Lumbar decompressive surgery

Questions to ask

We asked Mr Ioannis Fouyas, consultant neurosurgeon with a special interest in lumbar spine procedures, what he would ask if he was undergoing lumbar decompressive surgery.

When should I think about having surgery?

If you have experienced severe leg pain for two to three months and rest, painkillers and physiotherapy have failed to bring relief, you should consider surgery.

Will it be a permanent cure?

Even if the surgery is successful, there is still a small chance that the problem may recur. A disc can bulge out again and stenosis (a narrowing of the spinal canal) can reform.

How long will it be before I am out of pain?

Your leg pain will disappear almost immediately after the operation, but your back may still feel uncomfortable for a few weeks.

How successful is it?

Surgery can be very effective for relieving leg pain but is not always so successful for back pain. With back pain, the problem is more likely to stem from natural wear and tear, which is not so easy to reverse.

Is it ever an emergency?

Rarely, but seek immediate medical attention if you have difficulties passing water, in addition to your back and leg pain. This is caused by pressure on all the nerves in the lower back (cauda equina syndrome) and results in numbness in the buttocks that prevents you from urinating.

Lumbar decompressive surgery risks

Like all surgical procedures, lumber decompression surgery carries some risk of complications.

Repeat operations have a higher risk of complications than first-time operations.

Paralysis can occur in a number of ways, including:

• bleeding inside the spinal column (extradural spinal haematoma)
• leaking of spinal fluid (incidental durotomy)
• accidental damage to the blood vessels that supply the spinal cord with blood

Paralysis after surgery usually takes the form of:

• not being able to use your legs
• loss of sensation in the lower half of your body
• loss of bladder and bowel control (urinary and bowel incontinence)

In cases of extradural spinal haematoma and incidental durotomy, it may be possible to reverse the symptoms with surgery.

In cases of damaged blood vessels, the paralysis is likely to be permanent.

Can complications be fatal?

As with all types of surgery, there is a risk of dying during or following the operation, although this is rare.

A blood clot, bad reaction to anaesthetic and blood loss can all be life threatening.

The British Association of Spinal Surgeons estimates that surgery to treat spinal stenosis has a 1 in 350 chance of causing death, and surgery to treat a slipped disc has around a 1 in 700 chance.

The risk is higher for spinal stenosis as most people with the condition tend to be older and in poorer health than people with a slipped disc.

Recovery after surgery

When you wake up after your surgery, your back may feel sore and you will probably be attached to one or more tubes, including:

• an intravenous drip to make sure you do not get dehydrated
• a drain to take away any fluid from your wound
• a catheter if you are having difficulty urinating
• a pump to deliver painkillers directly into your veins every few hours

The tubes are usually attached for only a short while after your operation.

Discomfort

Immediately after surgery, you will have some pain in and around the area of your operation. You will be given pain relief to make sure you are comfortable and to help you move. The original pain in the leg usually improves immediately, but if it doesn't, tell the nurses and your doctor.

A very small number of people have difficulty passing urine after the operation. This is usually temporary, but in rare cases complications, such as nerve damage, may cause the legs or bladder to stop working properly. It is important to tell your doctor and nurses immediately if you have problems.

It can take up to six weeks to get over the general pain and tiredness after your operation.

Stitches

You will have stitches to repair any cuts or incisions made during your operation. Deep stitches beneath the skin will dissolve and do not need removing. Stitches or clips used on your skin will be removed 5–10 days after your operation. You will be given an appointment to have your stitches removed before you leave hospital.

Your stitches may be covered by a simple adhesive dressing, like a large plaster. When you wash, be careful not to get your dressing wet. After having your stitches out, you will not need a dressing and will be able to bath and shower as normal.

Rehabilitation

Your medical team will want you to get up and move about as soon as possible. This is because not moving can increase your risk of

and movement helps to speed up the recovery process.

