Microdiscectomy

Microdiscectomy, also known as microdecompression, is one of the most common minimally invasive spine surgery procedures. The main goal of microdiscectomy is to take pressure off your nerves to relieve your back pain.

A discectomy, also referred to as decompression surgery, relieves pressure on spinal nerves (and its resulting pain) by removing portions of spinal bone or disks. Traditionally, discectomies are performed as “open surgeries” that require large incisions to allow surgeons to properly view and access the areas on which the operations occur.

Microdiscectomy also relieves pressure on spinal nerves. However, unlike discectomy, microdiscetomy is a minimally-invasive procedure. Because it uses special tools, the procedure only requires a small incision. As a result, microdiscectomy can cause less damage to muscle and tissue, be less painful, and result in a faster recovery after surgery.

During a typical microdiscectomy, a small (1-1.5 inch) incision is made in the center of the back. The back muscles are lifted off the spine, and a membrane covering nerve roots is removed. Often, a small portion of the facet joint (the joint that connects one vertebra of the spine to another) is also removed. The nerve root is then moved to the side, and portions of disc material causing pressure on the spinal nerves are removed.

Health exam You will need a complete physical exam to be sure you are in good health. See a health care provider 3 to 30 days before surgery for a history and physical (H&P) exam. A blood test, electrocardiogram (EKG), and chest X-ray need to be performed. Discuss all medications (prescription, over-the-counter, and herbal supplements) you are taking with your health care provider. Some medications need to be continued or stopped the day of surgery. Medications that thin the blood should be stopped 2 weeks prior to surgery. Drugs that thin the blood include: 

• Aspirin 

• Ibuprofen (Advil, Motrin, Nuprin) 

• Anti-inflammatories (Aleve, Naprosyn)

• Fish oil 

• Vitamin E 

• Herbals (gingko, glucosamine) 

• Blood thinners (Coumadin, Heparin) 

• Antiplatelets (Plavix, Ticlid, Fragmin, Orgaran, Lovenox, Innohep) 

• Wintergreen snuff  

Also, stop drinking alcohol 1 week before and 2 weeks after surgery because these activities can cause bleeding problems. 

The hospital will ask for a complete list of medications including prescriptions, over-the-counter, and herbal supplements. 

The most important thing you can do to ensure the success of your spinal surgery is quit smoking. This includes cigarettes, cigars, pipes, chewing tobacco, and smokeless tobacco (snuff, dip). Nicotine prevents bone growth and puts you at higher risk for a failed fusion. Patients who smoked had failed fusions in up to 40% of cases, compared to only 8% among non-smokers.

Smoking also decreases your blood circulation, resulting in slower wound healing and an increased risk of infection. There are many ways to help you quit smoking: 

• Over the counter and prescription nicotine replacements (for use only before surgery) 

• Pills without nicotine (Wellbutrin, Chantix) 

• Tobacco counseling programs  

It’s a good idea to get your home ready before surgery. Move things that you use often to a level between your shoulders and hips, so you do not have to bend or reach. Tie up phone cords and pick up throw rugs so you don’t trip. Prepare and freeze meals. Put non-slip strips in the shower/tub. You may need grab bars in the tub or toilet area. Get a chair with a firm cushion, armrests and a seat at knee level.

Many patients have trouble with constipation after surgery caused by pain medication and anesthesia. The week before surgery eat foods high in fiber including fruits, vegetables, beans and whole-grain cereals and breads. 

Drink water; 8 to 10 glasses of fluid every day. Walking also helps the intestines move more rapidly and regularly.

Over-the-counter fiber supplements such as Metamucil, Fibercon and Citrucel can help keep stools soft and regular. Don't rely on laxatives, such as Correctol or Dulcolax, which cause muscle contractions in the intestines. Who will stay with me? Most patients go home 2 to 3 days after surgery. Identify someone who can be with you for the first week and help drive for you, take care of pets, housework, cooking, and shopping. 

Your medication list (prescriptions, over-the-counter, and herbal supplements) with dosages and the times of day usually taken. Bring a list of allergies to medications or foods. 

• Bathroom items 

• Co-pay for prescriptions. Leave all other money at home. 

