Laminectomy After Care and Pain Management

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Introduction   

Laminectomy is a surgical procedure that provides significant relief to patients experiencing chronic spinal pain. It has also been known as spinal decompression. The lamina is a bony prominence covering the spinal canal that can cause pressure on the canal, resulting in tingling, numbness, and pain in the back, legs, and arms. Symptoms depend on the location of the problem lamina and dictate where the laminectomy will take place—either in the cervical, thoracic, or lumbar regions [1].  

Lamina removal introduces more space in the spinal canal, relieving pressure on nearby nerves. Before surgical intervention, medication, physical therapy, and site injections are usually tried. If pain relief goals are not met, a surgeon may then recommend this procedure for patients still experiencing nerve pain stemming from conditions such as herniated disks and arthritis [1]. 

“The main indication for laminectomy is the presence of spinal canal stenosis; spinal canal narrowing has multiple etiologies, such as congenital, metabolic, traumatic, or tumoral; however, degenerative stenosis is the most common cause” [2]. Surgical goals include increased functional ambulation, reduced nerve compression, and decreased incidence of overall pain and deficit [2]. 

During the procedure, the surgeon will remove the lamina and any surrounding bone spurs, disk fragments, or affected soft tissue that compress the spinal column, thus reducing nerve pain. Surgical options include minimally invasive to the traditional open approach. Studies indicate that minimally invasive surgery promotes decreased intraoperative bleeding and post-operative pain while leaving more surrounding musculature intact [2]. 

There are different surgical techniques utilized for laminectomy. The older of the methods is the open laminectomy. This traditional approach involves a large incision to access the spine, removal of the lamina, and direct decompression of the neural elements. It includes muscle dissection, laminectomy, and possible spinal fusion if spinal instability is present. 

The Minimally Invasive Laminectomy (MIL) utilizes smaller incisions and specialized instruments to perform decompression with reduced muscle disruption. It can involve endoscopic or tubular retraction systems to minimize soft tissue damage and accelerate recovery. The emerging trends section will further discuss MIL. 

X-rays, CT scans, and MRIs, which are considered the gold standard, are diagnostic tools used to support a patient’s need for laminectomy [2]. 

Many of these procedures are now safely offered at an ambulatory clinic, and the patient can be discharged home the same day. However, depending on the patient’s health status, they may be required to have a short in-patient stay. [3]. 

Laminectomy Contraindications 

Certain conditions are contraindicated for laminectomy, including scoliosis (a deformity of the spine bending into a C shape), spondylolisthesis (a vertebrae moving forward causing pressure on the vertebrae below it), and lateral listhesis (a condition where the vertebrae rotate and slide sideways) [2].  

In addition to certain spinal deformities as a contraindication to laminectomy, some patients are poor surgical candidates in general. Those with extensive medical comorbidities compromised ambulation, or those who have had previous spinal surgeries may not be laminectomy candidates [2]. 

Laminectomy Risks 

Despite significant advancements in spinal decompression and laminectomy, like any procedure, it is not without its risks. Patients should be made aware of potential complications and issues that can arise postoperatively. According to the Cleveland Clinic [1] risk factors include: 

• Blood clots 

• Pulmonary embolus 

• Bowel or bladder issues, including incontinence 

• Excessive bleeding 

• Infection 

• Hematoma at the incision site 

• Nerve damage 

Patients should also be aware that surgery can prove unsuccessful or cause spinal pain to return in the future due to the decompensation of spinal tissue [1]. All of these risks should be thoroughly discussed with the patient so they can make the best decision for their situation. 

Pain Management 

Pain management plays a significant role in post-surgical care. Patients may experience considerable discomfort post-operatively, and appropriate pain management should be supported. “Inadequate pain management is one of the main reasons for delayed discharge or readmission after surgery” [3]. 

Pain management has a direct correlation with patient satisfaction and quality of recovery. If patients experience untenable pain and are unable to ambulate or attend to activities of daily living, they run the risk of a myriad of complications, such as pneumonia, blood clots,  

infection, and cardiac or pulmonary complications. Initial uncontrolled post-op pain can also lead to anxiety, depression, and chronic pain after surgical intervention.  

Pain management should be tailored to each patient instead of a one-size-fits-all approach [4]. Considerations when creating an appropriate pain management plan includes, but is not limited to, age, gender, previous use of opioids for pain management, pre-existing conditions and patient’s mobility level. Careful preoperative assessment of each patient should be conducted to develop a pain control plan before laminectomy [4]. 

