Microdiscectomy for prolapsed disc and sciatica
The following information is intended to give you some general guidelines on what to do after your operation. It is important that you understand what to expect and feel able to take an active role in your treatment. There will be many different health professionals involved in your care during your stay and there will be a clear plan for any after care when you are discharged from hospital. This information will answer some of the questions that you may have, but if there is anything that you or your family are not sure about then please ask Mr Seel or the nurse on the ward.
What is a prolapsed disc?
Your spine is made up of many vertebrae with ‘shock-absorbing’ discs between them. The structure of the disc is made up of the nucleus (middle) and annulus (outer ring). When there is an injury or tear to the annulus a disc prolapse (slipped disc) can occur. This normally causes back pain, but can also cause sciatica (leg pain) when the prolapsed disc compresses a nerve inside your back. This tear in the disc ring may also result in the release of inflammatory chemical mediators which may directly cause severe pain, even in the absence of nerve root compression. This condition is also known as a herniated, ruptured, prolapsed, or more commonly slipped disc.
Why have I got a disc prolapse?
Factors that lead to disc prolapse include aging with associated degeneration and loss of elasticity of the discs and supporting structures; Poor posture combined with the habitual use of incorrect body mechanics, hard physical work, improper lifting, especially if accompanied by twisting or turning; excessive strain, and sudden forceful trauma. A herniation may develop suddenly or gradually over weeks or months.
Prolapsed discs can occur in any part of the spine. Prolapsed discs are more common in the lower back especially at the L4-L5 and L5-S1 levels. This is because the lumbar spine carries most of the body’s weight. The second most common area is neck (cervical disc prolapse). The area in which you experience pain depends on what part of the spine is affected.
What are the symptoms?
Symptoms of a prolapsed disc can vary depending on the location of the problem and the size of the prolapse. They can range from modest pain in the back or neck, to severe and unrelenting neck/arm or back/leg pain. Other symptoms may include sensory changes such as numbness and tingling, and muscular weakness. If the prolapsed disc is in the lumbar region the patient may also experience leg pain (sciatica). If the prolapsed disc is in the neck, the patient may also experience arm pain (brachialgia).
Typically, symptoms are experienced only on one side of the body. If the prolapse is very large and presses on the spinal cord or the cauda equina in the lumbar region, you may have symptoms on both sides, often with serious consequences. Compression of the cauda equina can cause permanent nerve damage or paralysis. The nerve damage can also result in loss of bowel and bladder control as well as sexual function. This disorder is called cauda equina syndrome and is a surgical emergency.
What is the treatment?
Microdiscectomy surgery is performed under a general anaesthetic (you are asleep) and involves removing the part of the disc that has prolapsed and was trapping the nerve. The main part of the disc is probed to check for further loose fragments and then left alone as your spine needs it to continue functioning. Surgical treatment is done for those patients with unrelenting intolerable symptoms which have not responded to non-operative treatment. It is performed principally to improve leg pain, however back pain may also be improved.
What are the alternatives?
You probably have tried most of the alternatives before considering surgery, they include: gentle exercise and spinal physiotherapy, regular pain relief prescribed by your GP, avoiding heavy and physical activity and a nerve root steroid (cortisone) injection.
Surgical technique for microdiscectomy
A skin incision is made in the midline of the back, the spinal muscle is split and a small window (laminotomy) is made at the back of the spinal canal. The nerves are protected and the prolapsed disc is removed along with any loose fragments. The nerve is then relaxed back into its new space and the wound closed with sutures, surgical skin glue and steristrips. A dressing is applied. The operation will last approximately 45 mins but you will be away from the ward longer for longer than this (approx. 2 - 2.5 hours). You will normally stay in hospital 1 night following surgery and have physio before discharge.
What are the possible risks or complications of this surgery?
Deep infection – approx. 1 in every 100 cases, you will be given antibiotics into the vein at the time of surgery to minimise this..
Superficial wound infections – 4 in every 100 patients get this and may require a short course of antibiotics.
Bleeding – less than 1 in every 100 patients have a significant bleed, which may require treatment.
Durotomy – the dura is the delicate sac that contains the spinal nerves inside the spinal canal. Occasionally, 1 in 25, this can become snagged or torn inadvertently during the surgery. This can usually be recognised and repaired at the time and would not cause any long term problems, You might have a headache for a couple of days afterwards.
Blood Clots – in the deep veins of the legs or lungs. You will be given surgical stockings and pumps on your legs during surgery to minimise this risk, although we cannot eradicate it.
Sensory change or muscle weakness in legs – is uncommon, approx. 1 in 300, when it does occur, it is usually temporary but could be long-standing.
Post-op bladder or bowel dysfunction – The risk of damage to the nerves that supply your bladder and bowel is very rare, < 0.1% (1 in 1000).
Recurrence of Pain – In less than 1 in 100 people the natural process of healing by scar tissue causes pain to return by encasing nerves in too much scar tissue. This is treated by special medications.
Recurrent narrowing – is unlikely, and would take several years to develop.
Repeat surgery – 1 in every 100 patients have further back surgery during the ten years that follow due to continued back degeneration at other levels.
