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Lumbar Decompression / Laminectomy

Planning

B

Preoperative Plan

1

Identifies area of decompression on preoperative imaging

2

Execute surgical walkthrough

  • describe steps to the attending prior to the start of the case
  • describe potential complications and list steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • laminectomy set

2

Room setup and equipment

  • table
  • standard radiolucent table with Wilson frame vs. Jackson spine flat top table
  • C-arm
  • c-arm perpendicular to table
  • microscope (optional)
  • microscope in from opposite side of C-arm

3

Patient positioning

  • prone with arms at 90° max abduction and flexion to prevent axillary nerve injury
  • foam padding on chest so that nipples are pointing midline straight down
  • pads over ASIS and gel pads on knees
  • bilateral TED hose and SCDs

Technique

D

Superficial Dissection to Expose Spinous Process

1

Localize level of incision with anatomic or radiographic landmarks

2

Make midline incision.

  • midline incision with 10blade overlying the spinous processes between paraspinal muscles (erector spinae)
  • ~3-4cm in length for single level

3

Dissect subcutaneous tissue down to fascia

  • insert cerebellar retractors x2 for fascial exposure

4

Cauterize lumbodorsal fascia over spinous processes to just lateral of midline

E

Deep Dissection down to Lamina

1

Subperiosteal dissection with Cobb along spinous processes

2

Subperiosteal dissection of lamina

  • cranial to caudal down to lamina

3

Place probe under lamina to identify level radiographically

4

Use Cobb to strip laterally along lamina until facet capsules identified but not violated

5

Place deep retractors for better visualization

F

Laminectomy and Central Decompression

1

Remove spinous processes of operative levels with rongeur

  • save as bone graft for fusion

2

Remove lamina and identify origin of ligamentum flavum

  • begin with decompression into canal into inferior half of lamina of cephalad vertebrae first with small curette
  • burr lamina and to thin and then complete resection with Kerrison rongeurs

3

Resect ligamentum flavum

  • gently retract ligamentum flavum with woodsen elevator
  • resect remaining lamina and ligamentum with Kerrison rongeur of cephalad vertebrae
  • resect ligamentum from superior lamina of inferior lamina
  • use Kerrison to resect caudad lamina from inferior vertebra
G

Lateral Recess and Foraminal Decompression

1

Perform Medial facetectomy

  • decompress medial aspect of facet on each side (2-3 mm of medial facet)

2

Decompress lateral recess

  • locating pedicle key to safe decompression
  • kerrison to undercut medial edge of superior facet of caudad vertebra until medial edge of pedicle visualized
  • identify osteophytes that could impinge exiting nerve root around pedicle
  • undercut remaining superior facet using kerrison rongeur
  • no more than 50% superior facet should be resected

3

Confirm exiting and descending nerve roots are well decompressed

  • descending nerve root should be visualized

4

Check to make sure no disc herniation.

  • Dural sac/nerve root may be retracted to see if there is bulging disc is present
H

Wound Closure

1

Irrigation, hemostasis, and drain

  • flush out spine with saline bulb irrigation

2

Deep closure

  • close fascia with 0-vicryl
  • need water tight closure and need to decrease dead space for hematoma

3

Superficial closure

  • subcutaneous with 2-0 vicryl
  • skin closure with buried 3-0 monocryl

4

Dressing

  • soft incision dressings over spine

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic neurologic Exam

  • need to carefully document neurological status of bilateral lower extremities
  • strength, sensation, reflexes, and primary symptoms

2

Order basic imaging studies

  • order biplanar radiographs of the L-spine
  • review advanced imaging such as MRI
  • look for specific findings such as spondylolisthesis, central/lateral recess/foraminal stenosis, and levels of involvement

3

Recognizes indications for and initiates immediate additional work-up ("Red Flags") or urgent surgical care

  • cauda equina syndrome
  • progressive deficit

4

Screen medical studies to identify and contraindications for surgery

  • confirms no recent infection contraindicating surgery (UTI)

5

Perform operative consent

  • documents failure of nonoperative measures such as physical therapy and epidural streoid injections
  • describe complications of surgery including
  • persistent radiculopathy due to inadequate decompression
  • dural tear
  • iatragenic nerve root injury
  • segmental instability due to aggressive facet capsule and joint excision
  • superficial, deep wound infection
  • meralgia parasthetica due to compression of LFCN
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • check appropriate labs
  • appropriate wound care
  • changes dressing on POD #2
  • identifies CSF leak
  • foley catheter out when ambulating

2

Appropriate medical management and medical consultation

3

Orders appropriate inpatient occupational and physical therapy

  • weight-bearing as tolerated, physical and occupational therapy
  • no heavy lifting and limited flexion/extension

4

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow up appointment in 2 weeks
  • wound care
M

Outpatient Evaluation and Management

1

Obtain focused history and performs focused neurological exam

  • describe key physical exam maneuvers (lumbar nerve root function)
  • concomitant and associated orthopaedic injuries
  • differential diagnosis and physical exam tests
  • extends examination to nonspinal differential diagnostic possibilities
  • vascular claudication
  • hip arthritis

2

Interpret basic imaging studies

  • interpret radiographs of the L-spine

3

Order and interpret advanced imaging studies

  • CT scan
  • myelogram
  • MRI findings
  • central stenosis
  • foraminal stenosis
  • identifies nerve root anatomy
  • correlates clinical and imaging findings to form clinical diagnosis

4

Recommends appropriate surgical procedures considering indications and contraindications, risks and benefits for simple cases

  • single level HNP with radiculopathy

5

Prescribes and manages nonoperative treatment

  • medical management
  • attempts medical management of lumbar radiculopathy (NSAIDs, gabapentin)
  • orders appropriate diagnostic and therapuetic selective nerve root or epidural steroid injections
  • attempts trial of physical therapy
  • make referrals to other professionals

6

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

7

Provides, modifies and adjusts procedure and patient specific post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • diagnose and management of early complications
  • postop: ~ 3 month postoperative visit
  • repeat xrays of lumbar spine
  • advance spine restrictions and activity levels
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Provides complex non-operative treatment

  • individualized care, shared decision making, comprehensive informed consent

2

Recommends appropriate surgical procedures considering indications and contraindications, risks and benefits for complex cases

  • multilevel stenosis with deformity

3

Completes comprehensive pre-operative planning with alternatives and criteria for acceptable intraoperative result for complex cases

  • multi-level stenosis with deformity

4

Capable of surgically treating simple complications

  • drainage of hematoma
  • debridement of infection
O

Complex Patient Care

1

Completes comprehensive pre-operative planning with alternatives and criteria for acceptable intraoperative result for highly complex cases

  • revision surgery

2

Develops unique complex postoperative management plans when indicated

 

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