Laminectomy vs Discectomy in Rehabilitation

Differences Between
Discectomy & Laminectomy
in Rehabilitation
And other fun stuff
–Dr Andrea Ignacio DC- aignaciodc@gmail.com

Outline of CME
• Surgeries
– When to do/Timing/Justifications
– Cervical
• Anterior/Posterior
– Advantages/Disadvantages
• Individual Procedures
• Tissues Damage / Healing
• What we do at SSH
– Lumbar
• Anterior/Posterior
– Advantages/Disadvantages
• Individual Procedures
• Tissues Damage / Healing
• What we do at SSH
• Rehabilitation
– General Considerations
• Outcome Predictors
• General Back Pain Risk Factors
• Yellow Flag Form
• Basic Anatomy Considerations
• Surgical Side Effects and
Precautions
– Treatment Plan
• Timeline
• Restrictions
• Cervical Basics
• Low back Active Basics
– Lifestyle/Advice
• Nutrition / Supplements
• Herbs
• Misc Recommendations

To Operate or Not To Operate?
• Most certain surgical criteria:
– Cauda equina syndrome
– Paresis, rapidly progressive despite optimal treatment (conservative care for 4 weeks
to 3 months.
• Surgical Indications for Disc Herniation – Danish Guidelines
– After 4-6 weeks of conservative care
– …positive correlation between clinical findings and imaging reports
– Progressive weakness in the leg
– Severe leg symptoms in spite of medication
• Surgical Indications for Disc or Stenosis – Rand Corporation
– Appropriate – pain, imaging +, major/minor neuro findings, 6+ weeks restricted activity
• Major: Progressive unilateral weakness or
• + contralateral SLR
– Equivocal – dubious rad, minor neuro findings or < 4 weeks restricted activity
• Minor: Ankle DTR asymmetric, dermatome deficit, + ipsi SLR, Sciatica
– Inappropriate – + imaging, but minor neuro and < 4 weeks restricted activity
Rehabilitation of the Spine – 2nd Ed - 2007

Cervical
Anterior Approach
Posterior Approach
Discoplasty
Discectomy
Corpectomy
Fusion
&
Fixation
Laminoplasty
Laminectomy
Anterior
Advantages:
• Familiar Approach
• Less post-op pain
Disadvantages:
• Usually requires fusion
• Risk of recurrent laryngeal nerve
palsy
• Potential risk to vascular and visceral
structures
Posterior
Advantages:
• Straight forward, well known to all neuro-
surgeons
•Avoids risks to anterior vascular and visceral
structures.
Disadvantages:
• Potentially greater discomfort and
longer hospital stays due to takedown of
paraspinal muscles.
•Increased incidence of deformity post-
laminectomy
Atlas of Neurosurgical Techniques - 2006
Dr Khalid Siddiqui

Cervical
Anterior Approach
Posterior Approach
Discoplasty
Discectomy
Corpectomy
Fusion
&
Fixation
Laminoplasty
Laminectomy

Incision Damage vs. Healing
Anterior Approach:
•Verify with landmarks or fluoroscopy
•Horizontal incision
•Platysma is incised
•Fascial release
•Subplatysmal
•superficial layer of deep cervical
fascia enveloping SCM)
•Omohyoid muscle (fascial release
and retraction – or transection)
•Trachea and esophagus retraction
•Distraction of vertebral bodies with
pins/distractor
Posterior:
•Incision directly over spinous processes to
level of deep fascia
•Follows ligamentum nuchae trying to avoid
cutting through the paraspinous muscle
•Detach paraspinous muscles from spinous
processes and laminae & retract
•Avoid thermal damage to soft tissue & bone
•Greater force of traction must be used if
shorter segment which can lead to muscle
ischemia & post-op pain.
•For keyhole laminoforaminotomy
•Skin incision/soft tissue dissection of
about an inch centered at upper spinous
process

