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Introduction
Procedure
Risks
Alternative Treatments
The lumbar spine is comprised of vertebral bodies (also known as vertebrae) that are separated by soft intervertebral discs, which act to cushion the spine, allow mobility, and provide stability.
A variety of reasons can lead to protrusion (also known as herniation) of the intervertebral disc, which can cause symptoms such as pain, weakness, tingling, and/or numbness in the back and leg. This is usually the result of compression of one or more nerve roots, as illustrated in the figure below.
In select patients surgery (lumbar discectomy) may be the best option for relief of symptoms and prevention of loss of function by removing the protruded portion of the disc and providing more room for the nerve root. The success rate for lumbar discectomy is approximately 85-90%, although some patients may develop a recurrent disc herniation at some point in the future.
Traditionally, the surgery was performed with a relatively large incision in the lower back to gain access to the herniated disc, called the open method. However, with advances in surgical technology, a newer technique, called the minimally-invasive method, has emerged which allows for a smaller incision and less tissue manipulation. This, in turn, leads to less pain and a speedier recovery. Both of these methods are described below.
Open Method
After induction of general anesthesia, an incision is made in the lower back.
The muscle and other tissues are dissected until the bone is reached, and retractors are placed to keep the dissected tissue out of the way. Although so depicted in the figure below, the herniated disc is rarely visible at this stage, since it is covered by the bony back wall of the spine, called the lamina, as well other tissues.
The lamina and other intervening tissue are removed, and following careful dissection, the herniated disc is identified.
The herniated disc, which is compressing the nerve root, is removed.
The retractors are removed and the incision is closed prior to the termination of the operation.
Minimally-Invasive Method
The basic surgical principles of this method are the same as the open version. However, in the minimally-invasive method the size of the incision is smaller (typically one-half to two-thirds of an inch); and the retractor system that is used is a special cylindrical conduit called a tube retractor that allows for less tissue dissection.
After placing the small incision on the skin, the cylindrical tube retractor is passed through the muscle and other tissue, gently pushing them out of the way, until the tip of the retractor is docked over the lamina. The dark circle in the figure below shows the surgeon's view through the retractor.
The remainder of the surgery is performed with the help of a microscope through the tube, where the visible portion of the lamina is taken out and the herniated disc is removed, followed by removal of the retractor and closure of the skin.
Due to advances in medicine and technology, surgical procedures are generally considered to be safe, and a great majority of patients who undergo surgery will not experience any complications. However, there are certain risks involved in any procedure which are important to be aware of in order to make an informed treatment decision.
Risks Specific to this Procedure: The risks associated with this surgery include, but are not limited to, damage to spinal cord or nerve roots leading to increased pain or other neurologic problems, loss of bowel/bladder function, sexual dysfunction, weakness or paralysis, numbness, cerebrospinal fluid leakage requiring placement of lumbar drain, need for further surgery, and spinal instability leading to need for future surgery or treatment.
Infection: Invasion of tissue by bacteria or other germs occurs to some degree whenever a cut, incision or puncture is made. In most instances, through the natural defense mechanisms of the body, healing of the affected area occurs without difficulty. In some instances antibiotic medicines are prescribed and at times additional surgical measures may be necessary to combat infection.
Hemorrhage: The cutting of blood vessels causes bleeding and this occurs in every surgical incision. This bleeding is usually controlled without difficulty. At times, blood transfusions are required to replace blood loss. If blood transfusions are given, there are additional risks of liver inflammation, hepatitis, and the possibility of receiving Acquired Immune Deficiency Syndrome (AIDS). There is no absolutely reliable way to predict these unwanted reactions, some of which may be quite serious and even lead to death.
Drug Reactions: Unexpected allergies, lack of proper response to medications or illness caused by the prescribed drugs are possibilities. It is important for you to inform your physician and your anesthesiologist or certified registered nurse anesthetist of any problem you or your family have had with reactions to drugs and which medications you have taken in the past six months, including over-the-counter drugs, especially aspirin.
Anesthesia Reactions: There may be unusual or unexpected responses to the gases, drugs or methods used to anesthetize you which can lead to difficulties with lung, heart or nerve function. Eating or drinking before anesthesia increases the risks of vomiting which may cause significant complications. Inform your anesthesiologist or certified registered nurse anesthetist of problems you and your family have had with anesthesia.
Blood Vessel Inflammation and Clotting: It is impossible to predict the occurrence of blood vessel inflammation and clotting problems. If blood clots form, they can move from where they formed to other areas of the body and cause injury.
Injury to Other Organs: Because of the closeness of other organs to the area being operated on, there may be injury to other organs. The stress of surgery or the procedure may also harm other organ systems of the body.
The alternative management modalities for this procedure are physical therapy, pain management using medications or injections, certain alternative medicine therapies (acupuncture), possibly other surgical procedures, and expectant management with no treatment at all. If the decision is made to not have this procedure, there may be associated risks which need to be discussed with a physician.
