PATIENT GUIDE TO MINIMALLY INVASIVE LUMBAR MICRODISCECTOMY

Minimally invasive microdiscectomies are common, safe, and effective operations that are commonly performed by neurosurgeons. Our practice generally carries out three such procedures per week, and Dr. Saris and Mr. Casper have performed over a thousand. Below is a description of the procedure that we hope you will find helpful.

The most important thing to remember is that this operation has changed. We view this procedure the way you might view endoscopic knee surgery for a torn cartilage. A microdiskectomy is a 45-minute, outpatient procedure with a very high cure rate during which a small piece of cartilage (your disk herniation) is removed under a microscope. It is very safe, and the chance of something going wrong is well under 1 percent.

PREPARATION: There is almost no preparation for your microsurgery. You should have nothing to eat after midnight on the night before the procedure. If you take medications in the morning, you should do so with a sip of water as you normally would. You do not need to wash your back in any special manner.

THE DAY OF SURGERY: The day of the procedure you will have an intravenous catheter placed in the holding area of the Operating Room. You will be given a light sedative, and after being wheeled into the Operating Room, will be given another injection through the intravenous that will put you to sleep. You will feel and remember nothing of the procedure. In general, it takes under an hour. If you have friends or family waiting, from the time they leave you in the holding area to the time I come out to tell them how things went is about 90 minutes.

At the start of the operation, you will be rolled gently onto your belly. An incision, usually about 2/3 the length of a toothpick, is made in the small of your back just above your buttocks. This incision is just big enough so that we can use the microscope. The rupture (herniated disk, ruptured disk, slipped disk, and extruded disk all mean the same) is located where it is pressing into the nerve and compressing it against the bone. The rupture is removed, but the normal and healthy disc is left behind. In all, no more than about 5% of the disc is removed. The operation is done under the operating microscope that provides a minimally invasive opportunity to perform this operation.

The night of the surgery, people usually have stiffness and spasms in the back that is moderate, but not severe. Almost everyone wakes up from the procedure, gets up off the stretcher a couple of hours later, and goes home the same day.

POST-OPERATIVE CARE : A pinched nerve causes pain, weakness, and numbness; the pain is usually in the leg. Recovery from pain traveling down the leg is the norm, and the cure rate is over 90%. Usually it is immediate, but sometimes it is delayed over a few weeks. If one month has passed from the time of the surgery, and you still have not experienced relief of your leg pain, I might be concerned about nerve damage, and would likely order an MRI. Five to ten percent of the time, the pain you experience before surgery will not get better.

In regard to strength, that usually improves quickly and is back to normal in a matter of a few months. Numbness is the least predictable in terms of recovery. The majority of the time, it will completely go away and you will feel back to normal. However, sometimes even years later the numbness will persist. Although this is annoying, most people generally tolerate numbness without difficulty.

Most people return home the day of the operation. When you get home, you may experience some stiffness in your back as if you have pulled a muscle. The leg pain that you had before will generally be gone either right away, or over a few days. The back pain, also called "incisional pain", will be bothersome for a few days, but then will ease off over a week or two. When you return home, you can drive a car and do most of the things you did before. Only strenuous activities such as playing sports or shoveling snow are discouraged for at least several weeks.

If you have a "white collar" or clerical job, you can return to work one to two weeks after the procedure. For more physically demanding jobs, such as nursing, construction or truck driving, the standard is to go back in one to two months. You will find that as the weeks go by, the stiffness and tightness of the back will slowly go away and apart from occasional twinges and brief periods of discomfort, you will generally be pain-free.

Please feel free to call the office if you have any problems. My physician's assistant, Mr. Rodd Casper, and I are available at virtually all times.


COMPLICATIONS: Although this is an operation done with the greatest of care with a high-powered operating microscope, complications may occur. Fortunately, these are extremely uncommon, and microdiskectomies are generally considered amongst the safest operations in all of neurosurgery. Below is a list, though not all-inclusive, of the complications. Please ask Dr. Saris if you have any questions about any of them.

RISKS OF OUTPATIENT SURGERY: During my years of surgical training in the 1980s, the standard of care was to remain in the hospital for several days after this operation. However, as anesthesia has improved, and as the operation has become less invasive under the microscope, many surgeons have begun performing this as an outpatient. We have performed one and two level procedures in this manner for several years without a single major mishap at home on the night of the surgery. However, like any medical decision, there are benefits and risks.

The benefit is the simple advantage of being in your own home and bed to recover from the microsurgery. Any painkiller you might receive via an intravenous in the hospital, you can take as easily by mouth at home. We have become increasingly concerned about hospital-acquired infections. There is a particularly dangerous strain called "MERSA" that is resistant to many of our best antibiotics and potentially fatal. The sooner you go home, the less the chance of this occurring. The main risk is internal bleeding after the operation. In the lumbar spine after a microdiskectomy, this could result in weakness or paralysis of the legs. However, in over 25 years of performing this procedure, I have not caused or heard of a single case of this.

It is your option to remain in the hospital or return home. I recommend returning home, and waiting until at least 11pm before going to sleep. If there are any problems, call an ambulance or come immediately to the emergency room. If you are more comfortable remaining in the hospital overnight, let our staff know and we will arrange this for you.

1. Continued pain. In general, the operation recommended to you has a very high incidence of pain relief. This is generally not an operation for pain in the low back, but rather pain from the cheek of the buttocks down to the foot. The success rate in medical journals is between 80%-95%. In my experience, it is over 90%. The pain relief can either occur immediately or over a period of about one month.

2. Infection. The approximate incidence of infection after a lumbar microdiskectomy is 1%. The majority of these are superficial infections involving the skin. These are generally easy to treat with antibiotics or local hygiene. On rare occasion, the infection can track down to the disk itself. This is a very painful condition that I have seen approximately three times in my career of over 20 years. It responds well to several weeks of antibiotics.

3. Spinal fluid leakage. The lower spinal cord and nerves are covered by a membrane about half the thickness of a credit card, and is leathery tough in texture. On occasion, while working near the nerve or lower spinal cord, small perforations or holes in this membrane can occur. This can allow release of a watery fluid that will usually stop on its own, though it may cause your hospitalization to be prolonged by a day or two. On rare occasion, a second operation will needed to repair the membrane. I have had to perform a second operation for a so-called "CSF leak" about 5 times in the past 20 years. The chance of a second surgery for a CSF leak is under 1%.

4. Vascular or bowel injury. There is a large artery called the iliac artery that, along with the bowel, is just in front of the disks. In over 20 years, and in over 1000 procedures, I have never damaged the artery or bowel. However, there are reports in the medical literature of damage to these, and either has the potential to cause death. I estimate the incidence of this to be under 1/100,000.

5. Risk of anesthesia. In a generally healthy person, the risk from anesthesia is low. In a generally healthy individual, the chance of death from this form of surgery is less than 1:300,000. I have been performing these operations for over 25 years and this has not occurred to someone under my care for this condition.

6. Nerve damage. Manipulation of the nerve can cause damage in spite of gentle dissection under an operating microscope. This could result in partial weakness and numbness traveling down to part of the thigh, leg, or foot. This occurs less than 1% of the time. It will usually improve, and would generally not cause problems with walking or mobility.

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Stephen Saris M.D.

Neurosurgery Associates, Inc.
3 Davol Square, Suite B200
Providence, Rhode Island 02903

(401) 453-3545
FAX (401) 453-3533

email: questions@neurosurgery-associates.com

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