Procedures At Saad Hospital
Cervical
• Simple Disc Disease?
– Anterior approach, with Fusion
• Multi level? Add Screw Fixation
– Recently started doing Artificial Disc Replacement.
• Spondylosis, Multiple Discs, Cord Compression?
– Anterior or Posterior with Laminectomy
– Instability? Add Screw Fixation
Dr Malek Hubballah

Anterior Approach
Posterior Approach
Lumbar
Discectomy
Decompression
Regular w/ Laminotomy
Minimally Invasive (MIS)
(Microdiscectomy or Endoscopic)
Hemilaminectomy
Laminectomy
+
Foraminotomy
DLIF
(Post-Failed Back)
PLF ?
PLIF  TLIF XLIF
(Cages & Pedicle Screws w/Foraminotomy)
(Some can be done as MIS) (AxiaLIF)
Fusion
Fixation
Artificial Disc
Major Surgery
ALIF x
Discectomy
BCBS Michigan: Medical Policy -
Minimally Invasive Lumbar Interbody
Fusion Current Policy Effective Date:
5/1/12
Procedures described as minimally
invasive (MI) range from
percutaneous techniques to minimal
open access approaches that
decrease the size of the incision and
reduce muscle retraction.
AxiaLIF
Fusion
Fixation

Anterior Approach
Posterior Approach
Lumbar
Discectomy
Decompression
Regular w/ Laminotomy
Hemilaminectomy
Laminectomy
+
Foraminotomy
DLIF
(Post-Failed Back)
PLF ?
PLIF  TLIF XLIF
(Some can be done as MIS) (AxiaLIF)
Fusion
Fixation
Artificial Disc
Major Surgery
ALIF x
Discectomy
AxiaLIF
Fusion
Fixation
Anterior
Advantages:
• Enables visualization of all lumbar
vertebrae
• Access to lumbar sympathetic chain
• Allows for ventral decompression
Disadvantages:
• Access to L5 obstructed by iliac vessels
• Right side approach limited by liver
• Potential for complications to abdominal
viscera
• Rostral and caudal extent of dissection
may be limited
Posterior
Advantages:
• Well known technique
• Versatile and can address most lumbar
pathology
• Large spinal canal & low risk of spinal cord
injury
•Ease of localization of correct spinal level
Disadvantages:
• Deep soft tissue and muscular dissection
• Risk of iatrogenic spinal instability
• Restricted access to ventral pathology

Anterior Approach
Posterior Approach
Lumbar
Fusion
Fixation
Discectomy
Decompression
Regular
Hemilaminectomy
Laminectomy
+
Foraminotomy
DLIF
(Post-Failed Back)
PLF
PLIF  TLIF XLIF
(Some can be done as MIS)
Fusion
Fixation
ALIF x
Artificial Disc
Major Surgery
Discectomy

Anterior Approach
Posterior Approach
Lumbar
Fusion
Fixation
Discectomy
Decompression
Hemilaminectomy
Laminectomy
+
Foraminotomy
DLIF
(Post-Failed Back)
PLF
PLIF  TLIF XLIF
Fusion
Fixation
ALIF x
Artificial Disc
Major Surgery
Discectomy
Regular (laminotomy)
Minimally Invasive (MI)

Anterior Approach
Posterior Approach
Lumbar
Discectomy
Decompression
Regular
Hemilaminectomy
Laminectomy
+
Foraminotomy
DLIF
(Post-Failed Back)
PLF
PLIF  TLIF XLIF
Fusion
Fixation
ALIF x
Artificial Disc
Major Surgery
Discectomy
AxiaLIF
Fusion
Fixation

