion is recommended in addition to decompression.

Secondary Indications include recurrent lumbar disc herniations, lateral or massive disc herniations & failed fusions by other techniques.

“The rate of arthrodesis (binding, the fusion of two bones) has been shown to increase given placement of bone graft along the weight-bearing axis. The fusion rate across the disc space is further enhanced with the placement of posterior pedicle screw-rod constructs and the application of an osteoinductive material.” (Cole, C., McCall, T., Schmidt, M., 2009, p.118)

Osteoinduction (the use of osteoinductive material) involves the simulation of osteoprogenitor cells to differentiate into osteoblasts that then begin new bone formation. The most widely studied type of osteoinductive cell mediators are bone morphogenetic proteins (BMPs). A bone graft material that is osteoconductive and osteoinductive will not only serve as a scaffold for currently existing osteoblasts but will also trigger the formation of new osteoblasts, theoretically promoting faster integration of the graft. Decortication of the bone surfaces surrounding the graft helps to aid this process as well.

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The primary goal, and most important purpose of a fusion, is for the elimination of pain. Spinal fusion is performed to correct a fracture, and for several other severe conditions that cause spinal instability which include degenerative joint disease, spondylosis, infections and tumors or when the discs between the vertebrae rupture causing the vertebrae to grind into each other, or when the spine is unstable and can’t maintain the functional alignment between all of its important structures and when abnormal movements cause pain and put adjacent structures at risk of injury; this procedure is also done to reinforce stability of the spine that could worsen after a surgery that weakens the spines integrity, such as a Laminectomy2,5.

As with any surgery there is potential risk involved, complications such as infection, nerve damage, blood clots, blood loss and bowel and bladder problems, along with the indirect-complications such as those associated with anesthesia, are some of the potential risks patients face with this surgery. Another potential risk inherent specifically to spinal fusion is failure of the vertebral bone and graft to properly fuse, a condition that may require additional surgery(ies).

The success rates of lumbar fusion can decrease in patients who smoke, are overweight, have diabetes or other significant medical illnesses, have osteoporosis, or who have had radiation treatments that included the lower back. Good nutrition and slowly increasing activity in the recovery period can help achieve success.

Nursing considerations to keep in mind is that the implant may shift slightly after surgery to the point that it is no longer able to hold the spine stable. If the implant migrates out of position, it can cause injury to the nearby tissues. If an implant shift is suspected the patient should be bedfast and be instructed not to move until the surgeon is contacted and the position is checked, usually a fluoroscope is used to check the position. Hardware can also cause problems. Screws or pins may loosen and irritate the nearby soft tissues.

Also, not all patients achieve complete pain relief results with this procedure. Full fusion can take up to three months. As with any surgery, patients should expect some pain afterwards, however, if the pain continues, seems unusual, or becomes unbearable nursing-decisions, clinical judgment and professional discretion should be used and possible complications should be taken into consideration.

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5. Post-Op Rehabilitation and Patient EducationDressings should be inspected for bleeding and cerebral spinal fluid leakage

indicating dura sheath damage and needs to be documented and reported immediately. Specific positioning of individual patients and activities are followed per

surgeons’ post-op orders. In general, the patient should be maintained in a supine position with the head of the bed about 5-10 degrees for the first post-op hour, and then the head of the bed no higher than 45 degrees for the next 1-2 hours post-op, and repositioned every 2 hours by log-rolling the patient – pillow between their legs – educate the patient on the importance of NOT TWISTING their body and maintaining spinal alignment.

An incentive spirometer should be encouraged every hour to promote deep breathing and decrease the chance of developing a lung infection, such as pneumonia.

The patient should be encouraged to void 8-12 hours post-op, and should be assessed for bladder distention if urinary retention is suspected and indicators of the patient’s possible need for catheterization.

The patient is taken off NPO status and allowed to slowly start eating solid food only after bowel sounds can again be auscultated.Medications:Medication given after these procedures is usually anti-inflammatory, muscle relaxant and antibiotic/prophylactic and narcotic in nature.Fluid balance:

Fluid balance is closely monitored and maintained through the administration of intravenous fluids and assessing the patient’s output.Orders:

Post-op day 1, with assistance from the nursing staff or therapists, the patient can be encouraged to get out of bed and resume some normal activities like getting dressed, toileting and showering, depending on the patient’s pre-surgical activity level.Consults:

A physical therapist should be consulted, they can teach the patient special exercises to help improve movement and decrease pain. Physical therapy can also help improve the patient’s strength and limit the risk of loss of function.Patient Education and Post-Discharge Instructions:

Incisional care should be taught to the patient and family care givers.No heavy lifting, pushing, pulling or shoving anything heavier than 5lbs.Long car rides (>40min) are permitted only when absolutely necessary, instruct

the patient that they must be able to stop at intervals of not more than 45-60min & walk for a few minutes.

