The risks of endoscopic lumbar spinal surgery

The usual complications associated with major surgery are seldom encountered. Chest infection and blood clots forming in the deep veins of the legs (deep venous thrombosis or DVT) can occur but are very rare.

Parts of the blood clots may break off and fly up to the lung where they block the blood flow (Pulmonary embolus or PE). Very rarely people die from these blockages. You may have heard of these complicating long plane journeys. The most effective way to avoid these complications is to mobilise quickly after the procedure and this is one of the major advantages of endoscopic over open surgery. For those of you who are immobile, we can reduce the risks by giving you injections to thin the blood, supportive stockings and compression pumps on the legs worn while in bed.

There is a risk to life and limb. Any anaesthetic and any operation may kill you - even sedation and endoscopic surgery. Any spinal surgery may paralyse you which in the instance of a lumbar operation will mean loss of all leg, bowel, bladder and sexual function. At its worst, this may be complete and permanent. Such disasters are extremely rare – a risk in the order of the risk of your being run over by a bus. People do get run over by buses but it is exceptionally rare. Of course, if you do not have the operation the disc may fully prolapse and paralyse you itself. Again, we see this though it is very rarely. In other words, there are bad buses on which ever road you choose, they occur in approximately equal numbers on the two routes and rationally they should not influence your decision – though they clearly often do. These buses are indeed extraordinarily rare and we can usually see them coming and so take evasive action.

The “cauda equina syndrome” is the term used to describe paralysis of this part of your nervous system – the spinal nerve in the lumbar canal. The patient usually has a phase of excruciating pain followed by numbness, paralysis and an inability to pass urine which classically is painless. i.e., you know you have an overfull bladder but it does not hurt – “painless retention”. An early warning may be numbness around the perineum/private parts/the place where your pants go. If you notice anything like this you need to see a doctor, any doctor – don’t wait for us - immediately. This syndrome is a surgical emergency. You need to have the disc removed immediately i.e., that day / night.

Nerve root injury affecting the nerve that is being pressed on by the disc prolapse or the one exiting through the foramen we pass the endoscope through can occur though is also very rare. Obviously, the nerve roots are handled during the procedure though an endoscope provides excellent visualisation and patients being semi-awake alert us early if we are irritating the nerve. There is quite often a degree of increased numbness though more often patients describe the pre-operative numbness lifting somewhat and nearly all go on to improve thereafter. The risk will be less than 1%.

Failure of an operation to achieve its intended goal is always possible. In this instance it will mean the persistence of leg pain as it was before. This is uncommon though remember the purpose of these particular operations is to relieve leg and not back pain. The latter may remain though is often reduced to some degree. Further, rehabilitation for the back pain is more likely to prove effective when the nerves are no longer compressed and the legs are free. That is to say we get rid of the leg pain with surgery and the low back pain thereafter with rehabilitation physiotherapy. The persistence of some non-disabling levels of back pain is common after disc prolapse. It is not uncommon for a degree of pre-existing weakness and numbness to persist particularly if it was severe beforehand. The longer they have been present the more likely this is. However, most patients experience an improvement in weakness and numbness if not complete resolution.

Recurrence of symptoms may occur. That is to say you may get better only for things to get worse again later. There are a number of reasons why and again this may be in the form of back or leg pain. Back pain may occur in acute bouts and can be minimised by your being diligent with the post-operative physiotherapy. Leg pain may arise from a disc prolapse occurring at an adjacent level, a recurrence of the original disc prolapse, scarring occurring around the nerve root affected by the original disc prolapse, or damage caused by the original prolapse leaving the nerve root hypersensitive as it attempts to recover in the post-operative months. Usually, it is an element of each of these pathologies which operate together to cause recurrent leg pain. A degree of pain is not uncommon at times in the early phase though will usually settle over a period of a few weeks or months. Seldom are the troubles serious and rarely do they then persist though precisely how often is still a matter for some debate. To find out a true recurrence rate, thousands of patients need to be followed for tens of years and for none to drop out during that time. There has been no perfect study but it is our impression from those studies that have been done and from our experience, that perhaps 1 in 10 patients at some point in the future get into substantial recurrent trouble. That is to say we feel it is about the same as for standard open microdiscectomy procedures. Recurrence of course largely reflects the natural history of disc disease rather than anything relating to the surgery itself though it is important that you appreciate the operations simply tackle current troubles and offer no protection against future problems at other levels – the post-operative physiotherapy perhaps does. Obviously, we would not offer the surgery if we did not think that without it you are likely to fair worse than you are with it.