Incision Damage vs. Healing
Anterior Approach:
• Midline, paramidline or transverse
incision.
•Abdominal wall fascia incised and
peritoneum opened
•Intestines retracted
Posterior:
• Skin incision into subcutaneous tissues,
retracted
• Lumbodorsal fascia opened at midline or
slightly off midline
• Subperiosteal dissection of paraspinous
musculature at fascia just off midline
• Muscles stripped from superficial to deep
until lamina is reached, retracted
• For hemilaminectomy and discectomy,
unilateral retraction just to facet.
• For posterolateral fusion, wide bilateral
exposure exposing facet joint.
Healing Times:
• Incision site – 2 weeks
• Back to work (soft disc) – 1 month
• Bone Fusion – 3 months

Procedures At Saad Hospital
Lumbar
• Anterior approach – very rare
• Mostly Posterior approach
– Simple disc? Laminotomy
– Disc & Stenosis? Laminectomy
– Instability? Screw Fixation (usually don’t do)
– Foraminotomy? Almost always
Dr Malek Hubballah

Rehabilitation Considerations
• Eur Spine J (2009) 18:398–409 - Clinic-based training in
comparison to home-based training after first-time lumbar disc
surgery: a randomized controlled trial.
• “The main finding in this study was that there was no difference
between the outcome of clinic-based training with regular scheduled
visits to a physiotherapist and home-based training regarding back
pain-specific functional status 3 and 12 months after first-time disc
surgery. Back pain reduction and quality of life were significantly
better in the home-based training group 1 year after surgery.
However, those patients who followed the regular, multidimensional
physiotherapy programme had a significantly higher compliance
rate for future regular physical activity and were significantly
more satisfied with the help they had received from the
physiotherapist.”
• “The patients who completed the regular, multidimensional clinic-
based physiotherapy programme were more motivated to
continue regular physical activity and were significantly more
satisfied with physiotherapy care despite more persistent back
pain.”

Dimensions to Consider
• Biomedical - Mechanical / Anatomical changes
– “…most structural pathologies are present in asymptomatic individuals in nearly equal
degree as they are in those who are symptomatic.”
• Biomedical Approach
– Emphasize anatomy, injury & damage
– “let pain by your guide”
– Emphasize further tests
– Focus on pain rather than activity
– Encourage passivity & dependency
– Positive attitudes result in speedier recovery
• Biopsychosocial variables
– International Association for the Study of Pain (IASP) – pain is not simply the result of
structural injury or pathology but is “an unpleasant sensory and emotional experience
associated with actual or potential tissue damage…”
– “the potential for pain is heavily influenced both by nociception and by one’s attitudes,
beliefs, and social environment.” Klassen, Berman study
– Psychosocial illness behavior (depression, inactivity, pain avoidance) is the rule with chronic
pain sufferers.
• Biopsychosocial Approach
– Reassurance – no signs of serious disease
– LBP is symptom that back is biomechanically unfit
– Psychological treatment can help, but long term results depend on lifestyle.
– Recovery depends on restoring function – sooner the better
• Post Surgical patients should not be viewed as similar to chronic pain patients
– use functional approach.

Rehabilitation Considerations
Those at risk for difficult recovery post-surgery:
– Age of patient (patients > 50)
– Weight/fitness level of patient (patients > 20% overweight)
– Increased motor dysfunction
– Long delay pre-surgery and/or multiple surgeries
Predictors of poor surgical outcome:
– Tobacco use, depression, litigation
• Red/Yellow flags
– In chronic cases encourage behavior that “focuses on functional
reactivation, not pain avoidance. …it is necessary for patient to focus on
increasing their activities in spite of their pain.”
– Fear avoidance promotes deconditioning leading to less stability.
• Bed Rest:
– “…4 days of bed rest led to more sick leave than advice to continue
normal activity.” - Rozenberg et al 2001
– Danish guidelines - “…bed rest should only be used for severe pain
and then only for 1-2 days.”
•Red Flags of Serious Disease (tumor, infection,
fracture, serious medical disease)
•<20 or >50 yoa
•Trauma
•Hx of Cancer
•Night Pain
•Fevers
•Weight Loss
•Pain at Rest
•Immune Suppression (sig corticosteroid use)
•Recent Infection
•General Systemic Disease (diabetes)
•Failure of 4 weeks Conservative Care
•Cauda Equina, Saddle Anesthesia, Sphincter
Disturbance, Motor Weakness LL
• Yellow Flags Risk Factors for LBP Chronicity
• History and Symptoms
• 4-12 weeks symptoms, sciatica, hx of back pain needing
treatment, severe pain intensity long term, widespread pain.
• Examination
• + SLR, + Neuro, + ROM/Ortho
• Psychosocial
• 3+ Waddell signs, self-rated health=poor, fear avoidance
beliefs, anxiety, coping behaviors, distress/depression, low
expectations, blaming others, negative family/work, caring
for many children, anticipation of disability or inability to
work
• Work-Related
• Work comp (compensation, litigation), demanding job,
dissatisfaction, prior disability, no work light duty, low
job/supervisor support.
• Functional
• Low work tolerance, sleep disturbance, moderate physical
disability

