Herniated Disc Surgery

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Herniated Disc Surgery
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Anatomy
Your spine consists of vertebrae, all stacked in
a column, called the spinal column. The vertebrae
are a unique shape, and their job is to hold the
body upright and to protect the spinal cord,
which runs through them.The Spine consists of
33 verte- brae (bones). There are discs between
each of the vertebra that act like pads or shock
absorbers. Each disc is made up of a tire-like
outer band called the annulus fibrosus and a
gel-like inner substance called the nucleus
pulposus. Together, the vertebrae and the discs
provide a protective tunnel (the spinal canal) to
house the spinal cord and spinal nerves. These
nerves run down the center of the vertebrae and
exit to various parts of the body. Your back also
has muscles, ligaments, tendons, and blood
vessels. Muscles are strands of tissues that act
as the source of power for movement. Ligaments
are the strong, flexible bands of fibrous
tissue that link the bones together, and tendons
connect muscles to bones and discs. Blood vessels
provide nourishment. These parts all work
together to help you move about. A herniated disc
most often occurs in the lumbar region (low
back). This is because the lumbar spine carries
most of the body's weight. Sometimes the
herniation can press on a nerve, causing pain
that spreads or radiates to other parts of the
body. The amount of pain associated with a disc
rupture often depends on the amount of material
that breaks through the annulus fibrosus and
whether it compresses a nerve.
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Definition

• Very few people with herniated or bulging discs
  need surgery. However, if you have tried to
  manage your symptoms for six weeks or more using
  conservative treatments such as anti-inflammatory
  medications, physical therapy and ice or heat
  without relief, your doctor may recommend
  surgery. Surgery may be necessary if you are
  experiencing
• Muscle weakness or numbness, loss of sensation
• Problems walking or standing
• Difficulty controlling your bowels or bladder
• Many times, only the portion of the disc that is
  bulging or herniated is removed. In rare cases,
  it is necessary to remove the entire disc. If the
  entire disc is removed, the bones (vertebrae) on
  either side of the damaged disc may need to be
  permanently joined or fused together to provide
  stability for your spine. This is accomplished by
  using metal hardware to hold the two vertebrae
  together and in alignment while they heal, and
  new bone forms across the gap left by the damaged
  disc. Only in rare cases, surgeons suggest
  implanting artificial discs.

SURGERY CHOICES
MicroDiscectomy Percutaneous discectomy Laminotomy
and laminectomy
These procedures may be combined with a
discectomy or completed as separate procedures.
This surgery is considered by many surgeons to be
less successful than an open discectomy.
This is often chosen as the most effective
procedure for patients who have not obtained
relief with conservative treat- ment and who have
severe and disabling pain in their leg.
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MicroDiscectomy
Why it's done... A disc herniates when a crack or
tear develops in the tough outer rim and some of
the gel-like center of the disc escapes through
the crack or tear. This gel-like material takes
up space in the spinal canal, placing pressure on
the nearby spinal nerve or the spinal cord
itself. A Microdiscectomy is a surgical procedure
that is done to take the pressure off the nerves
or spinal cord by removing part or all of the
herniated disc. Herniated discs are sometimes
called slipped discs, ruptured or bulging discs,
or prolapsed discs. Your physician might advise
Microdiscectomy if Nerve weakness has progressed
to the point you have difficulty walking or
standing After six weeks of non-surgical
treatment, such as physical therapy, your
symptoms are not improving A fragment of a disc
becomes lodged in the spinal cord and is
compressing a nerve The pain radiating into your
arms, chest, legs or buttocks is no longer
manageable
How Microdiscectomy Surgery Is Performed A
microdiscectomy is performed through a small (1
inch to 1 1/2 inch) incision in the midline of
the low back. First, the back muscles (erector
spinae) are lifted off the bony arch (lamina) of
the spine. Since these back muscles run
vertically, they can be moved out of the way
rather than cut. The surgeon is then able to
enter the spine by removing a membrane over the
nerve roots (ligamentum flavum), and uses either
operating glasses (loupes) or an operating
microscope to visualize the nerve root. Often, a
small portion of the inside facet joint is
removed both to facilitate access to the nerve
root and to relieve pressure over the nerve. The
nerve root is then gently moved to the side and
the disc material is removed from under the nerve
root. Importantly, since almost all of the
joints, ligaments and muscles are left intact, a
microdiscectomy does not change the mechanical
structure of the patient's lower spine (lumbar
spine).
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MicroDiscectomy

