LUMBAR MICRODISCECTOMY

The Purpose of this Information

This information is being provided to you in order to prepare you to make decisions about your own health care. If you should ultimately decide that surgery is the best treatment option for you, this section will help you understand what happens during a lumbar microdiscectomy and will help you prepare for your role in the healing and recovery process. Read it thoroughly and answer the questions before making your final decision about your treatment options.

The Health Care Team's Role

The duty of your health care team is to:

1. evaluate your condition;
2. establish a diagnosis;
3. present the various treatment options;
4. offer a specific treatment recommendation;
5. provide you with the information you need to make a decision; and then
6. support you in the decision you make.

The Patient's Resposibilities

You are the only one who can decide to have surgery. It is important that you take ownership of this decision, recognizing the limitations your particular physical condition places on the potential success of each of the treatment options.

If you choose to have surgery, your physical condition and your mental attitude will determine your body's ability to heal. You must approach your surgery with confidence, a positive attitude, and a thorough understanding of the anticipated outcome. You should have realistic goals-and work steadily to achieve those goals.

The decision to have or not to have surgery includes weighing the risks and benefits involved. You will make the final decision, so ask questions about anything you do not understand.

Since medical care is tailored to each person's needs and differences, not all information presented here will apply to the patient's treatment or its outcome. Seek the advice of your physician and other members of the health-care team for specific information about the patient's medical condition.

NOTE: If there is anything you do not understand about the information provided here, it is your responsibility to ask a member of your health care team for assistance before you make your final decision.

Anatomy of the Lumbar Spine

 The Spinal Column and the Vertebrae

Your spinal column consists of 24 separate bones, called vertebrae, plus the five fused bones of the sacrum and the four fused bones of the coccyx (often referred to as the "tail bone") (Fig. 1, below). The vertebrae are stacked one on top of another and can be divided into:

1. The cervical (neck) spine: the top seven vertebrae,
2. The thoracic (chest) spine: the middle 12 vertebrae, and
3. The lumbar (lower back) spine: the bottom five vertebrae.

Support for the Vertebral (Spinal) Column

Attached to the vertebrae are muscles, tendons and a group of strong bands, called ligaments. Together, they support the spinal column and help to protect its delicate nerves.

The Role of the Vertebral (Spinal) Column

Your spinal column enables you to walk upright. It is the central support for your upper body and carries the weight of your head, chest and arms. The vertebrae in the lumbar (or lower back) portion of your spine carry the majority of this weight. The constant pressure from this weight, even when you are simply sitting in a chair, is what usually leads to problems associated with the lower back.

The Role of the Intervertebral Discs

The bony vertebrae of your spinal column are separated from one another by "pads" of tough cartilage, called intervertebral discs (Fig. 2, above). These discs act like "shock absorbers" during activity, allowing the spine to move freely. How a disc "ruptures" (bulges outward) is shown in the drawing to the right (Fig. 2, above) and will be discussed in detail on the following section.

The Intervertebral Disc Nucleus

The center of each intervertebral disc is made up of a gelatin-like substance (the nucleus ), surrounded by a fiber-like outer lining (the annulus) (Fig. 3). As your body ages, the disc's nucleus begins to stiffen. This reduces flexibility and increases the chances that a disc may "rupture," especially in the lumbar spine which carries so much of your body's weight.

The Spinal Canal

The spinal cord, which begins at the base of the brain and runs within the spinal canal, ends in the lumbar spine area in a bundle of nerves known as the cauda equina (Figs. 3 & 4). The spinal canal runs through the center of the spinal column and protects the spinal cord and other delicate spinal nerves.

The Spinal Nerve Roots

At each vertebral level, a pair of nerves branch off from the spinal cord or the cauda equina (one to the left and one to the right). These spinal nerve roots are part of the body's "electrical" system, carrying "current" (for sensation and movement) to specific parts of the body (Fig. 4). The nerve roots are protected by an "insulated" covering in the same way a "live" electrical line is coated to prevent direct contact with the bare wire. A nerve root damaged by a ruptured disc may have all or part of its "insulation" rubbed off at the point of injury. Prior to surgery there is no way of telling how much has been rubbed off or how much damage has been done to the nerve (the body's "live electrical wire").

