Lumbar Decompression / Laminectomy

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TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
E

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
F

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
G

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

H

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

I

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
J

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
K

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
Postoperative Patient Care
 

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