• Risks
• MicroDiscectomy is considered to be a safe
  operation. Just like any surgery, there is a risk
  of complications occurring. Possible
  complications include the following
• Bleeding
• Infection
• Spinal fluid leaking
• Damage to nerves or blood vessels around and in
  the spine
• Damage to the protective layer of tissues that
  surround the spine
• How you prepare
• You may not be able to eat or drink for several
  hours before your operation. Your doctor will
  provide you with instructions concerning this. If
  you have any questions, be sure to ask your
  physician.

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MicroDiscectomy
What you can expect During MicroDiskectomy A
microdiscectomy is typically completed under
general anesthesia, so you will be asleep during
the operation. You will be given medication to
make you sleepy to breathe in through a mask or
through an intravenous (IV) line. After the
incision is made, small portions of ligaments and
spinal bone may have to be taken out so the
surgeon can see and operate on the disc that is
damaged. The goal is to remove only the portion
of the disc that is compressing the nerve while
leaving the rest of the disc intact. Sometimes
the entire disc needs to be removed. When this
happens, the surgeon will need to fill the gap
left by the disc with another piece of bone or an
artificial bone. The vertebrae lying just above
and just below where the damaged disc was
removed, will be joined together using surgical
medical hardware. After MicroDiskectomy Following
surgery, you will wake up in the recovery room.
You will stay here for a short time to make sure
your condition is stable. Some people return home
the same day they have microdiscectomy, but if
there were any other medical problems, you might
have to stay a few days to help prevent
complications. Depending on the type of job you
do, you might be able to return to work within
two to six weeks. If your job requires operating
heavy machines or equipment, or heavy lifting,
you physician may not allow you to go back to
work for six to eight weeks. For at least four
weeks after surgery limit the amount of stooping,
bending and lifting you do, and you might also
need to decrease the amount of time you spend
sitting. A skilled physical therapist will be
able to instruct you in an exercise plan that
will improve the flexibility and strength of your
back muscles. Results Discectomy helps to
relieve the symptoms of a herniated disc in most
people who have clear indications of nerve
compression, such as pain that radiates from the
back into the arms or legs. This surgery may not
provide permanent relief however, because it does
not solve the underlying problem that initially
caused the disc to herniate. Your doctor may make
some recommendations that will help you avoid
injuring your spine again, such as a routine
program of low-impact exercise or weight
reduction. It may also be recom- mended that you
avoid activities that require repetitive or
extensive lifting, twisting or bending.
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Percutaneous discectomy
For some patients even more minimally invasive
(in comparison wit Microdiscectomy) methods have
been made available, whereby the entire
decompression is performed percutaneously through
a needle. Patients who may benefit from
percutaneous disc decompression or 'percutaneous
discectomy' as it is called, are those with pain
arising from a contained herniated disc - that is
a bulging disc where there is no rupture in the
outer wall. Percutaneous Discectomy An advanced
form of percutaneous discectomy developed to date
uses a plasma tech- nology to remove tissue from
the center of the disc. During the procedure, an
instrument is introduced through a needle and
placed into the center of the disc where a series
of channels are created to remove tissue from the
nucleus. Tissue removal from the nucleus acts to
decompress the disc and relieve the pressure
exerted by the disc on the nearby nerve root. As
pressure is relieved, pain is reduced, consistent
with the clinical results of earlier percutaneous
discectomy procedures. There is little tissue
trauma and recovery times may be improved in many
patients. Although long-term data is not
available, early studies show sustained pain
relief out to one-year, with patients remaining
steady at their initial post-procedure pain
levels. Evidence is mounting that pain relief is
sustained through two years post-procedure and
beyond.
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Percutaneous discectomy

