Laminectomy is a decompressive surgical procedure intended to relieve pressure on the spinal cord or nerve roots. A portion of the vertebra, known as the lamina, is removed to decompress the spine. The removal of the lamina allows greater space for the spinal cord and nerve roots, thereby relieving compression on these structures. Foraminotomy and laminotomy involve removal of a portion of the bony arch, or lamina, on the dorsal surface of a vertebra. These are typically performed to access the disc space and relieve pressure on the nerve roots and spinal cord.
The most common diagnosis for which laminectomy is performed is spinal stenosis. Spinal stenosis describes a condition in which there is diminished space available for the neural and vascular elements in the spine, secondary to degenerative changes in the spinal canal. Symptoms may include gluteal and/or lower extremity pain, as well as fatigue, which may occur with or without back pain. Other conditions that cause pressure on the spine and nerve roots include when a mass lesion, such as a tumor, is present, abscess, or other localized infection.
During laminectomy, an incision is made in the back over the affected region, and the back muscles are dissected to expose the spinal cord. The lamina is removed from the vertebral body, along with any inflamed or thickened ligaments that may be contributing to compression. Following resection, the muscles are reapproximated and the tissue is sutured back into place. There are numerous variations on the laminectomy procedure, including minimally invasive techniques. Spinal fusion may also be combined with laminectomy when instability of the spine is present preoperatively, or if the procedure is extensive enough to expect postoperative spinal instability. Complications of laminectomy may include injuries to the spinal cord and nerve root. Some studies estimate the incidence of these injuries to be up to 10%. Worsening myelopathy and/or radiculopathy may occur in a small percentage of individuals.
Spinal osteotomy procedures are reported when a portion or portions of the vertebral segment or segments is (are) cut and removed in preparation for realigning the spine as part of a spinal deformity correction. These procedures may be required for congenital, developmental, and degenerative spinal deformities.
Corpectomy typically reflects a longitudinal resection of the vertebral body from disc space to disc space, often resulting in a destabilization of the complex. In the cervical spine, at least 50% of the vertebral body is removed and in the thoracic/lumbar spine, at least 30% of the corpus is removed.
PEER-REVIEWED LITERATURE
In a prospective comparative study, Weinstein et al. (2007) evaluated the safety and effectiveness of standard decompressive laminectomy, with or without fusion, when compared to nonsurgical conservative treatment. Individuals with at least 12 weeks of symptoms and image-confirmed degenerative spondylolisthesis were enrolled in a randomized cohort (n=304) or an observational cohort (n=303). The primary outcome measurements were the Short-Form 36-Item General Health Survey (SF-36; 100-point scales, with higher scores indicating less severe symptoms) and the modified Oswestry Disability Index (ODI; 100-point scale, with lower scores indicating less severe symptoms) at up to 2 years. The 1-year crossover rates were high in the randomized cohort, but moderate in the observational cohort. The intent-to-treat analysis for the randomized cohort revealed no statistically significant effects for the primary outcomes. The as-treated analysis for both cohorts combined indicated a statistically significant advantage for surgery at 3 months that increased at 1-year and diminished slightly at 2-year follow-up. There was minimal evidence of harm from either the surgical or nonsurgical treatments. The authors concluded that in nonrandomized as-treated comparisons, individuals with degenerative spondylolisthesis and spinal stenosis had a substantially greater improvement in pain and function when treated surgically compared with individuals who were treated nonsurgically. The study is limited in its heterogeneous study design and cross-over.
In a follow-up study (i.e., Spine Patient Outcomes Research Trial [SPORT]), Weinstein et al. (2009) evaluated 4-year results from the Weinstein et al. (2007) study. In the randomized cohort (n=304), 66% who were randomly assigned to receive surgery received it by 4 years whereas 54% of those randomly assigned to receive nonsurgical treatment received surgery by 4 years. In the observational cohort (n=303), 97% of those who chose surgery received it, whereas 33% of those who chose nonsurgical treatment eventually received surgery. The as-treated analysis combining the randomized and observational cohorts demonstrated that the clinically relevant advantages of surgery that were reported at 2-year follow-up were maintained at 4 years. The authors concluded that compared with individuals who were treated nonsurgically, individuals with degenerative spondylolisthesis and associated spinal stenosis who were treated surgically maintained substantially greater pain relief and improvement in functional status at 4 years. The study is limited in its heterogeneous study design and cross-over.
In a systematic review, Chou et al. (2009) evaluated the available peer-reviewed literature to assess the safety and effectiveness of surgery for nonradicular back pain with common degenerative changes, radiculopathy with herniated lumbar disc, and symptomatic spinal stenosis. All relevant studies were methodologically assessed by two independent reviewers using criteria developed by Cochrane Back Review Group and Oxman. For individuals with symptomatic spinal stenosis with or without degenerative spondylolisthesis, the authors found good evidence indicating that decompressive laminectomy was moderately superior to nonsurgical treatment through 2 years.
