Overview
Lumbar discectomy refers to the procedure of removing a degenerative or herniated disc from the lower spine. To remove the nerve-pressing disc, the incision is made posteriorly through the back muscles. If medication and physical therapy fail to alleviate leg or Back Pain and Strain, or if nerve damage is suspected (weakness or loss of sensation in the legs), a discectomy may be performed. This surgery is either open or minimally invasive.
Figure 1.
What is Lumbar discectomy?
Discectomy simply means "cutting out the disk". A discectomy can take place anywhere along the spine, from the cervical (neck) to the low back and lumbar (lumbar). The surgeon will reach the disc by removing a portion of the lamina and muscles from the posterior (back) side of the spine. The surgeon removes a portion from the lamina to access the disc. The lamina, which forms the spine's backside and acts as a roof around the spinal cord, is what the surgeon removes. The spinal nerve is then retracted to the opposite side. Depending on the case, one or more discs (single-level or multi-level) can be removed.
A discectomy can be performed using a variety of surgical techniques and tools. A "open" procedure uses large incisions and muscle retraction to allow the surgeon to view the disc. A microendoscopic discectomy, or minimally invasive technique, uses a smaller incision. To tunnel through the muscles, a series of gradually larger tubes called dilators are used. Special instruments allow the surgeon to see and work in a smaller area. Minimally invasive incisions cause less damage to the back muscles, and can reduce recovery time. The best technique for you will be determined by your surgeon.
Patients who work hard, are competitive, or have severe spinal instability may need to have fusion done simultaneously with discectomy. Fusion is a combination bone graft and hardware (screws/plates), to join two vertebrae. The two vertebrae become one bone during the healing process. A herniated disc in the lumbar spine is not usually required to fuse [1].
Who are the candidates?
If you have the following:
- Diagnose tests ( MRI and CT) to detect a herniated disk
- You feel severe pain, weakness, or numbness at your foot or leg.
- Leg pain ( sciatica), worse than back pain
- Symptoms that do not improve with medication or physical therapy
- Leg weakness, loss feeling in the genital region, and loss bladder control ( cauda Equina syndrome).
Leg pain may be treated with posterior lumbar discectomy.
- Bulging and herniated disc: The gel-like substance within the disc may bulge or rupture through the weaker area of the surrounding wall (annulus). This material can cause irritation and swelling by pressing on a nerve (Fig. 1).
- The degenerative disc disease occurs when discs wear out. Bone spurs develop and the facet joints become inflamed. The discs shrink and dry out, losing flexibility and cushioning. The disc spaces shrink. This can lead to disc herniation or stenosis.
The surgical decision
After a few months, most herniated discs will heal. While your doctor may suggest treatment options, it is up to you to decide if surgery is right for yourself. Before making a decision, make sure you weigh the benefits and risks. Only 10% of patients with herniated disk problems feel enough pain after six weeks of nonsurgical treatment before they are ready to consider surgery.
Who is responsible for the procedure?
Spine surgery can be performed by either an orthopedic or neurosurgeon. Many spine surgeons are trained in complex spine surgery. Ask your surgeon for details about their training, especially in complex cases or if you have had multiple spinal surgeries.
What happens before and after surgery?
You will need to sign consent forms and other forms in order for the surgeon to know your medical history (allergies/vitamins/bleeding history, anesthesia reactions, prior surgeries, etc.). Talk to your doctor about all prescription, over-the counter, and herbal supplement medications. A few days prior to surgery, you may need to have presurgical tests such as a blood test, electrocardiogram, or chest X-ray. Talk to your primary care physician before you stop taking any medications.
Keep taking the medication your surgeon has recommended. All non-steroidal anti-inflammatory medications (ibuprofen and naproxen) should be stopped. Blood thinners (Coumadin and aspirin; Plavix, etc.) 7 days prior to surgery. To avoid bleeding and other problems, stop using nicotine and alcohol one week prior to and two weeks after surgery.
Before you have surgery, you may be asked to wash the skin with Hibiclens or Dial soap. It kills bacteria and prevents infections at the surgical site. Avoid getting CHG in the eyes, ears and nose.
Morning of Surgery
- If you are told otherwise by the hospital, don't eat or drink until midnight before your surgery. Allowable medicines may be taken with a small amount of water.
