Spinal Fusion Decompression

This is for two reasons : –

To try and prevent further collapse as the spine ages leading to more nerve compression
To stabilise the spine and relieve back pain as an accompanying symptom to nerve compression.

Why is it done ?

Historically spinal fusions have been used to correct degenerative spondylolisthesis. However, there are many indications for a spinal fusion and it is not the only procedure preformed to treat those various conditions. You should talk to your doctor about what procedure is best for you.

What is spinal decompression?

Spinal decompression can be performed anywhere along the spine from the neck (cervical) to the lower back (lumbar). The procedure is performed through a surgical incision in the back (posterior).The lamina is the bone that forms the backside of the spinal canal and makes a roof over the spinal cord. Removing the lamina and other soft tissues gives more room for the nerves and allows for removal of bone spurs. Depending on the extent of stenosis, one vertebra (single-level) or more (multi-level) may be involved.

There are several types of decompression surgery : –

Laminectomy is the removal of the entire bony lamina, a portion of the enlarged facet joints, and the thickened ligaments overlying the spinal cord and nerves.

Laminotomy is the removal of a small portion of the lamina and ligaments, usually on one side. Using this method the natural support of the lamina is left in place, decreasing the chance of postoperative spinal instability. Sometimes an endoscope may be used, allowing for a smaller, less invasive incision.
Foraminotomy is the removal of bone around the neural foramen – the space between vertebrae where the nerve root exits the spinal canal. This method is used when disc degeneration has caused the height of the foramen to collapse, resulting in a pinched nerve. It can be performed with a laminectomy or laminotomy.

Laminaplasty is the expansion of the spinal canal by cutting the laminae on one side and swinging them open like a door. It is used only in the cervical area.

What Happens During Surgery?

There are seven steps of the procedure. The operation generally lasts 1 to 3 hours.

Step 1: prepare the patient in India

You will lie on your back on the operative table and be given anesthesia. Once asleep you will be rolled over onto your stomach with your chest and sides supported by pillows. The area where the surgery is to be performed will be cleansed and prepped. If a fusion is planned and you have decided to use your own bone, the hip area will be cleansed and prepped to obtain a bone graft. If you’ve decided to use donor bone, a hip incision is unnecessary.

Step 2: incision in India

A skin incision is made down the middle of your back over the appropriate vertebrae The length of the incision depends on how many laminectomies are to be performed. The strong back muscles are split down the middle and moved to either side exposing the lamina of each vertebra.

Step 3: laminectomy or laminotomy in India

Once the bone is exposed, an X-ray is taken to verify the correct vertebra.

Laminectomy : – The surgeon removes the bony spinous process. Next, the bony lamina is removed with a drill or bone-biting tools. The thickened ligamentum flavum that connects the laminae of the vertebra below with the vertebra above is removed. This is repeated for each affected vertebrae.

Laminotomy : – In some cases, the surgeon may not want to remove the entire protective bony lamina. A small opening of the lamina above and below the spinal nerve may be enough to relieve compression (Fig. 4). Laminotomy can be done on one side (unilateral) or both sides (bilateral) and on multiple vertebrae levels.

Step 4: decompress the spinal cord

Once the lamina and ligamentum flavum are removed the protective covering of the spinal cord (dura mater) is visible. The surgeon can gently retract the protective sac of the spinal cord and nerve root to remove bone spurs and thickened ligament.

Step 5: decompress the spinal nerve

The facet joints, which are directly over the nerve roots, may be undercut (trimmed) to give the nerve roots more room. Called a foraminotomy, this maneuver enlarges the neural foramen (where the spinal nerves exit the spinal canal). If a herniated disc is causing compression the surgeon will perform a discectomy.

Step 6: fusion (if necessary)

If you have spinal instability or have laminectomies to multiple vertebrae, a fusion may be performed. Fusion is the joining of two vertebrae with a bone graft held together with hardware such as plates, rods, hooks, pedicle screws, or cages. The goal of the bone graft is to join the vertebrae above and below to form one solid piece of bone.There are several ways to create a fusion. The right one for you depends on your own choice and your doctor’s recommendation.

The most common type of fusion is called the posterolateral fusion. The topmost layer of bone on the transverse processes is removed with a drill to create a bed for the bone graft to grow. Bone graft, taken from the top of your hip, is placed along the posterolateral bed. The surgeon may reinforce the fusion with metal rods and screws inserted into the vertebrae. The back muscles are laid over the bone graft to hold it in place.

Step 7: closure

The muscle and skin incisions are sewn together with sutures or staples.

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