Pharmacological Pain Management  

Acute pain after laminectomy is managed with several different medications to achieve appropriate analgesia, including different routes of administration.  

Intravenous opioids are commonly offered immediately post-op to manage acute pain. Common treatments include fentanyl, hydromorphone, and morphine [5].  Depending on the patient, a personalized control analgesia pump (PCA) may be prescribed to ensure desired pain control, allowing the patient to access pain medication safely as they see fit.  

Local anesthetics are also helpful analgesics for acute pain management post-laminectomy. When possible, patients should benefit from a multimodal approach to pain control, not depending on only one type of analgesia for comfort. The American Society of Anesthesiologists (ASA) recommends regional pain blockades also be administered for patients undergoing laminectomy [6]. 

Bupivacaine can be administered at the surgical site to produce a robust, local anesthetic effect. One study conducted where patients received wound instillation with bupivacaine reported much lower pain scores along with decreased need for opiate medications [3]. There are several options for local spinal blocks, including those that are disposable and continue to deliver local anesthetic into the incision at various times throughout the post-operative period. These generally provide favorable pain management outcomes [4]. 

Nonsteroidal anti-inflammatories are another critical component of effective pain management after laminectomy. As part of the multimodal pain management approach, the ASA also recommends the use of regularly scheduled doses of acetaminophen post-operatively to reduce pain and inflammation [6].  

Gabapentinoids, including gabapentin and pregabalin, are also now commonly used in the multimodal approach to managing pain after laminectomy. These drugs cause decreased excitability in the central nervous system, diminishing the pain response. They are widely used to treat neuropathy pain following a spinal cord injury with very positive patient outcomes. However, clinical trials of their efficacy for pain management and their ability to reduce opiate use after laminectomy are still being determined [7].  

Ketamine is another promising treatment for laminectomy pain. The use of ketamine has become widespread not only in surgical suites but also in outpatient clinics, emergency departments, and ambulatory surgery centers. It’s a widely used adjunct to other anesthetics and is associated with enhanced patient comfort for those undergoing a laminectomy. “A recent review and meta-analysis examining the effect of perioperative ketamine for spine surgery found that ketamine reduces pain intensity and opioid consumption within the first 24 to 72 hours postoperatively” [4]. 

Ketamine’s unique dissociative properties and analgesic effects make it a valuable adjunct to fentanyl, propofol, and other anesthetic agents. Ketamine is particularly effective for patients who have consistently used opioids preoperatively and for those undergoing specifically painful spinal surgeries. Lower pain scores and decreased use of opiates have been associated with intraoperative ketamine infusions [4]. 

Opioid Cessation & Safety 

Due to the rapid increase in deaths from opiates and opiate addiction over the last decade, opiate cessation should begin as soon as possible. A significant benefit of the multimodal approach to laminectomy pain management is that it offers alternatives to opiate-only analgesia [4]. 

The patient’s doctor should closely monitor subacute management of opiate use. This includes discussing pain levels at follow-up visits and tapering down opiates appropriately. Studies have shown that patients prescribed smaller doses of opiates for self-management were more inclined to decrease and stop their use earlier compared to patients initially prescribed higher doses [4]. 

If postoperative opioid medication use is prolonged, the patient runs the risk of seeing less overall improvement in function and could experience less pain relief in the long term [4]. Many studies show that consistent preoperative opiate use is directly correlated to chronic opiate use postoperatively. These patients had significant adverse health outcomes and were much more likely to need increased healthcare visits compared to their counterparts [9]. 

Opiate use intraoperatively and immediately after laminectomy is necessary for adequate pain control and is a key component of the multimodal approach. However, after a patient is discharged home with opiates, education on extreme caution of their use should continue from the treatment team. The risk of overdose, the safe handling of opiate medications, and the plan for tapering off should be thoroughly reviewed with the patient [4]. 

Should the patient depend on prolonged opiate pain medication for post-laminectomy, a referral should be made to a pain management specialist and utilization of a multidisciplinary team [4].  

Non-pharmacological Pain Management 

Recent studies have indicated that acupuncture and acupressure may reduce pain post-spinal surgery. Other treatment options include cold therapy, and the use of a transcutaneous electrical nerve stimulation (TENS) unit placed in different areas of the back, which can help reduce pain post-laminectomy [4]. 

Patients should also be encouraged to practice other pain management techniques that are safe and comfortable for them, such as listening to music, practicing distraction techniques, aromatherapy, yoga, or meditation [8]. Repositioning as needed is also helpful to alleviate pain, and gentle walking should be encouraged when cleared by the surgeon. 

