Lumbar Spine
Decompression Surgery
The Purpose of this Information
This information is being
provided to you in order to prepare you to make decisions about your
own health care. If you should ultimately decide that surgery is the
best treatment option for you, this section will help you understand
what happens during a lumbar decompression and will help you
prepare for your role in the healing and recovery process. Read it
thoroughly and answer the questions before making your final
decision about your treatment options.
The Health Care Team's Role
The duty of your health care
team is to:
- evaluate your condition;
-
establish a diagnosis;
- present the various treatment options;
- offer a specific treatment recommendation;
- provide you with the information you need to make a decision; and
then
- support you in the decision you make.
The Patient's Responsibilities
You are the only one who can
decide to have surgery. It is important that you take ownership
of this decision, recognizing the limitations your particular
physical condition places on the potential success of each of the
treatment options.
If you choose to have
surgery, your physical condition and your mental attitude will
determine your body's ability to heal. You must approach your
surgery with confidence, a positive attitude, and a thorough
understanding of the anticipated outcome. You should have realistic
goals - and work steadily to achieve those goals.
The decision to have or not
to have surgery includes weighing the risks and benefits involved.
You will make the final decision, so ask questions about anything
you do not understand.
Since medical care is
tailored to each person's needs and differences, not all information
presented here will apply to the patient's treatment or its outcome.
Seek the advice of your physician and other members of the health
care team for specific information about your medical condition.
Anatomy of the Back
The spinal column, or
backbone, consists of 33 bones (vertebrae) and can be divided into
five segments (Fig. 1A). The uppermost 24 vertebrae are
separated from one another by fibrous cartilage pads, called
intervertebral discs (Fig. 1B), which provide flexibility to
the spine and act as shock absorbers during activity. In the lowest
part of the spine, the vertebrae are naturally fused to form the
sacrum and the coccyx (tail bone).
Protruding from the back of
each vertebral body is an arch of bone that forms the large,
vertical opening (the spinal canal) through which runs the spinal
cord and nerve bundles. A fluid-filled protective membrane, the dura,
covers the contents of the spinal canal from where the cord begins
at the base of the skull to where it ends (in a bundle of nerve
fibers known as the cauda equina).
A pair of spinal nerves
branches at each vertebral level (one to the left and one to the
right), providing sensation and movement to all parts of the body.
Three large, bony
projections, or processes, arise from the vertebra's arch - one to
each side (transverse) and one straight toward the back of the body
(spinous). Strong ligaments and muscles attached to the vertebra's
body and processes support the spine and further protect the
delicate spinal cord and nerves encased within.
Back and leg pain, among
other symptoms, may occur when an intervertebral disc herniates (Fig.
1B, above). This happens when some of the disc's jelly-like
center (the nucleus pulposus) bulges or ruptures through its tough,
fibrous outer ring (the annulus fibrosis) to press upon a nerve. (Fig.
1C, above).
Lumbar Decompression
What is It?
Lumbar decompression or
lumbar laminectomy is an operation performed on the lower spine to
relieve pressure on one or more nerve roots. The term is derived
from lumbar (lower spine), lamina (part of the spinal canal's bony
roof), and -ectomy (removal)
. 
Why is it Done?
Pressure on a nerve root in
the lower spine, often called nerve root compression, causes back
and leg pain. In this operation the surgeon reaches the lumbar spine
through a small incision in the lower back. After the muscles of the
spine are spread, a portion of the lamina is removed (Fig. 2)
to expose the compressed nerve root(s).
Pressure is relieved by
removal of the source of compression part of the herniated disc, a
disc fragment, a tumor, or a rough protrusion of bone, called a bone
spur.
What Happens Afterwards?