After your operation, a physiotherapist will monitor your specific needs and help you safely regain strength and movement. Exercising the spine as instructed will help you recover quicker than if you stay inactive.

Getting home

You will be able to go home one to four days after your operation. How long you have to spend in hospital depends on the type of surgery you had (recovery is quicker after a microdiscectomy) and your state of health.

It is important to take things easy at first. Some help at home is usually needed for at least the first week after surgery. Avoid heavy lifting, awkward twisting and leaning when you do everyday tasks.

When to seek medical advice

Lumbar decompression surgery is generally safe with a low risk of complications, but they can sometimes occur.

Contact your surgeon or doctor as soon as possible if:

• there is leaking fluid or redness at the site of your wound
• your stitches come out
• your dressing becomes soaked with blood
• you have a high temperature (fever) of 38C (100.4F) or above
• you have increasing pain or numbness in your legs, back or buttocks
• you cannot move your legs
• you cannot urinate or have lost control of your bladder
• you have a severe headache
• you have a sudden shortness of breath – this could be a sign of a blood clot inside your lung (pulmonary embolism), a lung infection (pneumonia) or other heart and lung problems

Work

When you can go back to work depends on how you heal after surgery and the type of job you do. Most people return after four to six weeks if their job is not too strenuous. If your job involves a lot of driving, lifting items that weigh over 5kg or potentially violent situations, you may be off work for up to 12 weeks.

Driving

Before starting to drive again, you should be free from the effects of any painkillers that may make you drowsy. You should be comfortable in the driving position and able to fully control your car, including being able to do an emergency stop without it causing you any pain. Most people feel ready to drive after two to six weeks, depending on the size of the operation.

Some insurance companies do not insure drivers for a number of weeks after surgery, so check what your policy says before you start to drive.

Repeat surgery

After back surgery, 20–30% of people experience recurring symptoms. These can be caused by a weakened spine or another slipped disc, formation of new bone or thickened ligament.

Other treatments, such as physiotherapy, will be tried in the first instance, but further surgery may be needed in some cases.

Getting ready

Before you are considered a suitable candidate for lumbar compression surgery, you will probably be offered a number of non-surgical treatments to see if these can help your symptoms.

These may include painkillers, antidepressants, physiotherapy or corticosteroid injections.

Decompression surgery is usually only recommended if:

• previous treatment has failed to relieve your symptoms
• your symptoms are severe and have a negative impact on your quality of life
• you are thought to be healthy enough to withstand the effects of the surgery

Some reasons why you may need lumbar decompression surgery are listed below.

Spinal stenosis

Spinal stenosis is a condition where the space around the spinal cord (the spinal column) narrows, compressing a section of nerve tissue.

Symptoms of spinal stenosis include:

• pain and cramping in the legs that can come on after walking and can be relieved by sitting down or leaning forward
• a feeling of weakness and numbness in the legs
• back pain that can spread around the buttocks

Most cases of spinal stenosis are age related and usually occur in people over 60. As a person gets older, the bones and tissues that make up the spine can become worn down, leading to a narrowing of the spinal column.

Slipped disc and sciatica

A

is when the tough coating of a disc in your spine tears, causing the jelly-like filling to seep out. The torn disc can press on a surrounding nerve, called the sciatic nerve, which triggers a condition called .

The most common symptom of sciatica is pain that radiates out from the lower back, down the buttocks and into one or both legs, right down to the calf. Sciatic pain can range from mild to very painful.

A slipped disc can happen at any age, but is more common in people between 20 and 40 years of age. It is usually caused by a combination of minor degeneration in the disc and trauma. The trauma can be minor, such as a cough or sneeze.

Injury

Injury to your spine, such as dislocation and fractures, or the swelling of tissue after spinal surgery, can put pressure on your spinal cord or nerves.

Metastatic spinal cord compression

Cancer in one part of the body, such as the lungs, sometimes spreads into the spine and presses on the spinal cord. This is known as metastatic spinal compression.

