Lumbar Microdiscectomy Surgery
In a microdiscectomy or microdecompression spine surgery, a small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to relieve neural impingement and provide more room for the nerve to heal.
A microdiskectomy is typically performed for a herniated lumbar disc and is actually more effective for treating leg pain (also known as radiculopathy) than lower back pain.
A microdiskectomy is performed through a small (1 inch) incision in the midline of the low back.
- First, the back muscles (erector spinae) are lifted off the bony arch (lamina) of the spine. Since these back muscles run vertically, they can be moved out of the way rather than cut.
- The surgeon is then able to enter the spine by removing a membrane over the nerve roots (ligamentum flavum), and uses either operating glasses (loupes) or an operating microscope to visualize the nerve root.
- Often, a small portion of the inside facet joint is removed both to facilitate access to the nerve root and to relieve pressure over the nerve.
- The nerve root is then gently moved to the side and the disc material is removed from under the nerve root.
Importantly, since almost all of the joints, ligaments and muscles are left intact, a microdiskectomy does not change the mechanical structure of the patient’s lower spine (lumbar spine).
Indications for Microdiskectomy Surgery
In general, if a patient’s leg pain due to a disc herniation is going to get better, it will do so in about six to twelve weeks. As long as the pain is tolerable and the patient can function adequately, it is usually advisable to postpone back surgery for a short period of time to see if the pain will resolve with non-surgical treatment alone.
If the leg pain does not get better with nonsurgical treatments, then a microdiskectomy surgery is a reasonable option to relieve pressure on the nerve root and speed the healing. Immediate spine surgery is only necessary in cases of bowel/bladder incontinence (cauda equina syndrome) or progressive neurological deficits. It may also be reasonable to consider back surgery acutely if the leg pain is severe or the herniated fragment is very large.
A microdiskectomy is typically recommended for patients who have:
- Experienced leg pain for at least six weeks
- Not found sufficient pain relief with conservative treatment (such as oral steroids, NSAID’s, and physical therapy).
However, after three to six months, the results of the spine surgery are not quite as favorable, so it is NOT generally advisable to postpone microdiskectomy surgery for a prolonged period of time (more than three to six months).
Preparation before SurgeryÂ
Optimizing your physical condition before surgery will certainly improve your recovery and outcome. Maintain a healthy, balanced diet before surgery. Stop Smoking. Smoking can significantly delay healing, increase risks, and adversely affect outcomes. Smoking cessation cannot occur with use of nicotine supplements such as nicotine patches and nicotine gum. Prior to surgery, try to minimize the use opiod pain medications, as decreased preoperative utilization correlates with both better long term outcomes and allows for more reliable postoperative pain management.
Risks of Surgery
The success rate for microdiskectomy spine surgery is approximately 90% to 95%, although 5% to 10% of patients will develop a recurrent disc herniation at some point in the future.
A recurrent disc herniation may occur directly after back surgery or many years later, although they are most common in the first three months after surgery. If the disc does herniate again, generally a revision microdiskectomy will be just as successful as the first operation. However, after a recurrence, the patient is at higher risk of further recurrences (15% to 20% chance).
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For patients with multiple herniated disc recurrences, a spinal fusion may be recommended to prevent further recurrences. Removing the entire disc space and fusing the level is the most common way to absolutely assure that no further herniated discs can occur. If the posterior facet joint is not compromised and other criteria are met, an artificial disc replacement may be considered.
Recurrent herniated discs are not thought to be directly related to a patient’s activity, and probably have more to do with the fact that within some disc spaces there are multiple fragments of disc that can come out at a later date. Unfortunately, through a posterior microdiskectomy spine surgery approach, only about 5 to 7% of the disc space can be removed and most of the disc space cannot be visualized.
Also, the hole in the disc space where the disc herniation occurs (annulotomy) probably never closes because the disc itself does not have a blood supply. Without a blood supply, the area does not heal or scar over. There also is no way to surgically repair the annulus (outer portion of the disc space).
As with any form of spine surgery, there are several risks and complications that are associated with a microdiskectomy, including:
- Dural tear (cerebrospinal fluid leak) — this occurs in 1% to 2% of these surgeries, does not change the results of surgery, but post-operatively the patient may be asked to lay recumbent for one to two days to allow the leak to seal.
