Breaking Down and Understanding Laminotomy, Laminectomy & Spinal Fusion

Breaking Down and
Understanding:
Laminectomy
Laminotomy,
&
Spinal Fusion

Laminotomy, Laminectomy and Spinal Fusion 2
1. The need for a Laminotomy, Laminectomy or Spinal Fusion
a. Causative Factors
b. Signs and Symptoms
2. Laminectomy
a. Description
b. Visualization
c. Primary Goal and Aims of Treatment
d. Risks
e. Clinical Nursing Considerations
3. Laminotomy
a. Description
i. Differentiation between a Laminotomy and a Laminectomy
b. Visualization
d. Risks
4. Fusion
a. Description
i. Posterior Fusion, Anterior Fusion, Posterior Interbody Fusion, and
Anterior Interbody Fusion
ii. Primary and Secondary Indications
b. Visualization
i. Primary treatment (Ffracture) vs
ii. Reinforcement (Laminectomy stabilization)
d. Risks
5. Post-Op Rehabilitation and Patient Education
6. EBP Research Articles and Conclusions on the Different Procedures
References

1. The need for a Laminotomy, Laminectomy or Spinal Fusion
Spinal Stenosis and a Herniated Disk are the two most common causative factors
leading up to a corrective Laminotomy or Laminectomy procedure.
Spinal stenosis is the result of degeneration of the spine, and refers to an abnormal
narrowing of the spinal canal, and this narrowing of the canal compresses the nerves as
they pass through the stenosed part of the spine. The
common symptoms of stenosis (depending on where
the location of stenosis is occurring) are numbness,
weakness or stiffness of the extremities, gait
abnormalities, neurogenic claudication (symptoms
which occur with activity), and pain.
Hypertrophy of the Ligamenta Flava (Latin for
yellow ligament) which are ligaments that connect the
laminae (the vertebral “roof”) of adjacent vertebrae,
can also cause spinal stenosis because it lies inside the
posterior portion of the vertebral canal (Fig.1). Each
ligament consists of two lateral portions which
commence one on either side of the roots of the articular processes (Fig.5), and extend
backward to the point where the laminæ meet to form the spinous process (Fig.2). Each
consists of yellow elastic tissue, the fibers of which, almost perpendicular in direction,
are attached to the anterior surface of the lamina above, some distance from its inferior
margin, and to the posterior surface and upper margin of the lamina below. In the cervical
region the ligaments are thin, but broad and long; they are thicker in the thoracic region,
and thickest in the lumbar region.
Disc herniations often require aggressive surgical repair, however, surgical repair
of a herniated disc is usually the last resort after conservative medical treatment fails or
the herniation is severe, or significantly impairs the patient’s quality of life. Discs are the
soft, gelatinous cushions that function as a shock absorber between the hard, bony
vertebrae. Lower back herniations are often caused by trauma such as a fall or lifting
something the wrong way, patients typically experience sudden and severe pain when the
trauma occurs, which then usually recedes without treatment and then gradually worsens
over time. Additional possible causes of disc herniations are disc degeneration, and loss
of elasticity, spur formation, spondylosis (degenerative arthritis causing pressure on nerve
roots and subsequent pain) and spondylolisthesis (any forward slipping of one vertebra on
the one below it). A herniated disk occurs when the nucleus of the disk protrudes out
through the disk wall and exerts pressure against a nerve in the spinal canal, which can
cause a wide range of symptoms depending on where the herniation occurs and the
degree to which the nerves entering the spine, or the spine itself, are affected. In addition
to pain around the site of the herniation, many patients also experience significant pain
elsewhere in the body other than where the herniation is physically located. This is due to
the pressure being exerted on the surrounding nerves that carry impulses from different
parts of the body to the spine and then to the brain. Thus, the pain feels as though it is
being experienced in the area from where this nerve originates. Symptoms include back
pain, aching/cramping of the legs, neurogenic claudication (pain that gets worse with
activity), muscle spasms, neurological deficits such as numbness and paraesthesia, reflex
loss, motor weakness and muscle atrophy.3

The two main causative factors requiring a spinal fusion is a vertebra fracture –
usually when a transverse process has been broken off, or after severe trauma to the body
of one or more vertebrae requiring surgical decompression and fusion, or after having a
laminectomy procedure. The most common symptom requiring spinal fusion to correct is
the immobilizing pain the patient feels with movement. Even just the movement of
breathing may be seen to cause the patient unbearable pain.

