Cervical Laminectomy Technique

Updated: Apr 01, 2015
  • Author: Lawrence S Chin, MD, FACS; Chief Editor: Cristian Gragnaniello, MD  more...
  • Print
Technique

Cervical Laminectomy

After the patient is positioned, the operative site is radiographically localized. The proposed midline incision site is marked and the surgical field prepared and draped. The incision site is infiltrated with 1% lidocaine mixed with 1:100,000 epinephrine.

A midline incision is made with a No. 10 scalpel and the dorsal spine approached through the subcutaneous tissue along the avascular ligamentum nuchae using monopolar cautery. Self-retaining retractors are used throughout to ensure adequate visualization. The paraspinal muscles are stripped from the spinous processes using a subperiosteal technique down along the laminar to the edge of the facets either bluntly or with monopolar cautery. This may be performed either bilaterally (laminectomy) for circumferential disease or unilaterally (hemilaminectomy) for unilateral compression or foraminal narrowing. If C2 is not included in the decompression, it is recommended that its muscle attachments remain to provide upper cervical stability.

Following adequate exposure and hemostasis, the levels to be decompressed are accurately radiographically localized. Many techniques can be used to perform a laminectomy, and surgical loupes or a microscope may be used at any time during the procedure. The conventional approach involves rongeurs (Leksell, Adson, Kerrison) to remove the spinous process and laminae, although this process requires that a portion of the rongeur (footplate) be placed between the laminae and dura. This should be carefully monitored, particularly in patients with severe stenosis.

An alternative method involves incising the interspinous ligament and using a high-speed drill to create a trough bilaterally at the facet-lamina junction. The trough is carried down to the inner cortical margin of the lamina. Care should be taken to prevent accidental damage to the dura with the drill. The thin inner cortical margin is then removed with a 1- or 2-mm Kerrison rongeur. The laminae with the spinous process attached are then removed en bloc. It is important to perform this process delicately, as the dura may be inadvertently attached to the ligamentum flavum and laminae. For a hemilaminectomy, this process is carried out ipsilateral to the pathology.

Any remaining ligamentum flavum is removed. Lateral decompression of the nerve roots may then be performed with a Kerrison rongeur. Not more than 50% of the facet should be removed to prevent joint instability. A more extensive foraminotomy to laterally decompress the exiting nerve root will require additional removal of the superior and inferior facet complex.

Bleeding points from bone are most effectively controlled with bone wax. Epidural venous bleeding may be difficult to control because access is often limited by the thecal sac, nerve root, and facet complex. Bipolar coagulation can be used when there is clear visualization, and it may be helpful to judiciously remove bone to see the bleeding vein. Otherwise, the bleeding must be controlled with cottonoid patties followed by placement of a topical hemostatic agent.

Surgicel (oxidized cellulose) and Gelfoam (Gelatin) act through chemical and direct contact activation of the clotting cascade. Other useful materials include Avitene (collagen fibers) and preparations of gelatin mixed with thrombin such as Floseal and Surgiflo. With any topical agent, the potential for swelling and spinal cord or nerve root compression must be considered.

After adequate decompression and hemostasis is achieved, the operative site is generously irrigated with saline or lactated ringers solution, with or without antibiotics. When the dura is opened, antibiotics are avoided. The incision is then closed in layers and the skin secured with sutures, staples, or skin adhesive.