A laminotomy is an orthopedic neurosurgical procedure that removes part of the lamina from the vertebral arch to reduce the pressure in the vertebral canal. A laminotomy is less invasive than conventional vertebral column surgery techniques, such as laminectomy because it leaves more ligaments and muscles attached to the vertebral column intact and that requires removal of fewer bones from the vertebra. As a result, laminotomies usually have a faster recovery time and result in fewer postoperative complications. However, the risks that may occur during or after procedures such as infection, hematoma, and dural tears. Laminotomy is generally performed as a treatment for lumbar spine stenosis and herniated disc. MRI and CT scans are often used before and after surgery to determine whether the procedure works.
Video Laminotomy
Anatomy overview
The spinal cord is housed in a bone hollow tube called the vertebral column. The vertebral column consists of many bones like a ring called the vertebra (plural: vertebrae) and extends from the skull to the sacrum. Each vertebra has a hole in the center called the vertebral foramen through which it crosses the spinal cord.
Laminae (singular: lamina) is an important anatomical structure in the laminotomy. Laminae is part of the vertebral arch which is the bone region on the back side of each vertebra that forms a protective cover for the back side of the spinal cord.
The vertebral lump consists of several anatomical features other than the lamina that must be taken into account when performing the laminotomy. At the center of the vertebral arch is a bony projection called the spinous process. The spinous process is located on the posterior or back side of the vertebra and serves as an attachment point for the ligaments and muscles that support and stabilize the vertebral column. Each vertebra has two lateral bone projections called transversal processes located on either side of the vertebral arch. The transverse process is in contact with the ribs and serves as an attachment point for the muscles and ligaments that stabilize the vertebral column. Lamina is a segment of bone that connects spinous processes to the transverse process. Each vertebra has two lamas, one on each side of the spinous process.
Maps Laminotomy
Type
Different types of laminotomy are determined by the type of instrument used to visualize surgical procedures, what vertebral procedures are performed, and whether the two laminae vertebrae are operated on or just one.
Common types of laminotomies include:
- Microscopic/Microdecompression laminotomy - uses an operating microscope to enlarge the area under operation. Operating microscopes are usually fitted to the operating table and held above the operating area
- Endoscopy/Microendocopy of laminotomy decompression using endoscopy to visualize surgical procedure. Endoscopy is a small tubular camera that is inserted into the patient to visualize surgical procedures internally.
- Cervical Laminotomy - is performed on the cervical vertebra which is the spine closest to the head.
- Thoracic laminotomy - is performed on the thoracic vertebrae, or the middle vertebra.
- Lumbar laminotomy - is done on the lumbar vertebrae which is the spine closest to the sacrum.
- Bilateral laminotomy - removal of bone parts from both lamina from one vertebra.
- Unilateral laminomy - removal of bone parts from only one lamina vertebra.
This laminotomy classification can be combined to form the most descriptive name for possible procedures. For example, unilateral lumbar laminotomy endoscopy is bone removal of only one lumbar lamina of the lumbar using endoscopy.
Procedures
The laminotomy procedure remains largely the same regardless of the instrument used, or the level of the spine inoperable. Laminotomies require general or spinal anesthesia and often require hospitalization after the procedure - although the duration of stay depends on the physical condition of the individual and their reason for having laminotomy. A laminotomy takes about 70-85 minutes depending on the type of procedure used. Unilateral laminotomies usually require less time because the bone is taken from only one lamina, whereas bilateral laminotomy usually takes more time because the bone is removed from both laminae. The vertebral level that the laminotomy is performed and what instrument is used does not produce a significant difference in length of procedure. Both unilateral and bilateral laminotomies are performed over a shorter period of time compared to conventional laminectomies which take more than 100 minutes.
During laminotomy, individuals put on their stomachs with their backs facing the doctor. The initial incision is made at the back of the back showing the spine where the laminotomy will be performed. In this procedure, the spinous and ligamentous processes of the vertebral column remain intact, but the muscles adjacent to the vertebral column known as the paraspin muscle (eg spinal muscle) should be separated from spinous processes and vertebral arches. In unilateral laminotomies, these muscles simply detach from the side where the laminotomy is being performed. During bilateral laminotomy, these muscles must be removed on both sides of the vertebra. The ligament that connects the upper and lower vertebral laminae, known as the flava ligament is often removed or rejuvenated in this procedure to adjust to the small amount of bone loss. Either using a microscope or an endoscope to have visual procedures, a small surgical drill is used to remove some bone from the lamina in one or both lamina vertebrae. Laminotomies may be performed on multiple vertebrae during the same operation; this is known as multi-level laminotomy.
