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Informed Consent

Advice cannot be provided on an individual basis. The Society cannot accept any responsibility for the use of the information provided, the user and their health care professionals must retain responsibility for their health care management.

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INFORMATION FOR PATIENTS UNDERGOING SURGERY


Lumbar Discectomy and Decompression

Informed consent is the process of the surgical team providing information to the patient and their carers to enable them to come to a decision regarding the benefits and risks of a proposed operation. This document is intended to assist in that process. It contains information that Spine Surgeons of the British Association of Spine Surgeons believe represents a reasonable information source so that you, the patient, can consider the advantages and disadvantages of this surgery.

Introduction

No surgery is guaranteed and all surgery has risks associated with it.

Your surgeon will discuss with you the potential risks and benefits of surgery specific to you. This is a general information source to complement that information. For further information see also “sciatica” and “lumbar spine of this patient line.

This type of surgery is normally carried out for patients suffering with nerve pain in the leg. (sciatica). Sciatica is common in patients in their 30s and 40s. In this group of patients, it is usually due to a disc prolapse or protrusion.

In the older patient it may be due to degenerative changes which can produce a narrowing or stenosis of the bony spinal canal. The condition is termed “spinal stenosis” and typically causes symptoms of pain and numbness to the legs with standing and walking.

Spinal claudication is the term used for leg pain or nerve symptoms that comes on specifically with walking.

In general terms a ‘discectomy’ operation is to remove the part of the disc that is producing the nerve pain down the leg. If the pain is improving or not significantly affecting quality of life it may be best to leave well alone. A ‘decompression’ is to remove bone or soft tissue compressing the contents of the spinal canal. In some patients a combination of the two procedures may be required.

Back pain is a common symptom and can be accompanied by milder symptoms into the legs. There are often safer and more effective ways of dealing with the distressing symptoms of back pain, both in the short term and the long term, that do not involve surgery. Some patients have a combination of leg pain and back pain.


This document is to tell you about the common operations for sciatica and spinal stenosis. There are general risks with any operation and spinal surgery has some specific risks that you need to know about.


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SOME IMPORTANT CONSIDERATIONS

Spinal surgery for sciatica and spinal stenosis is better for the leg pain than it is for back pain. Both the leg pain and back pain may improve.

Symptoms of numbness or weakness may well persist after surgery.

In patients attending general practice for the first time with sciatica 75% are better within 28 days. The sciatica pain may continue to improve without the need for surgery. The pain often gets better anyway and pain relief in the early stage may be achieved with tablets or injections.

Surgery seems to get people better quicker but has some risks associated with it.

Certain types of disc prolapse are more likely to recur than others. Surgery for disc prolapse has a recurrence rate of between 7% and 15% within ten years. This is the same whether or not you have an operation.

Surgery seems best when severe or quite bothersome symptoms have not settled to the patient’s satisfaction and have lasted more than 6-8 weeks. Recent studies suggest that waiting around four months after the onset may be the best timing for surgery in terms of recovery and outcome.

Surgery has less risk and is safer on fit and healthy patients. It is common sense to take responsibility as a patient to reduce the risks whenever possible. Simple measures such as stopping smoking, loosing weight and improving aerobic fitness all help.

Older patients may have specific risk factors such as heart disease. Tablets used to thin the blood such as Warfarin, asprin or Clopidogrel increase the risks of bleeding and you must inform your surgical team regarding these.

Patients who are diabetic have a slightly increased risk of infection generally and the nerves in diabetic patients may not recover as well as others.

Specific risk factors may apply to you as an individual.

Specific usual benefits

70-75% of patients experience a significant improvement in leg pain.
20-25% may be better but still have persistent leg pain
5% may have no benefit at all
1% may be worse in terms of pain.

Lumbar disc surgery - what do we know?

There are many studies published in the scientific literature. By combining them in a systematic review doctors can sometimes have an overview of the benefits of different treatments. The Cochrane review is an independent group of spine specialists that have done this, looking at 39 trials.

Cochrane Database Syst Rev. 2007 Jan 24;(1): Gibson A Waddell GAchtung Link öffnet sich in einem neuen Fenster

The authors conclusions: Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. Microdiscectomy gives broadly comparable results to open discectomy. The evidence on other minimally invasive techniques remains unclear (with the exception of chemonucleolysis using chymopapain, which is no longer widely available).

Recent findings from America are similar. Surgical vs non-operative treatment for lumbar disc herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial.
Journal American Medical Association 2006 Nov 22;296(20):2441-50 Weinstien et al. This large study of 501 patients found little difference long term between those that had surgery and those that did not. Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period.

Lumbar Spine decompression - what do we know?

The operation of lumbar decompression seems to improve pain in about 65-70% of patients and often improves the distance a patient can walk by a factor of about four. The operations are for quality of life issues. That is, if the symptoms are acceptable to the patient the question of having surgery or not having surgery should be made by patient in discussion with the surgeon. Many spinal disorders improve or do not get worse.
Surgical or nonoperative treatment for lumbar spinal stenosis? A randomized controlled trial. Malmivaara A Spine Jan 2007 1;32(1):1-8 A study of 94 patients. Although patients improved over the 2-year follow-up regardless of initial treatment, those undergoing decompressive surgery reported greater improvement regarding leg pain, back pain, and overall disability. The relative benefit of initial surgical treatment diminished over time, but outcomes of surgery remained favorable at 2 years.