In a prospective, multicenter study, Fehlings et al. (2013) evaluated the safety and effectiveness of decompressive laminectomy in individuals with cervical spondylotic myelopathy. A total of 278 individuals with mild (n=85), moderate (n=110), and severe (n=83) cervical spondylotic myelopathy were enrolled. Ultimately, 1-year follow-up data were available for 85.4% of participants (n=222). Outcome measurements included the Japanese Orthopedic Association (JOA) scoring system (score of 0 to 17, with lower scores indicating more severe deficits), SF-36, and the neck disability index (NDI; higher scores indicating more severe disability). There was a statistically significant improvement from baseline to 1-year follow-up in the JOA, NDI, and all SF-36 health dimensions, with the exception of general health (P<0.05). With the exception of JOA, the degree of improvement did not depend on the severity of preoperative symptoms. Fifty-two individuals experienced complications, with no significant differences among the severity groups. The authors concluded that decompressive laminectomy for the treatment of cervical spondylotic myelopathy was associated with improvement in functional, disability-related, and quality of life outcomes for all disease severity categories. The study is limited in its lack of comparisons with an appropriate control group, short-term follow-up period, and heterogeneous patient population.
In a retrospective analysis of the SPORT study, Rihn et al. (2015) evaluated whether standard decompressive laminectomy was safe and effective compared to nonsurgical treatment in the octogenarian population. Individuals who were at least 80 years of age (n=105) were compared with those younger than 80 years of age (n=1130) in this as-treated analysis. A total of 58 individuals in the octogenarian group and 749 of the younger individuals underwent surgery. In addition to ODI and SF-36, other outcome measurements included intra- and postoperative complications, reoperation, and postoperative mortality. There were no differences in complication, reoperation, and postoperative mortality rates between the older and younger groups. However, averaged over the 4-year follow-up period, individuals in the octogenarian group who were treated operatively had significantly greater improvement in ODI and most SF-36 domains. The authors concluded that there were no significant increases in complication and mortality rates following surgery in the octogenarian population compared with younger individuals. In addition, they noted that operative treatment of lumbar stenosis and degenerative spondylolisthesis offered significant benefit over nonsurgical treatment. The study is limited in its heterogeneous study design and cross-over.
A network meta-analysis of 34 randomized controlled trials (RCTs) was performed by Wei et al. (2021) that compared surgical and nonsurgical interventions for lumbar spinal stenosis. Nonsurgical interventions were not specified, and surgical interventions included decompression, decompression plus fusion, endoscopic decompression, interspinous process spacer device, laminectomy, laminotomy, minimally invasive decompression, and split spinous process decompression. Results demonstrated that there were no statistically significant differences between surgical and nonsurgical interventions for changes in short-term and long-term disability. On the other hand, surgical interventions were superior to nonsurgical interventions for the reduction of short-term and long-term pain. In the short-term, pain scores increased with nonsurgical interventions, and in the long-term, pain scores were reduced with laminectomy versus nonsurgical intervention. The authors concluded surgical interventions had a higher likelihood of being more effective at reducing short-term and long-term disability and pain when compared to nonsurgical measures.
SUMMARY
Laminectomy is a surgical procedure in which a portion of the vertebra (the lamina) is removed to decompress the spinal cord. Removal of the lamina creates greater space for the spinal cord and the nerve roots, thus relieving compression on these structures. Laminectomy is typically performed to alleviate compression due to spinal stenosis or a space-occupying lesion.
For individuals who have lumbar spinal stenosis and spinal cord or nerve root compression who receive lumbar laminectomy, the evidence includes RCTs and nonrandomized comparative studies. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. In individuals with spinal stenosis, there is sufficient evidence that laminectomy is more effective than nonoperative “usual care” in individuals with spinal stenosis who do not improve after 8 weeks of conservative treatment. The superiority of laminectomy is sustained through up to 8 years of follow-up. This conclusion applies best to individuals who do not want to undergo intensive, organized conservative treatment, or who do not have access to such a program. For individuals who want to delay surgery and participate in an organized program of physical therapy and exercise, early surgery with the combination of conservative initial treatment and delayed surgery in selected individuals have similar outcomes at 2 years. From a policy perspective, this means that immediate laminectomy and intensive conservative care are both viable options. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
For individuals who have cervical spinal stenosis and spinal cord or nerve root compression who receive cervical laminectomy, the evidence includes RCTs and nonrandomized comparative studies. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. There is a lack of high-quality, comparative evidence for this indication, although what evidence there is offers outcomes similar to those for lumbar spinal stenosis. Given the parallels between cervical laminectomy and lumbar laminectomy, a chain of evidence can be developed that the benefit reported for lumbar laminectomy supports a benefit for cervical laminectomy. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.
For individuals who have space-occupying lesion(s) of the spinal canal or nerve root compression who receive cervical, thoracic, or lumbar laminectomy, the evidence includes case series. Relevant outcomes are symptoms, functional outcomes, health status measures, quality of life, and treatment-related mortality and morbidity. Most case series are small and retrospective. They have reported that most individuals with myelopathy experience improvements in symptoms or abatement of symptom progression after laminectomy. However, this uncontrolled evidence does not provide a basis to determine the efficacy of the procedure compared with alternatives. The evidence is insufficient to determine the effects of the technology on health outcomes.
The current standard of care, clinical input, clinical practice guidelines, and the absence of alternative treatments all support the use of laminectomy for space-occupying lesions of the spinal canal. As a result, laminectomy may be considered medically necessary for individuals with space-occupying lesions of the spinal cord.
