Considerations for Lumbar Laminectomy (Open Decompression) in Treating Spinal Stenosis

Lumbar spinal stenosis can cause a variety of symptoms. However, an open laminectomy surgery may be useful only in a few, carefully selected patients.

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When Open Lumbar Laminectomy May Be Performed for Spinal Stenosis

The outcome of open lumbar laminectomy largely depends on the participating patient. In well-selected cases, the response to surgery and overall outcomes have reported being good, with almost 85% to 90% of patients experiencing a reduction in symptoms. ¹ Agabegi SS, McClung HL. Open lumbar laminectomy: Indications, surgical techniques, and outcomes. Seminars in Spine Surgery. 2013;25(4):246-250. doi:10.1053/j.semss.2013.05.004. ^{, 2} Dakwar E, Deukmedjian A, Ritter Y, Dain Allred C, Rechtine GR II. Spinal Pathology, Conditions, and Deformities. In: Pathology and Intervention in Musculoskeletal Rehabilitation. Elsevier; 2016:584-611. doi:10.1016/b978-0-323-31072-7.00016-6.

A few features of spinal stenosis that may result in a better outcome of an open lumbar laminectomy include:

• Confirmed central stenosis. Open laminectomy is typically useful in treating central spinal stenosis. ¹ Agabegi SS, McClung HL. Open lumbar laminectomy: Indications, surgical techniques, and outcomes. Seminars in Spine Surgery. 2013;25(4):246-250. doi:10.1053/j.semss.2013.05.004. This type of stenosis causes constriction of the spinal canal, irritating or compressing the spinal cord, thecal sac, spinal dura, and/or the cauda equina. Sometimes, the spinal nerve roots may also be inflamed. Diagnostic tests such as magnetic resonance imaging (MRI), computed tomography (CT) scan with or without myelography, and somatosensory evoked potentials test (SSEP) may be useful in confirming central spinal stenosis.

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• Presence of neurogenic claudication. Neurogenic claudication is a diffuse nerve pain that starts typically in the buttocks and extends to a variable distance in both legs. The characteristic feature of neurogenic claudication pain is that it increases while walking variable distances and bending the spine backward. The pain also decreases while sitting or bending the spine forward. Typically, patients with this condition are seen bending over the handles of shopping carts to relieve the walking-induced pain. ¹ Agabegi SS, McClung HL. Open lumbar laminectomy: Indications, surgical techniques, and outcomes. Seminars in Spine Surgery. 2013;25(4):246-250. doi:10.1053/j.semss.2013.05.004.

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• Poor functional outcome despite nonsurgical treatments. Open laminectomy surgery is generally considered only after 8 to 12 weeks of nonsurgical treatments have been tried for lumbar spinal stenosis pain. ³ Lee SY, Kim TH, Oh JK, Lee SJ, Park MS. Lumbar Stenosis: A Recent Update by Review of Literature. Asian Spine J. 2015;9(5):818–828. doi:10.4184/asj.2015.9.5.818 Nonsurgical treatments may include physical therapy, over-the-counter (OTC) and prescription pain-relieving medications, injection treatments such as epidural steroid injections, and/or activity modification. When relief is not obtained with sustained use of these methods and daily activities are significantly affected by leg pain, open laminectomy may be considered.

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• Single-level stenosis and shorter duration of symptoms. Studies suggest that stenosis affecting a single vertebral level causing weakness in the legs for less than 6 weeks have a better chance of successful surgical outcome compared to chronic and severe stenosis cases. ³ Lee SY, Kim TH, Oh JK, Lee SJ, Park MS. Lumbar Stenosis: A Recent Update by Review of Literature. Asian Spine J. 2015;9(5):818–828. doi:10.4184/asj.2015.9.5.818

Typically, good candidates for open lumbar laminectomy experience leg pain with standing and walking, and pain relief when bending forward.

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When Lumbar Laminectomy and Fusion are Performed Together

Typically, a single level laminectomy increases the range of motion of the treated lumbar level by 7% to 12% more than normal. ⁴ Bisschop A, van Engelen SJPM, Kingma I, et al. Single level lumbar laminectomy alters segmental biomechanical behavior without affecting adjacent segments. Clinical Biomechanics. 2014;29(8):912-917. doi:10.1016/j.clinbiomech.2014.06.016. An increase in this range or the presence of other factors and/or conditions may cause instability and necessitate fusion. Sometimes, fusion surgery may be required a few months or years after the original surgery if instability develops. ⁵ Ang C-L, Phak-Boon Tow B, Fook S, et al. Minimally invasive compared with open lumbar laminotomy: no functional benefits at 6 or 24 months after surgery. The Spine Journal. 2015;15(8):1705-1712. doi:10.1016/j.spinee.2013.07.46.

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Fusion surgery may be performed along with the laminectomy in the following cases ¹ Agabegi SS, McClung HL. Open lumbar laminectomy: Indications, surgical techniques, and outcomes. Seminars in Spine Surgery. 2013;25(4):246-250. doi:10.1053/j.semss.2013.05.004. :

• Accompanying conditions such as degenerative spondylolisthesis, lateral listhesis, or degenerative scoliosis
• Removal of more than 50% of facet joints during a laminectomy
• Tall disc space (especially in young patients)
• Multilevel laminectomies

As a general rule, instability of the spine preoperatively and/or a postoperative instability due to extensive laminectomy is considered for spinal fusion surgery. The presence of osteophytes, markedly narrow disc space, and older age of the patient may reduce the need for fusion after lumbar laminectomy because they provide additional stabilizing effects on the lumbar motion segments.

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When Open Lumbar Laminectomy May Not Be Successful

Sometimes, the presence of certain factors may negatively affect the outcome of an open laminectomy surgery. A few examples include ⁶ Wai EK, Roffey DM, Tricco AC, Dagenais S. Decompression Surgery. In: Evidence-Based Management of Low Back Pain. Elsevier; 2012:403-421. doi:10.1016/b978-0-323-07293-9.00029-5. :

• Inconsistencies in physical and medical imaging findings, such as leg pain without the evidence of spinal stenosis and vice versa.
• Physical deconditioning from being sedentary and avoiding physical activity due to lumbar stenosis pain before surgery and/or the lack of adequate physical activity after surgery.
• Chronic low back pain without leg pain despite the presence of spinal stenosis on medical imaging.
• Other factors such as smoking, mental health conditions, and/or having unrealistic expectations from the surgery.

Additionally, patients with severe infections and heart and lung problems may not be eligible for general anesthesia in order to undergo lumbar laminectomy.