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Step by step how to perform a lumbar laminectomy

hey everyone

dr armagani here today to talk to you

about the lumbar laminectomy this is a

procedure performed through your back

to help remove pressure off of your

nerves if you have severe compression of

your nerves in your lower back

you may be experiencing symptoms of

discomfort particularly in your buttocks

and hamstrings

but it can even go all the way down to

your calves and feet in this video we

will be discussing the normal anatomy of

your lower back

as well as step by step how i perform

this procedure

at the end of this video i'll discuss

risks expected recovery

as well as any post-operative

restrictions if you want to skip around

to different sections of this video

please see the timestamps in the

description below to find the parts you

want to learn about the most

now that we have an overview of the

video let's get started

okay now that we're here let's start our

discussion on the lumbar laminectomy

before we get started though we should

have a better understanding of what the

normal anatomy looks like in your lower

back

this is a particular view as if we're

looking at you from your back

in so this is going to be your lumbar

vertebrae

we're going to be looking at a few of

the anatomic landmarks that are

important the first of which being the

spinous process

this is the bone that juts out from your

vertebrae that you can actually feel

when you're touching your back

coming down from the spinous process is

what's called the lamina

the lamina is the bony covering that is

on top of your spinal canal

the lamina protects the spine and nerves

underneath

underneath the lamina is going to be a

protective covering which is a ligament

called the ligamentum flavum

this helps protect your spinal canal

below the ligamentum flavum and

inside of your spinal canal is actually

going to be the dura

the dura you can imagine is a long

balloon that begins from the base of

your skull and goes all the way down to

your lower back

inside of the dura contains spinal fluid

as well as your nerve rootlets lastly

the connection between the bones in the

lower back

are going to be called the facet joints

these are the areas where your bones

connect so if you could imagine

if we call this bone your lumbar fourth

vertebrae or l4

and this bone is going to be your lumbar

fifth vertebrae or l5

the connection between these bones is

going to be at this joint here

on the left and on the right these facet

joints help you

maintain your motion and flexibility

let's now move on to what the view of

these same structures would look like

from the top

this is again a top view or a cross

section where if we cut you in half this

is what we're looking at

so to orient you up top here is going to

be where the skin of your back is

and way down at the bottom is going to

be where the front of your body is

so going over those anatomic landmarks

that we looked at previously

the spinous process is going to be in

red remember again

the very tip of the spinous process is

the bone you can actually feel when

you're touching your lower back

coming down from the spinous process is

going to be the lamina

and the facet joints which are the

connections between adjacent vertebrae

are highlighted here in black this is a

joint just like any other joint that you

would have in your body like your knee

or your hip

it helps connect two bones together so

that you could have motion

directly underneath the lamina is going

to be that protective ligamentous

covering

that covers the spinal canal that's the

ligamentum flavum highlighted here in

green

beneath the ligament and flavum is going

to be that protective covering that

helps protect your nerve rootlets

which are highlighted here in purple so

again the dura

is that long balloon that we're just

seeing in cross-section here

that protects the nerve rootlets which

are inside

this white that's between the nerve

rootlets and the edge of the dura

is going to be spinal fluid which

basically gives nutrients to the nerves

within the lower back lastly the disc is

highlighted here in black

when you begin to discuss what spinal

stenosis is it means a narrowing of the

spinal canal

what is the spinal canal well we have

the spinal canal basically shown here

the borders of the spinal canal are

going to be highlighted by my laser

pointer here

in red and as you go around you can see

that there's ligamentum flavum

which is the pink on top you have the

disc below

and then you have bone on either side

this spinal canal is very large because

you can see with the black here which is

the dura

the dura contains spinal fluid which is

white

as well as the nerve rootlets but what

happens as we age

as we age we get some disc degeneration

we get bone spurs and then we get

ligamentum flavum thickening

and as you can see look what happens to

the size of the spinal canal

now this doesn't happen to everyone but

it does happen to people as they get

older to certain degrees

and you can see here the size of the

spinal canal

is significantly less than what it was

previously

because of these three things that

happen as we age

let's take a look at this another way

these nerve rootlets have plenty of

space

however as time goes on and the spine

starts to degenerate

we start seeing some changes that are

represented here

now look at the amount of space for

those nerves much much smaller

it's so small in fact that we can't even

see any of that white spinal fluid

anymore

that spinal fluid is completely gone

it's almost like as if someone took that

long balloon that extends down from the

base of your skull

all the way down to your lower back and

pinched it in one small area

and that's what we see here because of

the pinch we don't see any of that fluid

anymore

and we just see these nerve rootlets all

clumped up together

this is spinal stenosis where is the

incision

normally we have a less than one inch

incision in the middle of your back

some people though as i explained

earlier can have compression in a few

different areas

the size of the compression is directly

related to the amount of areas that you

have compressed

the lower the amount of areas that you

have compressed the smaller the incision

so here's another top view now let's go

through step by step how i perform this

procedure

you can see again you have severe

ligament thickening here

disc degeneration here and all these

nerves are clumped up within a

particular area

this is the top view again so your skin

