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Lumbar intervertebral disc operation

  • The appropriate procedure is always decided by a team of doctors
  • Guaranteed minimum invasiveness, use of a microscope
  • Team with extensive expertise and practical experience with the issues
  • Rigorous monitoring and consultation of postoperative condition

The human spine consists of 24 vertebrae connected by intervertebral discs. The basic function of the discs is to provide the flexibility that allows movement between the vertebrae while maintaining the sufficient strength of their connection. When there is a burden on the spine, all the discs (especially the lumbar discs) have to resist large forces (loads can be up to 700 kg while bending) while permitting smooth movements (bending backwards, bending forwards, and also while rotating).

The centre of the disc is made up of matter remotely similar to gelatine that surrounds the perimeter of the hard fibrous ring, and is bound to the surrounding vertebrae by a cartilage transitional layer. Intervertebral discs have no blood supply – they are the largest areas in the body where blood vessels do not go. The discs absorb all their nutrients from their surroundings. At night, when we lie down and put no pressure on our backs, the discs soak up fluids and swell up. During the day, as the back is burdened, the fluid is squeezed out. People are about 1 cm taller in the morning than in the evening. The discs are deformed during the day as the back moves around, together with the repeated exrtrusion and absorbtion and this mechanism the exchange of nutrients and oxygen is supported.

As life goes by the discs gradually get worn out. Signs of this process are already visible on specialized image screening (magnetic resonance) on people of around 20 years old. In some people a number of influences (inherited, movement, lifestyle, smoking etc.) cause the ageing process of these discs to be accelerated, they become worn out more quickly and finally their structure and function can fail. In the context of this acceleration, the hard ring can rupture and the core material can be squeezed out of the disc. This usually occurs while bending under a burden, but it can happen without any apparent cause. The herniated core mass puts pressure on the nerve structures located in the spinal canal. Sciatic nerve compression occurs most frequently, and is felt as a severe pain.

Information from the leg (sensitivity, pain) goes through the nerve roots to the spinal cord and then on to the brain, and information from the brain goes back to the muscles (movement) If the nerve is irritated, the patient feels it as pain in the lower limb. If the root is significantly compressed, then deterioration of sensitivity and weakening of the muscles, that is movement, are added to the pain.      In the most severe cases a large number of roots are compressed (Cauda equina syndrome), where besides pain, insensitivity and weakening of the lower limbs the patient has similar symptoms in the genital areaand cannot hold urine or faeces. These cases must be operated on urgently.

In the event that a disc herniates, there is a chance that the body will react and absorb the herniate. If the patient is in pain, but does not have impaired sensitivity and strength, it is usual to wait and treat them with infusions, painkillers (analgesics) and rehabilitation with the aim of relieving pain until the herniate absorbs itself. This treatment works well for a large number of patients and removes their problem. If the pain persists, or if painful periods repeat often, then an operation is required. In cases when the nerve roots are severely compressed, the patient loses feeling in their legs, which are weakened, a timely operation is required to prevent permanent disability. The herniated disc material is removed and the compressed nerve root is relieved. As well as correcting the patient’s condition, this operation has a preventative significance. If root compression lasts too long it can lead to permanent results even after a successful operation, either in the form of permanent pain, or permanent impairment to sensitivity and movement.

In earlier times “lumbago” was treated using various methods. However, the nature of the disease meant that people had this illness repeatedly and with more severe forms often suffered permanent consequences and even full invalidity and movement restricted to a wheelchair. The introduction of surgery has significantly improved the overall course of the disease and prevents severe permanent consequences.

Correctly indicated and conducted operations, however, do not only affect the purely medical aspects.  Repeated “lumbagos” and lengthy sick-leave in today’s demanding society significantly reduce the position of an otherwise capable person on the labour market. Long-term difficulties have financial and psychological effects, and in time can become manifest in personal relations in the patient’s family, areas of interest and professional circle. All these factors need to be taken into account both before and after the procedure is performed. Correcting the patient’s condition is a prerequisite for resolving these issues, but often the situation is the other way around, so that correcting these issues is a prerequisite for curing backache.

The issue of lumbar disc surgery – our view

We perform hundreds of intervertebral disc operations (microdiscectomies) a year, and even though this is a minor operation in neurosurgery, we do not underestimate it – on the contrary, we are striving to perfect it. Correct performance indications are a necessary prerequisite for any successful operation. Deliberations over indicators are more complicated for microdiscectomies, and require knowledge of non-operational treatment options, and this surgical rule is doubly valid. Although at our facility each patient is indicated by individual doctors, their case is presented to the entire team for assessment before operating. This approach enables us to optimize this crucial and sensitive part of care. Today we perform indications for lumbar disc surgery exclusively on magnetic resonance images, the quality and corresponding value of which far exceed those of the previously used CT scans.

On a technical level, our philosophy is to minimize the invasiveness of procedures while maintaining the necessary visibility and accessibility of technical possibilities of contemporary surgery. All doctors in our department use operating microscopes for all intervertebral disc operations. Even after testing alternatives, Caspar retractors still prove the most useful to us, preserving the aforementioned balance between minimum invasiveness and maximum visibility. We perform operations under general anaesthetic, after the patients have fallen asleep we put them in the knee-chest position (the patient is supported on their knees and chest), where the lumbar region of the spine is hunched. The position is surprisingly comfortable, and provides the surgeon with much more favourable conditions than the traditional alternatives and enables a gentler operation.

We perform operations in refurbished, fully equipped neurosurgical operating rooms, where brain tumours and extensive spinal procedures are conducted regularly. We have access to all available solutions and of course the facilities of all the other specializations at our hospital in the case of any complications.