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THE OPERATION

The operation is usually done under general anaesthetic and involves a short hospital day, quite often just overnight. Most surgeons encourage an early return to normal activities as that helps people to get better quicker.

The common techniques are a ‘microdiscectomy’ which involves using a microscope, or a ‘minidiscectomy’, the results of these operations are very similar. They are mainly to relieve pressure on nerves most commonly by removing a disc prolapse. A decompression is the term used for removing bone that may be causing pressure symptoms on the nerve. If the bone removed is from one under the small joints (or facets) of the spine it is called an ‘undercutting facetectomy’. It is quite common, particularly as people get older for a combination of ‘ discectomy’ and ‘decompression’ to be required.

Your surgeon will discuss the specifics and principles of the procedure with you. Often the specific operation is tailored to the individual.

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RISKS OF SURGICAL TREATMENT

Damage to spinal nerves

The spinal nerve causing the pain may be already damaged by the disease process. The disc prolapse can cause scarring with in the nerve such that it is unable to recover despite technically successful surgery. The nerve can be stretched in trying to remove the disc lying under the nerve. The nerve can also be damaged by direct surgical trauma or by pressure effects necessary to control bleeding. Symptoms following nerve root damage may vary from paralysis of certain muscles, loss of sensibility, blader and bowel dysfunction to simple numbness.

Damage to blood vessels

This can result in significant bleeding which can be life threatening. Damage to the main blood vessels at the front of the spine (the aorta) has been known to occur (rarely). The main blood vessels to the legs can also be damaged which could result in loss of limb. Events of this nature are rare, occurring in less than 1 per 10000 operations. Damage to vital organs: The liver, kidneys and bowel are in front of the discs and are theoretically at risk of injury. This again would be life threatening but extremely rare.

The wrong operation

The spine has many discs and vertebra looking all almost identical. During the operation the surgeon will commonly carry out x-rays to check that he is operating at the correct place in the spine. In spite of the fact that many safety checks occur to make sure that the patient has the correct procedure it might happen, that the wrong segment is decompressed. The correct level will be additionally approached either in the same procedure or later in a second intervention.

Infection

Superficial wound infections may occur in between 2% and 4% of spinal operations. Risks of infection are increased in diabetic patients, patients on steroids or those with lowered resistance to infection.

Deep spinal infections are much more serious but less common . A deep spinal infection occurs in approximately 1% (or less) of cases. To reduce the risks of infection antibiotics are often given and the surgery is often performed in ultra clean air flow theatres. If a deep infection occurs it can require repeat operations to washout the spine and a prolonged and extensive course of antibiotics.

Fluid leakage (Incidental durotomy)

This is where an opening occurs in the dura which is the lining of the spinal canal. The spinal fluid within the spinal canal will drain out of the hole. It may occur deliberately if the surgeon intends to do it as part of the operation. It may occur as a result of the disc or bone being very stuck to the lining of the spinal canal. In primary sciatica surgery it occurs in 3% of cases. In decompression surgery it is more common , happening in 8% of cases.

If there has been a previous spinal operation it is even more common because of scarring. Repeat or revision operations have a higher risk of complications than first time operations.

Sometimes the hole in the spinal lining (the dura) can be repaired with stitches or a patch. Sometimes it is safer to leave it to heal. Sometimes the surgeon will insert a drain to divert the fluid. Usually the leak of fluid dries up within a few days and there is no long term effect. Sometimes despite precautions spinal fluid will leak through the wound. This represents a risk of infection and meningitis and further surgery might be required to correct the situation.

Late scar formation

Scar formation is a natural response of the body to injury or surgical procedures. In the spinal canal, where the available space is limited, such scar formation after surgery may lead to new symptoms similar to the original ones. In cases with extensive scar formation, revision surgery and repeat decompression might be necessary. Additional fusion might be indicated to reduce mechanical irritation of the nerve roots.

Instability

Posterior elements of the lumbar spine, especially the facets (articulations between the vertebrae), are essential for the integrity and stability of the spine. If these structures have to be removed extensively during the decompressive procedure, instability of the spine may occur. This situation is usually painful and necessitates additional stabilization and fusion either during the decompressive procedure or in secondary surery.

Death

The risk of death is low, it is difficult to quantify and is probably less than one death per 700 operations for sciatica. It would be from unexpected events (usually not directly related to the spinal surgery) such as blood clots in the legs passing to the lungs (pulmonary embolus), or catastrophic blood loss from major blood vessels. The risk will vary according to patient factors such as heart disease, high blood pressure, smoking, and specific age related risks. The risk of death from decompression surgery for stenosis is higher (possibly one per 350) than for disc surgery as the patients are usually older and less fit.

Paralysis

The risk of paralysis, which means loss of use of the legs, loss of sensation and loss of control of bowels and bladder is low. Probably occurring less than one per 300 operations. It could occur through bleeding into the spinal canal after surgery (an extradural spinal haematoma). The risk of paralysis is higher if patients are taking blood thinning medication (warfarin) or if there is an incidental durotomy (leak of spinal fluid). If an adverse event of this nature was to occur every effort would be made to reverse the situation. Sometimes paralysis can occur as a result of damage to the blood supply of the nerves or spinal cord, and this is not reversible.

What you need to know

You will have several chances to discuss the operation with Health Care professionals looking after you. You must make sure that explanations are given in terms you understand.
© The above text, figures and data are property of EUROSPINE®, the Spine Society of Europe and may not be reproduced or used in any other way.

EUROSPINE, January 2008

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