Overview of Diskectomy
Diskectomy is a surgical operation done to remove a part of a spinal disc that’s damaged or has bulged out. This usually has to do with a condition called lumbar disk herniation. Lumbar disk herniation is when the inner part of a spinal disc sticks out through a tear or weak spot in its outer layer. This can result in discomfort such as pain, numbness, or weakness due to the pressing of spinal nerve roots.
Lumbar disk herniation is a common condition among individuals aged 35 or older, especially in men. It mainly affects the L4-L5 and L5-S1 levels of the spine. Typically, non-surgical treatments are the first options, like taking medication, rest, and physical therapy. However, if these treatments don’t work, a diskectomy may be necessary. Physical therapists play a significant role in providing effective non-surgical treatments.
The diskectomy procedure is done by making a small cut in the back to reach and remove the bulged-out disc material. This action helps relieve the pressure on the adjacent nerve structures. Despite the procedure remaining the same in its core aim, new surgical methods aim to cause less trauma to the spine muscle and improve the surgeon’s view during surgery. These enhancements aim to provide better treatment results and minimize complications after surgery.
The diskectomy procedure has seen historical changes since it was first described in 1934. The techniques have become significantly less invasive over the years, resulting in less tissue damage. Nowadays, there are various surgeries used for diskectomy, including surgeries that require small incisions, use microscope assistance, or even involve fully endoscopic (using a tube with a camera at the end) approaches. These surgical procedures have been successful in improving the patient’s quality of life.
Anatomy and Physiology of Diskectomy
A diskectomy is a surgical operation carried out to treat a spinal issue known as a herniated or damaged disk. The spine, also known as the vertebral or backbone, is made up of individual bones called vertebrae. These vertebrae are stacked one on top of the other to provide the body with structure and protect the spinal cord.
The vertebrae are separated by intervertebral disks, which are cushion-like structures that help lessen the impact on the spine when you move. These disks are composed of a tough exterior layer, the annulus fibrosus, and a softer, jelly-like interior part, the nucleus pulposus. On either side of the vertebrae are little openings known as foramina. These serve as exit points for nerve roots, which are offshoots of the spinal cord that aide in transmitting signals for feeling and movement throughout the body.
A disk becomes herniated when the soft nucleus pulposus pushes out through a tear or weakness in the tough annulus fibrosus. This can cause irritation to the nearby nerve roots, leading to symptoms such as pain, numbness, tingling, or weakness. Professionals think that these symptoms come from a combination of pain signals coming from the damaged disk, inflammation affecting nerve roots close by, and the physical pressure of the protruding disk onto nerve roots.
Why do People Need Diskectomy
A diskectomy is a surgery where doctors remove a part of a problematic spinal disk. There are a few reasons why someone might need this surgery:
Firstly, if they have “Cauda Equina Syndrome.” This is a very serious condition where the bundle of nerve roots at the lower end of the spinal cord (known as the “cauda equina”) is severely compressed. This can cause lower back pain, numbness or weakness in one or both legs, and even bowel or bladder dysfunction.
Secondly, a diskectomy might be needed if someone is experiencing severe and continuing pain despite 6 to 8 weeks of conservative treatments. These treatments might include physical therapy, medication, and lifestyle changes.
Lastly, if a person shows progressive or new-onset neurological deficits, surgery might be necessary. This could mean if someone is losing sensation, movement, or other nerve functions, indicating a worsening situation.
When a Person Should Avoid Diskectomy
There are certain situations where a diskectomy, which is a surgery to remove problem disks in the spine, might not be recommended:
If the patient has bony spinal canal stenosis, which is a narrowing of the space where the spinal cord is.
When a person has concurrent segmental instability, which means their spine is unstable in certain places.
In cases where there are malignant tumors that have spread to the dura, which is a membrane protecting the brain and spinal cord.
If the patient has neurological or vascular problems that look like disk herniations, meaning they have problems with their nerves or blood vessels that seem like they have problem disks in the spine.