Deterioration is a possibility. Operations can make you worse, can do you harm or may leave you with new problems to cope with. This is rare and deterioration directly as a result of the surgery probably affects a fraction of 1% of patients. Quite a few patients may have a transient increase in numbness or weakness though persistent significant problems are rare indeed.

Wound infection can occur with any operation. In the spine, it is rare as there is so much muscle covering it. Muscle fights infection well. However, if an infection ever sets in the effects can be very serious. Again the risks are less than 1%. Diabetic patients are at a slightly higher risk of this.

Obviously you must know what the aims and risks of any operation are. We will document in the notes that we have explained these to you as it is routine to do so. Do not sign the consent form if you feel we have not.

We will write something like this in your notes:- make sure you feel it is true

“I have explained the aims and risks of the procedure including those to life and limb (ie. death paralysis and disaster), of failure (the procedure does not work), recurrence (you get better but it comes back) and deterioration, (you are made worse), of death, paralysis, wound problems, of nerve/ nerve root injury, as well as the likely natural history of the condition (what happens if nothing is done), the possible impact of alternative managements and treatments, along with the usual post procedure recovery and its variants (i.e., how much time off from work, what help you will need at home, what the wound care is).”

These are all things you will need to have had covered. Again, do not sign the consent if you are not sure.

Eventually many people’s troubles will settle though again good data is hard to find. A general rule of thumb is that within the first six to ten weeks spontaneous resolution occurs for about 95% of patients – or at least a substantial and consistent decline in symptoms is evident. If you are having surgery before this time there needs to be a good reason – progressive motor or sensory loss, worsening rather than consistent or declining pain or a disc prolapse of such immense proportion that it threatens paralysis. You should know what the reason is for such rapid progress. However, if after this time there is no clear pattern of decline in symptoms many of you are stuck at least for a long time. Into this picture it may be reasonable to integrate any social, personal, occupational and domestic pressures.

Much of this is covered elsewhere and will form part of our discussions. Lumbar Microdiscectomy is the principle operative alternative. If this is relevant to you, we will discuss it. However, any operation is always the last resort. Instead, you could try injections or further conservative treatment (physiotherapy, osteopathy, chiropractic, acupuncture, tablets and time). Obviously, we will usually have formed the view that these are unlikely to bring you comfort any time soon before recommending surgery. Occasionally, we will have warned you that bad paralysis of nerves may occur if things are left and in these circumstances there is little choice but to proceed though this is rare. For the majority, it is pain that drives the surgery. In these circumstances, you have to feel that the degree of pain warrants the risk and effort involved in having the operation.

Planning your discharge

Do not have a fixed plan. Make arrangements that are flexible. Surgery is not like fixing a new car.

You need to be recovered enough so that you can manage the journey home and life at home. If you live a long way off, are on your own or have a dependant young family you will need to stay for longer. Occasionally, the less able who live alone might sensibly use a convalescent facility.

Remember there is no rush – go home when you are ready. You should be able to tick certain boxes:

• be able to mobilise and more or less dress yourself
• to have passed urine
• to have tried some stairs
• to be able to manage on just oral medication and pain relief
• to be able to cope with your journey home
• to be able to survive comfortably with your personal home circumstance

How to get home

The front passenger seat in a standard car is fine. If the journey is long, get out of the car every hour and do some simple stretches. Then get back in and carry on. It is often sensible to take some tablets before you leave the ward. Go to bed when you get home regardless of how you feel.

Done once, even a long journey is OK. This is not a licence to drive every day.

Post-operative Back Care

Physiotherapy

You may well have been given specific instructions by the hospital’s physiotherapist. Indeed you are likely to be given a sheet with diagrams of various exercises. The precise details of these exercises and how often they should be done are of less importance than your response to them. That is to say, if you develop pain on doing these exercises, you should stop them. In the first few weeks all that can occur is the simple healing process. Physiotherapy maintains your mobility during this time but should not be allowed to interfere with the healing process. Therefore, if it hurts, you should stop and you should not be anxious if, as a result, you are quite stiff by the end of this early period. Physiotherapy begins in earnest around the fourth week when the back will be stable enough to allow real progress to be made.

