Lumbar Discectomy

Lumbar Discectomy is a surgical procedure of the spine performed to remove part of a herniated disc from the spinal canal. To learn more about Lumbar Discectomy, let us first learn about normal spine anatomy.

Normal Spine Anatomy

The spine, also called the back bone, is designed to give us stability, smooth movement, as well as providing a corridor of protection for the delicate spinal cord. It is made up of bony segments called vertebrae and fibrous tissue called intervertebral discs. The vertebrae and discs form a column from your head to your pelvis providing symmetry and support to the body. The spine can be divided into 4 parts. The uppermost is the cervical region, consisting of 7 small vertebrae that form the neck. As we move down the body, the next 12 vertebrae make up the thoracic region or mid back from which the ribs are hinged. The 5 lumbar vertebrae are the largest of the mobile vertebrae and supports 2/3 of the body’s weight.

The lowest region of the spine is the sacrum and coccyx. The sacrum is a triangular plate made up of 5 fused vertebral segments while the 4 coccyxes terminate the bony spine. A single vertebra is made up of two parts; the front portion is called the body, cylindrical in shape, and is strong and stable. The back portion of the vertebra is referred to as the vertebral or neural arch and is made up of many parts. The strong 2 pedicles join the vertebral arch to the front body. The laminae form the arch itself while the transverse process spread out from the side of the pedicles like wings to help anchor the vertebral arch to surrounding muscle. The spinous process forms a steeple at the apex of the laminae, and is the part of our spine that is felt directly under the skin.

Laminae

The laminae of the vertebra can be described as a pair of flat arched bones that form a component of the vertebral arch.

Spinal Canal

This canal is formed by the placement of single vertebral foramina, one on top of the other, to form a canal. The purpose of the canal is to create a bony casing from the head to the lower back through which the spinal cord passes.

Pars Inter Articularis

Known as the Pars, it is the part of the vertebral arch where the pedicle, transverse process, and articular process transect.

Intervertebral Disc

The intervertebral disc sits between the weight bearing vertebral bodies, servicing the spine as shock absorbers. The disc has fibrous outer rings called the annulus fibrosus with a watery jelly filled nucleus called the Nucleus Pulposis.

Spinal Cord

The spinal cord is the means by which the nervous system communicates the electrical signals between the brain and the body. It begins at the brain stem and is held within the spinal canal until it reaches the beginning of the lumbar vertebrae. At L1 the spinal cord resolves down to a grouping of nerves that supply the lower body.

Facet Joint

Facets joints are the paired articular processes of the vertebral arch. These synovial joints give the spine it’s flexibility by sliding on the articular processes of the vertebrae below.

Indications for Lumbar Discectomy surgery include:

• Herniated intervertebral lumbar Disc: A condition caused by a tear in a disc causing the disc contents to bulge outside of the disc. Symptoms related to herniated discs in the lumbar region include sharp, continuous back pain, weakness in the legs, and some loss of sensation to the leg and foot.
• Cauda Equine Syndrome: A very serious compression disorder of the spine. The Cauda Equine is an area at the base of the spinal cord where the nerve roots of all spinal nerves are located. Compression in this area can cause loss of all nerve function below the site of compression and loss of bowel and bladder control. This condition is a surgical emergency requiring immediate decompression of the spinal nerves.
• Patient is showing progressive neurological deficits over a period of observation
• Persistent sciatic pain not responding to conservative treatment measures

Diagnosis

Evaluating the source of back pain is critical in determining your options for relief of the pain and the location of where to perform surgery.

Dr Hsu will perform the following:

• Medical History
• Physical Examination

Diagnostic Studies may include:

• MRI: magnetic and radio waves are used to create a computer image of soft tissue such as nerves and ligaments.
• CT Scan with myelogram: a type of medical imaging which is done by injecting contrast medium into the affected area of the spine followed by CT scan of the area that creates 3D images from multiple x-rays
• X-rays: a form of electromagnetic radiation that is used to take pictures of bones

Surgical Procedure

Lumbar Discectomy is a surgical procedure to alleviate severe pain and disability resulting from the compression of spinal nerves from a herniated disc. Lumbar Discectomy surgery is usually recommended for patients whose symptoms have not been relieved by other treatments such as rest, medication, Physical Therapy, and pain blocking injections.

This surgery is usually performed as a minimally invasive procedure. Dr Hsu may perform a “microendoscopic” discectomy which involves a slightly smaller incision.

Dr Hsu will decide which options are best for you depending on your specific circumstances.

The surgery is performed under sterile conditions in the operating room with the patient under general anesthesia and lying face down. Some doctors may use spinal anesthesia allowing the patient to stay awake during the procedure.

• Dr Hsu will make a small incision in the middle of the lower back area over the affected disc.
• A thin wire is inserted and dilators are used to stretch the muscles and make the opening larger in order to perform the surgery.
• Dr Hsu then inserts the endoscope, a viewing instrument with a camera on the end.
• The lamina of the vertebra, the bony roof portion over the spinal nerves, is partially removed in a procedure called a laminotomy, exposing the ligament which covers the spinal nerves.
• This ligament is then removed exposing the spinal nerves.
• The nerve root is then gently pushed aside so Dr Hsu can remove the ruptured disc material while leaving the rest of the disc intact.
• Dr Hsu will withdraw the endoscope which will cause the stretched tissues to come back together, and then close the incision with stitches and cover with a dressing.

Postoperative Care

You will be taught how to use proper body mechanics to turn in bed, reposition, and stand up, sit, and walk while the incision is healing.

• You will usually be discharged from the hospital 2-3 days post operatively depending on your circumstances.
• You will be given oral pain medications for the discomfort.
• You will be encouraged to walk as much as tolerated and avoid prolonged sitting.
• Avoid pulling, pushing, or lifting.
• A postoperative Rehabilitation program may be prescribed by Dr Hsu
• Keep the incision area clean and dry and report any signs or symptoms of infection to Dr Hsu’s Nurse such as redness, swelling, increased pain, excess drainage, odorous drainage, fever, or chills.

Risks and complications

• As with any major surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.
• It is important that you are informed of these risks before the surgery takes place.

Complications can be medical (general) or specific to spinal surgery. Medical complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete.

Complications include

• Allergic reactions to medications
• Blood loss requiring transfusion with its low risk of disease transmission
• Heart attacks, strokes, kidney failure, pneumonia, bladder infections
• Complications from nerve blocks such as infection or nerve damage
• Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death.

Specific complications of Lumbar Discectomy Surgery include:

• Skin infection at the incision line
• Recurrent Herniation of the disc
• Spinal fluid leak
• Spinal instability
• Nerve root injury/damage
• Failure to improve
• Discitis, a rare occurrence involving infection of the disc.