CHAPTER
Brandon G. Rocque
122
Postlaminectomy Deformities in the
Thoracic and Lumbar Spine
INTRODUCTION
Posterior spinal laminectomy is a commonly used approach for
the treatment of cervical, thoracic, and lumbar spinal pathol-
ogy. Common indications for laminectomy in adults include
herniated intervertebral disc, spinal stenosis, and intradural
tumor. In children, laminectomies are often performed for the
diagnosis and treatment of spinal cord tumors as well as for
other conditions such as neurofibromatosis and syringomy-
elia.11 Although laminectomies are generally considered to be
a safe procedure with few associated complications, they do
involve the interruption or removal of stabilizing anatomical
elements. The changes associated with laminectomy have been
shown by several studies to alter the motion, load-bearing prop-
erties, and biomechanical interaction of various spinal compo-
nents. This leads to the risk of development of a postlaminectomy
deformity.
Deformity development after laminectomy has long been
recognized as a potential complication following pediatric spi-
nal tumor removal,7 and therefore much of the literature has
focused on the pediatric population. In adults, the develop-
ment or progression of a spinal deformity has been noted after
decompressive operations for spondylolisthesis in the absence
of spinal fusion,2 a topic covered elsewhere in this textbook.
Cervical postlaminectomy kyphosis is seen in adults with some
frequency and is also discussed elsewhere in the text.
Postlaminectomy deformities in the thoracic and lumbar spine
in adults are rare; these will be discussed in conjunction with
pediatric disease.
ANATOMIC, BIOMECHANICAL, AND
SURGICAL CONSIDERATIONS
One common biomechanical model of the spine is the three-
column model of Denis.5 Although an analysis of the spinal
column in this fashion is relevant for traumatic injuries to the
spine, it is less helpful for nontraumatic spinal deformities. For
this purpose, the spinal column is conceptually divided into
two columns: anterior and posterior (Table 122.1). The ante-
rior column consists of all the anatomic elements ventral to the
posterior longitudinal ligament, including the anterior longitu-
1326
LWBK836_Ch122_p1326-1331.indd 1326
Sharad Rajpal
Daniel K. Resnick
dinal ligament, vertebral body, intervertebral disc, and annu-
lus. Everything dorsal to this, the laminae, facet joints, spinous
processes, supraspinous and interspinous ligaments, ligamen-
tum flavum, and facet capsules, is considered the posterior
column.
Although the osseous and ligamentous components of the
spine dictate the final position of the spine, the muscles con-
tribute to the instantaneous spatial arrangement of the verte-
brae. In the thoracic spine, the kyphotic curve is determined
mainly by the osseous structures; in the lumbar spine, the lor-
dotic curvature is determined more by the ligamentous struc-
tures. At any particular time, the effect of gravity on the spine
will depend upon the overall sagittal alignment and the loca-
tion of the center of gravity relative to the spine. When stand-
ing in a biomechanically neutral position, the anterior and pos-
terior elements are under counter forces to maintain balance.
In general, the anterior elements are under compression while
the posterior elements are under tension. When either one or
both of these elements are disrupted, there is potential for
development of a kyphotic deformity.15 Gravity tends to accen-
tuate the kyphosis of the thoracic spine and cause a kyphosis of
the lumbar spine because it places a flexion moment on the
spine. The actual development of an angular deformity is not
this simplistic, however, and other contributing factors such as
facet arthropathy, skeletal deficiencies, and neuromuscular
imbalance must be considered. Segmental and regional ana-
tomical structures, such as the rib cage in the thoracic spine,
the ligamentum flavum, and intervertebral discs are also impor-
tant. In summary, the spinal column is a three-dimensional
structure under the influence of multiple loading forces that
can, under certain circumstances, result in the development
and progression of a spinal deformity.
The effect of laminectomies on the thoracic spine has not
been studied as extensively as for the lumbar or cervical spine
likely because laminectomies are less often performed in this
region and because the rib cage is thought to mitigate the
destabilizing effect of the removal of posterior structures.
Yoganandan et al, however, did evaluate the effects of a lamine-
ctomy on thoracic spine biomechanics.28 In their experiment,
intact thoracic specimens were compared to specimens with a
midthoracic two-level laminectomy. The specimens, it should
be noted, did not include the rib cage. The ligamentum fla-
vum and spinous processes of the laminae were resected in the
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 Chapter 122 Postlaminectomy Deformities in the Thoracic and Lumbar Spine
Two-Column Model for
TABLE 122.1
Spinal Deformity
Anterior column
Anterior longitudinal ligament
Vertebral body
Intervertebral disc and annulus
Posterior column
Laminae
Facet joints
Facet capsules
Spinous processes
Supraspinous and intraspinous ligaments
Ligamentum flavum
laminectomy spines, but the integrity of the facet joints was
maintained. The specimens with laminectomy defects were
relatively more flexible, had a lower load carrying capacity,
and failed at a significantly lower level of applied force. The
degree of deformation at failure was similar in the laminecto-
mized group and the intact group, however, indicating a com-
mon mode of failure among the groups but a lower threshold
in the laminectomized specimens. The authors furthermore
found that the laminectomized spines failed one or two levels
rostral to the level of the laminectomy, suggesting a local
increase in stress at that end of the decompression. Their
results suggest that two-level laminectomy in the thoracic spine
decreases the strength and stability throughout the loading
range. These results have to be considered in light of the clini-
cal situation, where the sternum and rib cage contribute addi-
