Cervical laminectomy

Until the 1950s, virtually the only operation for taking pressure off of the cervical (neck) spinal cord was
cervical laminectomy. This review of cervical laminectomy is primarily for the treatment of cervical
spondylotic myelopathy, a disease in which the cervical spinal cord is compressed by overgrown bone
and soft tissues, usually as a result of degenerative arthritis. Cervical laminectomy for ruptured disc is
reviewed under discectomy for cervical ruptured disc. Cervical laminoplasty is another operation that
takes the pressure off the spinal cord but retains the lamina and spinous processes.

Anatomy
The normal cervical spine is composed of seven building blocks called vertebrae (labeled C1 through
C7) that sit on the thoracic (chest) spine (Figure 1).

Figure 1 - Cervical spine as seen from the back.

At the upper end of the cervical spine sits the head. The cervical spine allows you to bend your head
forward (flex) and backward (extend) and tilt and twist your head to the left and right. Each vertebrae is
constructed of a body, lamina, and pedicles which surround an opening, the spinal canal (Figure 2).

Figure 2 - Cervical spine as seen in cross-section.

On each side of a cervical vertebra lie the facets, the portion of the vertebra that forms the joints
between two vertebrae (Figure 3).

Figure 3 - Cervical spine as seen from the side.

Through the spinal canal passes the spinal cord. Nerve roots are present at each level and exit the
spine through holes (foramina) formed by two adjacent vertebrae. The nerve roots eventually form into
nerves that go to the arms. The spinal cord and roots float in fluid (cerebrospinal fluid) and are contained
within a fibrous sac called the dura.
Separating any two vertebral bodies is a soft elastic material called a disk. The disk is composed of two
parts, a soft center called the nucleus and a tough outer band called the annulus. Lining the surface of
the disk space of the two vertebrae on top and bottom are thin plates of cartilage. There are seven
cervical disks beginning below C2 and extending below C7. There is no disk between C1 and C2.
The spinal cord is made up of many nerve tracts that run the length of the cord and carry electrical
impulses from the brain to the nerve roots at every level and from the nerve roots to the brain. The major
tracts that control movement are in the front (anterior) part of the cord. The major tracts that carry
sensation to the brain are in the back (posterior) part of the cord.

Pathology
Some individuals have a congenital narrowing of the spinal canal (spinal stenosis) that causes spinal
cord compression when young. With advancing age, injury or surgical removal of a disk, several
changes occur in the bone, disk, joints and ligaments of the cervical spine that can produce neck and
arm pain as a result of a nerve root being compressed or weakness and loss of feeling in the arm and
legs because the spinal cord is compressed (Figure 4).

Figure 4 - MRI through the center of the

cervical spine showing a
spondylolesthesis of C3 on C4 causing
compression of the spinal cord (between
arrows) as indicated by a change in signal
(lighter area between asterisks).

Bones. With aging, bones tend to lose water and become less dense, a condition called
spondylolsis. These degenerative changes near the disk may cause an overgrowth of bone
producing bony spurs (osteophytes) that can compress the spinal cord (Figure 5)

Figure 5 - CT scan through the C6 vertebra

showing a bony spur that compresses the spinal
canal. (Same patient as in figure 4)

Disk - The disks also lose water and shrink thus narrowing the disk space. As the disk becomes
thinner the space between the vertebrae likewise narrows which narrows the foramina causing
nerve root compression and pain. As the disk space narrows, the annulus tends to bulge and
mushroom out causing pressure on the spinal cord
Joints - Along with the other degenerative changes, there can develop a degenerative arthritis of
the facet joints that causes the joints to enlarge. Sometimes the lining of the joint (synovium)
enlarges or becomes like a cyst. This combination of events results in narrowing of the spinal
canal and increasing stiffness of the spine. If the joints degenerate such that one vertebra slips
over the one below (called spondylolesthesis) the spine may become unstable resulting in pain
and the spinal cord may be compressed
Ligaments - With advancing age the ligaments tend to stretch and thicken. This may cause
instability between vertebrae, as well as result in pressure on the spinal cord and nerve roots
Spinal cord - Myelopathy (malfunction of the spinal cord) occurs due to compression of the
spinal cord. Motion of the spine rubbing on the cord may also contribute to the myelopathy.
Furthermore compression of the spinal cord may lead to a compromise of the blood vessels
feeding the spinal cord, which further aggravates the myelopathy. This myelopathy caused by
overgrowth of bone and supporting tissues in the neck is called cervical spondylotic myelopathy
(Figure 4)