2. Laminectomy
The term laminectomy is derived
from the Latin words lamina (thin
plate, sheet or layer), and -ectomy
(removal). The older, more radical
version of this type of surgery is the
laminectomy. This is where the
lamina, (posterior aspect of the
spinal canal) is removed entirely. A
laminectomy is used to remove the
lamina (roof) of the vertebrae to
provide access to a herniated disk
for a discectomy, or used to “trim” the lamina to create more space for the nerves
leaving the spine with spinal stenosis. Discectomy is the surgical removal of
herniated disc material that presses on a nerve root or the spinal cord. The procedure
involves removing the central portion of an intervertebral disc, the nucleus pulposus,
which causes pain by stressing the spinal cord or radiating nerves.
A laminectomy is a spinal surgery that involves removing bone to
relieve excess pressure on the spinal nerve(s). Conventional
laminectomy, as opposed to a laminotomy, remains the gold standard
of treatment for disc herniation and spinal stenosis. A laminectomy
treating a disc herniation involves removing the vertebral roof (which
involves removing the spinous process and removing lamina), pulling
aside the neuro components (dura) and locating the herniated disk,
discectomy of the disk material and then a spinal fusion. A
laminectomy treating spinal stenosis involves removing the vertebral
roof over the stenosed area of the spine in order to decompress the
narrowed areas exerting painful pressure on the nerves.
Problems with these procedures occur due to the extensive soft
tissue dissection and the risk of spinal instability, thus the need for
spinal fusion and stabilization. This current surgical treatment is not
entirely satisfactory.
Mahadewa (2010) explained how a Laminectomy with Fusion
is used to treat spinal stenosis; the decompressive procedure consists of removal of the
spinous process, bilateral laminectomy (explained in the next section), partial bilateral
facetectomy (surgical removal, excision
of the articular facet/s), and
foraminotomy (removal of the roof of
the intervertebral foramen), followed by
a spinal fusion using the current pedicle
screw and rod system and implanting the
harvesting bone graft material, usually
harvested from the iliac crest.
The primary goal and aim of
treatment is to restore quality of life and
the elimination of the pain and the other
signs and symptoms the patient experienced prior to the procedure6.

There are always risks even if the surgery is done correctly and effectively, such
as significant blood loss, postoperative wound pain, prolonged hospital stay and impaired
spinal stability requiring fusion or stabilization.
There is always the risk of infection whenever there is an opening in the skin’s
integrity. There’s a risk that the nerves could be damaged, especially in the area where a
herniated disk is removed, which could cause numbness or pain along a nerve path.
There’s a significant risk of instability of the spine due to the significant amount of bone
removal of the procedure; thus, concurrent spinal fusion or another surgery later may be
required to fuse that part of the spine. Graft rejection resulting in a failed fusion always
carries significant risk associated with a laminectomy as well.
Complications for nurses to watch for:
The dura (tough tissue surrounding the spinal cord) may be torn, causing cerebral
spinal fluid to leak out of the spinal cord. The nurse should look at the drainage and the
drain system in place and watch for worsening headaches that worsen upon
sitting/standing up. If a CSF leak is suspected instruct the patient to lie flat in bed for a
time and collect a sample of the fluid to test it in order to determine if it is CSF. Insertion
of a lumbar drain is one method of treatment for a CSF leak. Some patients with CSF
leaks need an additional surgery to repair the nicked dura in the spinal canal.

