Most likely, the pain in your back or legs, or both, ultimately led you to seek help. You have been diagnosed as having lumbar spinal stenosis and will require Lumbar Laminectomy. The condition of spinal stenosis results in the narrowing of the spinal canal in which your nerves are contained. This narrowing or stenosis and the pressure on the nerves can result in pain, numbness and or weakness of one or both legs. These symptoms are usually aggravated by walking and/or standing.

Often patients who have spinal stenosis also have a condition called spondylolisthesis, or slippage of one vertebral body over another. This also results in nerve compression and associated pain and other symptoms. The degree of "slippage" may cause spinal instability that would require a fusion operation to be done at the time your stenosis is surgically addressed.

Spinal stenosis, as pictured, can be caused by a variety of reasons, including age, repetitive stress, arthritis, thickening of the ligaments and a build up of calcium.

Some people are born with a narrow canal which can become symptomatic with age and stress.

The Lumbar Laminectomy procedure is designed to relieve this compression from the nerves. Generally, with the nerves decompressed symptoms will improve. The surgeon reaches the lumbar spine through a small incision in the lower back. Pressure is relieved by partial or complete removal of the back portion of the vertebrae called the lamina. The lamina is bone that covers the spinal nerves or cord. This bony removal generally does not effect the mobility or stability of your spine.

Spondylolisthesis most often occurs as a result of degenerative changes, but can likewise be seen secondary to trauma to the lumbar spine, or in those patients who are post-laminectomy. The levels most commonly involved are L4-5 and/or LS-SL. Risk factors for these changes to the spinal column include prior spinal or abdominal surgery, obesity, prior trauma or repetitive injury, and cigarette smoking.

Patients with degenerative spondylolisthesis typically present with a long and slowly progressive history of low-back and diffuse bilateral leg pain that increases with ambulating. Patients will commonly say that the distance they are able to walk has become shorter and shorter If the condition is left untreated, it may simply become too painful for the patient to walk, and they may then resort to the use of a wheelchair or other assistive device.

You have been referred to a neurosurgeon for an evaluation that may result in having a surgical procedure called Lumbar Laminectomy or Lumbar Laminectomy and Fusion. Lumbar Laminectomy is designed to remove pressure from your spinal nerves. Lumbar Laminectomy and Fusion is also done to relieve pressure from the nerves and to stabilize the bony slippage. Most likely, after surgery, you will return to the many activities you enjoyed before your back problems occurred. If your evaluation indicates you are a candidate for this surgery, the steps below will serve as a general guideline from your first office visit to your return home.

Your first office visit

· Please remember to bring your insurance information and a completed medical history form. You should have received this form by mail or at the time of your visit. This medical history form provides information about your current and past medical history, along with any prior anesthesia complications, your current medications and any drug allergies.

· Please bring the results of any prior diagnostic test related to your condition. Also bring the actual X-ray pictures from any computed tomography (CT) scan, magnetic resonance imagining (MRI) scan, myelogram, plain X-rays or other test that was done to evaluate your back problem.

Your examination

Your neurosurgeon and his staff will interview you in the examination room. This will include a review of the medical history form you have completed and questions about your back problem. A comprehensive neurological and physical exam will be performed, and any diagnostic tests and X-rays, will be reviewed. Results of this exam may indicate the need for further-diagnostic tests, conservative therapies or possible, surgical recommendation.

If Surgery is Required

· You may need to do several things to ensure that your insurance company has approved, the operation scheduled for you. Many insurance companies require pre-certification and second opinions. It is your responsibility to ask your insurance company about its particular requirements.

· If you have a pre-existing medical condition and are under a doctor's care, you will receive a consultation clearance form to be completed by your doctor. This should be faxed by your doctor to your neurosurgeon's office as soon possible, so surgery is not delayed. Also, plan to bring a copy of this form to the hospital's Same Day Surgery Unit on the day of your surgery.

Fax: 412-692-2955

Phone: 412-692-2222

Testing before your Surgery

· On the day of your office visit, you will receive a prescription for pre-surgical testing to detect any blood abnormalities. These tests can be done up to 14 days prior to your surgery date. The results must be reviewed by the neurosurgeon's office no later than two working days before your surgery date. The prescription allows Presbyterian University Hospital or any certified laboratory approved by your insurance company, to do the blood and urine tests and forward the results to the neurosurgeon's office for review.

