Laminectomy Surgery for Spinal Stenosis

Our spine (through the aging process) will begin to change, often

leading to degeneration of the vertebrae (bones), discs, muscles, and ligaments.

These changes may lead to spinal stenosis. The term “stenosis” comes from the

Greek word meaning “choking” and is often the result of degenerative conditions for

people most often over 50 years of age. It involves narrowing of the spinal canal,

nerve root canals, or invertebral foramina most often occurring in the cervical and

lumbar regions. When the spinal nerves in the lower back are choked, lumbar spinal

stenosis occurs and most often leads to different types of leg pain along with

tingling, weakness or numbness that radiates from the lower back into the buttocks

and leg. This is due to the pressure on the sciatic nerve roots within the spine that

travel down the back of the leg.

Etiology

Since spinal stenosis is part of the aging process, it’s difficult to predict who

will be affected.

There are two forms of spinal stenosis:

Primary stenosis is congenital and uncommon. The condition is diagnosed

more easily because patients are younger and usually lack other complicating

medical problems.

Acquired stenosis is a degenerative condition and the more common form.

Patients generally become symptomatic at age 50 years or older.

Degenerative changes of the spine, like bulging disks, can result in canal or

foraminal narrowing.

Factors related to increasing a persons risk of developing spinal stenosis are:

Sex, men are at greater risk due to carrying a greater proportion of total body

weight in their upper body. Age, as a person gets older the disks tend to lose their

moisture content an become thinner. Occupation, long periods of driving and/or

heavy lifting put extra stress on the lumbar vertebrae. Lifestyle like wearing high

heeled shoes, or carrying heavy briefcases affect the spines alignment. Obesity

especially concentrated in the abdomen adds strain on the supporting structures of

the spine. Finally, trauma to the back may lead to misalignment or a ruptured disk.

Treatments

Medical therapy involves physical therapy, anti-inflammatory drugs

(NSAIDS) muscle relaxants, narcotic opiods, anticonvulsants, and epidural steroid

injections. These treatments may be used to manage symptoms on a long-term basis

for patients who are not surgical candidates.

Surgical therapy is needed for patients that have spinal cord compression

and include laminectomy and posterior foraminotomy. Lumbar laminectomy is also

Known as open decompression.

Diagnostic tests

The patient's history and physical examination are 2 of the most reliable

means to establish the diagnosis. Although, imaging studies of the spine are

absolutely necessary to establish the correct diagnosis.

Plain spine radiograph

Although this is not the most sensitive imaging study to show stenosis from

degenerative changes, the flexion-extension views are very useful to show spinal

instability.

MRI or CT myelogram

These are the imaging studies of choice. MRI is the first choice because CT

myelogram is invasive. However, if a better delineation of the bony anatomy and the

specific nerve root's involvement is necessary, a CT myelogram has the advantage

over MRI. CT scan alone is not as helpful, but it is a good alternative if MRI or CT

myelogram is not possible. The prognosis for spinal laminectomy to alleviate pain

from spinal stenosis is generally favorable.

The expected outcome following a laminectomy:

Approximately 70% to 80% of patients will have significant improvement in their

function (ability to perform normal daily activities) and a markedly reduced level of

pain and discomfort associated with spinal stenosis. The procedure is much more

effective for the relief of sciatica, which can be very severe. It is less effective for the

patient suffering from lower back pain because lumbar stenosis is often created by

the joints becoming arthritic. Much of the lower back pain is from the arthritis. The

surgical removal of the lamina does create more room for the nerve root, but it does

not eliminate the degenerative process of arthritis therefore symptoms may recur

after several years.