tional stability.
Interruption of other spinal elements, in addition to the
lamina, can also contribute to deformity development. During
posterior decompressive laminectomies, it is not uncommon to
include a partial or complete facetectomy to help relieve neu-
ral compression. Several studies have assessed the contribution
of the facet complex to spinal stability, especially in the lumbar
spine.1,8,10,18,24 These authors have utilized several biomechani-
cal models of the lumbar spine to assess the impact of varying
degrees of lamina and facet disruption on the spines response
to several different loading forces.
The conclusion drawn from these biomechanical and
experimental studies has been that while there is some decrease
in the overall stiffness and strength of the spinal column from
laminectomy, the risk of postoperative deformities is greater
with facet destruction. Increasing facet interruption from par-
tial unilateral removal to total bilateral removal also results in
an increase in the motion of the studied segment. Increasing
compromise of the facet and facet capsule leads to an increased
risk of postoperative deformity. In an experimental model of
the adult spine, laminectomy without facet removal has only a
minor effect on the biomechanical properties of the tested
segments.
Skeletal deficiencies other than of the facet joints that can
also produce deformity include compromise of the anterior
column by tumor or surgical resection. This can add to the risk
of instability following laminectomy and contribute to the
development of a deformity. Other potential factors that may
contribute to spinal instability at the time of laminectomy
include a concomitant discectomy or performing the decom-
pression adjacent to a prior fusion.6
LWBK836_Ch122_p1326-1331.indd 1327
1327
CLINICAL IATROGENIC DEFORMITY
PRODUCTION
In 1959, Haft et al published their experience after resection of
spinal cord tumors in children.7 In this series, 10 of the
30 patients who underwent laminectomy for tumor removal
developed kyphoscoliosis. Although their manuscript did not
specify the exact levels of the laminectomy, the majority of
tumors were located between the cervicothoracic and the thora-
columbar junctions. A confounding factor was a high mortality
rate related to the primary disease process that lead to limited
follow-up. As the surgical treatment of children with spinal
tumors progressed over time to more aggressive approaches
with better microsurgical techniques and better postoperative
therapeutic options, the risk of postoperative deformity was
noted to be quite significant. In 1965, Tachdjian and Matson
reviewed a series of 115 children who underwent spinal tumor
resection followed, in some cases, by radiation. Ninety-one of
these tumors were located at or below the cervicothoracic junc-
tion and 31 patients (34%) developed postoperative scoliosis
while 30 patients (33%) developed postoperative kyphosis.23
Factors that the authors provided in explanation for the devel-
opment of postoperative deformity included spinal instability
after laminectomy, muscle weakness, tumor recurrence, lack of
postoperative spinal support, and postoperative radiotherapy.
Combining the cases from earlier reports, Lonstein con-
cluded that the incidence of spinal deformity in children after
laminectomy is approximately 49%.11 He postulated that the
most important factor in deformity development is the loss of
the posterior ligamentous complex, including the supraspinous
ligaments, ligamentum flavum, interspinous ligaments, and
facet joint capsules. In addition, he hypothesized that the
paraspinal musculature is often weakened by either the tumor
or operation, and therefore muscle tone is decreased. This in
turn leads to poor maintenance of posture and spinal align-
ment. He identified two different types of postlaminectomy
kyphotic deformities: a sharp-angled kyphosis and a gentle
sloping kyphosis. Lonstein hypothesized that the key factor to
differentiating these two is the integrity of the facet joint.
The pathogenesis of postoperative deformity development
in children is unique from adults and is thought to result from
wedging of the ventral part of the vertebral body. Prior to adult-
hood, the vertebral bodies are incompletely ossified. After
laminectomy, axial loading forces lead to higher stress on the
incompletely ossified anterior portion of the vertebral body.
This places increased strain on the remaining posterior liga-
mentous elements, including the intervertebral ligaments. In
children, these ligaments have higher viscoelasticity and there-
fore stretching can occur, thereby increasing the stress on the
vertebral body and leading to a vicious cycle.26 Eventually, the
growth of the anterior portion of the vertebrae is slowed accord-
ing to the HueterVolkmann principle resulting in progressive
wedging of the vertebrae. Factors believed to predispose chil-
dren to instability include increasing numbers of levels involved
in the laminectomy and cervical or high thoracic involvement.
In children, a deformity may develop suddenly or gradually
after laminectomy, and it may progress significantly during the
adolescent growth spurt.25 Although scoliosis can also occur
either as the primary deformity or in association with kyphosis,
kyphosis is the most common deformity following laminec-
tomy.25 Peterson describes three types of postlaminectomy
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 1328 Section XI Kyphosis and Postlaminectomy Deformities
kyphosis: (1) instability after facetectomy, (2) hypermobility
between vertebral bodies associated with gradual rounding of
the spine, and (3) wedging of vertebral bodies caused by growth
disturbances.17 Similar to the kyphus described by Lonstein,
kyphosis due to instability after facetectomy will tend to be
angular and sharp, usually occurs in the immediate or early
postoperative period, and can be associated with loss of neuro-
logical function. When the facet complex has been preserved,
the kyphosis tends to be round and gradual and increases slowly
over time as a result of the ongoing stress to the remaining pos-
