Laminectomy is an inpatient procedure performed under general anesthesia. 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 then 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 soft tissues sutured back into place. The extent of laminectomy varies, but most commonly extends two levels above and below the site of maximal cord compression.
Hemilaminotomy and laminotomy, sometimes called laminoforaminotomy, are less invasive than a laminectomy. These procedures focus on the interlaminar space, where most of the pathologic changes are concentrated, minimizing resection of the stabilizing posterior spine. A laminotomy typically removes the inferior aspect of the cranial lamina, the superior aspect of the subjacent lamina, the ligamentum flavum, and the medial aspect of the facet joint. Unlike laminectomy, laminotomy does not disrupt the facet joints, supra- and interspinous ligaments, a major portion of the lamina, or the muscular attachments. Muscular dissection and retraction are required to achieve adequate surgical visualization.
Cervical laminectomy maybe considered medically necessary when ALL of the following conditions are met:
Lumbar laminectomy maybe considered medically necessary when ALL of the following conditionsare met:
Laminectomy (cervical, thoracic, lumbar) may be considered medically necessary for space-occupying lesions of the spinal cord and/or spinal canal.
Laminectomy (cervical or lumbar) is not medically necessary for spinal stenosis when the above criteriaare not met.
Laminectomy is considered investigational for all other indications.
Cervical Myelopathy And/Or Cord Compression
Signs and symptoms of cervical myelopathyand/orcord compression include the following (Epstein, 2003):
Conservative nonsurgical therapy for the duration specified should include the following:
Persistent debilitating pain is defined as:
Laminectomy may occasionally be performed for the sole indication of radiculopathy due to herniated disc. In these cases, discectomy alone is not sufficient to relieve compression on vital structures, and laminectomy is requiredfor adequate decompression. Compression of the spine due to herniated disc is uncommon, and there are no standardized preoperative criteria to determine which individuals may require laminectomy in addition to discectomy.
The following procedures can be considered alternatives to laminectomy for decompression of the spinal cord. The specific indications for these alternative procedures are not standardized, and the evidence is insufficient to determine the effectiveness of these procedures compared with laminectomy.
Medical necessity is established by documentation of medical history, physical findings, and diagnostic imaging results that demonstrate spinal nerve compression and support the surgical intervention. Documentation in the medical record must clearly support the medical necessity of the surgery and include medical history, physical examination, and diagnostic testing.
Practice Guidelines and Position Statements
The North American Spine Society issued evidence-based guidelines (2011) on the diagnosis and treatment of degenerative lumbar spinal stenosis.The guidelines stated that individuals with mild symptoms of lumbar spinal stenosis are not considered surgical candidates; however, decompressive surgery was suggested to improve outcomes in individuals with moderate-to-severe symptoms of lumbar spinal stenosis (grade B recommendation). The Society also indicated that current evidence was insufficient to recommend for or against the placement of interspinous process spacing devices to treat spinal stenosis.
Excerpts from the North American Spine Society Coverage Recommendations
1. Spinal Stenosis (including recurrent spinal stenosis, congenital stenosis, stenosis associated with achondroplasia) meeting the following criteria:
a. signs and symptoms of neurogenic claudication or radiculopathy correlated with imaging:
b. at least 6 weeks of nonoperative treatment
c. the following can mitigate the need for initial nonoperative trial
i. severity of symptoms causes forced bed rest
ii. stenosis results in functionally limiting motor weakness (e.g., foot drop)
iii. progressive neurological deficit