When a local or systemic infection is present, which means an infection that’s limited to one spot or an infection affecting the whole body.
If a person has a broken bone in the spine that requires fusion or instrumentation, which are procedures to help stabilize the spine.
However, these factors don’t automatically disqualify someone from having a diskectomy. They are considered on a case-by-case basis and depend on the patient’s individual health and their surgeon’s expert opinion. Sometimes, a surgeon may decide that the possible benefits of a diskectomy outweigh the risks, especially if other treatments haven’t worked or if the person’s symptoms greatly affect their daily life. Therefore, it’s very important for the patient and their healthcare provider to have a detailed discussion about the potential benefits and risks before making a decision about surgery.
Preparing for Diskectomy
Before a diskectomy, which is a surgery to remove a problematic disc in your spine, your doctor needs to do several things to make sure the operation is successful. First, they will ask you a lot of questions about your medical history and perform a thorough examination to identify any signs of a herniated disk, like trouble walking normally, depending on the level of the disk involved. Then, they use a dermatomal map, which is a kind of body map, to accurately find the affected nerve roots.
Next, they will use several medical imaging techniques such as x-rays, CT scans, MRI, and diskography. These procedures will confirm the presence and specifics of the herniated disk, such as its location, type and details about its appearance. Doctors use terms like ‘protrusion’, ‘extrusion’ and ‘sequestration’ to describe the condition of the herniated disc which simply mean to what extent the disc material is bulging out from its normal place.
It’s also super important for the doctor to talk to you about the natural course of your condition. Lumbar disk herniation, for instance, usually causes the symptoms to relieve quickly within 4 to 6 weeks, and about 66% of the times, the material bulging out of the herniated disk contracts on its own thereby reducing the symptoms over time. But the symptoms can recur in 5-10% cases. Therefore, understanding the various management strategies along with their pros and cons is useful in making an informed decision.
Next, your doctor will choose the right kind of anesthesia – spinal anesthesia or general anesthesia – based on your individual health status and your preference, both of them are equally reliable. An aspect to note here is that a research study showed that general anesthesia could significantly reduce postoperative pain as compared to the other types, but the other types are less expensive and risky.
On the day of surgery, several safety measures are put into place, ensuring a clean and sterile environment in the operating theater, and applying the required antibiotics. The way you are made to lie on the operating table is important – placing you in a specific position to provide your abdomen and chest the support they need and helps in making an easy access to the surgical site. Use of protective gear, like eye protection, is also vital. Lastly, using markers on the surface of your body and a technique called fluoroscopy your doctor ensures they are targeting the right spot for surgery.
How is Diskectomy performed
The typical treatment for a lumbar disk herniation, or a “slipped” disk in your lower back, is an operation called a diskectomy. In this procedure, the surgeon removes the part of your spinal disk that is causing your symptoms. Such operations can be successful in relieving symptoms in 60% to 90% of cases. In the past, this type of surgery was only done with a larger incision (open diskectomy), but now there are also less invasive options available.
In an open diskectomy, you will be placed face down on a table after being put to sleep with general anesthesia. The doctors will mark a spot on your lower back and make a 3-4 cm long cut along that line. Using a tool that uses electricity for cutting and cauterizing tissue, they then expose the lumbar fascia, a band of connective tissue along your lower spine. They will then separate the muscles around your spine, being careful to avoid any important structures in the area. They will use a needle with a camera to precisely locate the disk causing problems. The surgeon then removes the troubling disk tissue with a special tool.
Occasionally, part of the herniated disk might be hidden under a ligament along your spine. In this case, the surgeon might need to cut the ligament to access and remove the disk. They will carefully examine the area and flush it with saline to ensure all parts of the disk have been removed. Once they have stopped any bleeding and cleaned the area, they will stitch up the layers of tissue they cut through and finally close up your skin.