terior elements with the development of wedging of the verte-
bral bodies.
In concordance with biomechanical principles and the
investigational findings detailed above, facet injury is thought
to produce the greatest predisposition to deformity in adults.
In a retrospective study comparing children and adults all
under the age of 30 years, 33% of the children suffered postop-
erative deformity compared with only 8% of the adults.16 It is
important to note that deformities may develop in a delayed
fashion, mandating long-term follow-up of patients after a mul-
tilevel laminectomy. In one series, the time to development of
first signs of kyphosis was 2 to 74 months, with several first
noted as late as 6 years following surgery.27
The risk for postlaminectomy kyphosis is dependent on the
patients age and the level of the laminectomy. A retrospective
study of 58 patients who underwent multilevel laminectomy
over a 10-year period compared patients younger than 15 years
with patients between 15 and 25 years of age.27 Forty-six percent
of patients younger than 15 years developed a deformity in
comparison to 6% of those aged 15 to 25 years. In the thoracic
spine, 36% of young patients developed a deformity, while in
the lumbar spine no patient developed deformity. No patient
in either group underwent facetectomy or postoperative radia-
tion therapy. A significant number of patients from both groups
were lost to follow-up.
Ofluoglu et al recently published their retrospective analysis
of the effects of laminectomy on spinal stability in the manage-
ment of adults with degenerative lumbar stenosis.13 The aver-
age patient age was 58 years, and the average follow-up time was
23 months. In all cases, laminectomy was completed with pres-
ervation of the facet joints bilaterally. Seven patients underwent
single-level laminectomy, 20 patients underwent two-level
laminectomy, and 10 patients underwent three-level laminec-
tomy. Of the 34 patients with stand-alone laminectomy, only
one patient (3%) developed segmental instability, following a
two-level laminectomy. Postacchini et al, in a retrospective study
designed to compare multiple-level laminotomy to laminec-
tomy, noted the development of marked segmental instability
in 3 out of 32 patients following laminectomy versus none with
laminotomy.19 They note, however, that these three patients
had either preoperative lumbar scoliosis or spondylolisthesis,
both known risk factors for deformity development. Please see
Table 122.2 for a summary of factors that may increase risk of
postlaminectomy spinal deformity.
PREVENTION
The adult patient without spondylolisthesis or preoperative
deformity is at little risk for developing kyphosis following
single- or double-level laminectomy if the facets remain intact.
LWBK836_Ch122_p1326-1331.indd 1328
Factors that Increase Risk of
TABLE 122.2 Postlaminectomy Spinal
Deformity
Facet joint disruption
Spinal cord tumor
Radiation exposure
Involvement of cervical or high thoracic spine
Preoperative kyphosis or scoliosis
Age less than 15 years
Increasing number of laminectomies
Because of the high incidence of deformity following thoracic
laminectomy in children, however, efforts to prevent deformity
in these patients may be warranted. Similarly, adults with preex-
isting or potential iatrogenic biomechanical instability or defor-
mity may benefit from concomitant stabilization at the time of
decompression. Considerations for determining preoperative
biomechanical instability include careful analysis of the intrin-
sic elements of the spine as well as the anterior and posterior
stabilizing elements. This may include evaluating the adequacy
of anterior bone quality (osteoporosis) and the presence of
preoperative deformity.
Initial attempts at bracing at the first sign of deformity were
marginally successful, and the kyphosis often progressed. Once
the deformity has occurred and progressed, bracing becomes
ineffective in preventing further progression.11 In 1976,
Raimondi et al introduced the concept of the osteoplastic lami-
notomy in an attempt to decrease the incidence of postopera-
tive spinal deformity in children.21 This technique has since
been widely adopted in the pediatric population. The tech-
nique involves either the replacement of the laminae after their
removal or hinging them to the side, top, or bottom like a
door to expose the spinal cord. The laminae are either sutured
into place in children or fixed into place in adults using a
screwplate system. Several different techniques for osteoplas-
tic laminotomy have been described in the literature but are
beyond the scope of this chapter.
The rate of deformity following such procedures has recently
been described in a large cohort study.20 In a retrospective
review of 70 pediatric patients treated with osteoplastic lamino-
tomy, results were compared with the cumulative results of pre-
viously published series involving more than 10 patients (the
details of several having already been noted above). Laminotomy
varied from 2 to 13 levels, and all but 6 patients involved the
thoracic, thoracolumbar, or lumbar spine. Good results were
defined as no deformity development or a lack of progression
of a previous deformity. Twenty-seven percent of patients fol-
lowing laminotomy were found to have a new or progressive
deformity. This is compared with 46% of the 330 cases reported
in the literature, many of which excluded malignant tumors,
and operation on the cervical spine, factors that would likely
increase the incidence of deformity. It has now become com-
mon practice to perform osteoplastic laminotomy rather than
laminectomy in patients younger than 15 years.
In their guidelines for performance of fusion procedures in
adult patients with degenerative disease of the lumbar spine for
stenosis without spondylolisthesis, Resnick et al acknowledged
that there is no treatment standard.22 However, they were able
to recommend the use of posterolateral fusion for patients with
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 Chapter 122 Postlaminectomy Deformities in the Thoracic and Lumbar Spine 1329

