Far lateral discectomy and decompression
INDICATIONS: Severe sciatica (pain radiating down the back or side of the leg) or severe femoratica (pain down the front of the thigh) that has persisted despite eight or more weeks of conservative management which may include drugs for pain or inflammation, physiotherapy, manipulation or epidural steroid injection. When the pain is reducing it is appropriate to wait longer. When there is severe weakness surgery is considered sooner. In this case the disc prolapse is situated more lateral than usual, outside the spinal canal and the operation is somewhat different to the standard procedure (and more difficult).
PROCEDURE: After appropriate medication the patient is taken to the operating room where he or she is anaesthetised (full general anaesthetic with a tube into the trachea). The patient is rolled onto their front and placed on a sheepskin lined frame which allows the tummy to hang free (this relieves pressure on the veins in the spine and reduces bleeding). The elbows are flexed and lie on pillows while the face sits in a specially cushioned mask.
Local anaesthetic (for post-op pain relief) is injected into the skin of the back before making a cut about 4 - 6 cm (1 - 2 inches) long about 3cm lateral and parallel to the midline. The muscles are separated gaining access to the space between the transverse processes and/or sacrum. Part of the membrane between the vertebrae is removed and the lateral part of the facet joint may be trimmed allowing access to the nerve and disc protrusion. An X-ray is usually taken to confirm the level. There are arteries and veins around the nerve which may require diathermy. The nerve that is being compressed is shifted off the disc bulge which is then removed. At conclusion, a small piece of fat is placed around the nerve to reduce scarring and a drain may be placed to remove blood before closing the skin with a single long 'invisible' stitch which does not need removal.
COMPLICATIONS: Potential complications include those associated with general anaesthesia, eg sore throat, nausea, vomiting, rash, sore muscles, tiredness, numbness of forehead or hands. All steps are taken to minimise these problems. If you are a smoker you are advised to give up before your operation.
Bleeding can occur and it is best to avoid aspirin or other anti-inflammatory drugs for two days before your operation (unless you are taking asprin or Cartia for your heart - don't stop this but please warn me).
After any operation infection can occur in the wound, lung or bladder. You will be given antibiotics (usually Kefzol) to reduce this risk.
Other general complications include clots in the leg or lung, sore veins from IV drips, indigestion and peptic ulcers, heart attack and stroke but these are rare. Death can occur.
Specific complications of lateral discectomy include operating at the wrong site (very rare) injury to the nerve, a risk that the prolapse can occur again(small) and a chance that the pain may not be completely relieved. Very occasionally the pain may be made worse.
Paralysis does not occur due to the surgery as the operation is not near the spinal cord.
POST OPERATIVE INSTRUCTIONS: You will be discharged home after one or occasionally two nights. You will have tape on your wound which you should take off after five days. If you are worried about the wound - soreness or redness - speak to me or your GP. The sutures do not need removing.
I encourage you to walk initially five to ten minutes twice a day increasing over the first four weeks to 30 to 60 minutes twice a day. Early return to work is encouraged.
You will be shown an exercise to keep your nerve mobile. This is usually done lying on your back, lifting your thigh up to a right angle and then straightening the knee until it gets tight. Hold for fifteen seconds, relax then repeat ten times. Do this with each leg, one at a time, two or three times a day. If you have had pain in the front of your thigh (femoratica) I encourage you to stretch the thigh muscle (quadriceps) and femoral nerve by lying prone (face down) and flexing your knee (moving your foot towards your bottom) up to ten times twice a day - do this with each leg. It is not usually necessary to have physiotherapy.
After a month I will see you or talk to you over the phone if you live far away.
Please ring on the day of discharge for an appointment.
You will usually be able to start swimming or exercycling after one month.
I advise against driving for one month - this is more for the protection of others and potential insurance problems.