Exercise

The aim here is to do small amounts but often. For most of the first week you will either be in hospital or should be pottering about inside your home. For the second week the amount of activity undertaken should essentially be unchanged. You should simply be moving about as if you were in fact still in hospital. It would be perfectly reasonable to fix your own meals and to look after yourself though you should not be doing housework or looking after others. You may go out for short walks. From the second week onwards, light exercise may be taken. You may go on very short car journeys (10-15 minutes) and go out for longer walks. Prolonged outings, lengthy or frequent trips to the office will be bad for you. Problems most often arise when patients do a little too much a little too often, i.e., one trip to the office may be alright but three cause troubles.

Sitting

You are better to be standing or lying following back surgery. If you wish to sit, a high, upright dining room style chair is the most appropriate. It is certainly reasonable to start sitting for your meals when you have gone home but it is sensible to stand up and stretch between courses. This should be back to normal around about the four to six week mark. However, it will always be advisable to avoid prolonged periods sitting and very soft or low armchairs.

Sex

If it hurts, don’t. If you think it will hurt, don’t - until of course you think it won’t and it doesn’t.

Wound care

You should not get the wound wet until the day after the sutures have been removed. It is perfectly reasonable to have a shower, providing the wound is covered with a waterproof dressing. The ward may provide you with this before you leave. In general, we like to change the dressings on wounds as infrequently as possible. The wound should be kept dry and a dressing used that allows the wound to breathe.

Removal of Stitches

The stitches should be removed at or shortly after the tenth day. We mostly use a single stitch which runs under the skin and can be pulled from one end. (Get an adult to help you.) I also usually put steristrips (small sticky tapes) across the wound and two in parallel with the wound to hold the stitch ends. The ones holding the stitch ends need to be pulled off and then the suture can be removed. Most often a nurse linked to your G.P. or the district nursing service do this. If you are near one of my hospitals you may be able to have these removed there. You need have agreed an arrangement for this to be done before you, leave hospital - our ward nurses who will liaise with your GP, district nurse or one of the local hospitals as is appropriate.

Bending, lifting, carrying

In the first few weeks you should not be doing this. The physiotherapy, which will begin about the fourth to sixth week, will teach you how to bend correctly and how best to lift. It should certainly be something that you keep to a minimum in the first months.

Driving

In the first few weeks you should be driven i.e., you should not drive the car yourself. In the weeks that follow, you should limit journeys to short periods. As physiotherapy commences and progress is made, you may gradually start to extend this. In general it is best to have the car seat set as high and as upright as possible. If you are becoming uncomfortable you should stop, get out and do some light stretches before continuing.

Sports

You should not do this until we have reviewed your progress. It should be deferred until you have completed the fitness programme that only begins with the physiotherapy at the fourth to sixth week and is likely to take a further four to six weeks at least.

General philosophy

The aim is for you to avoid things which aggravate your pain. Once recurrence of back and leg pain has occurred, it is much more difficult to get it to go away. It is much simpler to avoid it in the first place. If in doubt, err on the side of caution. You can do most things after the first week or so. However, you will not be able to do much of them. “Can I drive?”, “pick up the baby?”, “go into the Office?” or “fly?” are all frequently asked questions. The answer is usually yes BUT not very often. It is not so much what you do but how often you do it.

Planning your return to work

This may reasonably be considered after two weeks though there is a wide variation in this. Much of this relates to the job in question. Clearly a brick layer commuting 50 miles by car each way will take longer than a librarian working next door to home.

Whatever the work a gradual return is best – perhaps two half days the first week (Tuesday and Thursday), three the second (Monday Wednesday and Friday) and four the fourth (Monday, Tuesday and Thursday, Friday). Work five half days the next and then start to increase the length of the days. It is important to keep up the physiotherapy during this phase. The program outlined above is very gradual and more rapid progress may be possible but if pain recurs you should ease off.

Done in a graduated way the return to work is a very positive part of your rehabilitation. It needs to be in your control and with the encouragement of your employer. If they will put up with you being part-time and unreliable they will see you sooner.

If, by contrast, your job is one whereby you have to be there fulltime and reliably or not at all, it will take longer. Then the job is not a part of the rehabilitation but the hurdle rehabilitation has to prepare you for. You will get back later as you need to fully recovered before starting. If you have a long commute your return will be further delayed.

The average commute time for our patients is in the region of one hour each way. From the spinal perspective that is a two hour physical job in addition to your real work. Days spent working from home help.