• CPAP machine (if you use one at home) 

• Brace (if you’ve been given one) 

• Personal items (book, music) to help you relax 

• Wear loose fitting clothes and flat-heeled shoes with closed backs 

• Leave all valuables and jewelry at home (including wedding bands) Night before surgery 

• Do not drink any alcoholic beverages. 

• If you have a cold, fever, or some other illness the day before surgery, please call your surgeons office. 

• No food or drink is permitted past midnight.  

• Shower using antibacterial soap and dress in freshly washed clothing. 

• Shower again using antibacterial soap and dress in freshly washed clothing.  

• You may brush your teeth.  

• If you have instructions to take regular medication the morning of surgery, do so with small sips of water. 

• Remove make-up, body piercings and nail polish. 

Arrive at the hospital 2 hours before (surgery center 1 hour before) your scheduled surgery time to complete the necessary paperwork and pre-procedure work-ups.

The nurse will ask you to remove your clothing (including underwear and socks) and to put on a hospital gown. In addition, you should remove any contact lenses, dentures, wigs, hairpins, jewelry or artificial limbs. Please give these and other personal belongings to your visitors to hold while you are in surgery and until you are in your assigned room.  

An anesthesiologist will talk with you and explain the effects of anesthesia and its risks. An intravenous (IV) line will be placed in your arm. You will be given antibiotics to decrease the risk of infection. 

You will be transported to the Operating Room on a stretcher. At that time, the nurse will direct your visitors to the Surgery Waiting Area. When surgery is over, your doctor will phone your visitors there.

The surgery is performed utilizing general anesthesia. A breathing tube (endotracheal tube) is placed and the patient breathes using a ventilator during the surgery. Preoperative intravenous antibiotics are given. Patients are positioned in the prone (lying on the stomach) position, generally using a special operating table with special padding and supports. The surgical region (low back area) is cleansed with a special cleaning solution. Sterile drapes are placed, and the surgical team wears sterile surgical attire such as gowns and gloves to maintain a bacteria-free environment.

A 1-2-centimeter longitudinal incision is made in the midline of the low back, directly over the area of the herniated disc. Special retractors and an operating microscope are used to allow the surgeon to visualize the region of the spine, with minimal or no cutting of the adjacent muscles and soft-tissues. After the retractor is in place, an x-ray is used to confirm that the appropriate disc is identified.

A few millimeters of bone of the superior lamina may be removed to fully visualize the disc herniation. The nerve root and neurologic structures are protected and carefully retracted, so that the herniated disc can be removed. Small dental-type instruments and biting/grasping instruments (such as a pituitary rongeur) are used to remove the protruding disc material. All surrounding areas are also checked to ensure no additional disc fragments are remaining.

The wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer and subcutaneous layers are closed with a few strong sutures. The skin can usually be closed using special surgical glue, leaving a minimal scar and requiring no bandage.

You will wake up in the recovery area called the post-anesthesia care unit (PACU). You may have a sore throat from the tube used during surgery to assist your breathing. You may feel tired, thirsty, cold, or have a dry mouth. Once awake you will be moved to a regular room. Pain and anti-nausea medication will be given as needed. 

Pain medication may be given in different ways: Through your IV line by a patient-controlled analgesia (PCA) pump. 

Only you know how to describe your pain. Your healthcare team will ask you to rate your pain on a scale of 1 to 10. 

1 = mild pain and 10 = worst possible pain. Using the scale, you will be asked to decide your comfort goal number. 

Most patients are able to go home the same day or early the next day after surgery. Before patients go home, physical therapists and occupational therapists work with patients and instruct them on proper techniques of getting in and out of bed and walking independently. Patients are instructed to avoid bending at the waist, lifting (more than five pounds), and twisting in the early postoperative period (first 2-4 weeks) to avoid a strain injury or recurrent disc injury. Patients should try to avoid sitting in the same position for more than 45-60 minutes in the first few weeks after surgery. After sitting for 45-60 minutes, patients should get up and stretch or walk for a little bit, then sit down again if desired.

