Surgery to remove part of a disc in the lower back (lumbar discectomy)

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1 Surgery to remove part of a disc in the lower back (lumbar discectomy) Brought to you in association with EIDO Healthcare and endorsed by the Royal College of Surgeons England. Discovery has made every effort to ensure that we obtained the information in this brochure from a reputable source. We have adapted the content to reflect the South African market or healthcare environment. You should not only depend on the information we have provided when you make any decisions about your treatment. The information is meant to act only as a guide to the treatment you are considering having. Please discuss any questions you may have about your treatment with your treating healthcare professional. Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider, administrator of medical schemes.

2 What is a slipped disc? A slipped disc is where the spongy centre of a disc bulges out and puts pressure on a nerve where it leaves your spine. About this document Your surgeon has recommended a microdiscectomy. However, it is your decision to go ahead with the operation or not. We understand this can be a stressful time as you deal with different emotions and sometimes have questions after seeing your surgeon. This document will give you a basic understanding about your operation. We tell you about the things you can do to help make the operation a success. It is also important to remember to tell your surgeon about any medicine you are on so he or she can manage this, if necessary. It will also tell you about what to expect after the operation while in hospital and in the long term. Your surgeon remains the best person to speak to about any questions or concerns you may have about the operation. How does a slipped disc happen? Your spine is made up of a column of bones called vertebrae. The vertebrae are arched at the back and are joined together by small facet joints and spongy discs between the vertebrae. The arches (laminae) form a protective tunnel called the spinal canal. The spinal cord passes down the spinal canal from your brain. Nerves from your spinal cord pass from the spinal canal through small gaps between the vertebrae. These gaps also allow blood vessels that supply the nerves and cord to pass into the spinal canal. The nerves carry messages from your brain so you can move your muscles. They also carry messages from your skin so you have the sense of touch and feel pain. Each disc is made up of a tough fibrous outer coat with a soft spongy centre. As we get older the disc dries out and becomes less spongy, and small tears appear in the fibrous coat. The fibrous coat is thinner at the back near the nerves so this tends to wear out first. Eventually the spongy centre can bulge out and press on a nerve, or else some of the spongy centre can squeeze out of the fibrous coat and press directly on a nerve (see figure 1). This is called a slipped disc and it can cause severe pain, as well as weakness and numbness in the area that the compressed nerve supplies. For a disc in your lower back (lumbar disc) the symptoms are felt down your leg and into your foot. Some older people have uneven bony lumps on their vertebrae (osteophytes) that can also press on the nerves or spinal cord. a b Spinal nerve Disc Disc bulge Spinal canal Figure 1 a A normal spinal canal and disc b A disc bulge pressing on a spinal nerve Copyright 2016 Page 1 of 4

3 What are the benefits of surgery? The aim is to relieve the pressure on the nerve so it can recover. Your symptoms should improve and this should help you to get back to your normal activities. Are there any alternatives to lumbar microdiscectomy? For many people, symptoms get better without surgery. For 9 in 10 people this takes 12 weeks or less. Treatment involves painkillers and rest, followed by an exercise programme. If you have a lot of pain, you can also have a steroid injection into an area called the epidural space in your spine near the affected nerve. What will happen if I decide not to have the operation? If the bulge is not too big and there is enough room within your spine, you should recover after 6 to 8 weeks of rest. Your surgeon may refer you to a physiotherapist for an exercise programme. If the bulge is large and your symptoms do not improve with rest and pain relief, you may decide to have a microdiscectomy. Sometimes the bulge can press on nerves that control your bladder, causing you to have difficulty passing urine and, in severe cases, can cause leg paralysis. What does the operation involve? You will have an MRI scan to confirm the diagnosis and help your surgeon to plan the operation. The healthcare team will carry out a number of checks to make sure you have the operation you came in for. You can help by confirming to your surgeon and the healthcare team your name and the operation you are having. Various anaesthetic techniques are possible. Your anaesthetist will discuss the options with you and recommend the best form of anaesthesia for you. You may be given antibiotics during the operation to reduce the risk of infection. The operation usually takes 45 minutes to an hour. Your surgeon will make a cut on the centre of your back between the vertebrae. They will use an operating microscope to make a hole in the ligament between the vertebrae to show the nerve and the disc. Your surgeon will hold the nerve out of the way and remove the disc. Your surgeon will usually close your skin with dissolvable stitches. They may insert a drain (tube) under your skin to help your wound to heal. This is usually removed after one to two days. What should I do about my medicine? Let your doctor know about all the medicine you take and follow their advice. This includes all blood-thinning medicine as well as herbal and complementary remedies, dietary supplements, and medicine you can buy over the counter. What can I do to help make the operation a success? If you smoke, stopping smoking several weeks or more before the operation may reduce your risk of developing complications and will improve your long-term health. Nicotine is known to prevent wounds from healing properly following back surgery, and increases the risk of unsightly scarring and chronic pain. Try to maintain a healthy weight. You have a higher risk of developing complications if you are overweight. Being overweight puts unnecessary strain on your back. Regular exercise should help to prepare you for the operation, help you to recover and improve your long-term health. Before you start exercising, ask the healthcare team or your GP for advice. You can reduce your risk of infection in a surgical wound. In the week before the operation, do not shave or wax the area where a cut is likely to be made. Try to have a bath or shower either the day before or on the day of the operation. Keep warm around the time of the operation. Let the healthcare team know if you feel cold. What complications can happen? The healthcare team will try to make the operation as safe as possible but complications can happen. Some of these can be serious and can even cause death. You should ask your doctor if there is anything you do not understand. Your doctor may be able to tell you what the risk of a complication for you is. 1 Complications of anaesthesia Your anaesthetist will be able to discuss with you the possible complications of having an anaesthetic. Copyright 2016 Page 2 of 4