Making the Diagnosis

Because of the variety of ways the degenerative process in the cervical spine may cause compression
of the cord, the medical picture (syndrome) that a patient with cervical spondylotic myelopathy presents
to the physician may vary in degree and position of pain, numbness, paresthesias (tingly sensations),
weakness, loss coordination in the arms and weakness or unsteadiness in walking.

When all the nerve tracts are involved, the patient presents with weakness in the arms and legs
and inability to normally feel pain and touch
The patient may present only with weakness. Sometimes this may occur only in the legs or only
in the arms
There may be pain in the arms similar to that presented by a person with a ruptured cervical
disk (discectomy for cervical ruptured disc) combined with weakness in the legs
The patient may present with weakness on one side of the body and numbness on the other
side (Brown-Sequard syndrome)
Weakness in the hands and forearms

Special Testing
You may need certain tests to help your doctor decide whether you need surgery, and to determine the
exact location of the cervical spinal stenosis. Some of these tests are:

X-ray of the cervical spine. The x-ray may show narrowing of the disk space, bony overgrowth
of bone or evidence of instability of the spine,
An electromyogram or EMG which measures nerve function. This is accomplished by placing
small needles in the muscles and recording the result on a special machine
A CT (computerized tomography) scan or MRI (magnetic resonance imaging). These scans
produce detailed computer generated images of the bony spine (CT) and spinal cord and
surrounding tissues (MRI). These tests may also rule out other causes of pain and weakness
(Figures 4 & 5)
A myelogram followed by a CT scan. A myelogram is an invasive test. Though invasive, a
myelogram is probably the most accurate test for determining the degree of spinal stenosis
(narrowing). An iodine containing dye which shows-up on x-rays is injected into the
cerebrospinal fluid in the lumbar spine. The dye is then positioned in the cervical spine and Xrays followed by a CT scan are taken. Leakage of cerebrospinal fluid following the procedure
may cause subsequent headaches which usually does not last more that a couple of days

Non-operative Treatment
Non-operative treatment is recommended for those individuals who have
only mild or moderate complaints and are not disabled
advanced cervical spondylotic myelopathy with nerve deficits that cannot be changed with
surgery
advanced age or medical conditions that pose a considerable risk for surgery
Non-operative treatment includes

the use of a firm collar

cervical traction - this usually can be done at home 2-3 times a day
anti-inflammatory medication such as motrin
physical therapy
epidural steroid injection (injection into the cervical spine between the covering of the spinal
cord and the bone) to control symptoms in those individuals who are poor surgical risks in order
to control complaints

Indications for Cervical Laminectomy

The most common reason is cervical spondylotic myelopathy particularly when there is

1. acute or progressive muscle weakness

2. disabling loss of sensation
3. difficulty in walking
Cervical laminectomy is also used for
1. tumors within and outside the spinal cord
2. trauma to the cervical spine
3. congenital stenosis (narrowing from birth) of the spine
Disease at one or more spinal levels
Carrying out the surgery from in front is difficult because of
1. failure of prior surgery
2. obesity, particularly with a short, stout neck
Factors that make the surgery less risky
1. decrease in operative time
2. older patients tolerate laminectomy better than surgery from in front 3. better exposure
of the nerve roots
The need to fuse the spine from behind
The presence of a tracheostomy (opening into the windpipe) or other obstruction to an approach
from in front

Relative contraindications for decompressing the cervical spinal cord

Elderly patient particularly combined with osteoporosis

Severe lung disease
Severe heart disease
Loss of the normal curve of the cervical spine
Instability because of inadequate structures in the anterior parts of the cervical spine

The Operative Procedure

There are two procedures for decompressing the cervical spine

1. Cervical laminectomy in which the lamina and spinous processes are removed to
expose the dura covering the spinal cord
2. Cervical laminoplasty in which the lamina are lifted off of the dura but not removed
(Figure 6)