Successful recovery from
lumbar laminectomy requires that you approach the operation and
recovery period with confidence based on a thorough understanding of
the process. Your surgeon has the training and expertise to correct
physical defects by performing the operation; he and the rest of the
health care team will support your recovery. Your body is able to
heal the involved muscle, nerve, and bone tissues. Full recovery,
however, will also depend on your having a strong, positive
attitude, setting small goals for improvement, and working steadily
to accomplish each goal.
The Operation
The Incision
Surgery for lumbar
decompression is performed with the patient lying on the abdomen. A
small incision is made in the lower back (Fig. 3). The size
of the incision depends on the severity of the problem but the
surgeon makes every effort to keep the incison as small as possible.
Laminectomy
After a retractor is used to move aside fat and muscle, the lamina
(bone covering the spinal canal) is exposed. Part of it is cut away
to uncover the ligamentum flavum - a thick ligament that covers the
spinal canal (Fig. 4).
Entering the Spinal Canal
Next an opening is cut in
the ligamentum flavum through which the spinal canal is reached. The
compressed nerves are now seen, as is the cauda equina (bundle of
nerve fibers). The cause of compression may now also be identified -
a bulging, ruptured or herniated disc, a bone spur or, or perhaps
only thickened ligamentum flavum (Fig. 5).
  
Removal of a Herniated Disk
The compressed nerve is
gently retracted to one side, and if a herniated disc is the cause
of the compression then this is removed. As much of the disc is
taken out as is necessary to take pressure off the nerve (Fig. 7).
The surgeon will remove all "safely available" disc material but not
the entire disc. After the cause of compression is removed, the
nerve can begin to heal. The space left after removal of the disc
should gradually fill with connective tissue.
Incision Closure
The operation is completed
when the incision is closed in several layers. Absorbable suture
material is used but we advise that the suture is removed at 2 weeks
by attending your GP surgery. Occassionally the suture ends need to
be clipped if it can not be removed in one piece.
Risks
Certain risks must be
considered with any surgery. Although every precaution will be taken
to avoid complications, among the most common risks possible with
surgery are: infection, excessive bleeding (haemorrhage), and an
adverse reaction to anaesthesia. Since lumbar laminectomy involves
the nervous system, nerve damage is another possible risk.
Clinical experience and
scientific calculation indicate that these risks are low; but
surgery is a human effort. Unforeseen circumstances can complicate a
normally no-risk procedure and lead to serious or even
life-threatening situations. Although such complications are rare,
you should feel free to discuss the question of risk with your
doctor.
Hospital recovery
Pain
It is normal to have some
pain after the operation, especially in the lower back. This does
not mean that the procedure was unsuccessful or that your recovery
will be slow. Leg aching is also not unusual, caused by inflammation
of the previously compressed nerve. It will go away slowly as the
nerve heals. You may experience muscle spasms across your back and
even down your legs. Medication will be given to control pain and
relieve spasm. Moist heat and frequent repositioning may also help.
Physical Activity
You may move about in bed
and rest in any comfortable position when you have recovered from
anaesthesia. Walking may begin within several hours. The easiest way
for you to get out of bed is to raise the head of the bed as far as
it will go, and then swing your legs to the floor. You may change
positions in bed. During the first few trips from bed, you will
require help from a nurse to avoid falls or injury.
Hygiene
Usually, you may take a
shower a couple of days after surgery. This will make you feel
better and should be done with a waterproof dressing left in place
to protect the incision. Your nurse will be able to change your
dressing to a waterproof one. Lotion may be massaged into the lower
back, including the area around the incision to eliminate dryness
and help relieve muscle spasm.
Nutrition
Intravenous (I.V.) fluids
will be discontinued when you can tolerate regular liquids without
nausea or vomiting. Your diet will then be adjusted back to normal
as your appetite returns. Constipation will be treated with
laxatives and a diet of whole grain cereals, fruits, and fruit
juices.
Emotional Changes
It is normal to fee
discouraged and tired for several days after surgery. These feelings
may be your body's natural reaction to the cutback of extra hormones
it put out to handle the stress of surgery. Although emotional
let-down is not uncommon, it must not be allowed to get in the way
of the positive attitude essential to your recovery and return to
normal activity.