Operative Candidate

Patients Age >15 Preexisting Spinal Instability or Deformity

15 y Yes No

Laminoplasty Possible? No Consider Fusion Yes Aggressive Facetectomy

or 5 Levels
Figure 122.1. Algorithm for selection of operative
Yes
patients in whom concomitant fusion procedure should
No
be considered. Each patient should be considered on
an individual basis, however, with the following algo- Fusion
rithm provided only as a general guideline. Not Necessary

spinal instability or deformity (scoliosis or kyphosis) undergo- kyphosis from 84 to 49 using posterior instrumented fusion
ing decompression for lumbar stenosis. Fusion was also recom- with anterior grafting. There were no cases of pseudarthrosis
mended as an option in cases where aggressive facetectomy was and an average progression of kyphosis of 5 in the follow-up
anticipated. In patients with lumbar stenosis in whom there is period (mean 5 years). Combining posterior instrumentation
no evidence of preexisting spinal instability and low likelihood to provide corrective force and anterior bone graft to provide
of iatrogenic instability from aggressive facetectomy, posterolat- a better environment for bone healing therefore appears to be
eral fusion is not recommended. one effective strategy.
As noted above, several authors have already demonstrated
that removal of the interspinous ligament and facetectomy of
greater than 50% affect the motion of the intervertebral joint
and induce additional stress at the other spinal components.1,8,18
Therefore, in general, it is important to preserve as much facet
joint and pars interarticularis as possible at the time of surgery
because destruction of these structures will lead to an increased
rate of spondylolisthesis postoperatively.9 Figure 122.1 illus-
trates an algorithm for selection of patients who would likely
benefit from osteoplastic laminotomy rather than laminectomy,
and for patients in whom concomitant fusion procedure should
be considered.