We should give a mention to our team of doctors. Our younger doctors quickly acquire erudition thanks to the collective assessment of findings and careful introduction to surgery under the leadership of experienced colleagues. They are thus exposed to a large number of cases, and during their certification, our doctors have surpassed the number of lumbar spine operations required for granting independent activity in this field several times over.

Care for the patient is not nearly over with the operation procedure itself, however. The biggest problem has been removed from the spinal area and the patient is typically ordained bed rest until the next day, when they are given detailed instruction by a rehabilitation nurse and start to walk again under her guidance. Over the next few days further physiotherapy continues and 3-5 days after the operation they are discharged to home care.

All patients are provided with information guides and receive the exact date of check-ups in our clinic (about 6 weeks after surgery), which evaluates the condition and adjusts the recommendation for further treatment and possible workload. This check-up is carried out for all patients regardless of their outcome and so we have an excellent overview of the results of our work. We cooperate with spa facilities.

Further work with the patient, especially in terms of physiotherapy, is crucial for maintaining results in the long term. The vast majority of patients benefit from high-quality diagnostics of the causes of overloading the spine (kinesiology analysis). The correct exercise routine, prepared directly for each specific person, is an important prerequisite for long-term functioning of the lumbar spine. However, this is only a projection, because patients have to exercise themselves and only by doing so can they help themselves – the physiotherapist plays the role of an advisor, recommending exercises and checking they are being done correctly.

Before surgery

The procedure itself is performed under general anaesthesia. Prior to the operation the patient cannot eat, drink or smoke. This ban is generally valid from midnight to morning. Before surgery patients carry out their bodily needs, wash themselves with special antibacterial soap and have stockings put on their lower extremities to prevent blood clots in the veins.

Patients are taken to the operating theatre, transferred to a wheelchair and after administration of their preoperative medication transported to the operating theatre. The anaesthetist puts the patient to sleep, then the patient is placed in the operating position. In our hospital this is usually the knee-chest or “Mecca” position, which is comfortable for the patient and gives the surgeon better access to the spine. X-ray targeting of the diseased discs is conducted, cutting lines are marked and the entire area is thoroughly disinfected. Then the whole patient is covered in sterile drapes.

During surgery

The procedure itself is performed under general anaesthesia. The anaesthetist needs information on all the relevant parameters in the body of the specific patient to put them to sleep, all their current diseases and also medicaments used by the patient. Prior to the operation the patient cannot eat, drink or smoke. This ban is generally valid from midnight to morning. Before surgery patients carry out their bodily needs, wash themselves with special antibacterial soap and have stockings put on their lower limbs to prevent blood clots in the veins. If a clot was to be released into the bloodstream, it could cause a serious complication – pulmonary embolism.

Patients are taken to the operating theatre, transferred to a wheelchair and after administration of their preoperative medication transported to the operating theatre. The anaesthetist puts the patient to sleep, then the patient is placed in the operating position. In our hospital this is usually the knee-chest or “Mecca” position, which is comfortable for the patient and gives the surgeon better access to the spine. X-ray targeting of the diseased discs is conducted, cutting lines are marked and the entire area is thoroughly disinfected. Then the whole patient is covered in sterile drapes.

The surgical procedure begins with either a transverse or longitudinal incision of about 5 cm (the surgeon’s decision depends on the nature of the findings) and removing some muscle from the vertebrae. The surgeon then penetrates the spinal canal between two vertebral arches towards the places where the nerve roots run. On the bottom of the canal they reveal the herniated disc material and remove it using special forceps. Then they penetrate the disc itself and remove its available free and degenerated parts to avoid repeated herniation. The internal “springy” part of the disc (nucleus pulposus) is removed and and the hard ligamentous ring (annulus fibrosus) remains to hold and connect the vertebrae. No replacements or implants are inserted to replace the removed material. This ends the procedure itself and the wound is gradually closed (sutured), anatomical layer by layer. The operation lasts 30-90 minutes according to difficulty. In some cases it is desirable to leave drainage (tubing) in the wound to get rid of blood residues.

After surgery

After surgery, an anesthetist brings the patient out of their artificial sleep and after the effect of the medicaments has died down sufficiently the patient is transported back to the ward, where they receive an infusion. The patient cannot eat or drink for at least 6 hours after the operation, after which they can receive a small intake of fluids (tea), taken by the teaspoon. The next morning drainage is removed and the patient gets up and practices routine activities with the help of a rehabilitation worker. Instruction on suitable exercises takes place and 3-4 days after the procedure the patient is discharged to home care – transportation is lying down in an ambulance. At home the patient has to walk and gradually (as instructed) sits up. After lumbar intervertebral disc surgery all patients are invited for a check up 6 weeks after the operation. The final report gives the exact day and time of the check up.

Convalescence

One to two months of sick leave are usually recommended until full healing and the achievement of a normal physical routine have been achieved. Postoperative convalescence is highly individual and varies according to the severity of preoperative troubles and their duration, among other things. If the nerve root had been compressed by the herniate heavily and/or for a long time,  some preoperative problems can endure even after successful surgery, in particular residual pain, numbness, feelings of electric shocks, residual numbness or weakened limbs. Correction of nerve function is a lengthy process  and can take many months. The pattern of movement of the vertebrae changes with the removal of material, back pain can be present temporarily during movement and changing position – so-called “mechanical” backache. The optimal solution here is the gradual exercising and loading of the spine. Like any other surgical procedure, a disc operation is an intervention into the body and is felt by the patient, especially during changes of weather, greater exertion and so on.

During convalescence the patient adjusts their daily routine so as to cope with normal daily life and prepare to return to work. If the patient works on their rehabilitation, it is common for them to return to more demanding activities, sport and so on. As well as the character of the impairment and surgical procedure, the overall result depends heavily (even mostly) on the motivation and