of your back

is going to be up here and the front of

your

body is going to be highlighted down

below the goal here though

is to drill through the lamina on both

sides staying away from the facet joints

we want to be able to drill through the

lamina until we encounter the ligamentum

flavum

let's see that here so here are the

green cuts that we're going to make in

the bone

and you can see the location of the cuts

here they go all the way down through

the bone stopping when we get to the

ligamentum flavum

these bone cuts are actually outside of

the facet joints

which are highlighted here you want to

stay out of these facet joints because

that can cause some instability after

surgery

that's not something that we want that

can lead to re-operations

once we have an idea of where we want

our bone cuts to be

we then take our high-speed drill over

here on the right and we're able to

drill

right through the lamina on both sides

again all the way down to the ligamentum

flavum

that is shown here now with these long

troughs that go all the way down from

the top of the lamina all the way

through to the ligamentum flavum

our next step is to try to remove this

bone in the middle

and the way we try to remove that bone

in the middle is with this instrument

called a curette

so we're able to sneak our curette right

underneath and we're able to slowly lift

up that bone in the middle

and it slowly disappears and it's taken

out from the wound

now with the laminar removed the only

thing that we have between

us and decompressing the thecal sac or

dura

is this ligamentum flavin that i have

here highlighted in red

that is the next thing that has to be

removed and to do this we use an

instrument called the pituitary

this instrument can go in kind of like

alligator teeth and it slowly picks away

at the ligamentum flavum

as we have here and as we have on this

side

now once that's done we can see the dura

a little bit peeking out

that's highlighted here in black so we

still see a little bit of this dura

but we do know that it's still

compressed over on this side and this

side

so that ligamentum flavum has to be

removed that is highlighted here

now we use this special instrument

called the kerosene to remove these

ligamentum flavum on either side

once that's complete the thecal sac will

be completely decompressed

please notice that here so we've gone

through and we've removed that

ligamentum flavum

and now you can see that there's nothing

touching the spine or nerves anymore at

this

point at this point the nerve rootlets

are completely free

the dura is totally expanded now and now

that you see that there is

expansion of the dura you have spinal

fluid surrounding the nerve rootlets

which lets us you know that this has

been completely decompressed

this is the goal remember all we had to

do in this procedure is

we removed the bone and we removed the

ligamentum flavum

and that took away all of the

compression in the process though we

also remove any bone spurs that may also

causing compression of the nerves

so here's the before look you can see

before from this top view

you have this lamina and spinous process

with a

very very thickened ligamentum flavum

causing severe compression of where the

nerve rootlets are

you can't see any spinal fluid within

here so

after surgery though what happens is all

of that's removed

we have removed the spinous process and

lamina

and now we've removed the ligament and

flavum as well that allows the dura to

fully expand

refill up with spinal fluid and now

nothing is touching these nerve rootlets

anymore

let's take a look at what i'm looking at

from the back view as well to give you a

little

bit more understanding of the amount of

bone that we are taking so we have to

remove bone from a couple different

areas

we remove it from this area of the

vertebrae as well as down below

remember again up top here is going to

be where your head

is and down here is going to be where

your feet are

let's call this bone l5 and let's call

this bone l4

you have the facet joint connecting both

vertebrae

on this side and this side and you can

see the ligamentum flavament nerve roots

below

so the area that we're trying to remove

is going to be highlighted here

in red and green and that's the way that

we're going to do this procedure

we also want to make sure that we keep

about one centimeter of space

between where we make our bone cuts and

the very edge of the bone here

to help prevent any fractures now let's

move everything over to the side here

and bring in our high speed drill the

high speed drill is going to go over all

the areas in red where we want the bone

removed which we're doing now

with that all removed now we take that

instrument again the kerosene

and we try to gently remove some of the

area in green

once we remove some of this bone here

and pick it out pick it out pick it out

now we see that there is nothing

touching the nerve roots anymore

these nerve roots are now completely

decompressed and now let's bring in the

top view just to give you a better

understanding of what we're looking at

from both views

finally let's take a peek at the before

and after before

you can see that you had this spinous

process here in the middle

with the lamina on either side on the

back view

spinous process here with the lamina out

flaring on this side

with the ligamentum flavum down below

which we also needed to remove

but after the procedure we made those

proper bone cuts

and removed that ligamentum flavum and

now there is no more pressure on the

thecal sac there's no more pressure on

these nerve rootlets and is completely

filled up with spinal fluid

this is what that final bone removal

looks like as well

and that concludes how i perform a

lumbar laminectomy procedure

step by step

now that i've described step by step how

i perform this procedure

what are the risks infection is risk

that we worry about with any sort of

procedure where we have to make an

incision

because the incision is so small the

risk is very low for this

way under one percent patients who have

an increased risk of infection tend to

be those who are obese

diabetic or are smokers if you have one

of these conditions

we do talk to you about it beforehand to

let you know about this slightly

increased risk

next is really the only thing that i

worry about during the surgery and

that's getting a hole

within that fluid-filled sac that holds

your spine and nerves

that's your dura if there's a hole in

the dura some of that spinal fluid can

leak out