3. Laminotomy
The term laminotomy is derived from the Latin word lamina (thin plate, sheet or
layer), and the Greek word -tome
(incision; division of one of the
vertebral laminae). In a laminotomy
(or lumbar microdiscectomy) only a
small part of the lamina directly over
the affected area is removed. For
example, to correct a herniated disc,
in this procedure, a small piece of
bone (lamina) is removed from the
affected vertebra, allowing the
surgeon to better see and access the
area of disc herniation for a
discectomy without compromising
the integrity and stability of the spine
or requiring spinal fusion, which is
often the result of a laminectomy
procedure.
Discectomy is the surgical
removal of herniated disc material
that presses on a nerve root or the
spinal cord. The procedure involves
removing the central portion of an
intervertebral disc, the nucleus
pulposus, which causes pain by
stressing the spinal cord or radiating nerves. A. a small incision is made B. portions of the lamina
are removed C.neural elements exposed D. all
herniated discmaterial is removed.
Mahadewa (2010) explained how a Laminotomy is used to also
treat spinal stenosis, instead of completely removing the vertebral
arches and then using spinal fusion as in a Laminectomy. The
spinous processes are removed at
their insertion into the posterior
arch, flavectomy (removal of the
ligamentum flavum) is done leaving
a narrow channel exposing the
spinal canal. The lamina is undercut
at the stenotic levels, then laterally
to undercut the medial facets on
each side to decompress the nerve roots (and visualize the
dura - tough tissue surrounding the spinal cord) while
leaving most of the facets intact. The decompression is
advanced to the lateral recesses and foraminal areas (Fig.8)
until all hypertrophic flavum ligaments and hypertrophic and stenosed (narrowed,
constricted) facet joints compressing the roots have been completely removed.
The primary goal of the treatment procedure is to restore quality of life and eliminate
the pain and other signs and symptoms the patient was experiencing.

There are always risks even if the surgery is done correctly and effectively, such as
significant blood loss and postoperative wound pain, the risk of infection and the nerves
may be damaged, especially in the area where the disk is removed, which could cause
numbness or pain along a nerve path.
Possible complications for nurses to consider:
The dura (tough tissue surrounding the spinal cord) may be torn, causing cerebral
spinal fluid to leak out of the spinal cord. The nurse should look at the drainage and the
drain system in place and watch for worsening headaches that worsen upon
sitting/standing up. If a CSF leak is suspected, instruct the patient to lie flat in bed for
some time and collect a sample of the fluid in order to test and determine if it is CSF.
Another surgery to correct this is highly likely, if the leak is not closed, this condition
predisposes the patient to infection of the spinal column (meningitis).
Although some doctors still prefer the older more radical surgery, there is growing
evidence that the Laminotomy, the newer, less invasive procedure, is superior to the
Laminectomy with fusion.
A review of several professional journals and research articles revealed that
Laminotomy and Laminectomy with fusion are equally effective over the short time the
follow ups were conducted (all patients underwent serial clinical fallow-up evaluations
for periods ranging from 3-36 months). 4,3,1
Compared to a Laminectomy without Fusion, a Laminotomy procedure may in fact
better preserve a person’s quality of life by not requiring the spinal fusion often found to
be needed at a later time with a Laminectomy without fusion. The reason is simple: the
more bone that is removed, the less strong and stabile the remaining structure is. While
removing more lamina often does better relieve symptoms initially, there is a far greater
rate of postoperative complications resulting from the spinal instability that are often
worse than the original problem. These complications often require subsequent spinal
fusion and additional surgeries to treat the postoperative complications caused by the
spinal instability resulting from the Laminectomy without Fusion.

