Lumbar Surgery and Post-Operative Considerations

Natural history of disc injury

Non-operative treatment is the first line treatment for most patients with lumbar disc herniation due to favorable prognosis in most with stable neurology

Non-operative management usually consists of combination of:

• analgesia

• manual therapy (incl. mobs and traction)

• exercise (such as mckenzie repeated movements)

• steroid + local anesthetic injections

Most common reason a nerve is compressed

disc buldge (that is touching or compressing a nerve root)

many people have disc buldges but are asymptomatic because it is not touching a nerve

disc herniation

normal

disk protrusion

disk extrusion

disk sequestration

Big disc protrusion

More likely it is going to go away on its own

Types of medical interventions: Non-surgical procedures

Lumbar corticosteroid injection

• Facet joint injection

• Nerve root block

Rhizotomy or Facet Joint Neurotomy

Types of medical interventions: Spinal Surgery

Discectomy

• Microdisectomy

• LESS (Laser Endoscopic Spinal Surgery)

Laminectomy

Disc Arthroplasty (disc replacement)

Lumbar fusion

Non-Surgical: Nerve Root Block

Used namely in conditions with severe radicular pain, a nerve root block bathes the nerve root in local anesthetic and corticosteroid

The steroid acts as a potent anti-inflammatory which directly affects the area of nerve root irritation

Expected improvement in radicular symptoms for up to 3 months post injection (however up to 75% have good success >1 year post injection)

Rhizotomy or Facet Joint Neurotomy

The nerves providing afferent sensory input from the facet joint are, for a few minutes, either:

• cut

• cauterized (burned)

• frozen, or

• electrically-pulsed (pulsed radiofrequency)

If successful, this procedure removes afferent pain signals coming from the painful facet joints

Spinal Surgery Aims

To Manage:

• Neurological pathology (leg symptoms such as weakness but also leg pain)

• Major structural deficits (fractures, scoliosis, instability)

Treating back pain is not the primary focus

Discectomy

Microdiscectomy:

• minimally invasive surgery

• removes the small part of the nucleus pulposis touching the nerve root or cauda equina nerves

• immediate reduction in radicular pain + / - weakness post operatively

• sensory disturbance may persist for months / indefinitely

Laminectomy

Often called a decompressive laminectomy

Tends to be performed after failure of non-surgical management, or in case of need for rapid decompression of neural tissues (like CES)

Procedure where lamina is removed from one or multiple spinal levels to decompress the neural tissue

Indications for Laminectomy

Cauda equina syndrome

Large disc herniations not amenable to microdiscectomy

Degenerative canal stenosis (symptomatic)

Epidural abscess (infection)

Hemilaminectomy

half lamina is removed

Disc replacement

Mostly when there are no radicular symptoms

Post-surgery protected mobility (avoid what)

Avoid positions that will put the nerve on stretch after spinal surgery

Post Fusion Surgery Protocol

often avoid bending for 3 months

focus on neutral spine exercise

walking is important

return to vigorous lifting, activity, sport can be one year or longer

Discectomy/Laminectomy Post Surgery Protocol

Gradual increase in lifting allowance (<10kgs for 3 months)

Often avoid bending for 6 weeks

Disc Replacement Post Surgery Protocol

Often avoid bending for 6 weeks

Return to vigorous lifting, activity, sport 6-9 months or longer

Neurological change

Any pt. with neurological changes (worsening) or true myotomal + reflex loss should be referred for neurosurgical opinion

Non-surgical management

Often 1st line management for true lumbar radiculopathy due to the highly positive prognosis for most disc injuries (symptomatically within 8 weeks, on imaging in 8 months)

Surgical techniques

Range from minimally invasive (microdiscectomy) to open procedures with variable outcomes

Post-operative physio

There should be guidance from the surgeon regarding rehab timeframes, goals, and limitations