A slightly different laminotomy procedure, but commonly used is unilateral laminotomy for bilateral spinal decompression. This minimally invasive procedure is often used to treat patients with excessive pressure in the vertebral column that should be released. In this procedure, the same ligament of the spine remains intact and the paraspinous muscle must remain separate. A unilateral laminotomy is performed on one lamina vertebra. The removal of the bones from one lamina opens the way to the spinal canal. Using a microscope or an endoscope to visualize the procedure, the surgical tool is inserted through this opening into the spinal canal. The surgical instruments are then navigated under the spinous process and cross the spinal canal to reach the other lamina on the opposite side of the vertebra to perform a second laminotomy. The incision for this procedure is smaller because doctors only need access to one lamina but can perform bilateral laminotomy bone - release from both laminae of the single vertebra. The unilateral laminotomy with bilateral spinal decompression procedure was developed nearly 20 years ago and is a successful general surgical treatment for lumbar spine stenosis.
Reasons for laminotomy
A laminotomy is usually used to remove pressure from the spinal canal. Excessive pressure in the spinal canal causes the spinal canal and spinal cord to be compressed which can be very painful and can damage motor control and/or sensation. A common disorder that causes increased pressure in the spinal canal is lumbar spine stenosis. Lumbar spine stenosis is formally defined as a decrease in the diameter length of either the neural foramen, the lateral recess, or the spinal canal. Stenosis is classified as a decaying disease because it causes the channel to gradually become narrower which can cause pain or loss of function. Common symptoms of lumbar stenosis are pain, fatigue, muscle weakness and numbness. Stenosis can be caused by old age or injury to the vertebral column and usually requires a CT scan or MRI to diagnose. Doing laminotomy can reduce the pressure in the spinal canal caused by lumbar stenosis and therefore relieve the symptoms.
Laminotomy is also done to create a window into the spinal canal to correct the problems that exist within the spinal canal. Laminotomy is often used as a way to repair spinal herniation surgery at each vertebral column level (cervix, thorax, lumbar). Herniated disks can suppress the spinal cord and cause severe pain and sensation disturbance. Removing a portion of the lamina allows the doctor to be able to access and repair the disc herniation. Laminotomy may also be used to treat intraspinal lesions such as spinal tumors or problems with blood vessels supplying the spinal cord. In any scenario where the inside of the spinal canal should be accessed or there is increased pressure in the spinal canal, laminotomy may be used to treat disorders or relieve symptoms.
Benefits
The laminotomy procedure has many benefits as to why spine surgery is preferred because it is less invasive than other spinal procedures such as laminectomy or spinal fusion. Once the laminotomy procedure is completed, patients experience a major increase in their pain and mobility. Laminotomies are usually safer than other open or invasive surgeries. Surgery is usually shorter than other spinal decompression procedures with an average duration of 70-85 minutes, while other decompression operations can have durations anywhere from 90 to 109 minutes. Laminotomies are usually more cost-effective than other surgical decompression surgeries. In 2007, it was seen that the laminotomy was about $ 10,000, while the other surgical procedure was about $ 24,000. Smaller skin incisions and less scarring and surgical trauma are also a benefit of laminotomy. With this procedure, there is usually a faster recovery time that results in shorter hospital stay if necessary. During surgery there is also the benefit of minimizing injury to the muscles, ligaments, and bones in the spine because more invasive surgery has a greater risk of damaging it. General anesthesia is usually necessary, but postoperative spine instability is usually limited.
Risk and potential complications
Because this procedure is a surgical technique, many complications can occur either during or after surgery. Some of the major complications that can occur are leakage of cerebrospinal fluid, dural tears, infection, or epidural hematoma. Death is also a risk, but only one per one thousand operations. Other complications that can occur during surgery are nerve root damage, which can cause nerve or paraplegia injury, and large amounts of blood loss that will cause blood transfusions.
Laminotomy vs. laminectomy
Historically, laminectomy has been the primary way to treat lumbar spine stenosis. Laminectomy is a more invasive method with the aim of reducing the total amount of pain and numbness associated with lumbar spine stenosis. It is an operation that removes the entire lamina to allow the nerves around the region to function properly. Laminectomy also often results in longer recovery times as well as greater risks for post-operative complications. Usually there is more damage to the surrounding muscle tissues accompanied by laminectomy. Because the laminectomy involves the excision of the entire lamina, a laminectomy will usually cause spinal instability more than a laminotomy. When going with the laminotomy option, this procedure reduces the total number of disconnected muscles. Because laminotomy does not damage the important spinous and ligament processes, there is not much muscle weakness, pain, and lumbar instability seen with laminectomy. Laminotomy is fairly new compared to laminectomy, and involves the use of less invasive methods with the right instruments to minimize the risk of tissue damage.
Radiographic imaging
X-Rays
For radiographic imaging, x-rays are the most effective way to gather information when observing patients with lumbar spine stenosis. CT scans provide a 360 degree view of a more precise vertebra than x-rays.
