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General information
Most of the Patients with a slipped lumbar intervertebral disc, (lumbar disc herniation) in the lower back do not usually require surgery. Conservative treatment is the recommended approach to over 90% of patients with this condition. The symptoms will resolve of variable period around 6-12weeks, sometimes up to 6 months. However, there are few indications of surgery, which may need to be done as soon as possible or as an elective. The indications for surgery include:
- Long duration of symptoms for more than 12 weeks
- Severe intractable pain that is not responding to analgesia.
- Progressive neurological deficit in form of weakness or sensory changes.
- Features of cauda equina nerves compression (Cauda Equina Syndrome, saddle area sensory changes, paresthesia, urinary and bowel symptoms with/without weakness of the legs), indication for an emergency operation.
- Patient preferences.
Target and results: The results of surgery are generally good. For patients with sciatica and leg pain, will usually improve after surgery. The surgery is usually target the leg pain and radicular symptoms of the lower limbs rather than the back pain which may get worse after the surgery. For CES, the results of the surgery are depending on the timing, complete or in complete syndrome and on the degree of nerve compression.
Risk of complications:
- Infection is less than 2 percent. It may affect the superficial tissues and skin, or may affect deep spinal structures, diskitis or vertebral osteomyelitis which is very rare.
- Bleeding which may lead to heamatoma collection that need further surgery.
- Cerebrospinal fluid (CSF) leak, inadvertent breach of the thecal sac may lead to leaking of the fluid surrounding the brain and the spinal cord. Instant repairs is possible, however, it may need an extended admission in the hospital or further procedures. There is also very small risk of meningitis.
- Neural tissue injury: the most serious complication may cause life changing consequences in form of weakness or paralysis of legs, sphincters, sensory or sexual changes. The risk is very small, <1%.
- Disc re-herniation in 3-4% that may need revision surgeries.
- Worsening of back pain which is about 20%, most of the patient will improve after 4 weeks after the surgery. However, chronic back pain is not uncommon.
- Failure to improve symptoms.
- General anesthetic complications (heart attack, stroke)
- Deep venous thrombosis/pulmonary embolism (clots in legs / lungs).
- Small risk of blindness related to prone position during the surgery
- Small risk of injury to major vessels in the abdomen.
Procedure
Lumbar spine microdiscectomy is a standard procedure that is carried out on routine base. The procedure is usually done under general anesthesia and lasts approximately 60-90 minutes. The patient is positioned on his face (prone), torso is slightly flexed. It involves making a small midline incision at the lower back, followed by dissection of the muscles on one side to expose the lamina. X-rays guided confirmation of the correct level. Small bony window will created using high speed drill to expose the dura. Using Microscope, removal of the herniated/protruded part of the disc and freeing the nerve roots.
The wound is closed in layers with dissolvable stitches; skin is closed with clips which need to be removed in 10 days. After the operation, some of the patient will have a drain in the wound for 24 hours (this is removed on the ward before discharge). Most patients will go home the next day and will be recovering at home for approximately 4 weeks. Following surgery the patient may notice some back pain and stiffness but this should settle with simple pain killers. Specialist spinal physiotherapists will advice each patient on a postoperative exercise regime, to encourage movements. Further outpatient physiotherapy sessions will be offered, where indicated. Patient is usually followed up in the clinic in 8-12 weeks after surgery. If any complication happens, the patient will stay until everything gets sorted. All regular medication will continue except the blood thinning medication like Warfarin, Apixoban, Aspirin, cloidogrel etc, needs advised individually. Most of the cases can started after 48 hour from the surgery.