Prior to Surgery

Diagnostic tests are required prior to surgery and may include lumbar

computed tomography (CT), magnetic resonance imaging (MRI), and Myelograms

all of which can indicate the degree of herniation, bone spurring, or disc space

collapse and allow the neurosurgeon to perform the procedure according to the

level of severity. One or more of these tests may be required in order to diagnose the

problem most accurately. Most hospitals require patients to have the following tests

before a laminectomy:

-A complete physical examination

-Complete blood count (CBC)

-An electrocardiogram (EKG)

- A urine test

- Tests that measure the speed of blood clotting. (PTT)

Aspirin and arthritis medications should be discontinued seven to 10 days before a

laminectomy because they thin the blood and affect clotting time. Patients should

provide the surgeon and anesthesiologist with a complete list of all medications,

including over-the-counter and herbal preparations, that they take on a regular

basis. The patient is asked to stop smoking at least a week before surgery and to

take nothing by mouth after midnight before the procedure. The patient may not eat

or drink anything after midnight, the night before surgery, unless otherwise

directed by their doctor.

Preoperative medications include IV antibiotics.

PREOPERATIVE TEACHING

• Demonstrate and ask the client to practice logrolling;. To ensure healing, the spinal

column must remain in alignment when turning and moving.

• Explain the importance of taking pain medications regularly and to ask for them

before the pain is severe. Include information about the possibility of the pain being

much the same after surgery. Pain is easier to control if medications are taken

before the pain is severe. Pain may be the same following surgery for a herniated

intervertebral disk because edema due to surgery irritates and compresses the

nerve roots.

• Demonstrate the use of a fracture bedpan and ask the client to practice its use. The

client usually must remain flat in bed for a period of time following surgery. A

fracture bedpan is more comfortable for clients who must lie flat.

• Explain that the client may need to eat while lying flat. This position prevents

flexion of the spine.

• Demonstrate and ask the client to practice deep breathing, the use of the incentive

spirometer, and leg exercises. Ask the client to practice these skills. These measures

prevent respiratory and circulatory complications.

Intraoperative Care

The lumbar laminectomy is designed to remove a small portion of the bone over the

nerve root and/or disc material from under the nerve root to give the nerve root

more space and a better healing environment. To obtain effective decompression of

the lateral recess, the surgeon should remove the medial part of the hypertrophic

facet joint. This is done utilizing general anesthesia on patient, with an endotracheal

tube for ventilator breathing during the surgery. A 4-8 centimeter (depending on

the number of levels) longitudinal incision is made in the midline of the low back,

directly over the area of the spinal stenosis. The fascia and muscle is gently divided

in the midline, and retractors are used to allow the surgeon to visualize the

posterior vertebral arches. After the retractor is in place, an x-ray is used to confirm

that the appropriate spinal level(s) is identified. The wound area is usually washed

out with sterile water containing antibiotics. The deep fascial layer and

subcutaneous layers are closed with a few strong sutures. The skin is closed using

stitches or surgical staples. A sterile bandage is applied, and is changed daily while

in the hospital. The total surgery time is approximately 1 _ to 3 hours, depending on

the number of spinal levels involved.

Risks associated with a laminectomy include: bleeding infection damage to the spinal cord or other nerves weakening or loss of function in the legs blood clots leakage of spinal fluid resulting from tears in the dura, the protective

membrane that covers the spinal cord worsening of back pain

POSTOPERATIVE CARE

Phase 1 or PACU (Post Anesthetic Care Unit) is where a patient goes

immediately after their time in the OR. This is a critical care area - a patient's airway,

vital signs, pain, nausea management, and fluid status are the primary focus here.

Due to all anesthetics - general or spinal, sedatives, analgesics, and nerve blocks

have the potential to affect vital signs (usually a depressive effect), patients are

carefully monitored to assure safe recovery. Usually done every one to four hours

depending on the patient, frequency may increase to every 15 minutes if results are

abnormal. An artificial airway is usually maintained in place until reflexes for

gagging and swallowing return. When the reflexes return, the patient usually spits

out the airway. When the patient's physical status and level of consciousness are

stable, the surgeon clears the patient for transfer to his room. Call the nursing unit

and give a verbal report to include the following:

(a) Patient's name

(b) Type of surgery.

(c) Mental alertness.