if it leaks out is something that we

need to repair sometimes we're able to

put a stitch in it to repair it just

like we would a leaky balloon

other times we have to patch it if that

has to happen we may have to keep you in

the hospital for a day or two

to make sure that it's not continuing to

leak if a spinal fluid leak does happen

during surgery

and it is repaired there's about a 10

percent chance that we do have to bring

you back to the operating room to fix it

again

this is exceedingly rare risk of

re-operation is always something that

comes up from time to time with patients

what we know about this particular

procedure is that there's about a 15 to

20 percent chance within 10 years

that you may need another surgery done

in the area where surgery was originally

performed

sometimes that surgery can involve a

fusion if it has to happen again

but that percentage is again only about

15 to 20 percent within 10 years

nerve injury is another risk that could

occur with this procedure although

exceedingly rare

if you do sustain an injured nerve

during this procedure it may give you

difficulty lifting your foot up

very rare that this occurs though lastly

persistent pain is also something that

can occur from time to time

it's very important for you to

understand expectations

your nerves have been compressed for a

very long time as a surgeon all we can

do is remove that compression and allow

your body time to heal any potential

damage that's been done to the nerves

we cannot fix a permanently damaged

nerve though however

while many patients see significant

benefit following this surgery

some patients may have pain afterwards

to some degree

normally patients can go home with this

right after surgery meaning same day

but some patients may need to stay for a

night or two depending on their age

and the amount of areas that we had to

work on because of the amount of

compression that they may have had

within their spines

patients do complain of back pain to

some degree following surgery because of

the incision

as well as the duration at which the

retractors were inside of the wound

this generally subsides after about a

month now some patients do have long

standing back pain from things like

arthritis at their joints

that we're not going to be able to fix

with surgery this is going to be the

incisional type pain that you have on

top of what your normal back pain is

the goal of surgery though is to make

your legs better

now this brings me to my last point

nerves generally take about one year to

reach their

full recovery potential some patients

recovery potential may be

upwards of 95 of what they had before

others may only be in the 70s or 80s

we just don't know who those patients

are gonna be until the one year mark

that's because it takes that long for

nerves to fully heal themselves

immediately after surgery though you may

have some good days and some bad days

with that nerve

you just have to let the dust settle

particularly within those first six

weeks to let your brain remake the

connections with the nerves down below

which have been compressed for a very

long time

over the course of that year though you

may have good weeks and bad weeks

again i try to tell patients all the

time though give it until one year

and how you feel at one year is going to

be how you feel long term

things like numbness and tingling and

sometimes weakness take a very very long

time

to show whether they're going to improve

or not we know that at about the one

year mark

the last question i usually go over is

what can i do post-op

when you go home you're going to have a

small bandage that's going to be over

your incision

underneath that bandage is going to be

some butterfly strips which help keep

the incision closed

and all the stitches are on the inside

so after the third day after surgery you

can remove that bandage

and shower normally simply let soap and

water run down their back

and then pat a try afterwards probably

put a new bandage over the incision for

about the first week after surgery

because it may rub on your pant line

after about one week if those butterfly

strips haven't fallen off on their own

it is okay to pull them off yourself

after one week though you may not even

have to cover the incision anymore

from a restriction standpoint we say no

bending twisting or lifting greater than

20 pounds for six weeks

this is because that small hole within

the disc where that disc

herniated out and we had to pluck it out

takes about six weeks to fully scar over

during this time period we don't want

you doing anything strenuous because we

don't want more disc material

to come out of the back after six weeks

you can return to any activity that you

were previously doing

some people ask do i need physical

therapy after we make that determination

at the six-week follow-up visit

to see how you're doing the vast

majority of patients are doing so well

at that time

that they really don't need physical

therapy during those six weeks though

it is okay for you to walk as much as

you would like remember

you're going to have some mild lower

back pain and some days with your leg

are going to be good and other days may

not be so good

just listen to your body the more you

walk though the more you will remake

those connections that may have been

lost between your brain and your leg

from a pain management standpoint we

like to stress the use of

over-the-counter medication

i generally tell patients to take two

extra strength tylenol three times a day

that's one thousand milligrams of

tylenol for breakfast lunch and dinner

in between those meals you can take

ibuprofen 600 milligrams

what that allows you to do is take

alternating tylenol and ibuprofen

six times a day which may give you a

great background effect of pain relief

so that you don't have to take as much

prescription pain medication or muscle

relaxer

generally though my patients are not

taking prescription pain medication for

more than a week or two

i hope this gave you a good overview a

frequently asked questions

and there you have it the lumbar

laminectomy hopefully after this video

you have a better understanding of the

normal anatomy of the lower back

as well as step by step how i perform

this procedure

and what to expect post-operatively if

you're curious about conditions that can

be treated with this particular

procedure

please see the links in the description

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regarding your spine

you can call our office phone number

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you