After surgery, pain is managed with narcotic medication. Because narcotic pain pills are addictive, they are used for a limited period (4 to 8 weeks). Also, their regular use may cause constipation, so drink lots of water and eat high fiber foods. Stool softeners (e.g., Colace, Docusate) and laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) can be bought without a prescription. 

Thereafter, pain is managed with acetaminophen (e.g., Tylenol). Do not drink alcohol or operate a vehicle while using pain medication. Pain medications will not be refilled on evening or weekends, so plan accordingly. If you need a refill, call at least 48 hours before your bottle will be empty.  

 

Do not use non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve) for six months after surgery. NSAIDs may cause bleeding and interfere with bone fusion. Do not drive for 2 to 4 weeks after surgery or until discussed with your surgeon. Avoid sitting for long periods of time. Stand or take a few steps every 20 minutes. Do not lift anything heavier than 10 pounds (e.g., gallon of milk). 

Do not bend or twist at the waist. Housework and yard-work are not permitted until the first follow-up office visit. This includes gardening, mowing, vacuuming, ironing, and loading/unloading the dishwasher, washer, or dryer. Postpone sexual activity until your follow-up appointment unless your surgeon specifies otherwise. Do not smoke. Smoking delays healing by increasing the risk of complications (e.g., infection) and inhibits the bones' ability to fuse. 

Do not sit in tub baths, hot tubs, swimming pools, or lakes until your health care provider says it’s safe to do so.

You may need help with daily activities (e.g., dressing, bathing) for the first few weeks. Fatigue is common. Let pain be your guide. Gradually return to your normal activities. Walking is encouraged; start with a short distance the first 2 weeks. Then gradually increase to 1 to 2 miles daily. 

Physical therapy may be recommended. Sit in a firm chair with arm rests. Use a support cushion in the small of your back as needed. Log roll in and out of bed as you did in the hospital. Lie on your back with a pillow under your knees. Lie on your side with a pillow between your knees. If applicable, know how to apply the brace before leaving the hospital. Wear it for daily activities (excluding sleep) unless instructed otherwise. 

You may shower after surgery unless instructed otherwise. No tub baths. Steri-strips may cover the incision. After showering, gently pat dry the steri-strips. Gently remove steri-strips after one week. Staples or stitches that remain in place when you go home will need to be removed. Ask your surgeon or call the office to find out when. Keep your dressing clean and dry. Change the dressing daily. Wash your hands before and after. Check for signs of infection such as swelling, redness, yellow or green discharge, warm to the touch. Do not apply creams, lotions or ointments on or near your incision. 

If your temperature exceeds 101.5° F or if the incision begins to separate or show signs of infection, such as redness, swelling, pain, or drainage. Make an appointment for a follow-up visit 2 to 4 weeks after surgery unless otherwise instructed.  

You will need to set up an appointment for a follow-up visit with your doctor 1 week after surgery. You may be given light stretching exercises to do on your own. Your level of commitment to exercise will determine how fast and how well you recover. About six weeks later, routine visits should start with physical therapy to begin your rehabilitation. 

A physical therapy program will likely include exercises to strengthen your back and low-impact aerobics, such as walking or swimming. Your physical therapist will show you how to make modifications to your daily standing, sitting, and sleeping habits-for example, learning how to lift properly or sitting for shorter periods of time. Regular back exercises strengthen muscles that support your spine, easing pain and preventing further injury.

Recurrences of back pain are common. The key to avoiding recurrence is prevention:

• Proper lifting techniques

• Good posture during sitting, standing, moving, and sleeping

• Appropriate exercise program

• An ergonomic work area

• Healthy weight and lean body mass

• A positive attitude and relaxation techniques (e.g., stress management)

• No smoking Most people who have spinal fusion surgery are off work for approximately 6 to 12 weeks. You may or may not need to return to work with restrictions based upon your job. If you have a physically demanding position, you may need to be on restrictions when you return.

The results of microdiscectomy surgery in the treatment of a painful, herniated disc are generally excellent. Numerous research studies in medical journals demonstrate greater than 90-96% good or excellent results from microdiscectomy surgery. Most patients are noted to have a rapid improvement of their pain and return to normal function.