Lumbar intervertebral disc operation

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.

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.

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, 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.

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