4. Fusion (fig 9)
This is a surgical immobilization where two or more
adjacent vertebrae are joined together through the
placement of posterior pedicle screw-rod constructs, the
application of an osteoinductive material along, and bone
grafts or implants. Spinal Fusion is used to correct
stability problems and to promote bone growth between
the vertebral bodies; the graft material acts as a binding
medium – as the body heals, the vertebral bone and bone
graft eventually grow together to join the vertebrae and
stabilize the spine5.
Posterior Spinal Fusion: This
procedure involves accessing the
posterior aspect of the spine by making
an incision in the patient’s back thus
allowing direct access to the posterior
aspect of the spinal column, and
involves the lateral placement of
posterior pedicle screws through the transverse processes
and rod constructs and harvested autogeneous bone grafts.
There are 3 types of Interbody Spinal Fusions (fig 12)
, with
2 Lateral variations: There are two lateral-interbody
variations of the three primary interbody spinal fusion
techniques: Transforaminal and Posterior
Later-Interbody Spinal Fusions (fig 11)
.
These procedures both involve accessing
the posterior aspect of the spinal column by
going through an incision made in the
patient’s back, thus allowing access to both
the posterior aspect of the vertebral column,
lateral access to the anterior aspect of the
vertebral column, and the lamina of the
transverse processes which are necessary for a
screw-rod construct for a posterior lateral bone graft
fusion/stabilization. Then a Postero-lateral Spinal Fusion is
performed.
Transforaminal Interbody: A unilateral laminotomy
and a partial facetectomy (surgical removal of the articular facet
(Fig.5)) are performed on the side consistent with the patient’s
symptoms or anatomical abnormalities. This procedure preserves
spinal integrity by minimizing lamina facet, and pars dissection
and places the graft in the middle and anterior section of the
vertebral disc space.2 Then a Posterior Spinal Fusion is performed.

Laminotomy, Laminectomy and Spinal Fusion 1 0
Posterior Interbody: Posterior spinal elements are removed to expose the
traversing nerve roots and lateral extent of the disc space. The dura matter is retracted
to the midline and the interbody space is exposed and discectomy is performed. This
procedure places the graft in the posterior section of the vertebral disc space.2 Then a
Posterior Spinal Fusion is performed, “after the interbody construct is placed, pedicle
screw/rod are attached. The transverse processes are then decorticated [shaved and
bleeding, to make the body’s natural repair system think that one large bone has
broken], and the bone graft material is placed over them for a posterolateral fusion.”
(Domagoj, C., 1997, p.121)
Anterior Interbody Spinal Fusion:
This procedure involves accessing the
anterior aspect of the spinal column by
going through the abdominal cavity and
usually involves the placement of a fusion
cage that is in the form of an artificial disc
which uses hollow threaded cylinders filled
with bone graft and osteoinductive material
to fuse two adjacent vertebrae into one long
bone.2
Primary Indications include
stabilization & fusion of adult spinal
deformity, such as symptomatic
spondylolisthesis, degenerative scoliosis,
and spinal stenosis associated with
instability. For those with stenosis, but without deformity, surgical management has
traditionally involved posterior decompressive procedures, including laminectomy &
laminotomy. In patients with spinal instability, fusion is recommended in addition to
decompression.
Secondary Indications include recurrent lumbar disc herniations, lateral or
massive disc herniations & failed fusions by other techniques.
“The rate of arthrodesis (binding, the fusion of two bones) has been shown to
increase given placement of bone graft along the weight-bearing axis. The fusion rate
across the disc space is further enhanced with the placement of posterior pedicle
screw-rod constructs and the application of an osteoinductive material.” (Cole, C.,
McCall, T., Schmidt, M., 2009, p.118)
Osteoinduction (the use of osteoinductive material) involves the simulation of
osteoprogenitor cells to differentiate into osteoblasts that then begin new bone
formation. The most widely studied type of osteoinductive cell mediators are bone
morphogenetic proteins (BMPs). A bone graft material that is osteoconductive and
osteoinductive will not only serve as a scaffold for currently existing osteoblasts but
will also trigger the formation of new osteoblasts, theoretically promoting faster
integration of the graft. Decortication of the bone surfaces surrounding the graft helps
to aid this process as well.