Initial symptoms can include:

• back pain, which may be mild at first but then usually gets worse over time
• numbness in your toes and fingers
• problems passing urine

If it is not treated, metastatic spinal cord compression is potentially very dangerous and can result in permanent paralysis (inability to move parts of your body, which in this case would be your legs).

Metastatic spinal cord compression can be treated with surgery, but because of the underlying cancer, many people are too ill to withstand the effects of surgery.

Spinal tumours

Abnormal growths and tumours can form along your spine. These are usually not cancerous (benign), but growing tumours may compress your spinal cord and nerve roots, causing pain.

Lumbar decompression surgery

If you and your consultant decide that you could benefit from lumbar decompression surgery, you will be put on a waiting list. Your doctor or surgeon should be able to tell you how long you are likely to have to wait in your area.

To help you recover from your operation and reduce your risk of complications, it helps if you are as fit as possible beforehand. As soon as you know you are going to have lumbar decompression surgery, try to:

• stop smoking
• eat a healthy diet
• do regular exercise
• lose weight if you are overweight

You will be given a pre-assessment appointment a few days before your operation. Your surgeon will do an X-ray and MRI (magnetic resonance imaging) scan of your spine. The appointment may also involve having some blood tests and a general health check to make sure that you are fit for surgery.

You can also use your pre-assessment appointment as an opportunity to discuss any concerns or ask any questions about your operation.

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The operation

You will be admitted to hospital on the day of your operation or the day before. Your surgeon and anaesthetist will explain what will happen during your operation. This will give you the opportunity to ask any questions you may have.

Before going for your operation, you will be asked to sign a consent form for the operation and the anaesthetic. This confirms that you know what the operation involves and the risks.

You will not be allowed to eat or drink for six to eight hours before your operation.

During lumbar decompressive surgery, you will usually lie face down on a special curved mattress. This reduces the pressure on your chest, abdomen and pelvis. Your spine will be flexed to help expose the compressed nerve. Surgery usually takes between one and two hours.

The goal of lumbar decompressive surgery is to relieve pressure on your spinal cord or nerves and to maintain the strength and flexibility of your spine.

Surgical techniques

There are three techniques that can be used during spinal decompression surgery:

• laminectomy – where an arch of bone, known as the lamina, is removed from one of your vertebrae
• discectomy – where a section of a damaged disc is removed
• spinal fusion – where two or more vertebrae are joined together with a bone graft

Depending on the reasons for your surgery, you may just need a laminectomy, or a laminectomy followed by a discectomy, or in some cases, a laminectomy followed by a discectomy followed by spinal fusion surgery.

Your surgeon will be able to provide more information on what techniques are going to be used during surgery.

Each technique is discussed in more detail below.

Laminectomy

A laminectomy is done to remove areas of bone or, in some cases, ligament that are putting pressure on your spinal cord. Ligaments are tough bands of tissue that connect one bone to another.

• The surgeon makes a straight incision over the affected section of the spine and down to the lamina, the bony arch of your vertebra.
• The ligament joining the lamina is removed to view the affected nerve root.
• The surgeon will then pull the nerve root back towards the centre of your spinal column and remove part of the bone or ligament causing you pain. This will relieve the pressure on your spinal nerves.

Discectomy

A discectomy is done to release the pressure on your spinal nerves caused by a bulging or slipped disc.

• The surgeon makes an incision over the affected area of your spine down to the lamina, the bony arch of your vertebra.
• The ligament joining the lamina is removed to view the affected nerve root.
• The surgeon will then pull the nerve root back towards the centre of your spinal column and will remove just enough of the disc to stop pressure on the nerves. Part of the disc needs to stay to keep working as a shock absorber.

Spinal fusion

Spinal fusion is based on the principle that bone is a living tissue, which makes it possible to join two or more vertebrae together by placing an additional section of bone in the space between the vertebrae.

This helps prevent the damaged vertebrae from irritating or compressing nearby nerves, reducing the symptoms of pain.