(d) Care given in the recovery room.

(e) Vital signs, at what time they were taken, and any symptoms of complications.

(f) Presence, type and functional status of intravenous fluids, and any suction or

drainage systems.

(g) Whether or not the patient has voided, if a catheter is not in place.

(h) Any medications given in the recovery room.

Usually a patient controlled analgesia (PCA) pump, or an epidural is used to

control pain for one to three days before switching to oral pain medications. When

they go home, most people are taking Oxycontin, MS Contin, Percocet, Vicodin,

Oxycodone, or a combination of narcotic and muscle relaxant. After surgery, the

patient spends an hour or so in the recovery room. A drainage tube is often used to

remove excess fluid from the surgical area. The drain is usually removed on the first

or second day after surgery. Bandages cover the incision. They are usually changed

the second day after surgery.

The ICU nurse should maintain proper functioning of drains, tubes, and

intravenous infusions, prevent kinking or clogging that interferes with adequate

flow of drainage through catheters and drainage tubes. Monitor intake and output

precisely, to include all Intravenous fluids and blood products, urine, vomitus,

nasogastric tube drainage, and wound drainage. Implement safety measures to

protect the patient. Keep the side rails raised at all times. If the patient had a spinal

anesthetic, observe and report any feeling or spontaneous movement. Movement

usually returns before feeling. Movement returns in the patient's toes first, and

moves upward. As the anesthesia wears off, the patient will begin to have sensation

often described as "pins and needles."

• Maintain the client in a position that minimizes stress on the surgical wound.

For clients with lumbar laminectomy:

a. Keep the bed flat or elevate the head of the bed slightly.

b. Place a small pillow under the head.

c. Place a small pillow under the knees, or use a pillow to support the upper leg

when the client lies on one side.

• Turn the client every 2 hours, using the logrolling technique.

• Monitor the client for signs of nerve root compression. Assess leg strength, ability

to wiggle the toes, and ability to detect touch. Compare bilateral findings.

• Assess for hematoma formation as manifested by severe incisional pain that is not

relieved by analgesics and decreased motor function.

• Assess for leakage of cerebrospinal fluid. Assess the dressing for increased

moisture. Check the sheets for wetness when the client is lying supine; check for

clear liquid running down the back when the client is sitting or standing. Gently

palpate the sides of the wound to detect a bulge. Use a Dextrostrix strip to

assess any leakage for the presence of glucose, a positive indicator of cerebrospinal

fluid.

• Assess for nerve root injury. Assess the client’s ability to dorsiflex the foot

Nerve root compression may cause permanent damage, resulting in footdrop.

. • Assess for urinary retention. The client should void within 8 hours after surgery.

Compare intake and output for each 8-hour period. All clients who have received a

general anesthetic are at risk for urinary retention. The client who has had a lumbar

laminectomy may have even more difficulty voiding as a result of stimulation of

sympathetic nerves during surgery.

• Assess for pain using a scale from 0 (no pain) to 10 (severe pain). Administer

prescribed analgesics on a regular basis, or teach client to use PCA analgesia, if

prescribed .

• Assess for infection by taking and recording vital signs at least every 4 hours;

report increased body temperature. Assess the wound and dressing for signs of

infection.

• Encourage deep breathing and the use of the incentive spirometer every 2 hours;

coughing may be discouraged. Anesthesia and immobility depress respiratory

function. Coughing may be discouraged because it can disrupt healing tissues.

• Increase mobility as prescribed. Many clients ambulate the first or second

postoperative day. Early ambulation increases respiratory and circulatory function

and decreases the risk of thrombophlebitis of the lower extremities.

Aftercare

Aftercare following a laminectomy begins in the hospital. Most patients will remain

in the hospital for one to three days after the procedure. During this period the

patient will be given fluids and antibiotic medications intravenously to prevent

infection. Aftercare during the hospital stay is also intended to lower the risk of a

venous thromboembolism (VTE), or blood clot in the deep veins of the leg.

