Procedure description

A posterior thoracic laminectomy for arteriovenous malformation (avm) is an operation performed to remove or decompress the spinal cord from a vascular (related to blood vessels) lesion.   We focus here on the posterior (from the back) approach.   The patient is brought to the operating room, and put to sleep.  Then, once asleep and on a ventilator (breathing apparatus), the patient is carefully turned into the prone position (face down).  Care is taken to ensure that all "bony" areas are well protected, to prevent pressure sores.  The surgeon will now incise the skin overlying the appropriate levels of the spine,   and push the muscle away from the spine.  Retractors hold the muscle aside, and the surgeon then removes several levels of lamina (roof of the spinal cord).  The surgeon will now, using microscopic guidance, either close off a fistula (communicating arterial vessel) or dissect and cut out a vascular malformation.  There are a number of complex varieties of avm's, and your surgeon will go into more detain about the intricacies pertinent to your condition.   Often, spinal cord monitoring may be used during the case.  After avm removal or partial removal has been accomplished,  the surgeon will close the muscle layer, deep fascia (deep fibrous tissue) and skin.

Procedure Risks

Posterior thoracic laminectomy  for removal of spinal cord avm's may have moderate risks.   Risks can be broken down into two categories, 1) those related to the operative site, and 2) those related to the risks of anesthesia. 

Risks related to the operative site: 

Surgical Exposure:  The patient is placed in the prone position (face down).  In this position, there can be pressure sores, pressure injuries to nerves, and injury to the eyes as a result of pressure to them.  During surgical dissection, injury to muscle surrounding the spine can occur.

Spinal Cord/Nerve Root injuries: If there is any injury to the spinal cord in the thoracic area, this  could result in paralysis of the lower extremities, as well as loss of bowel, bladder and sexual function.     There may be a spinal fluid leak, which could occur after a tear of the covering of the spinal cord or nerve roots.    There is a small chance of causing instability.

       Risks of avm removal depend to some degree upon the type and location of tumor.

•  If an avm is epidural (surrounding the tough covering of the spinal cord), the cord itself does not need to be entered.  There may be a fistula (communicating vessel) supplying the avm, and once this is divided, the avm within the cord may "deflate."
• If an avm is intradural extramedullary (within the covering of the spinal cord but outside of the spinal cord itself), there are some increased risks because the delicate spinal cord must be exposed, and the risk of postoperative spinal fluid leaks increases.
• If an avm is intradural intramedullary (within the covering of the spinal cord and within the spinal cord itself), the risks are highest.  Depending upon the extent and depth of the avm within the cord, surgical risks may be great, with significant chances of postoperative neurological deficits.

        There is also the possibility that only a portion of the avm may be removed. 

General Risks:  These include  general difficulties, such as bleeding, infection, stroke, paralysis, coma and death.  Incisions on the back generally heal well, but the incision site could   be tender, or may heal in an unpleasant manner, with scarring.  There is also the possibility that the surgery may not relieve the symptoms for which the procedure was performed.  The problem for which the surgery was performed may recur, requiring additional surgery in the future.  In addition, although every attempt is made to protect all areas of the body from pressure on nerves, skin and bones, injuries to these areas can occur, particularly with prolonged cases.

Risks of Anesthesia: Blood clots in the legs, heart attacks, reaction to the anesthetic, reaction to blood transfusion, if  given.

 

Post-operative care:

There shall be no bending, twisting, or heavy lifting for several weeks after surgery.  Physical therapy may or may not be implicated.  Your doctor will gradually ease your work restrictions, depending on your progress. 

Remember to keep the wound dry and clean.  Notify your surgeon of any drainage or temperatures greater than 101 Fahrenheit.

The goal of this surgery was to achieve diagnosis and remove as much of the tumor as possible.  The healing process may be a long one, depending on whether nerve root or spinal cord damage was involved.   Some continuing back  pain is not unusual during the first few days and weeks following surgery.  The following is a list of suggestions that should help speed your recovery and give you every possible chance for the best results from your surgery.

1. Immediately upon discharge, contact our office and set up an appointment for staple removal if one has not already been set up.
2. Take it easy until seen by the physician.  This does not mean bed rest, but athletic activities during this period are definitely not recommended.  Please give your incision a chance to heal.  Avoid bending.
3. If your surgeon has prescribed for you a brace or corset, make sure to wear it when you are out of bed.  It will help to support your spine while your own bone is healing.
4. Lift nothing heavier than a half gallon of milk until seen by your doctor.
5. Avoid sitting for periods of time longer than 45 minutes.  It is OK to sit in a lounge chair which is laid back, for as long as you wish.
6. No jogging or running.
7. After you get home, you may begin walking up to one mile per day.
8. You may walk up or down steps as often as you like.  Please take them smoothly and slowly.
9. No driving until OK with your physician.  Do not ride further than  50 miles at a time.  This applies during the first month after surgery.
10. You may shower after you go home unless otherwise instructed.  Cover the incision with plastic wrap before the shower and remove it afterward.  Change dressing immediately.  Tub baths are not advisable.  You may shower without covering the incision one week after the staples are out.  Follow instructions concerning care of tapestrips, stitches or staples.  Your surgeon or his nurse clinician will explain the techniques used in the closure of your incision.
11. Sexual activities are permitted.
12. If you notice swelling, redness or opening of the incision, or if there is any clear fluid draining from it, please contact your surgeon immediately!  If you develop a fever, stiff neck or chills, contact the office immediately.  Take your temperature at 4:00 PM daily until the clips are removed.  Call in greater than 101 degrees Fahrenheit.
13. If you have any questions, call our office, and for after hours emergencies, call the medical society.
14. Take your medications prescribed on discharge, as directed.
15. It takes 6 - 18 months for a nerve to heal.  During that time you may experience numbness, tingling, fleeting pain, or creepy/crawly sensations.
16. If there has been spinal cord damage due to long term spinal cord compression, it may take 1-2 years for an improvement, and often, improvement will be very limited, if it does occur at all.