TREATMENT
Treatment of postlaminectomy deformity is not trivial and thus
it is best to prevent its development. Details of operative correc-
tion of spinal deformities are covered extensively elsewhere
and will only be covered briefly in this chapter. Options for cor-
rection of a postoperative deformity depend on the extent of
the previous bony removal. Early studies, prior to pedicle screw
availability, focused on anterior fusion using a variety of tech-
niques.3,7,12 However, posterior instrumentation and fusion
techniques have improved tremendously to become the cur-
rent treatment of choice in many situations. When a posterior
fusion construct is used in isolation, the instrumentation is sub-
ject to three-point bending and distraction forces. These forces
are disadvantageous for graft healing. The suboptimal environ-
ment for bone healing is thought to contribute to a rate of A B
pseudarthrosis as high as 57% and failure to maintain correc-
tion.11 In a retrospective review of 12 patients treated for post- Figure 122.2. (A and B) A 25-year-old woman underwent a T7-10
laminectomy for resection of an intramedullary low-grade astrocy-
laminectomy kyphotic deformity, Otsuka et al found posterior
toma. A few years later, she developed gradually worsening low back
instrumentation alone to be an effective treatment.14 All and thoracolumbar pain relieved with recumbency and a progressive
patients had previously undergone laminectomy of three to clinical deformity consisting of thoracolumbar kyphosis and lumbar
seven levels, and all had progressed at least 20 from the point hyperlordosis. Nonoperative management failed to ameliorate her
when kyphosis was identified as a potential problem. Staged symptoms and she subsequently underwent posterior instrumented
anterior and posterior approach was used, but without anterior fusion with posterior column osteotomies for correction of her defor-
instrumentation. The group reports a correction of the mean mity. (Courtesy of P. Angevine.)

LWBK836_Ch122_p1326-1331.indd 1329 8/26/11 5:42:42 PM

 1330 Section XI Kyphosis and Postlaminectomy Deformities
A B
Another approach to kyphosis correction is posterior osteot-
omy. Either Smith-Peterson osteotomy (SPO) or pedicle sub-
traction osteotomy (PSO) may be used. Decision as to which
technique to use must be individualized based on the degree of
kyphosis and of sagittal imbalance. One might expect up to
approximately 10 of kyphosis correction for each SPO per-
formed, compared with 30 to 40 of correction for each PSO.
A direct retrospective comparison between three-level SPO and
single-level PSO showed no difference in degree of kyphosis
correction.4 Figures 122.2 and 122.3 are illustrations of two
patients treated with osteotomies after development of post-
laminectomy kyphosis.
The use of a combined or stand-alone procedure, either at
the time of the first surgery or in stages will depend, again, on
the individual patient characteristics.
CONCLUSION
Although many experimental models have studied effects of
laminectomy and graded facetectomies on the thoracic and
lumbar spine, the surgeons clinical acumen is most critical
when determining which patients are best suited for surgical
decompression and simultaneous fusion. Each patients situa-
tion is unique, and the intrinsic physical properties of the spine
must be considered against physiologic loading conditions.
Surgical disruption of the spinal elements undoubtedly causes
altered kinematics that must not be ignored in their contribu-
tion to the potential development of postoperative deformity
and complications. Utilization of strategies to prevent the
development of deformity is warranted when the facets are
LWBK836_Ch122_p1326-1331.indd 1330
Figure 122.3. (A and B) A 42-year-old man underwent
L2-5 laminectomies for lumbar spinal stenosis. Over a 5-year
period, he developed progressive low back pain and an
inability to stand erect. After failure of nonoperative manage-
ment, he underwent a T10 to pelvis posterior instrumenta-
tion with an L2 pedicle subtraction osteotomy and posterior
fusion. Six weeks later, he underwent a minimally invasive
transpsoas approach for L2-3 interbody fusion. (Courtesy of
P. Angevine.)
disrupted in adult patients and at all times in patients younger
than 15 years.
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