MRI
Because MRI provides excellent vascular and tissue imaging, MRI is recognized as the best type of imaging to observe signs associated with lumbar compression. The exact measurement of the diameter of the spinal canal is a very important component when determining the severity of the stenosis itself. The high-strength 3-Tesla MRI machine is being used because of the increased vascular imaging capability. Better resolution capacity allows more detailed observation by healthcare providers. The sharp contrast of MRI's high strength describes the spine's crucial details when examining patients with lumbar spine stenosis that may require laminotomy. MRI postoperative invasive scans are used to see the quality of the surgery itself, but the right postoperative time elapsed before performing the MRI is a contentious topic.
CT scan
CT scanning is not the most effective imaging technique when observing lumbar abnormalities, but CT scans may complement MRI by detecting certain degenerative processes. When determining whether or not the laminotomy will benefit the patient, the health care provider should assess the severity of the possible abnormalities. Of all the potential reasons for laminotomy, lumbar spine stenosis is the main reason. CT scans are used specifically to determine the ligated ligament ligament ligament and facet hypertrophy, which are some of the major pathophysiological changes that indicate lumbar spine stenosis. Although CT scans may reveal signs of lumbar spine stenosis, it can sometimes provide cloudy images because of contrasting tissue shadows. When this occurs, contrast intrathecal mielography is performed with a CT scan to correct abnormal contrast. CT scans may also reveal an increase in the cross sectional area of ​​the L3 vertebra, which in turn lowers the cross-sectional area of ​​the spinal canal. As an increase in the size of the L3 vertebra occurs, the pressure accumulates in the cauda equina, usually causing pain in the lower back and lower extremities. Cauda equina compression can also be caused by L4-5 region stenosis as well. Although CT scans make it possible to study intensive images, the permanent nature of the drawing process alone is not sufficient to achieve a definitive diagnosis of lumbar spine stenosis. CT scan results can help compile the physiological evidence that the patient has lumbar spine stenosis, and that the patient has the potential to benefit from laminotomy to improve the quality of life.
In addition to the static imaging process, CT scans can also be used to observe changes in the features of the spinal canal before and after laminotomy. One of the major signs of lumbar spine stenosis is the thickening of the flavum ligament, causing it to extend into the spinal canal. When looking at the area of ​​the spinal cord cross section of human corpses, it was found that the area has decreased due to thickening of the flavum ligament. The flavum ligament does not appear to alter the dynamic changes in the spinal dimension of the spinal cord. Even after the intervertebral disc is removed, the flavum ligament does not become a factor in the dimensional changes in the spinal canal. By understanding the magnitude of the role played by ligamentum flavum hypertrophy in lumbar sacral stenosis, the need for invasive spinal lumbar procedures can be accurately measured.
Alternative minimally invasive procedure
Minimally invasive procedures are a more common alternative because of a significantly reduced risk of damaging muscle tissue. The difference between invasive and minimally invasive spinal surgery is that minimally invasive procedures involve a series of small incisions. Minimally invasive procedures can be performed anywhere along the spine, and have been used to treat a variety of disorders. Percutaneous pedicle screw fixation techniques allow procedures that provide minimal risk to the patient. The fluoroscopic photographed navigation guided through this portal allows the surgeon to perform more efficient procedures. Minimally invasive procedures often result in a much faster recovery time than fully invasive surgery, making them more attractive to patients. Laminectomy has always been the gold standard when treating lumbar spine stenosis, but more recently, less invasive surgery has emerged as a safer alternative treatment that helps maintain structural integrity post-spine surgery.
Spinal microsurgery
Spinal cord surgery is a minimally invasive unilateral laminotomy used to improve bilateral spinal lumbar compression. Spinal cord surgery is the most common and effective microsurgical decompression treatment for patients present with moderate to severe spine stenosis. Spinal microsurgeries are performed with high-magnification 3D imaging from a central area of ​​the spine, reducing the potential risk of damaging the spine's architecture itself.
Endoscopic spine surgery
Endoscopic spine surgery can be used to treat thoracic lesions, and has proven to be a much safer option than thoracotomy. However, endoscopic spine surgery may be performed to treat other spinal conditions, such as the lumbar disc hernia. The recovery time of this type of surgical treatment is often very rapid, with the patient performing an ambulation within hours of the procedure.
Spinal Fusion
Spinal fusion involves combining two vertebrae together using a spacer, and is intended to prohibit movement in certain segments. Screws are usually inserted to ensure that the spacer is held in place. The most common lumbar spine fusion occurs between L4 and L5. Lumbar spine fusion may be recommended if non-surgical treatment options for severe degenerative disc disease are not effective. A laminotomy will not be effective in this case, as it relates to a degenerated disk that needs to be removed to revive certain symptoms.
See also
- Laminectomy
- Spinal stenosis
References
Source of the article : Wikipedia
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