- Use antibacterial soap to wash your skin. Wear loose-fitting, freshly washed clothing.
- Flat-heeled shoes should be paired with closed backs
- Remove make-up, hairpins, contacts, body piercings, nail polish, etc.
- All jewelry and valuables should be left at home.
- A list of medications, including dosages and times of use, is helpful.
- A list of your allergies to medications and foods.
To complete paperwork and perform pre-procedure checks, arrive at the hospital two hours prior to your scheduled surgery. An anesthesiologist will discuss the risks and effects of anesthesia with you.
What happens during surgery?
The procedure consists of five steps. The procedure usually takes between 1 and 2 hours.
Step 1 - Prepare the patient The anesthesia will be administered to you as you lie down on your stomach on the operating table. After you have fallen asleep, roll onto your stomach and support your chest with pillows. You must clean and prepare the area where the incision is to be made.
Step 2 - Make an incision A fluoroscope, a special Xray device, is used to guide the surgeon through the skin to the bone.
An open discectomy involves a skin incision at the mid-back of the patient, over the affected vertebrae. 2). The number of discectomies performed will determine the length of the incision. An incision of one level is approximately 1 to 2 inches in length. To expose the bony vertebra, the back muscles must be pulled down on one side. To confirm the correct vertebra, an X-ray is taken.
Figure 2. Figure 2. The muscles that are over the vertebrae must be retracted to one end. A small stab entry (greenline) is used to perform a minimally invasive discectomy.
A minimally invasive discectomy involves making a small incision to the back of one side (Fig. 3). The next step is to pass progressively larger dilaters, one around each muscle, to slowly separate them and create a tunnel leading to the bony vertebra.
Figure 3. Figure 3.
Step 3 - Make a laminotomy Next, a small hole is made in the lamina above and below the spinal cord using a drill or bone-biting tool (Fig. 4).
Step 4 - Remove the disc fragments After removing the lamina, the surgeon gently retracts its protective sac. To locate the herniated disc, the surgeon uses a surgical microscope. To decompress the spinal root, the surgeon only removes the ruptured disc. The disc is not completely removed (Fig. 5). Also, bone spurs and synovial cysts that might press on the nerve roots are removed.
Figure 5. Figure 5.
Fusion is not usually performed for a single-level lumbar diskectomy. Fusion may be used to treat other conditions such as spinal instability or recurrent disc herniation.
Step 5 - Close the incision The retractor that holds the muscles together is removed. Stitches or sutures are used to join the muscle and skin incisions. The incisions are closed using skin glue.
What happens after surgery?
In the postoperative recovery area, you will be awakened. You will be closely monitored for blood pressure, heart rate and respiration. Any pain will be treated. You can then begin to move, such as sitting in a chair or walking. Most patients are able to go home that day. Others can be discharged from the hospital within 1 to 2 days. For the first 24 hours, ensure that someone is available to assist you at home.
Follow the instructions of your surgeon for home care until your follow up appointment. In general, you can expect:
Restrictions
- Avoid twisting or bending your back.
- Do not lift more than 5 pounds.
- There is no need to engage in strenuous activities such as yard work, housework, or sex.
- Do not drive for the first 2 to 3 days, or while you are taking pain medication or muscle relaxers. You can drive if your pain is under control.
- Don't drink alcohol. It can thin the blood and increase the risk of bleeding. Don't mix alcohol and pain medications.
Incision Care
- You can shower the day following surgery if Dermabond skin glue is covering your incision. Every day, gently wash the incision with soap and warm water. Do not rub or pick at glue. Pat dry.
- You can shower two days after your surgery if you have steri-strips, staples, or stitches. Use soap and water to gently wash the area every day. Pat dry.
- Cover the incision with dry gauze if there is any drainage. Call the office if drainage occurs after applying more than one dressing in a single day.
- Do not soak the incisions in a pool or bath.
- Do not apply lotion or ointment to the incision.
- After each shower, dress in clean clothes. Clean sheets are a must for your bed. You can't allow pets to sleep in your bed until you heal.
- At your follow-up appointment, stitches, steri-strips and staples will be removed.