Return to Contents

What Happens When a Disc Ruptures?

When the outer lining (annulus) of a disc "tears," its center (the nucleus ) may rupture and press a spinal nerve(s) against the bony surface of a vertebra (Fig.5). This condition is often referred to as a ruptured disc. You could think of it as having a tube of toothpaste with a crack in it. Exert pressure on the cracked tube (disc annulus,) and toothpaste (disc nucleus) flows out the crack. Even pressure from everyday activities can push the disc's nucleus through the ruptured annulus and pinch a spinal nerve root(s).

What Causes a Disc to Rupture?

As we've discussed, your lumbar spine supports the weight of your entire upper body and is under stress every day. Simple "wear and tear" or the effects of aging can contribute to a disc rupture. In some cases, the rupture happens during the course of normal, everyday activities. In other cases, it occurs as the result of a specific injury. Usually there is no way to "prevent" it from occurring, however, you can reduce your risk by staying in good physical condition and by using proper lifting techniques.

What are the Symptoms of a Ruptured Disc?

When a lumbar spinal nerve is pinched, you may experience pain in your lower back, pain or numbness in your leg(s), weakness in your legs or feet, or numbness in one or both of your feet. The pain can come from the pressure on the nerve, the swelling within the nerve (caused by the pressure) or injury to the nerve itself. Taking pain medication or drugs which reduce the swelling may provide relief, but healing may not occur as long as the nerve itself remains pinched. It's similar to having your finger caught in a door. An aspirin may help to ease the pain, but healing won't begin until the door is opened and your finger is no longer being pinched.

How is a Ruptured Lumbar Disc Diagnosed?

The diagnosis of a ruptured lumbar disc is based on:

1. your history of back and/or leg pain;
2. a physical examination of your back and legs; and
3. diagnostic tests, which may include spine x-rays, an MRI, a CAT scan or a myelogram. (Each of these examination has a specific purpose.)

Return to Contents

Your Treatment Options...

Treatment Options There are a number of treatment options for a ruptured lumbar disc, each accompanied by its own set of risks and benefits. The four basic approaches are as follows:

1. Taking Time: For some patients, all that is required in order to heal and recover is time.
2. Taking Medication: For others, medication may reduce the inflammation or ease the pain in the affected area and thereby provide relief from their symptoms.
3. Using Physical Therapy: For some, physical measures such as physical therapy (or gentle exercise) may provide relief and aid in the recovery from a ruptured disc.
4. Having Surgery: For those patients whose ruptured disc is causing a "pinched" nerve, lumbar microdiscectomy often is the recommended treatment.

 When Lumbar Microdiscectomy is NOT an Option

The severity of your symptoms (pain, weakness, lack of mobility) and your general health and physical condition will play an important part in determining when surgery is not an option for you. In general, surgery is not an option when:

1. your back and leg pain is not caused by a ruptured disc; or
2. you do not have leg symptoms;
3. there is a medical reason which prevents you from having surgery;
4. medication which reduces swelling or relieves pain would provide you with adequate relief;
5. physical measures would improve your condition.

...and Their Risks and Benefits

When Lumbar Microdiscectomy IS an Option

Lumbar microdiscectomy is usually recommended only when specific conditions are met. In general, surgery is recommended when a ruptured disc is pinching a spinal nerve root(s) and you have:

1. leg pain which limits your normal daily activities; or
2. weakness in your leg(s) or feet; or
3. numbness in your extremities; or
4. impaired bowel and/or bladder function.

The Risks of Having Surgery

Some of the more common risks of having any surgery include excessive bleeding, infection, or a negative reaction to anesthesia. Certain unforeseen circumstances could even lead to death. Clinical experience and scientific calculation indicate that these risks are low, but surgery is still a human effort. You should feel free to ask any questions you have about your specific risk factors.

Since microdiscectomy involves surgery in and around the spine, further nerve damage is a possibility. In some cases, the nerve is already so damaged that the surgical procedure required to simply reach the nerve could be the "straw that breaks the camel's back." The end result could be numbness, paralysis or a loss of bowel and bladder control. (However, deciding not to have surgery may have exactly the same consequences. Your decision should be based on a weighing of the risks of having surgery versus the risks of not having surgery.)