- Nerve root damage
- Bowel/bladder incontinence
Fotunately, the above complications for microdiskectomy spine surgery are quite rare.
I pride myself in having an extremely low complication rate, far below the published norms. I attribute this to having greater than ten years of experience, constantly staying up to date with the spine surgical literature, and the fellowship training I received at the Mayo Clinic in Rochester, Minnesota.
Risks are further minimized by the utilization of Intraoperative Neuromonitoring (IONM). IONM offers insight into the nervous system during spinal surgeries. Use of IONM facilitates the surgical process and can reduce surgical risk by providing critical information and alerts to surgeons of potential harm or compromise to the spinal cord or neural structures.Â IONM provides better insight into a patient’s condition during surgery to support better decision-making that enables the practice of better medicine.Â On the day of your surgery you will meet a member of IONM team that will provide your neuromonitoring for you during your surgery.
Time Away from Work
Some spine surgeons restrict a patient from bending, lifting, or twisting for the first six weeks following surgery. However, since the patient’s back is mechanically the same, it is also reasonable to return to a normal level of functioning immediately following this spine surgery.
There have been a couple of reports in the medical literature showing that immediate mobilization (return to normal activity) does not lead to an increase in recurrent lumbar herniated disc.
How much time you need off work primarily depends on the type of work you have.Â After the surgery, you can expect to have a lumbar brace in place.Â I think all patients need some time at home recovering after surgery, usually at least a week. During the postoperative period, you will observe restrictions to your activity level to the level you feel are warranted. During the first six weeks as you are wearing the lumbar brace as you feel is needed. Some patients wear the brace for the entire 6 weeks while others rapidly discontinue using it.
You should not drive a car for the first 6 weeks.
If your job is sedentary, then you may feel comfortable returning to work within a few days. However, if your work is very strenuous, I recommend allowing the back to fully heal which requires an entire 6 weeks off of work. Generally, I advise patients to inform their employers that they are going to require 6 weeks to recover. If post-operatively, you feel you can return sooner, our office will always be happy to provide the proper documentation to you to allow for such. Remember, no one knows your work environment better then you, thus our work release are always predicated on your consensus.
When you arrive for your surgery, you will meet the anesthesiologist, neuromonitoring technician, and surgical nurses.Â They will discuss with you their procedures and probably make you feel more at ease. Usually, general anesthesia will be given for your surgery. You will be given antibiotics to prevent infection, and support stockings along with sequential compression devices will be placed on your legs. We will then go to operating room and I will perform your procedure. Most Microdiskectomies require between one to two hours, and postoperatively you spend about an hour in the recovery room. Â During the surgery, I will call out to the waiting room and give your family routine updates. Afterwards, routinely patients are transferred back to the day surgery unit where they started and are discharged home.
When you awaken after surgery, you will receive pain medication and your nurses will closely monitor you. You will have a postoperative lumbar dressing in place usually. You will resume a normal diet and be mobilized immediately after surgery. You usually will be discharged the day of surgery. On discharge, you will be given a detail set of discharge instructions and prescription pain medications.
The support stockings you are given in the hospital should be utilized for the first six weeks after surgery. These reduce the risk of blood clots after surgery.
Patients with external stitches will return two weeks post-operatively just for a wound check and to have their stitches removed.Â Otherwise, patients will return for their first postop visit usually six weeks after their date of surgery. I will check radiographs of your back. At that time we will discontinue the brace if you have already not done this on your own.
Successful Microdiskectomy Surgery not only is the result of the procedure, but also very importantly is the result of aftercare and rehabilitation. The initial rehab program is simply composed of performing routine day to day activities while observing your post-operative restrictions. I encourage patients to participate in a daily walking program, progressing at their level of comfort. Following a microdiskectomy spine surgery, an exercise program of stretching, strengthening, and aerobic conditioning is recommended to help prevent recurrence of back pain or disc herniation.
I do not start this formal outpatient physical therapy until the six week postoperative visit, if warranted.
During this process, please do not hesitate to ask questions. My team is always available to help you. Our goal is to give you best possible care in the most safe and pleasant way possible. Although surgery is not always â€œeasyâ€ for you and requires some work, remember that you are having the surgery because we expect a good result. I wish you a speedy recovery.
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