Cognitive behavioral therapy (CBT) has also been used to decrease pain long-term after spinal surgeries [4]. With the help of an appropriately trained practitioner, patients are taught to reframe their experience of pain and develop thoughts and behaviors to better manage it. This includes incorporating an improved, positive mindset while increasing activity [10]. 

Laminectomy Aftercare 

In addition to appropriate pain management, several other factors, such as wound care, mobility, and participation in physical therapy, are essential to successful laminectomy aftercare. 

Patients and family members or caregivers should be given specific instructions on managing their incisions depending on the closure type, e.g., dissolvable stitches or those needing removal. The area should be kept clean and dry, and patients should follow their physician’s orders about when it is okay to shower and change their dressing [11]. 

Patient teaching should include how to monitor for signs and symptoms of infection, including fever, malodorous or concerning discharge from the incision site, and/or redness. They should be instructed to contact their provider immediately should any of these symptoms arise [11].  

Mobility is a crucial component of successful laminectomy aftercare. Mobility significantly reduces the risk of blood clots and embolism. Early ambulation within the first 24 hours post-laminectomy directly correlates with improved clinical outcomes. Rates of deep vein thrombosis, pneumonia, urinary tract infection, pulmonary embolus, and hematoma at the incision site are decreased when patients ambulate soon in the post-op phase [12]. 

At this time, there is no standard, one-size-fits-all criteria for when ambulation should occur post-laminectomy; it is patient-dependent. However, studies do indicate that ambulation should occur as soon as it is clinically safe to do so. Early ambulation is a direct indicator of improved patient outcomes [12]. 

Physical therapy is also an integral part of recovery after laminectomy and should begin as soon as clinically indicated. Exercises should focus on strengthening and flexibility to reduce pain and improve function. Patients return to independence, and the ability to complete activities of daily living on their own improves mental health and correlates with better health outcomes overall [13].  

Nursing Considerations 

Before surgery, nurses have an essential role in educating patients about their upcoming procedures and assisting the physician with preassessment. As with any surgery, nurses should follow specific criteria to ensure the patient is stable for their surgery. This includes but is not limited to [14]: 

• Vital signs 

• Pertinent lab work 

• Complete medical history 

• Fall risk 

• Baseline functioning and ambulation 

• Ongoing education  

• Informed consents/documents 

Nurses play a critical role in recovering the laminectomy patient and have numerous responsibilities to the patient. Immediately post-op, nurses should carefully monitor and document vital signs, manage the Foley catheter until the patient can safely ambulate, administer medications, and frequently check in with the patient about pain levels and respond accordingly [2].  

Nurses will also manage intravenous fluids and pain medications. They should ensure patients understand the pain scale accurately to provide proper analgesia without oversedation. 

Nurses must also carefully examine the incision site and ensure the dressing is clean and dry, free from excessive drainage. Spinal surgery complications can include leakage of cerebral spinal fluid (CSF). Wound bulging and patients reporting dizziness or extreme headache may be indicators of CSF leakage and should be promptly reported to the physician [2]. 

Patients should be encouraged to ambulate as soon as possible, so nurses and healthcare team members should ambulate the patient as soon as clinically safe and ordered by the physician. If nurses cannot ambulate the patient safely, they should ensure physical therapy is ordered for evaluation [12]. 

Nurses should ensure patients understand discharge instructions and respond to any questions they or their caregivers have. Clear instructions on who to contact should be provided in case of complications. Specific patient education will be further discussed in the next section. 

Patient & Family Education 

Patient education is central to effective nursing care. Nurses provide invaluable information to their patients, which helps ensure safety, promotes positive health outcomes, and empowers them to take control of their care. Nurses will need to provide the necessary following teaching to aid in the best outcomes for their patients who are undergoing laminectomy: 

• Understanding the Procedure 

• Description of Surgery: Provide a clear explanation of the laminectomy procedure, including its purpose, the expected outcomes, and the potential risks and benefits [14]. 

• Visual Aids: Use diagrams, models, or videos to help patients visualize the procedure and understand the surgical site [14]. 

• Pain Management 

• Medication Instructions: Educate patients on using prescribed pain medications, including dosages, timing, and potential side effects [14]. 

• Non-Pharmacological Methods: Discuss complementary pain management strategies such as ice packs, relaxation techniques, and positioning for comfort [4]. 

• Opiate Safety 

• Starting Dosage: Use the lowest effective dose. Never exceed the prescribed dosage; advise the patient to contact the physician if the dose does not effectively manage pain [4]. 