· The same procedure is followed if you require a chest X-ray and EKG. These tests, however, may need to be done at Presbyterian University Hospital, your local hospital or doctor's office, because some labs do not have these capabilities.

· A pre-admission packet will be given to you by the neurosurgeon's office on the day of your visit or mailed to you if surgery is required.
Included in the packet is general information about Presbyterian University Hospital and its procedures. Please read all of the pre-admission materials completely. This brochure does not cover all the steps you'll need to take on the day of your surgery.

You have been referred to Presbyterian University Hospital for a procedure called Lumbar Laminectomy and/or Fusion. Our goal is to return you to optimum health following surgery and send you home some time within the two to three days after your operation.

The following information should help you understand what will be involved with the surgery. This guide is not intended to take the place of the neurosurgical team's explanation, but is designed to answer some common questions and make you familiar with common terms and procedures related to Lumbar Laminectomy with or without Fusion.

Patients are considered for surgery when efforts at conservative treatment have failed to relieve symptoms. Conservative measures typically include physical therapy, strengthening and conditioning exercises, back bracing, weight loss or other lifestyle changes.

The Lumbar Laminectomy procedure is designed to relieve this compression from the nerves. Generally, with the nerves decompressed symptoms will improve. The surgeon reaches the lumbar spine through a small incision in the lower back. Pressure is relieved by partial or complete removal of the back portion of the vertebrae called the lamina. The lamina is bone that covers the spinal nerves or cord. This bony removal generally does not effect the mobility or stability of your spine.

Patients who exhibit radiographic evidence of spondylolisthesis, or slippage, are those most likely to benefit from Lumbar Laminectomy and Fusion. Functional outcome following this surgery is generally better and more rapid if the patient is diagnosed early, and surgical intervention is accomplished prior to muscle atrophy and an inability to ambulate secondary to neural compression. Lumbar laminectomy is intended to decompress the area of stenosis and the fusion (if required) is to prevent any progression in the degree of spondylolisthesis and give stability to the spinal segments. Generous foraminotoimies are performed in order to decompress the neural foramina. Only rarely is it necessary to realign the spine or reduce the slippage in non-traumatic spondylolisthesis.

Fusion part, if required, uses pedicle screws and bone for stabilization. These screws hold the spine in place until natural bony fusion can occur in approximately three months. These screws, however, are generally left in place even after the bony fusion has occurred. Patients often ambulate with a brace the same day as surgery, so the incidence of complications associated with immobility is greatly reduced.

Testing and therapy before Surgery:

Conservative therapy or non-surgical treatment is often used before surgery. Occasionally, conservative therapy may relieve the symptoms associated with spinal stenosis and eliminate the need for surgery. Because conservative therapies such as bed rest, medications and physical therapy have not been effective for you, your neurosurgeon has recommend Lumbar Laminectomy with or without fusion.

Diagnostic tests such as lumbar computed tomography (CT), magnetic resonance imaging (MRI) and myelograms indicate the level degree of herniation and allow your neurosurgeon to precisely perform the procedure. One or more of these tests may be necessary to accurately diagnose the problem.

The Procedure and its Benefits:

Lumbar Laminectomy takes about one to two hours to perform. Your incision will be about 3 to 6 inches long on the mid-low back area. Generally, you will be walking the day of surgery and can be discharged one or two days after your operation. Please arrange your transportation home in advance.

Lumbar Laminectomy with Fusion takes about two to four hour and generally requires the above laminectomy procedure first. The fusion is generally done with pedicle screw and bone fusion.

The risks involved with this type of surgery are: Infection, excess bleeding, no relief of symptoms, excess scarring, increased neurological dysfunction, anesthetic complications, and/or death.

After surgery, minor discomfort from your incision is common but temporary. This can be relieved with mild pain medication. Following the procedure, you may experience persistent numbness, weakness and pain, but these symptoms are generally temporary and gradually go away.

Discharge instructions will be provided to you in a informational packet and review with you prior to discharge.. Your activities will be limited until you come for your postoperative follow-up visit.

Members of the health-care team:

You will meet a number of health professionals during this time. Their goal is to help you recover and return you to your prior activities. A brief description of each of these professionals follows:

Neurosurgeon. You have already met this person, who will perform the surgery and direct your care afterward. Please feel comfortable asking questions of your surgeon - communication is an essential key toward recovery.