Yellow Flags Form - Scale of 0-10 (none-worst, never-always, poor-excellent,
I can-I can’t, agree-disagree)
Risk? Low<55, Mod55-65, High>65
1. Usual level of pain during the past week.
2. Does pain, numbness, tingling or weakness extend into your leg (from
low back) and or arm (from neck)?
3. How do you rate your general health?
4. If you had to spend the rest of your life with your condition as it is
right now, how would you feel about it?
5. How anxious have you been feeling this last week?
6. How much have you been able to control your pain yourself the last
week?
7. Indicate how depressed you have felt this last week.
8. How certain are you that you will be doing normal activities or working
in 6 months?
9. I can do light work for an hour?
10.I can sleep at night.
11.An increase in pain is an indication that I should stop what I am
doing until the pain decreases.
12.Physical activity makes my pain worse?
13.I should not do my normal activities including work with my present
pain.

Considerations
Range of Motion Changes
•Cervical
• Flexion/Extension – total 130 degrees
• 50% of flexion/extension are between atlas/occiput
• 50% subaxial from C3-C7 (~ 10% each segment)
• Rotation – total 140 degrees
• 50% of rotation between atlas and axis
• 50% from C3-C7
• Lateral Flexion – total 75 degrees. Atlas of Neurosurgical Techniques - 2006
Phys Exam of Spine & Extremities - 1976
•Lumbar
• Relatively less motion in L spine compared to extremities. “Major
motion such as flexion primarily involves motion in the hips;”
• Lateral flexion occurs in combination with rotation.
• “Vertebral motion is greatest where the discs are thickest and joint
surfaces largest.” (and more motion = greater chance of breakdown)
• “..motion taking place between L5-S1 is greater than between L1-
2.”

Side Effects/Precautions
• Cervical
• Recurrent Laryngeal Nerve
• Incision (left better than right)
• Hoarseness, voice fatigue, difficulty with high tones
• Refer to Speech Therapy
• Post-laminectomy kyphosis
•Lumbar
• Secondary Piriformis Syndrome (& other ddx contributing to pain)
• Flat Back Syndrome, or sway back posture
• Bone Mineral Density issues
• Brachial plexopathy following lumbar surgery from excess/
prolonged arm traction
•General
•Complications of Fusion
•Hardware malalignment/failure, pseudoarthrosis, infection
•Adjacent segment degeneration
• Scar tissue at nerve roots
• Thrombophlebitis (DVT)
•Blood thinners, pressure stockings, movement, electrical stim
Eur Spine J (2012) 21:530–536 The impact of bone mineral density and disc
degeneration on shear strength and stiffness of the lumbar spine following
Laminectomy.
• “standard surgical procedure for elderly patients with symptomatic degenerative lumbar
stenosis”
• “chances of developing postoperative pars interarticularis fractures and spondylolisthesis after
laminectomy seem quite substantial, especially when the patient has low BMD. It may be
questioned whether patients can safely perform physically demanding tasks after lumbar
laminectomy.”
• “The decrease in amplitude of displacement at failure after laminectomy also shows that less
‘slipping’ (i.e. absolute shear displacement) is necessary before trauma occurs..”
• “Subjects with low BMD may require additional posterior instrumented stabilization to prevent
postoperative instability. In clinical practice, laminectomy is often, but not always, combined with
posterior instrumentation and fusion to prevent complications such as Spondylolisthesis.”
•“The procedure of stabilization itself increases the probability of implant-related complications,
including infection, nerve injury, possible adjacent disc degeneration, increased blood loss,
extended surgery time, and instrumentation failure…”
•“The probability of implant-related complications needs to be weighted against the risk of
postoperative complications after laminectomy without stabilization..”