The primary goal, and most important purpose of a fusion, is for the elimination
of pain. Spinal fusion is performed to correct a fracture, and for several other severe
conditions that cause spinal instability which include degenerative joint disease,
spondylosis, infections and tumors or when the discs between the vertebrae rupture
causing the vertebrae to grind into each other, or when the spine is unstable and can’t
maintain the functional alignment between all of its important structures and when
abnormal movements cause pain and put adjacent structures at risk of injury; this
procedure is also done to reinforce stability of the spine that could worsen after a
surgery that weakens the spines integrity, such as a Laminectomy2,5.
As with any surgery there is potential risk involved, complications such as
infection, nerve damage, blood clots, blood loss and bowel and bladder problems,
along with the indirect-complications such as those associated with anesthesia, are
some of the potential risks patients face with this surgery. Another potential risk
inherent specifically to spinal fusion is failure of the vertebral bone and graft to
properly fuse, a condition that may require additional surgery(ies).
The success rates of lumbar fusion can decrease in patients who smoke, are
overweight, have diabetes or other significant medical illnesses, have osteoporosis, or
who have had radiation treatments that included the lower back. Good nutrition and
slowly increasing activity in the recovery period can help achieve success.
Nursing considerations to keep in mind is that the implant may shift slightly after
surgery to the point that it is no longer able to hold the spine stable. If the implant
migrates out of position, it can cause injury to the nearby tissues. If an implant shift is
suspected the patient should be bedfast and be instructed not to move until the
surgeon is contacted and the position is checked, usually a fluoroscope is used to
check the position. Hardware can also cause problems. Screws or pins may loosen
and irritate the nearby soft tissues.
Also, not all patients achieve complete pain relief results with this procedure. Full
fusion can take up to three months. As with any surgery, patients should expect some
pain afterwards, however, if the pain continues, seems unusual, or becomes
unbearable nursing-decisions, clinical judgment and professional discretion should be
used and possible complications should be taken into consideration.

5. Post-Op Rehabilitation and Patient Education
Dressings should be inspected for bleeding and cerebral spinal fluid leakage
indicating dura sheath damage and needs to be documented and reported immediately.
Specific positioning of individual patients and activities are followed per
surgeons’ post-op orders. In general, the patient should be maintained in a supine position
with the head of the bed about 5-10 degrees for the first post-op hour, and then the head
of the bed no higher than 45 degrees for the next 1-2 hours post-op, and repositioned
every 2 hours by log-rolling the patient – pillow between their legs – educate the patient
on the importance of NOT TWISTING their body and maintaining spinal alignment.
An incentive spirometer should be encouraged every hour to promote deep
breathing and decrease the chance of developing a lung infection, such as pneumonia.
The patient should be encouraged to void 8-12 hours post-op, and should be
assessed for bladder distention if urinary retention is suspected and indicators of the
patient’s possible need for catheterization.
The patient is taken off NPO status and allowed to slowly start eating solid food
only after bowel sounds can again be auscultated.
Medications:
Medication given after these procedures is usually anti-inflammatory, muscle relaxant
and antibiotic/prophylactic and narcotic in nature.
Fluid balance:
Fluid balance is closely monitored and maintained through the administration of
intravenous fluids and assessing the patient’s output.
Orders:
Post-op day 1, with assistance from the nursing staff or therapists, the patient can
be encouraged to get out of bed and resume some normal activities like getting dressed,
toileting and showering, depending on the patient’s pre-surgical activity level.
Consults:
A physical therapist should be consulted, they can teach the patient special
exercises to help improve movement and decrease pain. Physical therapy can also help
improve the patient’s strength and limit the risk of loss of function.
Patient Education and Post-Discharge Instructions:
Incisional care should be taught to the patient and family care givers.
No heavy lifting, pushing, pulling or shoving anything heavier than 5lbs.
Long car rides (>40min) are permitted only when absolutely necessary, instruct
the patient that they must be able to stop at intervals of not more than 45-60min & walk
for a few minutes.
No driving until seen by their physician at their post-op/follow-up visit.
Instruct patient to walk as often as can tolerate after discharge, this should be
explained as aiding & increasing the rate of arthrodesis (binding, fusing two bones).
Do exercises given in the Post Laminectomy & Post Fusion Back Program.
Instruct patients to circle and omit any exercise that hurts abnormally, or causes
unusual discomfort but to continue the other exercises given in the post-laminectomy or
post-fusion back program until their follow up visit, at which time they should bring the
booklet and inform their doctor of the painful exercises. Each exercise targets specific
muscles, so this will give their doctor an indication of what to address to fix the problem.
Do not wear anything tight over the incision.
Do not take tub baths. NO TUB BATHS. This includes Jacuzzis as well.