Discuss this advice with your employer and make a plan. Obviously, the best laid plans may change due to circumstances and we will advise on how likely your plan is to come off at the first out-patient session post surgery i.e., at about the four week mark.

A safe return to sport

Clearly, the situation is different for the occasional exerciser than it is for the keen amateur sports person. Equally, the elite athlete or professional sports person will have particular demands. Certain sports are more trouble than others. With that in mind, here is some general advice tailored to the two broad groups:-

Advice for the amateur

In general terms, for members of the general public it takes three months to get over the surgery and return to normal life. It takes a further three months to train you back up to competitive sport.

Some sports are tougher than others. We would not recommend significant long distance running, rowing machines or squash, (tennis and badminton are usually fine). However, most other sports are fine- after an appropriate training schedule to get you fit and to strengthen the spine.

Two sports need a special mention. You should miss a ski season, i.e., this needs to be a good six months off. Likewise, it should probably be six months before you do serious riding – much depends on the horse of course! Essentially, done properly, skiing and horse riding are like advanced Pilates or core muscle exercises, i.e., they can be good for you. However, you would not leap into an advanced Pilates class any more than you would yoga and neither would you expect to do them if you were injured.

You may get back to your sport safely when the disc has firmly healed, (and you can do nothing to speed that up), and when you are cardiovascularly fit, have achieved good flexibility and basic core muscle strength. Your physiotherapist will guide you.

It is all about being reasonable and phasing in the return. Start with a few holes of golf and don’t go for the big drive on your first few visits. Make sure there is time to recover before and after you play. Gently build it up.

Whatever your sport, now is a good time to see a coach. Most professionals have injuries and there are ways to T off, to serve, to set up your bike and even to run, that are more back friendly than others. A professional coach will be able to help you if you explain your problem – “I have a bad back and want to run like Usain Bolt, please”. Good luck.

Elite or professional sports people

For elite athletes, the situation needs to be tailored to your specific sport and any neurological weaknesses. The latter can be frustratingly slow.

We can nearly always get you doing fitness work within a few weeks and will often use water-based exercise.

The younger you are, (i.e., the earlier in your career), and the tougher the sport is for the spine, the longer it takes. Likewise, many of you will have other injuries we need to work around.

There are nearly always specific competitions and events you are hoping to target and we will tailor the return to play in that context as much as is sensible.

We will always need to look at the routine of your training as well as technique if we are to prevent further injury. This is where the cause of so many injuries hides. It is therefore a process that will involve not only your physiotherapy team, but the coaches and managers so that with you we can put together a strategy that is most likely to see rewards.

It is the routine that most of you get back to your professions.

The trick is to cover all the angles and the devil is in the detail. Do try to be patient. It is like trying to escape from a field full of lions – you have to plan the route exactly and if you bolt for it they will see you. Take it gently, very gently at first, until we are certain we are fit and fast enough to smile while we bolt over the horizon.

This philosophy has worked well for many.

Please click here for details of the teams and organisations we have helped.

Where can I get help?

First, you may ring my office number. If it is during working hours this is certainly what you should do. My secretarial staff will be able to contact myself, my clinical assistants or our spinal nurse and obtain advice for you. If it is out of hours you may also ring this number and the machine will tell you what to do in the event of an urgent enquiry or you may leave a message.

Second, you may ring the hospital and ask to speak to my Spinal Nurse. In her absence, you should ask to speak to the hospital’s Duty Manager or to the ward staff. Telephone numbers are given at the end of this information sheet.

You may of course contact your general practitioner or any emergency service should you so wish or if the other avenues fail.

A separate information sheet is available which covers all aspects of this. Please obtain this and read it before you confirm your surgery. The costs of private surgery are considerable and if you are hoping to use insurance you will need to obtain authorisation from your insurer and register this with us prior to admission. Some insurers/policies may not pay all surgical, anaesthetic or hospital fees. All costs remain your responsibility even if your insurer has agreed to help/pay direct. There are usually three bills you need to know about; the hospital, the anaesthetist and the surgeon. You are responsible for ensuring all are paid.

Other sources of information

We produce a number of other information sheets. You may obtain a title list from my office.

The Princess Grace Hospital produces information on a number of surgeries including spinal procedures. We were also involved in their production so they are not entirely independent. You can obtain these from our Spinal.

Your General Practitioner will have seen other patients going through spinal surgery though will not likely have seen folk having endoscopic discectomy. Of course, they may also be familiar with any other health concerns you have and be able to offer advice on how these might impact on recovery.