Nurse. A nurse will assess your condition both in the surgeon's office and in the hospital. The office nurse will evaluate you before you see the surgeon and again with the surgeon at the time of your visit. The office nurse will help explain the procedure, answer questions and arrange your surgery. The hospital nurse will assess you in the hospital, and help you before, during and after your surgery. The nurse also will answer questions from you and your family.

Physician assistant.- The physician assistant (PA) has -been trained to perform many tasks done by a physician. The PA may perform your history and physical examination and review the surgical procedure. The PA can answer questions and will follow you in the hospital after surgery, along with your physician. The PA will review your discharge instructions on the day after your procedure and facilitate your discharge planning.

The day of surgery:

Several days prior to surgery you will be contacted by the Same Day Surgery Unit's Nurse, who will review your health and medication history. If you have not received a call by 5:00 pm, the day before your surgery, please call 412-692-4990. Please be prepared and have a list of questions and your medications by the phone.

You will be thinking of many things on the day of your surgery, and it is only natural to be overwhelmed and possibly confused about what to do. This information and other information provided can help you become familiar with the process involved with your hospitalization and surgery. We hope that these help to answer your questions and reassure you about your procedure.

Plan to arrive at Presbyterian University Hospital on the first floor (take the escalator or elevators from the lobby area and follow overhead signs to Admitting).

· Eating or drinking after midnight the night before surgery is NOT permitted unless otherwise instructed.

· You will be visited by a nurse and/or PA, who will perform a preoperative assessment. You will sign your surgical consent form.

· Results from your laboratory work will be reviewed again.

· If you have a family doctor clearance letter, it will be collected.

· Your back will be scrubbed by the nurse in preparation for surgery, and you will go to the bathroom.

· Your family should wait in the Surgical waiting room (located on the second floor outside the Operating Rooms).

· After your preparation, you will go to the Holding Area located next to the Operating Rooms.

· This is an area just outside the Operating Room.

Here, you will see your neurosurgeon and discuss anesthesia with the anesthesiologist

· An intravenous, (IV) line will be inserted, and you will be given antibiotics and fluids.

· You will be in surgery for about one to two hours. You will receive a general

anesthetic, which means, you will be asleep during the procedure.

· After surgery, you will be taken to the Recovery Room.

Outside Operating Room

· Your vital signs will be checked frequently, the surgical dressing will be checked and your symptoms will be assessed.;

· You may receive pain medication.

· Your IV fluids will continue.

· You will not be allowed to eat or drink.

· An anesthesiologist will discharge you from the Recovery Room after you are completely awake, which usually takes one to two hours.

· You then will be taken to the Patient Unit located in Presbyterian University Hospital

Your family will be informed as to which Unit you will go to.

Patient Unit

· The nursing staff will assess you on arrival to the floor and monitor your progress.

· Your IV line will be removed after you drink fluids.

· You will be asked to take deep breaths to prevent pneumonia and do ankle and calf exercises to prevent blood clot complications. Pain medications is available; you should ask for this if you need it.

· You will be assisted out of bed the first time you get up. Then, you are encouraged to walk on your own in your room and the halls.

· The nursing staff will remove the operative dressing the morning after surgery and allow you to shower with a plastic dressing covering this area.

If you have had a fusion you may spend the first night in the Step-down Unit and then go to the regular Nursing Unit.

If you already have a brace this can be wore the first night after surgery. If you need a brace it will be fitted and custom made for you to wear the following day.

A drain is sometime placed in the wound after surgery in order to drain excess fluids. This will be removed in one or two days.

Discharge

· Patients who have had Lumbar Laminectomy are discharged one or two days after surgery. Your nurse and PA will discuss your discharge instructions. Please prepare questions to ask at this time.

Patients who also require a fusion will be asked to wear a supportive brace for up to three months and obtain monthly X-rays.

· You will be given a discharge instruction sheet that will include restrictions, activities, physical therapy, medications and care of the incision.

· Remember to arrange your transportation home prior to this day. You will not be allowed to drive yourself home. If you anticipate a problem with your arrangements to go home, please notify the staff the day of surgery. The discharge time is before 11 am.

Most of the information you will need about your stay is in a brochure you will receive or the UPMC Information Handout, included in your admission packet. Pertinent telephone numbers, directions, maps, lodging and parking information are highlighted in the handbooks Your discharge instructions will help you become familiar with any limitations you will have after surgery.

For questions or comments, please contact: bostj@msx.upmc.edu