Figure 6 - CT scan through a cervical

vertebrae showing a laminoplasty using a

bone graft and titanium miniplate. (Same

patient as in Figure 4)

With cervical spondylotic myelopathy, the patient is positioned on the operating table with the
head and neck in a neutral position since undue flexion or extension of the neck may cause
pressure on the spinal cord
Because placing a tube in the airway (endotracheal tube) may result in excessive extension of
the neck, the tube is frequently inserted with the patient awake
Steroid medication may be given to help in protecting the spinal cord
In some instances the surgeon may monitor the ability of the spinal cord to transmit impulses
(somatosensory evoked potentials). Such monitoring is more often used when the laminectomy
is used for the removal of a spinal cord tumor
The patient is placed prone (face down)on the operating table with the head held firmly by pins
by a special headrest
After the skin is cleaned and disinfected and sterilely draped, an incision is made in the skin of
the back of the neck
The muscles are elevated and the spinous processes, lamina and facets are exposed
Cervical laminectomy (Animation A)
1. Usually the lamina and spinous processes are removed from 3 or 4 vertebral levels
2. Using a small burr, a cut is made through the lamina at their junctions with the facets at
each level
3. The ligament lining the inner surface of the spinal canal (ligamentum flavum) is cut and
the lamina are removed
4. If there is any evidence of instability or anterior angulation of the cervical spine, fusion
from behind is usually indicated. Fusion is frequently accomplished using titanium
plates secured over the facets
5. All bleeding is controlled and the muscles, fascia and skin are brought together in layers

Click image to view animation

Animation A -Cervical laminectomy of C4,

C5 and C6 as seen from behind. The
upper two lamina have already been cut
through. The lamina of C6 are shown
being cut and then the lamina of these
vertebra are removed to expose the dura
over the spinal cord.

Cervical laminoplasty (Figure 7 and Animation B)

1. As in a cervical laminectomy, a small burr is used to make a cut through the lamina at
their junctions with the facets. On one side the cut is complete while on the other, the
cut is made almost through the lamina
2. On the side where the lamina is cut, the ligamentum flavum is likewise cut

3. The lamina are then elevated from the cut side in the manner of a "trap door"
4. The open side of the lamina is held open with a strut of bone and secured in place with
a small titanium plate
5. The canal is thus made wider which decompresses the spinal cord
6. All bleeding is controlled and the muscles, fascia and skin are brought together in layers

Figure 7 - Cervical spine X-ray taken from the side

(Same patient as in Figure 4). Titanium plates are
used to stabilize the unstable spondylolesthesis by
fusing C3 to C4. The miniplates are part of a
laminoplasty to widen the cervical canal at C4, C5
and C6.

Animation B - Cervical laminoplasty as seen

in cross-section. The lamina on each side
are cut and the lamina elevated one on side
like a trap door. The lamina are held away
from the spinal cord by a small bone graft
and secured with a titanium miniplate and
screws.

Posterior cervical fusion (Figure 7)

1. Used with cervical laminectomy or laminoplasty when there is instability of the vertebra
at any level.
2. The cartilage is removed from the facet joints at the unstable level
3. Titanium plates are then fastened with screws to the facets on each side

Complications

Worsening of the neurologic condition such as increased paralysis or loss of sensation

Bleeding
Forward bending of the cervical spine (kyphosis)
Air embolus- air entering the blood stream and causing clotting of blood in the heart
Tear in the dura covering the spinal cord
Injury to nerve roots
Leaking of the fluid surrounding the cord (cerebrospinal fluid) through to the skin
Injury to the nerves going to the arms (brachial plexus)
Infection

Postoperative instability of the spine

Postoperative Care

Following surgery, the patient may wear a collar for several months
Unless there is weakness or paralysis the patient may be discharged in 2-4 days
If there is weakness or paralysis the patient may go to a rehabilitation unit
Pain medication is given as necessary
After discharge, the patient is seen in the surgeons office in one to three weeks
Follow up X-rays, CTs or MRIs may be obtained as required by the surgeon

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