Instruct the patient that they may shower and pat the incision dry afterward.
Proper body mechanics should be taught to the patient to lessen the strain and
pressure on their spine; those include maintaining proper body alignment and good
posture and sleeping on a firm mattress.
Sexual intercourse can be resumed around 2 weeks after surgery and with good
back support. Patients often ask the inevitable question, “What exactly does ‘good back
support’ mean?”, or variations thereof, and the blunt answer to that is “You have to be on
the bottom, with a firm mattress”.
Full fusion of the spinal graft itself may take up to three months, and full
rehabilitative recovery could take up to eight months.
Ensure that the patient understands their need to make a follow-up visit in 2
weeks, and that they understand the importance of their follow-up visit.

6. EBP ResearchArticles and Conclusions on the Different Procedures
Comparative Study of Laminotomy vs. Laminectomy with Fusion:
Cole, C., McCall, T., Schmidt, M. (2009)
The aim of this study was to observe the outcome of canal decompression in
lumbar stenosis using bilateral Laminotomy and Laminectomy with Fusion and compare
the results.
The results showed “that bilateral laminotomy and laminectomy with fusion are
equally effective over a short follow up. However, bilateral laminotomy is a less invasive
procedure.” (Mahadewa, 2010, p153)
These results can only be generalized to patients with lumbar canal stenosis and
compression due to hypertrophy of the flavum ligament, hypertrophic facet joints,
posterior spur formation and disc bulging.4
Mahadewa, 2010 states that laminectomy decompression is effective though
associated with significant blood loss, postoperative wound pain, prolonged hospital stay
and impaired lumbar stability requiring fusion or stabilization. Complications with the
procedure occur due to the extensive soft tissue dissection, paraspinal muscle
devascularization and the risk of spinal instability, thus the need for a corrective spinal
fusion or stabilization. Bilateral laminotomy decompression and laminectomy with fusion
were used to specifically treat lumbar stenosis for this research article.
“In 46 cases, bilateral laminotomy was performed; in 59 patients, laminectomy
with spinal fusion was performed…there were no postoperative complications among the
105 patients …No patient had additional surgery in the lumbar spine during the follow-up
study of 3-36months, and no patient experienced worsening back pain or neurological
function. …moreover, the surgical outcome, including results of the postop Visual
Analog Scale (VAS) for pain evaluation, Neurogenic Claudication Outcome Score
(NCOS) and Oswestry Disability Index (ODI) for neurological outcome evaluation [and]
radiographs obtained postoperatively and at regular intervals to evaluate the correct
placement and stability of the implant system, did not differ between the two groups.
Bilateral Laminotomy thus has the advantage as a less invasive method.” (Mahadewa,
2010, p155, 157)

Designof Lamifuse: a randomized, multi-centre controlled trial comparing
laminectomy without or with dorsal fusion for cervical myeloradiculopathy
(Study Protocol)
Bartels, R., Verbeek, A., Grotenhuis, J. (2007)
Bartles (2007) identifies that the complications related to adding lateral mass
screws or pedicle screws are vertebral artery injury and temporary or permanent nerve
root damage. In order to prevent damage to the spinal cord, the instrumentation should be
completed before the laminectomy with fusion. Also, since instrumentation is added in
the fusion group, the costs will be higher.
In the article, Bartles (2007) addresses the quality of life after a spinal fusion,
spinal stenosis naturally limits spinal mobility, so a laminectomy with fusion won’t
decrease the patient’s quality of life, and in fact, when indicated/required may even have
better clinical outcomes when compared to a laminectomy without fusion.
The main hypothesis of the article was that patients who are surgically treated for
signs and symptoms due to a stenosis of the cervical spinal canal have a better clinical
outcome when a fusion is performed in addition to a laminectomy when compared to
those that solely have a laminectomy.
Bartles (2007) addressed that the quality of life, the complications and the costs of
the two procedures needs to be evaluated comparing these two treatment groups in a
future study.1
“Despite a long-lasting interest in the various techniques, the clinical superiority
of one method over the other has never been established. To our knowledge, a
randomized-controlled trial comparing laminectomy with or without fusion has never
been performed.” (Bartles (2007, p.2)