Walk Lifting Restrictions
Begin Rehab
Return to Play
Non-Contact Sport
Return to Play
Contact Sport
•General
•Recommendations
Treatment Plan

Treatment Plan
Day
1
Day
2
Week
2
Week
3
Week
4
Week
6
Week 8
Month 2
Month
4
Month
6
Month
8
1 Year
< than Coffee Cup No more than 9 kg
No more than 9 kg< than Coffee Cup
• Annular disruption has started healing
• Add into core stabilization program
• Wound is checked, activity levels can be increased
•Advanced stabilization/
functional training
•Normal pain free ROM required
?
• Gentle core stabilization
< than Coffee Cup No more than 9 kg
No more than 4.5 kg
• Basic Stability EP
• Emphasize neutral
postural alignment (i.e.
Brugger Relief)
•Mild endurance training
•Work from bottom up
X

Patient Restrictions
Day
1
Day
2
Week
2
Week
3
Week
4
Week
6
Week 8
Month 2
Month
4
Month
6
Month
8
1 Year
Bending
Lifting
•Bending only
w/knee flex & squat
•Limit sitting to 20
min, up/walk, sit
•No sitting low soft
couches/chairs
Driving
Bending,
Lifting,
Twisting
Driving
Driving
•Bending only
w/knee flex & squat
•Limit sitting to 20
min, up/walk, sit
•No sitting low soft
couches/chairs
Bending
Lifting
•No brace required for 1 level fusion
Overhead
Work
•C Strengthening / ROM
•C Retraction / Dorsal Glide
•Head contact sports

Treatment Plan – Modalities
• Electrical Stimulation
– Interferential current most commonly used for pain management
– The farther apart the electrodes, the deeper the current flow.
– Relevant Contraindications
• Swollen, infected or inflamed areas
• Electrical stimulation has no curative value
• Avoid producing muscle contractions in any situation where contraction may disturb
the healing process (recent surgical procedures)
• Ultrasound
– Thermal effects - Produces motion/friction which increases tissue temperature,
increase local blood flow, enzyme activity and collagen extensibility, reduce pain
and muscle spasm and produces a mild inflammatory response.
• Use to increase ROM when used in conjunction with stretching
– Non-Thermal effects – may promote soft and body tissue repair and increase cell
and tissue membrane permeability.
– Relevant Contraindications
• Use over the spinal cord after Laminectomy
• Use over ischemic tissue
• “is has been shown that ultrasound does not adversely effect the mechanical properties
of…the fixation of metal pins, screws or plates.”
• Laser
Pocket Guide – Mettler Electronics - 2000

Treatment Plan – Cervical
• Exercises should emphasize neutral postural alignment
– Teach patients neutral sleeping position, and how to rise from side lying
– In fusion, avoid cervical retraction and dorsal gliding mobilizations
– Use the trunk, hips and chest to produce proper cervical alignment
– Brugger relief position
– Cog wheel, minus the neck motion
• Hakkinen et al. reported disappointing long-term compliance with home
exercise prescriptions and suggested “Progressive loading, supervision of
training, and psychosocial support is needed in long-term rehabilitation
programs to maintain patient motivation.”

