GUIDE TO MINIMALLY INVASIVE LUMBAR MICRODISKECTOMY
Minimally invasive microdiskectomies
are common, safe, and effective operations. Our practice generally
carries out three such procedures per week, and Dr. Saris and Mr.
Casper have performed over a thousand. Below is a description of
the procedure that we hope you will find helpful.
The most important thing to remember is that this operation has
changed. We view this procedure the way you might view endoscopic
knee surgery for a torn cartilage. A microdiskectomy is a 45-minute,
outpatient procedure with a very high cure rate during which a small
piece of cartilage (your disk herniation) is removed under a microscope.
It is amongst the safest operations procedures in medicine.
PREPARATION: There is almost no preparation for your microsurgery.
You should have nothing to eat after midnight on the night before
the procedure. If you take medications in the morning, you should
do so with a sip of water as you normally would. You do not need
to wash your back in any special manner.
THE DAY OF SURGERY: The day of the procedure you will have
an intravenous catheter placed in the holding area of the Operating
Room. You will be given a light sedative, and after being wheeled
into the Operating Room, will be given another injection through
the intravenous that will put you to sleep. You will feel and remember
nothing of the procedure. In general, it takes about 45 minutes.
If you have friends or family waiting, from the time they leave
you in the holding area to the time I come out to tell them how
things went is about 90 minutes.
the start of the operation, you will be rolled gently onto your
belly. An incision, usually about 2/3 the length of a toothpick,
is made in the small of your back just above your buttocks. This
incision is just big enough so that we can use the microscope. Most
people understand a herniation like the jelly coming from a jelly
donut when it is squeezed. In your case, the herniation is a piece
of cartilage about the size of a pea. This disk fragment is pressing
the nerve against the bone. The rupture is removed, but the normal
and healthy disc is left behind. In all, no more than about 5% of
the disc is taken out. The operation is done under the operating
microscope that provides a minimally invasive approach. You will
lose almost no blood (perhaps a third of a thimble).
When the nerve is free,
the operation is finished. We rarely put stitches in the skin, and
more commonly use paper strips called "steri-strips."
The hole through which the rupture occurred will seal over very
quickly (in a few days).
The night of the surgery,
people usually have stiffness in the back that is moderate, but
not severe. Almost everyone wakes up from the procedure, gets up
off the stretcher a couple of hours later, and goes home.
A pinched nerve causes pain, weakness, and numbness; the pain is
usually in the leg. Recovery from pain traveling down the leg is
the norm, and the cure rate is over 90%. Usually it is immediate,
but sometimes it is delayed over a few weeks. If one month has passed
from the time of the surgery, and you still have not experienced
relief of your leg pain, I might order an MRI to see if everything
than can be done, has been done.
In regard to strength,
that usually improves quickly and is back to normal in a matter
of a few months. Numbness is the least predictable in terms of recovery.
The majority of the time, it will completely go away and you will
feel back to normal. However, sometimes even years later the numbness
will persist. Although this is annoying, most people generally tolerate
numbness without difficulty.
Most people return home
the day of the operation. When you get home, you may experience
some stiffness in your back as if you have pulled a muscle. The
leg pain that you had before will generally be gone either right
away, or after a few days. The back pain, also called "incisional
pain", will be bothersome for a few days, but then will ease
off over a week or two. When you return home, you can drive a car
and do most of the things you did before. Only strenuous activities
such as playing sports or shoveling snow are discouraged for several
If you have a "white
collar" or clerical job, you can return to work one to two
weeks after the procedure. For more physically demanding jobs, such
as nursing, construction or truck driving, the standard is to go
back in 4-6 weeks. You will find that as the weeks go by, the stiffness
and tightness of the back will slowly go away and apart from occasional
twinges and brief periods of discomfort, you will generally be pain-free.
Please feel free to call
the office if you have any problems. My physician's assistant, Mr.
Rodd Casper, and I are available at virtually all times.
COMPLICATIONS: Although this is an operation done with the
greatest of care with a high-powered operating microscope, complications
may occur. Fortunately, these are extremely uncommon, and microdiskectomies
are generally considered amongst the safest operations in all of
neurosurgery. Below is a list, though not all-inclusive, of the
complications. Please ask Dr. Saris if you have any questions about
any of them.
RISKS OF OUTPATIENT
SURGERY: During my years of surgical training in the 1980s,
the standard of care was to remain in the hospital for several days
after this operation. However, as anesthesia has improved, and as
the operation has become less invasive under the microscope, many
surgeons have begun performing this as an outpatient. We have performed
one and two level procedures in this manner for several years without
a single major mishap at home on the night of the surgery. However,
like any medical decision, there are benefits and risks.
The benefit is the simple
advantage of being in your own home and bed to recover from the
microsurgery. Any painkiller you might receive via an intravenous
in the hospital, you can take as easily by mouth at home. We have
become increasingly concerned about hospital-acquired infections.
There is a particularly dangerous strain called "MERSA"
that is resistant to many of our best antibiotics and potentially
fatal. The sooner you go home, the less the chance of this occurring.
The main risk is internal bleeding after the operation. In the lumbar
spine after a microdiskectomy, this could result in weakness in
the legs. However, in over 25 years of performing this procedure,
I have not caused or heard of a single case of this.
It is your option to remain in the hospital or return home. I recommend
returning home, and waiting until at least 11pm before going to
sleep. If there are any problems, call an ambulance or come immediately
to the emergency room. If you are more comfortable remaining in
the hospital overnight, let our staff know and we will arrange this
1. Continued pain. In general, the operation recommended
to you has a very high incidence of pain relief. This is not an
operation for pain in the low back, but rather pain from the cheek
of the buttocks down to the foot. The success rate in medical journals
is between 80%-95%. In my experience, it is over 90%. The pain relief
can either occur immediately or over a period of about one month.
2. Infection. The approximate incidence of infection after
a lumbar microdiskectomy is 1%. The majority of these are superficial
infections involving the skin. These are generally easy to treat
with antibiotics or local hygiene. On rare occasion, the infection
can track down to the disk itself.
3. Spinal fluid leakage. The lower spinal cord and nerves
are covered by a membrane about half the thickness of a credit card,
and leathery tough in texture. On occasion, while working near the
nerve or lower spinal cord, we detect small holes in this membrane.
This can allow release of a watery fluid that will usually stop
on its own, though it may cause your hospitalization to be prolonged
by a day or two. On rare occasion, a second operation will be needed
to repair the membrane.
4. Vascular or bowel injury. There is a large artery called
the iliac artery that, along with the bowel, is just in front of
the disks. In over 20 years, and in over 1000 procedures, I have
never damaged the artery or bowel. I estimate the incidence of this
to be under 1/100,000.
5. Risk of anesthesia. In a generally healthy person, the
risk from anesthesia is low. In a generally healthy individual,
the chance of death from this form of surgery is almost unmeasureable
(less than 1:300,000). I have been performing these operations for
over 25 years and this has not occurred to someone under my care
for this condition.
Stephen Saris M.D.