Comparison of low back fusion techniques: Transforaminal lumbar interbody
fusion (TLIF) or posterior lumbar interbody fusion (PLIF) approaches
Cole, C., McCall, T., Schmidt, M. (2009)
The advantages of the TLIF procedure stems from the approach of the procedure and
includes a lesser risk of neurological injury and impairment, better positioning of the
graft implementation within the intervertebral disc space, improved spinal alignment due
to the graft placement within the anterior spinal column, and increased stability and
integrity of the spinal column via increased preservation of the lamina and the
articulating facets.
The advantages of the TLIF technique relies on distracting the motion segment
through pedicle screw placement before cage insertion, thus decreasing the risk for a
durotomy (dural sheath tear) and limiting the risk of neurological injury. With TLIF the
graft is placed within the anterior or middle of the disc space to restore the normal
curvature of the spine and correct lordosis. Lastly, posterior fusion is better achieved with
a TLIF because this procedure allows additional surface area by preserving the spinal
processes and lateral laminae.
Medical doctors and research agrees that most cases of low back pain are transient,
with only 5% becoming chronic and disabling which needs aggressive treatment,
however that’s where the agreement ends, the cause of spinal pain is not completely
understood and remains controversial, therefore surgical treatment is also controversial.
Thus, the aim of this research article focused on addressing the risks associated
with each procedure and which procedure had the least.
The comparison of each procedure and which procedure was concluded as being
“better” than the other was based solely on which procedure had the least risk, rather than
patient outcome postoperatively.
According to Cole, McCall, Schmidt (2009), there is no convincing evidence to
support routine use of lumbar treatment for primary lumbar disc excision, but may be
used as supplementary tx in patients with a herniated disc in whom there is evidence of
pre-op spinal deformity.
Because lumbar deformity, instability, or even chronic low back pain may occur
as a result of a reoperative lumbar discectomy, fusion is often considered part of the
primary tx in the setting of repeated lumbar disc herniation repairs.

Reference:
1. Bartels, R., Verbeek, A., Grotenhuis, J. (2007). Design of Lamifuse: a
randomized, multi-centre controlled trial comparing laminectomy without
or with dorsal fusion for cervical myeloradiculopathy. BMC
Musculoskeletal Discorders. 8(111). (This article is available from:
http://www.biomedcentral.com/1471-2474/8/111.
2. Cole, C., McCall, T., Schmidt, M. (2009). Comparison of low back fusion
techniques: transforaminal lumbar interbody fusion (TLIF) or posterior
lumbar interbody fusion (PLIF) approaches. Curr Rev Musculoskelet Med.
Volume 2 : 118 – 126.
3. Domagoj, C. (1997). Posterior lumbar interbody fusion in the treatment of
symptomatic spinal stenosis. Neurosurg Focus. 3 (2), article 5.
4. Mahadewa, T., Maliawan, S. (2010). A comparative Study of bilateral
laminotomy and laminectomy with fusion for lumbar stenosis. Neuology
Asia. 15(2) : 153 – 158.
5. Resnick D, Choudhri T, Dailey A, et al. (2005) Guidelines for the performance of
fusion procedures for degenerative disease of the lumbar spine. Part 1:
introduction and methodology. J Neurosurg Spine. Volume 2 : 637-638.
6. Silvers, H., Lewis, P., Asch, H. (1993). Decompressive lumbar laminectomy for
spinal stenosis. J Neurosurg. Volume 78 : 695 – 701.
7. Taber’s (2001). Cyclopedic Medical Dictionary. F.A. Davis Company :
Philidelphia.

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