No driving until seen by their physician at their post-op/follow-up visit.Instruct patient to walk as often as can tolerate after discharge, this should be

explained as aiding & increasing the rate of arthrodesis (binding, fusing two bones).Do exercises given in the Post Laminectomy & Post Fusion Back Program.Instruct patients to circle and omit any exercise that hurts abnormally, or causes

unusual discomfort but to continue the other exercises given in the post-laminectomy or post-fusion back program until their follow up visit, at which time they should bring the booklet and inform their doctor of the painful exercises. Each exercise targets specific muscles, so this will give their doctor an indication of what to address to fix the problem.

Do not wear anything tight over the incision.Do not take tub baths. NO TUB BATHS. This includes Jacuzzis as well.

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Instruct the patient that they may shower and pat the incision dry afterward.Proper body mechanics should be taught to the patient to lessen the strain and

pressure on their spine; those include maintaining proper body alignment and good posture and sleeping on a firm mattress.

Sexual intercourse can be resumed around 2 weeks after surgery and with good back support. Patients often ask the inevitable question, “What exactly does ‘good back support’ mean?”, or variations thereof, and the blunt answer to that is “You have to be on the bottom, with a firm mattress”.

Full fusion of the spinal graft itself may take up to three months, and full rehabilitative recovery could take up to eight months.

Ensure that the patient understands their need to make a follow-up visit in 2 weeks, and that they understand the importance of their follow-up visit.

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6. EBP Research Articles and Conclusions on the Different Procedures

Comparative Study of Laminotomy vs. Laminectomy with Fusion:Cole, C., McCall, T., Schmidt, M. (2009)

The aim of this study was to observe the outcome of canal decompression in lumbar stenosis using bilateral Laminotomy and Laminectomy with Fusion and compare the results.

The results showed “that bilateral laminotomy and laminectomy with fusion are equally effective over a short follow up. However, bilateral laminotomy is a less invasive procedure.” (Mahadewa, 2010, p153)

These results can only be generalized to patients with lumbar canal stenosis and compression due to hypertrophy of the flavum ligament, hypertrophic facet joints, posterior spur formation and disc bulging.4

Mahadewa, 2010 states that laminectomy decompression is effective though associated with significant blood loss, postoperative wound pain, prolonged hospital stay and impaired lumbar stability requiring fusion or stabilization. Complications with the procedure occur due to the extensive soft tissue dissection, paraspinal muscle devascularization and the risk of spinal instability, thus the need for a corrective spinal fusion or stabilization. Bilateral laminotomy decompression and laminectomy with fusion were used to specifically treat lumbar stenosis for this research article.

“In 46 cases, bilateral laminotomy was performed; in 59 patients, laminectomy with spinal fusion was performed…there were no postoperative complications among the 105 patients …No patient had additional surgery in the lumbar spine during the follow-up study of 3-36months, and no patient experienced worsening back pain or neurological function. …moreover, the surgical outcome, including results of the postop Visual Analog Scale (VAS) for pain evaluation, Neurogenic Claudication Outcome Score (NCOS) and Oswestry Disability Index (ODI) for neurological outcome evaluation [and] radiographs obtained postoperatively and at regular intervals to evaluate the correct placement and stability of the implant system, did not differ between the two groups. Bilateral Laminotomy thus has the advantage as a less invasive method.” (Mahadewa, 2010, p155, 157)

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Design of Lamifuse: a randomized, multi-centre controlled trial comparing laminectomy without or with dorsal fusion for cervical myeloradiculopathy(Study Protocol)Bartels, R., Verbeek, A., Grotenhuis, J. (2007)

Bartles (2007) identifies that the complications related to adding lateral mass screws or pedicle screws are vertebral artery injury and temporary or permanent nerve root damage. In order to prevent damage to the spinal cord, the instrumentation should be completed before the laminectomy with fusion. Also, since instrumentation is added in the fusion group, the costs will be higher.