Prevention of VTE involves medications to thin the blood and wearing compression

stockings or boots.

Most surgeons prefer to see patients one week after surgery to remove

stitches and check for any postoperative complications. Patients should not drive or

return to work before their checkup. A second follow-up examination is usually

done four to eight weeks after the laminectomy.

Patients can help speed their recovery by taking short walks on a daily basis;

avoiding sitting or standing in the same position for long periods of time; taking

brief naps during the day; and sleeping on the stomach or the side. They may take a

daily bath or shower without needing to cover the incision. The incision should be

carefully patted dry, however, rather than rubbed. The surgeon will often

recommend that the patient avoid bending over or lifting heavy objects for several

weeks or months following back surgery. Prepare the patient and the family for,

discharge. Supply the patient or family member with written instructions for

wound care, medications, and making outpatient appointments.

Here are several practical guidelines to help ease the transition home

following back surgery:

Toilet riser

A toilet riser comes in handy for people who anticipate difficulty getting on or off

the toilet in the weeks after surgery.

Common items within easy reach

Place frequently used objects in a convenient location within easy reach. For

example, it may be beneficial to have frequently used items such as dishes and pans

in upper cabinets to avoid having to bend over to reach for them in the lower

cabinets.

Slip on shoes

If bending needs to be avoided, buying slip-on shoes will allow patients to avoid

having to bend down to tie shoes.

NURSING DIAGNOSIS 1

Ineffective tissue perfusion r/t degenerative disease as evidenced by decreased

ROM.

DESIRED OUTCOMES

PATIENT WILL:

Report normal sensations and movement 4 to 6 weeks post-op.

INTERVENTION 1

Assess movement/sensation of lower extremities and feet q4 hr. post-op.

RATIONALE

Tissue hemorrhage may be compressing the spinal cord, requiring

prompt medical intervention.

INTERVENTION 2

Inspect dressing for excess drainage and test for glucose if halo sign is seen.

RATIONALE

Change in contour of operative site suggests hematoma/edema formation.

Inspection may reveal dura leak of CSF (will test glucose-positive),

requiring prompt intervention.

INTERVENTION 3

Monitor blood counts, e.g., hemoglobin (Hb), hematocrit (Hct), and red blood cells

(RBCs) including platelet count, as ordered.

RATIONALE

Aids in establishing replacement needs and monitors effectiveness of therapy,

including PTT, which monitors clotting time ensuring efficient healing time of

surgical incision.

NURSING DIAGNOSIS 2

Knowledge deficit regarding self care r/t information misinterpretation as

evidenced by inaccurate follow-through of instructions.

DESIRED OUTCOME:

Patient will verbalize understanding of therapeutic regimen prior to discharge.

INTERVENTION 1

Stress the importance of avoiding activities that increase the flexion of the spine like

bending at the knees with legs straight, or prolonged sitting.

RATIONALE

Flexing and twisting of the spine aggravates the healing process and increases risk

of injury to spinal cord.

INTERVENTION 2

Provide written copy of all instructions given prior to discharge.

RATIONALE

Provides patient with poor recall a reference to use for self care after discharge.

INTERVENTION 3

Listen and communicate with patient regarding alternatives and lifestyle changes.

Be sensitive to patient’s needs.

RATIONALE

Lower back pain is a chronic disability and patients may have to modify work,

creating relationship and financial crisis.

NURSING DIAGNOSIS 3

Impaired physical mobility r/t limitations imposed post-op as evidenced by pain.

INTERVENTION 1

Encourage participation in ADL’s within individuals limitations.

RATIONALE

Patient participation promotes independence and sense of control.

INTERVENTION 2

Review proper body mechanics for participation in activities

eMedicine Specialties > Neurosurgery > Spine

Spinal StenosisAuthor: John Nk Hsiang, MD, PhD, Director of Spine Surgery, Swedish Neuroscience InstitueContributor Information and DisclosuresUpdated: Jul 30, 2009

www.spine-health.com

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