Treatment Plan – Lumbar
Strengthening
• “…the safest and mechanically justifiable approach to enhancing lumbar
stability through exercise entails a philosophical approach consistent with
endurance, not strength; that ensure a neutral spine posture when under
load, and that encourages abdominal co-contraction and bracing in a
functional way.”
• Lumbar Stabilizers:
– Rectus Abdominis, Obliques and Transverse Abdominis
– Quadratus lumborum
– Back Extensors and stabilizers
• Begin program with flexion/extension (Cat/Cow) cycles to reduce spine
viscosity and floss the nerve roots. Cat/Cow is intended as motion, not
stretch, so no pushing at end ranges. 5-6 cycles.
• As patients progress – consider conscious simultaneous contraction of the
abdominals (bracing).
• Balls should only be introduced once the spine load-bearing capacity has
been sufficiently restored.

• Rectus Abdominis
– Curl ups
• With lumbar stabilization, and one leg
bent to assist in pelvic stabilization and
preservation of neutral lumbar curve
• Co-activate - Transverse Abdominis/Internal & External Obliques
– Isometric abdominal brace
– Transverse Abdominis is selectively
activated by dynamically hollowing
the abdominal wall.
Abdominals

Quadratus lumborum
• “optimal technique to maximize activation but minimize spine load…”
• Side Bridge

• Single leg extension & Bird Dog (no more than 7-8 seconds)
– This exercise can be enhanced with abdominal bracing and deliberate
mental imaging of activation of each level of local extensors.
– Lying prone on the floor and raising upper body and legs off the floor is
contraindicated for anyone at risk for low back injury or re-injury.
Back Extensors/Stabilizers

Nutrition
After Surgery:
• Acidophilus – stabilizes intestinal flora if antibiotics are used.
• Coenzyme Q10 – improve tissue oxygenation
• Essential Fatty Acids – cell growth and tissue healing
• Garlic – natural antibiotic
• L-Cystine/L-Glutamine/L-Lysine – speeds wound healing
• Multivitamin – duh.
Vit A needed for protein utilization/tissue repair and free
radical scavenger.
• Pycnogenol/Grape seed extract – powerful antioxidants
• Vitamin C with bioflavonoids – tissue repair/wound healing
• Vitamin E – improves circulation/tissue repair (d-alpha-tocoph.)
• Vit E oil – promotes healing and reduces scar formation
• Vitamin K – needed for blood clotting
• Zinc/Calcium/Magnesium/Silica/Vitamin D – tissue repair
• Support Healing Process
• Reduce Post-Surgical Discomfort/Pain
Prescription for Nutritional Healing, 4th Ed. 2006

• Bromelain & Turmeric – potential anti-inflammatory properties
• Echinacea – enhances immune system function
• Goldenseal – natural antibiotic, helps prevent infection >1 wk/not preg
• Green Tea – powerful antioxidants
• Kelp/reishi/St John’s word – may help mitigate effects of x-ray rad
• Milk Thistle – protects liver from toxic drug/chemical buildup
• Rose Hips – Vitamin C – enhance healing
Herbs
• Support Healing Process
• Reduce Post-Surgical Discomfort/Pain

Recommendation
• Weight loss – gradually, before surgery – excess weight can increase
surgical difficulty and length of recovery time.
• Smoker? – STOP – smoking delays healing and interferes with meds
– Smoking also increases disc degeneration rate by 300%
• Inform Dr of any meds/herbs/nutrition you take, prior to surgery
• Eat fiber – improves intestinal function
• Positive Attitude!! – get out of bed and back to normal asap – helps
prevent post op infection, and this mentality reduces chronicity.
• Avoid over-processed foods post-surgery – lots of liquids and try to eat
5-7 small, light, nutritious meals in a day.
• Arnica montana – homeopathic remedy, reduces swelling, promotes
healing.
• “patients who ate potatoes, tomatoes and eggplants prior to surgery
reacted unpredictably to anesthesia.” Journal American Health,
University of Chicago Medical Center research report.

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