The Benefits of Having Surgery

You can think of surgery as the first step in the healing and recovery process. It can help relieve pressure on your spinal nerve(s) and, thereby, help relieve your pain. It also may help you begin the process of regaining some of the lost mobility in your extremities.

Microdiscectomy and its Specific Benefits

Lumbar microdiscectomy is an operation on the lumbar spine performed using a surgical microscope and microsurgical techniques (Fig. 6). A microdiscectomy requires only a very small incision and will remove only that portion of your ruptured disc which is "pinching" one or more spinal nerve roots. The recovery time for this particular surgery is usually much less than is required for traditional lumbar surgery.

Your Chances for Success

Your level of healing will be determined by your age, your general health and the severity of the damage to your spinal nerve, as well as your attitude and your willingness to work at recovery.

Making Your Decision When you consider your options, keep in mind the impact your condition has on your way of life and carefully weigh the risks and benefits of having surgery against the risks and benefits of not having surgery. The decision is yours!

If You Decide to Have Surgery...

Approach your surgery with a positive mental attitude and with full confidence that you have made the right decision. While the surgeon concentrates on finding and removing the cause of your pinched nerve, you must concentrate on the recovery process. Cooperate fully with your surgeon and focus on the improvements you will make in the future-not on the problems of the past.

Return to Contents

The Surgeon's Role

Your surgeon will:

1. review your neurological history and examination;
2. review your diagnostic studies (such as a myelogram, CAT scan or MRI);
3. plan a surgical approach; and
4. review the procedure with you.

Your Role

You must have a thorough understanding of the diagnosis (what is causing your back and/or leg symptoms) and the risks and benefits of the proposed surgery. Once you are confident that surgery is the correct option for you, turn your thoughts to the future and the recovery process.

Beginning the Operation

In the operating room, a lumbar microdiscectomy begins with a small incision in your lower back. Through this opening, your surgeon will insert microsurgical instruments. Because the work is viewed through a microscope (Fig. 6, above), this approach requires a relatively small incision.

 Reaching The "Pinched" Nerve

Guided by diagnostic studies, your surgeon will remove a small portion of bony material from the back of your vertebra (Fig. 7). Once this material is removed, the surgeon can locate the exact area where the nerve root is being pinched.

Identifying the Cause of the Pressure

Once the "pinched" nerve is located, the extent of the pressure on the nerve can be determined. Using microsurgical procedures, your surgeon will remove the ruptured portion of the disc and any disc fragments which have broken off from the main disc (Fig. 8). The amount of work required to complete your microdiscectomy will depend in part on the number of disc fragments present and the difficulty presented in finding and removing them.

Closing the Incision

The operation is completed when each layer of the incision is closed with suture material (stitches) or surgical staples. If the outer incision is closed with staples or non-absorbable sutures, they will have to be removed after the incision has healed.

The Healing and Recovery Process

Once the ruptured disc has been removed, healing can begin (Fig. 9). Healing is the body's natural process of restoring its damaged tissues to a normal, or nearly normal condition. Healing occurs on its own, but is influenced by such factors as general good health, physical fitness, nutrition and rest. Recovery is the process during which you work at becoming well. You must commit yourself to staying in good health (exercising), maintaining a positive mental attitude and following your physician's instructions.

Return to Contents

Have Realistic Expectations

Recognize that healing and recovery will not happen overnight. It is a process. You may find that much of your progress will be like taking "two steps forward and one step back." Accept it! And then do all that you can to make sure your steps "forward" are large ones and your steps "backward" are small ones.

Be Patient and Persistent

During the recovery period in the hospital and at home, try to rebuild your strength gradually. Rest when you feel fatigued - but be persistent in your efforts.

It is important for you to recognize that we all heal at a different rate. The speed at which you will recover depends in part on your age, your general level of health, your overall physical fitness and your mental attitude. Generally, you will heal more slowly if you are overweight, out of shape or smoke, or if you are a diabetic or have other pre-existing medical problems.