• Who is the right patient?
• For appropriately selected patients, percutaneous
  discectomy can help relieve back and leg pain
  symptoms, including sciatica and radiculopathy
  and even pure axial pain caused by a 'central
  focal protrusion' or central bulge of the disc.
  Percutaneous discectomy is a widely accepted
  treatment for patients with small contained
  herniations for whom open surgical discectomy
  offers a outcome. It may also be a promising
  option for patients with large contained
  (non-ruptured disc) herniations for whom open
  surgery is not considered an appropriate
  treatment.
• What to Expect
• Percutaneous discectomy is a straightforward
  procedure. The patient receives a local
  anesthetic and possibly mild sedation no general
  anesthesia is required. Needle insertion is
  simple, with little pain. Once the needle is
  inserted into the disc, the disc decom- pression
  itself takes only a few minutes. The entire
  procedure takes about 30 minutes and the patient
  is able to leave the recovery area with only a
  small bandage over the needle insertion site.
• Post-op recovery is not demanding. Patients
  typically feel little pain after the procedure.
  Patients are required to avoid lifting and
  strenuous exercise for a period of time. A
  patient may resume sedentary work after a week or
  two. Patients with more physically demanding
  occupations may need to wait longer to return to
  work. Physical therapy may be prescribed.

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Laminotomy and laminectomy
Each back bone or vertebra has two laminae. These
laminae are arch-shaped and are located closer to
the internal body than the outside of the body.
Other parts of the vertebra are located near the
laminae the facet joint and the spinal
process. The laminae are made of bone and they
rarely cause problems. However, surgery on them
can be helpful in other conditions. Spinal
conditions may cause severe pain if the spinal
cord or nearby nerves are compressed. Operations
performed on the laminae can help to make the
spinal column wider, which relieves the pressure
and pain. Surgery on the laminae is also used to
help treat spinal defor- mities. What is the
Difference Between Laminectomy and
Laminotomy? Sometimes even doctors and nurses
interchange these two words, but there is a
distinction. In a laminectomy, the lamina is
com- pletely removed. Only a portion of the
lamina is removed in a laminotomy. Reasons for a
laminectomy or laminotomy The main reason for
either of these procedures is to remove the
pressure from the nerves near the spinal cord or
from the spinal cord itself. Even though a
portion of the vertebra is removed, the spinal
cord remains protected inside the spinal column
which consists of hard backbones, even when a
laminectomy or laminotomy is performed. What to
Expect from Laminectomy/Laminotomy Laminectomy
and laminotomy procedures are performed for many
different conditions, so much depends on your
underlying condi- tion. Discuss your particular
situation with your doctor. In general, if the
lamina are easily removed and no further measures
need to be taken to support the spine, your
rehabilitation and recovery could be very quick.
If other procedures are necessary to stabilize
the spine, such as spinal fusion, recovery may
take more time. The World Health Organization
reports that the majority of patients who
underwent laminectomy or laminotomy surgery on
their lower back had recovered to their normal
state of health within one year after surgery.
While these operations can take pressure off the
spinal cord and the nerves, they do not stop the
normal process of wear and tear that leads to
degeneration, or other underlying causes such as
obesity. This means the relief they provide may
not be permanent.
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Experimental procedures
There are several procedures being done that
involve either very small incisions or the use of
injections for destroying the damaged disc. For
example, Disc decompression with chemical,
mechanical or thermal devices. If your doctor
suggests using one of these techniques to treat
your ruptured disc, get all the information you
can about the procedure and also consider seeing
another doctor for a second opinion. Laser
discectomy is a procedure that some surgeons have
been practicing for several years, but it is
still considered to be experimental due to the
lack of research to prove its safety and
effectiveness. It uses a laser to dissolve a
ruptured or herniated disc.