Back pain – Around 1-2 out of every 100 patients develop long term low back pain after spinal decompression, and this can often be treated non-surgically.
For elderly patients some risks are slightly increased. Risk of blood clots, heart attacks, urine/chest infection, and heart failure are all increased with advancing age.
What happens after the operation?
Once you have had your surgery, you will be taken to one of the orthopaedic wards to be looked after for the rest of your stay. You may return from theatre with a ‘drip’ until you are drinking which, if you are able, may be when you come round from the anaesthetic. You may have a PCA (patient controlled analgesia) which provides you with painkillers through a drip tube until you are drinking, and then you will be able to have tablet painkillers. Patients do not tend to have a drain attached (to drain fluid/blood off your wound) but this does occur sometimes. You may have a urinary catheter, which would normally be removed on the first post-operative day.
Immediately after your surgery
If your pain is controlled, you should be able to sit up in bed, and mobilise to the toilet on the evening of the operation, with assistance.
Day following your surgery
With assistance you will be able to mobilise if your surgeon is happy with your progress. A physiotherapist may see you and assist you to move around. Your wound dressing will be changed only as needed and is usually kept covered until the stiches are trimmed at 14 days post-op.
You will be encouraged to walk and manage stairs as quickly as possible and the ward nurses and physiotherapists will guide you as to how quickly you can go home. This varies between 1 and 3 days after the operation. You will be given a 2 week follow up appointment with Mr Seel for a wound check and to trim your stitches (the rest will be dissolving stitches).
You will be given a outpatients physiotherapy appointment between 2-4 weeks after your surgery. Until that point it is important to do your own exercises. Each exercise should be performed ten times, regularly throughout the day. You should start the exercises on the day after your operation and continue them at home.
This muscle is a deep support muscle for your spine.
Whenever you move it contracts and stabilises the lower spine. Your physio will teach you to locate it.
Lying on your back with knees bent and arms by your side
Pull stomach up and in by tightening your pelvic floor muscles/ lower abdominal muscles.
Breath normally whilst holding this contraction
Try not to arch your back or push down into the bed
Hold 10 secs, then relax. Repeat 10 times.
Lie on your back with your knees bent up
Gently roll the knees from side to side.
Don’t push through any pain.
Repeat 20 times.
Lie on your back with your knees bent up
Gently flatten the small of your back onto the floor and tilt your hips up.
Repeat 15 times.
Alternate Leg Hugs
Lying on your back with a cushion under your head.
Pull your knee onto your stomach helping with your hands.
Push your other leg down towards the floor.
Hold approx. 20 secs, then relax
Repeat 5 times on each leg
What will happen after I am discharged?
Pain: Some pain is usual up to the first 2 weeks following surgery. The back pain from surgery will die down to a dull ache after 48 to 72 hours post op. This is usually managed with regular painkillers. Information regarding what to do if you are in undue or extreme pain after surgery can be found here.
Wound care: Your wound dressing will be checked before you leave hospital. You will be given a 2 week follow up appointment with Mr Seel for a wound check and to trim your stitches (the rest will be dissolving stitches). You should keep your wound clean and dry following surgery. Most dressings are shower-proof, but ask your nurse before discharge.
Sitting: You may find that perching on the edge of a bed or perching stool is more comfortable to begin with. You should sit on an upright chair and avoid low chairs or sofas for the first couple of weeks. Try using a lumbar roll or cushion positioned in the small of your back when sitting. Change position regularly, alternating between lying, sitting and walking.
Activity and exercise: Walking is the best activity to do following your surgery. It helps improve your general fitness and leg strength. Gradually build up the amount of walking that you do each day. Try to get into a routine so that you gradually get in the habit of walking a bit further and faster. You may swim as soon as your wound is healed which is normally around 2-3 weeks. Any other sports should be avoided until you can discuss them with Mr Seel in your follow-up appointment.
Heavy lifting and carrying: Should be avoided for the first 4 weeks. Lift weights close to your body, keeping your back as straight as possible and bending your hips and knees to make use of the thigh muscles.
Work: You may return to work as soon as you feel comfortable to do so. If your work involves sitting at a desk you may return to work after about two to three weeks. If you have a heavy job you may need longer to recover (up to 6-8 weeks).
Driving: You will be unable to drive for at least 2 weeks. When considering whether to drive, you have to be able to safely perform an emergency stop, with full pressure on the brake pedal, without significant back/leg pain. Further advice can be sought at your outpatient appointment. Break up long journeys so you can change position and move around. Check with your insurance company as they may wish to know that you have had an operation.
Sex: There is no reason to avoid sexual relations during the recovery period. You might prefer to be the passive partner or try different positions to find the most comfortable for you.
Follow up outpatient appointment: You will be given a 2 week follow up appointment with Mr Seel for a wound check, and a further appointment around 6 weeks after the operation to check your progress. Please discuss any queries you may have when you are at the clinic. Further outpatient appointments are made as necessary. You will also be followed up with a physiotherapy outpatients appointment between 2-3 weeks following surgery.