Expect Some Pain After Surgery

It is normal to have some pain after any operation. After a lumbar microdiscectomy, there may be some leg "aching" which occurs as the nerve(s) attempts to heal. You also may feel some muscle spasms across your back and down your leg(s). And if there was inflammation in the nerve root, some pain may persist until this inflammation diminishes. You will be given appropriate medication to control your pain, relieve back spasms and reduce inflammation.

Be Prepared for Some Emotional Changes

It is not unusual to feel tired and discouraged for several days following surgery. These feelings may be your body's natural reaction to the cutback of extra hormones it generated during surgery. Although some emotional letdown can be expected, you must not let it get in the way of your recovery. Don't look back at past problems. It is important for you to look at even the smallest positive steps you make as progress towards your recovery goal.

Develop a Positive Mental Attitude

You should begin to work on a positive mental attitude even before the surgery is performed. Direct your energies toward the solution of your problem, rather than worrying about what caused your problem. Don't be discouraged by minor setbacks during the recovery process. Concentrate on the progress you make, and will continue to make in the future.

Commit to a Healthy Lifestyle

Now is the time to commit yourself to a healthier lifestyle. You can begin by taking these important steps:

* Watch your weight: If you are overweight, you must gradually return to your proper weight. Crash diets rarely work. Commit yourself to better eating habits and stay with them for the rest of your life.

* Become more active: Your physician will tell you when you can resume normal physical activities after surgery. Make up your mind now that you will develop a regular aerobic exercise routine, such as walking, swimming or riding a bike. However, always check with your physician before starting any exercise program.

Return to Contents

Going Home From the Hospital

In general, hospital stays are becoming shorter, especially for microsurgical procedures. Even though you may feel somewhat uncomfortable at the time you are released, your physician usually will allow you to go home when:

1. your vital signs are stable;
2. you can walk on your own;
3. you can eat without having nausea;
4. you have resumed normal bladder activity; and
5. your wound is healing.

Recovering at Home

Once you are at home and you begin to resume your normal activities, follow the guidelines listed below (and contact your physician's office if you have any questions):

* Exercise: Try to do as much as you can. Daily walking is the best exercise. Set reasonable goals, but gradually increase the distance you walk each day. Check with your physician before starting any exercise program.

* Sitting and standing: Do not sit or stand for long periods of time. If you have muscle spasms in your back or pain in your leg(s), changing positions frequently should help.

* Sleeping: Rest when you feel fatigued, but do not spend all of your time in bed. Please note that waking up with a "stiff " back is not uncommon. For relief, try taking a short walk or a warm shower. If you do not have a firm mattress, invest in one - it is important for proper back support.

* Caring for your Incision: Wash your incision gently and pat it dry. If you see any increased redness, swelling or drainage, notify your physician.

Medication

You should gradually reduce the amount of pain medication you take. Begin by increasing the amount of time between pills, and then reduce the number of pills taken each time. A certain amount of discomfort can be expected until the swelling goes down and the nerve sensitivity decreases. Substitute moist heat, gentle exercise and short rest periods for pain medication whenever possible.

Preventitive Measures

The best way to avoid the recurrence of a ruptured disc is to maintain a healthy lifestyle. It is important that you:

1. eat a well-balanced diet in order to aid proper healing (avoid foods high in calories and fat content);
2. continue to eat a healthy diet in the future to reach and maintain your proper body weight;
3. get the proper amount of sleep;
4. participate in some form of regular aerobic exercise (such as walking, swimming, or riding a bike);
5. take extra care when lifting, bending or twisting; and
6. take care of other health problems (such as heart disease or diabetes).

Return to Contents

A Patient-Centered Approach

This information is provided to help you make an informed decision about your health care. It is an essential part of a patient-centered approach to medicine, called collaboration, in which the health care team (physicians, nurses and technicians), the health care institutions (hospitals, insurance companies, etc.) and the patient's family all work towards achieving the best possible recovery for the patient.

Why the Patient is at the Center

Experience has shown that patients who are given the opportunity to make decisions about their own health care have less anxiety before their surgery and recover more quickly after their surgery. Recognize that you have a right and a responsibility to participate in the decisions involving your health care.