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General information: Posterior lumbar decompression is a standard procedure for treatment
of neurogenic claudicating of sciatica related to lumbar canal stenosis. The canal stenosis can be mild, moderate, severe and very severe. Most of the symptoms appear on severe and very severe category. Sometimes, lateral recess stenosis may cause significant pain and symptoms that warranties surgical intervention. Canal stenosis is usually resulted from degenerative changes of
the spine (wear and tear), leading to spinal facet joints hypertrophy, in combined with ligaments hypertrophy, causing spinal canal stenosis.
Target and results: The results of surgery are generally good. For patients with neurogenic
claudication, and leg pain, will usually improve after surgery. The surgery is usually target the leg pain and radicular symptoms of the lower limbs rather than the back pain which may get worse after the surgery.
Risk of complications:
- Infection is less than 2 percent. It may affect the superficial tissues and skin, or may affect
deep spinal structures, diskitis or vertebral osteomyelitis which is very rare. - Bleeding which may lead to hematoma collection that needs further surgery.
- Cerebrospinal fluid (CSF) leak, inadvertent breach of the thecal sac may lead to leaking of the fluid surrounding the brain and the spinal cord. Instant repairs is possible, however, it may need an extended admission in the hospital or further procedures. There is also very small
risk of meningitis. - Neural tissue injury: the most serious complication may cause life changing consequences in form of weakness or paralysis of legs, sphincters, sensory or sexual changes. The risk is very small, <1%.
- Worsening of back pain which is about 20%, most of the patient will improve after 4 weeks after the surgery. However, chronic back pain is not uncommon.
- Failure to improve symptoms.
- General anesthetic complications (heart attack, stroke)
- Deep venous thrombosis/pulmonary embolism (clots in legs /lungs).
- Small risk of blindness related to prone position during the surgery
Procedure
Posterior cervical decompression (laminectomy, foraminotomy inter-segmental decompression) is a standard procedure that is carried out on routine base. The procedure is usually done under general anesthesia and lasts approximately 60-90 minutes, depending on the number of levels. The patient is positioned on his face (prone), with the head fixed with pins and Meyfield clamp. It involves making a small midline incision in the back of the neck, followed by dissection of the muscles on both sides to expose the lamina. X-rays guided confirmation of the correct level. Small bony window will created using high speed drill to the nerves in case of foraminotomy or removal of the whole lamina to decompress the spinal cord in case of myelopathy. Partial removal of the lamina with the inter-laminar ligaments (ligmentum Flavusm) is called inter-segmental decompression.
The wound is closed in layers with dissolvable stitches; skin is closed with clips which need to be removed in 10 days. After the operation, some of the patient will have a drain in the wound for 24 hours (this is removed on the ward before discharge). Most patients will go home the next day and will be recovering at home for approximately 4 weeks. Following surgery the patient may notice some neck pain and stiffness but this should settle with simple pain killers. Specialist spinal physiotherapists will advice each patient on a postoperative exercise regime, to encourage neck movements. Further outpatient physiotherapy sessions will be offered, where indicated. Patient is usually followed up in the clinic in 8-12 weeks after surgery. If any complication happens, the patient may need to stay until everything gets sorted. All regular medication will continue except the blood thinning medication like Warfarin, Apixoban, Aspirin, cloidogrel etc, needs advised individually. Most of the cases can started after 48h from the surgery.