Discharge from the Hospital
The hospital stay for lumbar
decompression patients usually lasts from 3 to 5 days. For a single
level discectomy the hospital stay may be shorter This will be
determined by your progress and by the amount of comfort and help
available to you at home.
Home Recovery
Physical Activity
Daily walking is the best
exercise. Try to increase your distance a little each day, setting a
pace that avoids fatigue or severe pain. You may climb stairs when
you feel able.
Avoid sitting or standing
for long periods of time. Change positions frequently to help
eliminate lower back muscle spasms and leg aching.
Sexual relations may be
resumed during the recovery period, but positions that strain the
back or cause pain should be avoided.
"Listen" to your body.
Discomfort is normal while you gradually return to normal activity,
but pain is a signal to stop what you are doing and proceed more
slowly.
Sleep
During the recovery period,
it will help to take several short rests throughout the day. If
lying flat, place a small pillow or rolled towel under the small of
your back. The best positions for resting are on one side with the
top leg bent up, or on your stomach. Waking up with a stiff back is
not uncommon and may be relieved by taking a short walk or a warm
shower. A firm mattress is important for proper back support.
Working
Your doctor will help
determine when you can return to work and with what limitations. If
your job requires lifting, twisting, or bending, a work release may
be given to you during the first postoperative visit.
Driving
Drive a car only when you
have recovered full coordination and are experiencing minimal pain.
Do not drive after taking pain medication.
Medication
You should gradually use
less pain medication while recovering at home. This can be
accomplished by increasing the amount of time between taking pills,
then by reducing the number taken each time. A certain amount of
discomfort and pain in the lower back can be expected until the
inflammation and nerve sensitivity have subsided. Heat, exercise,
massage, and short rest periods will also help relieve pain.
Physical Fitness
It is important that you
develop a general physical fitness program. Being overweight or out
of shape strains the lower back and will delay recovery. Controlling
weight will help you develop a stronger and more flexible back.
Exercises must also be done every day to build up strength and keep
muscle tone.
Hygiene
Once the skin sutures are
removed, it is not necessary to keep the incision covered. Unless
instructed otherwise, you may take a daily shower or tub bath, which
will help you feel better. Let the water run over the incision, but
do not scrub or rub over it. Pat it dry. After bathing, massage
lotion over the tightened muscles of the lower back and buttocks.
Inflammation
If you notice increased
redness, swelling, or any drainage around the incision after leaving
the hospital, notify your doctor.
Nutrition
A well balanced diet is
necessary for proper healing. Include foods from each basic food
group: dairy products, meats, vegetables, and fruits. Since you will
be less active during recuperation, avoid rich, heavy foods and
those high in calories but low in nutrients.
Healing and Recovery
Healing
Healing is the body's
natural process of restoring its damaged tissues to a normal or
nearly normal state. Although healing may be improved by general
good health, proper nutrition, rest, and physical fitness, it will
occur without your having to work at it.
Recovery
Recovery is the process
during which you work to become well. It requires a gradual but
persistent effort to increase physical strengths and minimize
weaknesses. You must concentrate on what is improving, rather than
on what symptoms remain. This focus on progress that has been made,
combined with the constant effort to improve, make up the positive
attitude that will speed your return to normal daily activity.
The human body is an
intricate network of interrelated systems. Each system functions on
its own but is also influenced by and dependent upon the others.
When illness or injury occurs, it disrupts the function of one or
more of these systems.
Surgery is a human effort
made to correct one system's malfunction, but it will affect all
others. Because of this complex interrelationship, surgical outcomes
cannot be predicted.
When
recovery is possible, it occurs as a combination of the surgeon's
effort, the patient's faith, and a positive acceptance of the
outcome.
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Lumbar Decompression