In the article, Bartles (2007) addresses the quality of life after a spinal fusion, spinal stenosis naturally limits spinal mobility, so a laminectomy with fusion won’t decrease the patient’s quality of life, and in fact, when indicated/required may even have better clinical outcomes when compared to a laminectomy without fusion.

The main hypothesis of the article was that patients who are surgically treated for signs and symptoms due to a stenosis of the cervical spinal canal have a better clinical outcome when a fusion is performed in addition to a laminectomy when compared to those that solely have a laminectomy.

Bartles (2007) addressed that the quality of life, the complications and the costs of the two procedures needs to be evaluated comparing these two treatment groups in a future study.1

“Despite a long-lasting interest in the various techniques, the clinical superiority of one method over the other has never been established. To our knowledge, a randomized-controlled trial comparing laminectomy with or without fusion has never been performed.” (Bartles (2007, p.2)

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Comparison of low back fusion techniques: Transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) approachesCole, C., McCall, T., Schmidt, M. (2009)

The advantages of the TLIF procedure stems from the approach of the procedure and includes a lesser risk of neurological injury and impairment, better positioning of the graft implementation within the intervertebral disc space, improved spinal alignment due to the graft placement within the anterior spinal column, and increased stability and integrity of the spinal column via increased preservation of the lamina and the articulating facets.

The advantages of the TLIF technique relies on distracting the motion segment through pedicle screw placement before cage insertion, thus decreasing the risk for a durotomy (dural sheath tear) and limiting the risk of neurological injury. With TLIF the graft is placed within the anterior or middle of the disc space to restore the normal curvature of the spine and correct lordosis. Lastly, posterior fusion is better achieved with a TLIF because this procedure allows additional surface area by preserving the spinal processes and lateral laminae.

Medical doctors and research agrees that most cases of low back pain are transient, with only 5% becoming chronic and disabling which needs aggressive treatment, however that’s where the agreement ends, the cause of spinal pain is not completely understood and remains controversial, therefore surgical treatment is also controversial.

Thus, the aim of this research article focused on addressing the risks associated with each procedure and which procedure had the least.

The comparison of each procedure and which procedure was concluded as being “better” than the other was based solely on which procedure had the least risk, rather than patient outcome postoperatively.

According to Cole, McCall, Schmidt (2009), there is no convincing evidence to support routine use of lumbar treatment for primary lumbar disc excision, but may be used as supplementary tx in patients with a herniated disc in whom there is evidence of pre-op spinal deformity.

Because lumbar deformity, instability, or even chronic low back pain may occur as a result of a reoperative lumbar discectomy, fusion is often considered part of the primary tx in the setting of repeated lumbar disc herniation repairs.

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Reference:

1. Bartels, R., Verbeek, A., Grotenhuis, J. (2007). Design of Lamifuse: arandomized, multi-centre controlled trial comparing laminectomy without or with dorsal fusion for cervical myeloradiculopathy. BMC Musculoskeletal Discorders. 8(111). (This article is available from: http://www.biomedcentral.com/1471-2474/8/111.

2. Cole, C., McCall, T., Schmidt, M. (2009). Comparison of low back fusion techniques: transforaminal lumbar interbody fusion (TLIF) or posterior lumbar interbody fusion (PLIF) approaches. Curr Rev Musculoskelet Med. Volume 2 : 118 – 126.

3. Domagoj, C. (1997). Posterior lumbar interbody fusion in the treatment of symptomatic spinal stenosis. Neurosurg Focus. 3 (2), article 5.

4. Mahadewa, T., Maliawan, S. (2010). A comparative Study of bilaterallaminotomy and laminectomy with fusion for lumbar stenosis. Neuology Asia. 15(2) : 153 – 158.

5. Resnick D, Choudhri T, Dailey A, et al. (2005) Guidelines for the performance offusion procedures for degenerative disease of the lumbar spine. Part 1: introduction and methodology. J Neurosurg Spine. Volume 2 : 637-638.

6. Silvers, H., Lewis, P., Asch, H. (1993). Decompressive lumbar laminectomy for spinal stenosis. J Neurosurg. Volume 78 : 695 – 701.

7. Taber’s (2001). Cyclopedic Medical Dictionary. F.A. Davis Company : Philidelphia.