Medications
- Your surgeon may direct you to take pain medication. As your pain subsides, you can reduce the frequency and amount of your medication. Don't use pain medication if you don't feel the need.
- Constipation can be caused by using narcotics. Get plenty of water and eat lots of high-fiber food. Laxatives and stool softeners can be helpful in moving the bowels. There are many over-the-counter options, including Senokot and Miralax, Dulcolax, Senokot and Dulcolax.
Activity
- To reduce swelling and pain, ice your incision for 15-20 minutes three to four times daily.
- If you're sleeping, don't stay in one place for more than an hour. More pain can be caused by stiffness.
- Every 3-4 hours, get up and walk for 5-10 minutes. Gradually increase your ability to walk.
When to call your doctor
- Fever exceeding 101.5deg (unrelieved with Tylenol).
- Unrelieved nausea or vomiting.
- Incision infection signs
- Itching or rash at the incision (allergy Dermabond skin glue).
- Tenderness and swelling in one leg's calf.
- A new onset of weakness, numbness or tingling in the arms and legs.
- You may experience dizziness, confusion or extreme sleepiness.
Recovery and prevention
For 2 weeks following surgery, schedule a follow up appointment with your surgeon. Some people may need physical therapy.
The time taken to heal depends on your overall health and the severity of the underlying condition. The incision may cause pain. You may feel some discomfort at the site of surgery. Keep a positive outlook and do your physical therapy exercises diligently if you are prescribed.
With jobs that aren't physically demanding, most people can return to work within 2 to 4 weeks. For jobs that require heavy lifting, or heavy machinery, some people may have to wait 8-12 weeks before they can return to work.
What is Spinal Stenosis? Prevention is the key to avoiding recurrence.
- Proper lifting techniques
- Good posture while sitting, standing, moving and sleeping
- Appropriate exercise program
- A well-designed work space
- Healthy weight and lean body mass
- Positive attitude and relaxation techniques (e.g. stress management) are key.
- No smoking
What were the results?
The good results of lumbar discectomy are seen in between 80 and 90% of patients [2,3,]. The results of a study comparing surgery and nonsurgical treatment of herniated disks were [2]
- Surgery is more beneficial for people with leg pain (sciatica), than it is for those with back pain.
- Nonsurgical treatment is a good option for people with pain that is less severe or worsening.
- Patients with moderate to severe pain that had surgery experience a greater recovery than those who didn't.
Minimally invasive discectomy has been shown to have comparable outcomes to open discectomy. These newer techniques may have some advantages, such as a shorter recovery time, less blood loss, muscle trauma and a faster operative time. However, they are not suitable for all patients. Ask your surgeon whether minimally invasive microendoscopic discectomy might be right for you.
Nonsurgical treatments may not provide the same pain relief as discectomy. It is not clear if surgery has an effect on what treatment will be required later. Recurrent disc herniations are common in 5-15 percent of patients.
What are the potential risks?
There are always risks involved in surgery. There are many complications to any surgery, including bleeding, infection and reactions to anesthesia. There is a higher chance of complications if spinal fusion is performed simultaneously with a discectomy. A discectomy can lead to the following complications:
Deep vein emboli is a serious condition that occurs when blood clots develop in the veins of the legs. Lung collapse, or even death can occur if the blood clots travel to the lungs. There are many ways to prevent or treat DVT. So that your blood vessels are moving more efficiently and less likely to clot, get out of bed as soon possible. You can prevent blood from pooling by using support hose or pulsatile stocks. You may also use drugs such as Coumadin, Heparin or Aspirin.
Problems with the lungs. The lungs need to function at their best after surgery in order to give tissues enough oxygen to heal. Mucus and bacteria buildup can cause pneumonia in the affected lungs. The nurse will remind you to take deep, shallow breaths and to cough up often.
Permanent pain or nerve damage. Any spine operation can cause nerve damage. Paralysis or numbness can result from nerve damage. The most common reason for persistent pain is nerve damage caused by the disc herniation. A disc herniation can permanently damage nerves, making them unresponsive to decompressive surgical (Fig. 6). These cases may be treated with spinal Cord stimulation, or other therapies. You should have realistic expectations about the pain you will experience during surgery. Talk to your doctor about your expectations.