The additional section of bone can be taken from somewhere else in your body (usually the hip) or from a donor.

Sealing the incision

Once surgery is complete, the surgeon will seal the incision with stitches or staples.

Keyhole surgery

Spinal compression surgery is usually performed through a large incision in the back, known as open surgery. In some cases, it may be performed using a microscope (microdiscectomy) or a keyhole technique known as microendoscopic surgery.

In this case, the operation is done using a tiny camera and surgical instruments that are inserted through a small incision in your back. The surgeon is guided by viewing the operation on a video monitor.

Microendoscopic surgery is complicated and is not suitable for all patients (this depends on the exact problem causing your back and leg pain). There is a slightly higher risk of injury than with an open operation.

Some of the techniques used during microendoscopic surgery, such as using a laser or a heated probe to burn away a section of damaged disc, are relatively new. Therefore, it is still uncertain how effective or safe they maybe in the long term.

An advantage of microendoscopic surgery is that it usually has a much quicker recovery time. In many cases, people can leave hospital the day after surgery has been completed.

Introduction

Lumbar decompression surgery is a type of spinal surgery. It is used to treat some types of back and leg pain, which have failed to respond to other treatments.

The spine

The spine is made up of 24 individual bones, called vertebrae, which are stacked on top of each other. In between each vertebra are protective, circular pads of tissue called discs. The discs help cushion the vertebrae during activities such as walking and running.

Through the centre of the spine runs a bundle of nerve fibres known as the spinal cord. These help relay signals from the brain to the rest of the body.

The spinal cord is located inside a hollow cavity, known as the spinal column, which helps protect the nerves from damage.

Why do I need spinal surgery?

Decompression surgery is most commonly used to treat a condition called spinal stenosis. This is when a section of the spinal column becomes narrowed and places pressure on the nerves inside, leading to persistent pain and numbness and weakness in the lower back, buttocks and legs.

Decompression surgery can also be used to:

• treat a
  slipped disc
  – where one of the discs becomes damaged and in some cases presses down on an underlying nerve
• treat a spinal injury
• relieve pressure on the spinal cord that is caused by an abnormal growth of tissue (tumour) – spinal tumours can be both cancerous and non-cancerous
• relieve pressure on the spinal cord caused by cancer spreading into the spine – this is known as metastatic spinal cord compression

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What happens during spinal surgery?

There are three main techniques used during spinal surgery:

• laminectomy – where a section of vertebrae (the lamina) is removed to relieve pressure on the affected nerve
• discectomy – where a section of a damaged disc is removed or destroyed to relieve pressure on a nerve
• spinal fusion – where two or more vertebrae are jointed together with a section of bone to strengthen the spine

In many cases, a combination of these techniques may be used.

For example, the surgeon may perform:

• a laminectomy to gain better access to a damaged disc
• then a discectomy to remove a section of the disc
• and then finally spinal fusion to reduce the chance of the spine becoming damaged again in the future

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Recovering from lumbar decompression surgery

Depending on the complexity of the surgery, you may be well enough to leave hospital 1–10 days later.

You will need to avoid strenuous activities for around six weeks. Most people can return to work after this time.

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Results

There is good evidence that decompression surgery can be an effective treatment for people with severe pain caused by compressed nerves. Four out of five people treated with surgery will experience a significant improvement in pain.

Complications

An infection at the site of the incision is the most common complication of lumbar decompression surgery and will need to be treated with antibiotics. Post-operative infection occurs in

around 1 in 25 cases.

More serious complications are rare and include:

• damage to the spinal cord resulting in some degree of paralysis (inability to move one or more parts of the body) – this is thought to occur in around 1 in 300 cases
• death due to an unforeseen complication, such as a blood clot – this is thought to occur in around 1 in 350 cases where surgery is used to treat spinal stenosis and 1 in 700 cases where surgery is used to treat a slipped disc

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