• Educate patients and family members regarding the risk of overdose. 

• Short-Term Use: Limit the duration of opioid therapy to the shortest time necessary to manage acute pain. Instruct patients to work with their healthcare team to down-taper opioids if necessary [4]. 

• Advise patients if they have any concerns about their opiate use to contact their healthcare team immediately [4]. 

• Keep opiates in a safe place where others don’t have access to them. Offer patients resources for appropriately disposing of opiates if they have leftover medication [4]. 

• Discuss side effects such as constipation, drowsiness, pruritis, and confusion. 

• Ensure patients understand driving or other potentially dangerous activities should not be performed until they have discontinued opiates. 

• Wound Care 

• Incision Care: Instruct patients on caring for their surgical wound, including cleaning, dressing changes, and recognizing signs of infection [15]. 

• Activity Restrictions: Emphasize the importance of avoiding activities that could strain the surgical site or impede healing [15]. 

• Mobility and Physical Activity 

• Postoperative Mobility: Explain the importance of early mobilization to prevent complications like deep vein thrombosis and pneumonia [11]. 

• Safe Movement: Teach patients proper body mechanics and techniques for safe movement and transfers to prevent injury [15]. 

• Rehabilitation and Exercises 

• Rehabilitation Plan: Outline the expected rehabilitation process, including the role of physical therapy and the types of exercises that may be prescribed [15]. 

• Home Exercises: Provide instructions on any home exercises or activities that should be performed to enhance recovery [15]. 

• Signs of Complications 

• Monitoring Symptoms: Educate patients on signs and symptoms of potential complications such as infection, hematoma, or worsening neurological symptoms [11]. 

• When to Seek Help: Inform patients about when and how to contact their healthcare provider if they experience concerning symptoms [11]. 

• Long-Term Management 

• Follow-Up Care: Discuss the importance of attending follow-up appointments and adhering to long-term care plans to ensure continued recovery and address any ongoing issues [1]. 

• Lifestyle Modifications: Provide guidance on lifestyle changes that may support spinal health and prevent future issues, such as weight management and ergonomic adjustments [1]. 

Emerging Trends in Laminectomy 

Laminectomy procedures have grown and changed over the last decades. Exciting advances in laminectomy have been made, including a minimally invasive option as opposed to the traditional open surgical option. These surgical trends and advancements aim to produce better patient outcomes by decreasing hospital stays, reducing complications, and reducing recovery times.  

Patients are now mainly receiving laminectomy in surgical centers where they are discharged the same day. Outpatient spine surgery trends are linked to reduced complications and lower healthcare costs. However, there are still significant benefits for patients who have an inpatient stay post-laminectomy, such as access to their healthcare team immediately if there are complications, along with onsite supportive nursing care and physical therapy [16]. 

Minimally invasive advancements in laminectomy have supported patients receiving the procedure in outpatient settings and promoted improved outcomes. Endoscopic laminectomy uses an endoscope to perform the procedure through small incisions, which reduces tissue damage and postoperative pain. This approach minimizes muscle dissection, reduces blood loss, and shortens recovery time compared to traditional open laminectomy [16] 

Surgeons also have access to specialized tools that assist them in ensuring increased accuracy and precision. Intraoperative CT and MRI are now being employed to provide real-time imaging. Along with 3D navigation systems, visualization has dramatically improved outcomes. Surgeons also benefit from robotic systems, which aid in decreased tissue damage and greater precision. 

Technological advancements in spine surgery continue to benefit patient outcomes, making the procedures quicker and more efficient, posing fewer risks in the long term. 

Conclusion

Laminectomy for spinal decompression is an excellent option for patients experiencing spinal pain, numbness, tingling, or other discomfort impacting their everyday lives. Although it is deemed a safe and successful procedure, patients should always be educated regarding contraindications and possible risks.  

Managing pain and patient education around pain management is a critical function of the nurse. They should continually revisit pain scales, provide detailed education about safe opiate use and opiate cessation, and offer other alternatives to increase comfort. The healthcare team will use the multimodal approach to reduce pain management and the risk of opiate misuse or overdose. Patients should be encouraged to employ non-pharmacological methods to manage pain, such as cold therapy, movement, physical therapy, and cognitive behavioral therapy. 

Nurses are vital in providing laminectomy patients with appropriate education and aiding in assessing their fitness for surgery. Fortunately, due to innovations and advancements in laminectomy, minimally invasive options are now available, reducing in-patient hospital time, infection rates, and intraoperative bleeding, amongst many other benefits. 

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