In a microlumbar diskectomy, the same process is followed, but with a smaller incision – only 2-3 cm. This type of surgery uses special magnifying glasses or a microscope to see the area more clearly. This technique still requires removing the problematic disk tissue and may also require removing part of a ligament or other tissue in the area to access the disk. After all problematic tissue is removed and the area is cleaned, the incision is closed with stitches.
Finally, in a minimally invasive surgery tubular diskectomy, the procedures are largely the same, but the tools used are specially designed to work through a tubular retractor. This allows the surgeon to work through a much smaller opening, reducing damage to the surrounding tissue. After the surgery is complete, the small incision is closed similarly to the other procedures.
All three of these methods aim to relieve your back pain by removing the part of your spinal disk that is causing problems. The best method for you will be determined by your surgeon based on your individual situation.
Possible Complications of Diskectomy
During a lumbar diskectomy, or surgery to remove a part of the spine called a disk to relieve lower back pain, there can be several complications.
One such complication is a ‘Dural tear’, where the protective layer over the brain and spinal cord, called the dura mater, can get accidentally torn. This can lead to leakage of cerebrospinal fluid– the fluid that cushions the brain and spinal cord, potentially leading to infections like meningitis. This may happen in about 9% of surgeries and is often due to pulling the nerves too hard during surgery. In most cases, this can be fixed by suturing the tear or using biological glue to seal it.
Another issue may be an ‘Iatrogenic neuropraxia’, a complication where the nerves get damaged during surgery. This complication affects around 1% to 2% of patients.
Infections can occur at the site of surgery in about 2% to 3% of cases. In addition, the surgical wound can split open in about 1% to 2% of cases.
Internal bleeding in the epidural space, an area in your spine, can also happen. There are methods to manage this, like compressing the area or using blood clotting agents.
Vascular injury, or injury to a blood vessel, although rare (less than 1%), can still occur. Certain blood vessels in the spine are more at risk and managing these cases may require repairing the injured vessel.
Other complications include the risk of not identifying the correct disk to be removed, the recurrence of disk herniation (bulging of the disk), leading to repeated surgery. According to one study, at a 5-year follow-up, 6.27% of patients had recurrent herniated disks, with 63% of the recurrences happening within the first six months.
Lastly, ‘Failed back surgery syndrome’ is also a possibility where patients continue to have back pain despite surgery. The recurrence rates vary greatly (from 3% to 15%) and can increase due to factors such as type of disk herniation, a patient’s gender, smoking habits, the nature of their work, obesity, and presence of diabetes.
Follow-up studies showed varying results for recurrence rates, reoperation rates, and other complications depending on the surgical approach used to perform the diskectomy.
What Else Should I Know About Diskectomy?
Endoscopic techniques, which involve using a small camera to perform surgery, have shown promise in treating lumbar disk herniation, a condition where the cushioning disks in your lower spine are damaged. These techniques often lead to a quicker recovery and a shorter hospital stay compared to other techniques like minimally invasive surgery or open surgery. However, more long-term studies are needed to determine the best approach.
Research has shown that outcomes for patients who have minimally invasive surgery are similar to those who undergo standard diskectomy, a surgery where part of the damaged disk is removed. Although minimally invasive techniques can speed up recovery, they may be more expensive, and there may be a higher risk for the condition to return compared to traditional diskectomy. Additionally, it’s been shown that there might not be a significant difference in muscle damage with endoscopic approaches compared to traditional diskectomy.
While minimally invasive techniques can offer benefits like shorter hospital stays and lower infection rates, they also carry a higher risk for complications, including damage to the nerves during surgery. A recent review suggested that minimally invasive techniques might lead to less improvement in lower back and leg pain compared to open diskectomy. However, the long-term effects of these less invasive surgeries are still being studied.
It’s important to note that the best surgical approach can vary depending on the patient’s situation, which is why doctors often favor an approach that allows for a quick return to physical activity after surgery. Regardless of the technique, diskectomy is a crucial treatment for relieving the symptoms of lumbar disk herniation. It’s hoped that as surgical techniques continue to evolve they will offer better patient outcomes and care.