4 2 General complications of any operation Pain. The healthcare team will give you medicine to control the pain and it is important that you take it as you are told so you can move about as advised. Bleeding during or after the operation. This can cause pressure on the nerves (extradural haematoma) (risk: 3 in 200). You may need another operation. Unsightly scarring of your skin, although the cut usually heals to a neat scar. Infection of the surgical site (wound) (risk: 3 in 200). It is usually safe to shower after two days but you should check with the healthcare team. Let the healthcare team know if you get a high temperature, notice pus in your wound, or if your wound becomes red, sore or painful. An infection usually settles with antibiotics but you may need another operation. Blood clot in your leg (deep-vein thrombosis DVT) (risk: less than 1 in 100). This can cause pain, swelling or redness in your leg, or the veins near the surface of your leg to appear larger than normal. The healthcare team will assess your risk. They will encourage you to get out of bed soon after the operation and may give you injections, medicine, or special stockings to wear. Let the healthcare team know straightaway if you think you might have a DVT. Blood clot in your lung (pulmonary embolus), if a blood clot moves through your bloodstream to your lungs. Let the healthcare team know straightaway if you become short of breath, feel pain in your chest or upper back, or if you cough up blood. If you are at home, call an ambulance or go immediately to your nearest casualty unit. Difficulty passing urine. You may need a catheter (tube) in your bladder for one to two days. Chest infection. You may need antibiotics and physiotherapy. Heart attack or stroke (loss of brain function resulting from an interruption of the blood supply to your brain). Sometimes a heart attack or stroke can cause death. 3 Specific complications of this operation Worse pain or numbness down your leg caused by damage to nerves near the disc (risk: 1 in 200). Numbness between your legs, loss of normal bowel and bladder control and, for men, problems having an erection. These problems can happen because nerves near the disc can get damaged during surgery. Although the nerves should get better over time, three in five people with nerve damage do not get completely back to normal. Neuropathic pain. This is a burning pain that may happen once the pressure on the nerves has been released. You may need a special form of pain relief. Tear of the thin membrane that covers the nerves in your spine (dural tear) (risk: less than 3 in 100). Spinal fluid can leak out and you may get a bad headache for a few days. Your surgeon may need to repair the tear, either during the operation or with another operation later. How soon will I recover? In hospital After the operation you will be transferred to the recovery area and then to the ward. Sometimes you may go to the intensive care unit or high care unit for up to 24 hours so the healthcare team can monitor you more closely. You will be able to drink after you have recovered from the anaesthetic. The healthcare team will help you to start walking as soon as possible. The physiotherapist may give you an exercise programme to help you to strengthen your back. It is important to do your exercises as you are told to reduce the risk of getting back problems again. You should be able to go home the same day or the day after. However, your doctor may recommend that you stay a little longer. If you do go home the same day, a responsible adult should take you home in a car or taxi and stay with you for at least 24 hours. Be near a telephone in case of an emergency. If you are worried about anything, in hospital or at home, contact the healthcare team. They should be able to reassure you or identify and treat any complications. Returning to normal activities Do not drive, operate machinery or do any potentially dangerous activities (this includes cooking) for at least 24 hours and not until you have fully recovered feeling, movement and co-ordination. Copyright 2016 Page 3 of 4

5 If you had a general anaesthetic or sedation, you should also not sign legal documents or drink alcohol for at least 24 hours. To reduce the risk of a blood clot, make sure you follow carefully the instructions of the healthcare team if you have been given medicine or need to wear special stockings. Keep your wound dry for 10 days. The healthcare team will tell you if you need to have any stitches or clips removed, or dressings changed. The healthcare team will tell you when you can return to normal activities. Do not lift anything heavy or twist your body. Make sure you keep a good posture when sitting and walking. Regular exercise should help you to return to normal activities as soon as possible. Before you start exercising, ask the healthcare team or your GP for advice. Do not drive until your doctor tells you that you can. Acknowledgements Author: Mr Stephen Milner DM FRCS (Tr. & Orth.) and Mr Richard Ashpole FRCS (Neuro. Surg.) Illustrations: Copyright. All rights reserved. and Medical Illustration Copyright Medical-Artist.com This document is intended for information purposes only and should not replace advice that your relevant healthcare professional would give you. You can access references online at Use reference OS15. The future Nine in 10 people make a good recovery from surgery and are able to return to normal activities. Leg pain is usually the first symptom to improve. You may feel a tingling sensation or pins and needles for some months. Sometimes this can be permanent. You may get more back pain or continued symptoms because of wear of other discs. Pain can be caused by another disc bulge or scar tissue around the nerves. Summary A slipped disc is where the spongy centre of a disc bulges out and puts pressure on a nerve where it leaves your spine. The aim is to relieve the pressure on the nerve so it can recover. Surgery is usually safe and effective but complications can happen. You need to know about them to help you to make an informed decision about surgery. Knowing about them will also help to detect and treat any problems early. Keep this information leaflet. Use it to help you if you need to talk to the healthcare team. Copyright 2016 Page 4 of 4