What you should know

You should start planning your post-operative recovery, before you have your spinal surgery. The fitter you are before surgery the better for your recovery. Discuss with your surgeon and the hospital team issues such as going up and down stairs, return to driving and return to work and exercise. Every patient is different. The specifics of what you should know to speed your post-operative recovery depend very much on the condition you have and the operation you have. Surgeons vary a lot in their views about what you should and shouldn’t do, so make sure you ask.

These are some general guidance related to the most common spinal operations.

Early movement is good for you. It stops you getting too stiff and it reduces the risk of complications such as blood clots in the legs. After the operation you will be quite sore and so good pain control as directed by your health professional will help you to move around more easily. Time in hospital will be longer or shorter, depending on the surgery and the patient. Most operations for nerve compression pain do not de-stabilise the spine and so there is no reason to worry about harming yourself by moving around and getting back to normal. In common operations such as a discectomy or decompression you may only be in hospital for a short time, such as overnight or a day or two. Some spinal clinics will do nerve decompression surgery as a day case. Generally, the bigger and more complex the surgery, the longer your hospital stay will be. You need to discuss this with your Doctor and the hospital team, such as the physiotherapist. They are there to help you get better as soon as possible. A return to driving is generally safe once you are walking well and confident in movement. That will vary from patient to patient and also depends on the surgery. A fit younger patient having a simple discectomy operation might well be safe to return to driving and work, depending on the job, by two weeks. An older patient having a more extensive procedure will take longer, more often between 6 weeks and 12 weeks. With some types of pain symptoms can persist after surgery. If nerve pain was present before the operation it may take longer to improve. Generally, it is clear if surgery has helped by about 6 weeks. Nerve pain doesn’t always completely recover. Symptoms of ‘numbness’ may take many months to improve and sometimes will persist. Before discharge, make sure you have had all the advice you need. Usually before hospital discharge, the health care team will prepare you for safe discharge home. This may involve assessments of walking, going up and down stairs, and the use of walking aids and toileting aids if needed.

What to look out for

Complications after hospital discharge are fortunately infrequent but they do occur. Increasing wound pain, redness of the wound and a temperature might indicate an infection and you should seek medical advice and reassurance as soon as possible. If you have a new or very different nerve pain after surgery you should seek medical advice. A new onset of difficulty in passing urine, particularly if associated with numbness around the anus or back passage should be medically assessed with urgency- try to get to your doctor within 24 hours. If you develop pain or swelling in your calf or leg this could be a sign of a blood clot (Venous thromboembolism) and may require treatment. You should seek medical advice.

Lumbar Discectomy

This type of surgery is normally carried out for patients suffering with nerve pain in the leg (sciatica). Sciatica is common in patients in their 30s to 50s. In this group of patients, it is usually due to a disc prolapse or protrusion (a ‘slipped disc’).

A ‘discectomy’ operation is done to remove the part of the disc that is producing the nerve pain down the leg. A ‘decompression’ is to remove bone or soft tissue compressing the contents of the spinal canal. In some cases a combination of the two procedures may be required.

A micro discectomy simply refers to the use of an operating microscope rather than the size of the incision or the amount of disc removed. A mini-open discectomy is the same operations done using magnifying loupes or specialist glasses.

Spinal surgery for sciatica is usually better for the leg pain than it is for back pain. However, both the leg pain and back pain may improve.

Discectomy surgery provides an early improvement in symptoms but there are some risks associated with it.

Symptoms of numbness or weakness can persist after surgery.

Certain types of disc prolapse are more likely to recur than others. Surgery for disc prolapse has a recurrence rate of between 7% and 15% within ten years. This is the same whether or not you have an operation.

Surgery is a better option when severe symptoms have lasted more than 6-8 weeks. Recent studies have shown that waiting at least four months after the onset of back and leg pain, may be better timing for surgery in terms of recovery and outcome.

Surgery has less risk and is safer for fit and healthy patients. In order to reduce the risks, simple measures such as stopping smoking, losing weight and improving aerobic fitness all help.

Older patients may have specific risk factors such as heart disease. If you are taking tablets used to thin the blood such as warfarin, aspirin or clopidogrel which increase the risks of bleeding, your surgical team must be informed.

Patients who are diabetic have a slightly increased risk of infection generally and the nerves in diabetic patients may not recover as well as others.

Your surgeon will discuss with you the potential risks and benefits of surgery specific to you.

Spinal Stabilization

This is a term which used along with the term 'spinal instrumentation'. It is where the area to be fused is also fixed with an implant device such as a rigid system of screws and rods to reduce movement and possiblly improve a solid fusion.The implants, screws, and rods are usually made of titanium so that an MRI can be done if needed.

When the spine is unstable as a result of fractures or bone loss because of tumours, stabilizing the spine with an internal scaffold of metal, will enable an earlier return to walking and reduce the risk of the spine displacing and becoming painful.

Surgery for scoliosis will usually involve stabilization of the spine with rods and screws to hold the spine in a realigned position until bone healing and fusion has occured.

Spinal Fusion

Cervical Fusion: Cervical fusion is most commonly done to treat a cervical herniated disc, it is also done to remove bone spurs associated with cervical spinal stenosis and arthritis. Cervical fusion is usually performed with an approach though the front of the neck.

Lumbar Fusion: The goal of a lumbar spinal fusion is to stop the painful motion segment in the lower back. Most commonly this type of surgery is done for pain and disability caused by lumbar degenerative disc disease or a spondylolisthesis - where 2 vertebrae are slipping against each another. The joint between two bones is removed and replaced with bone graft which will grow the 2 bones together. This graft can be taken from the patient's hip, or a synthetic bone graft substitute can be used. In the spine, because there are so many mobile joints, the patient may not be aware of stiffness if only 1 or 2 joints are fused.
The approach to the spine can be made from the front, the back, both front and back or the side depending where the fusion needs to be performed.

Interspinous Process Spacers

Lumbar spinal stenosis is common among individuals over 60 years, and surgery for lumbar spinal stenosis is one of the most often performed procedures for the adult lumbar spine. The tunnel where the spinal cord travels through the bones of the spine becomes narrow due to wear and tear of the spinal discs and joints and the nerves that go through this narrowed canal may be squeezed when the person stands or walks any distance, causing nerve tingling, pain, numbness or weakness in the legs (this is called neurogenic claudication). Symptoms are relieved when the spine is flexed (when sitting or leaning forwards). Bending forward creates a slight increase in the space where the spinal cord is situated, and thereby relief of symptoms.

This is the rational of the interspinous spacers.

Interspinous spacers are implanted between the bones in the back of the spine - called the spinous process, at the affected level of the spine, and thereby forcing this level into forward bending. This relieves pressure on the nerves which leads to relief of pain in the legs. Often the surgery is performed under local anesthetic but can also be done under a general anesthetic.

Very many patients reported a significant relief of pain after implantation of this device and current evidence shows that these procedures are efficacious for carefully selected patients in the short and medium term, although failure may occur and further surgery may be needed. Patient selection should be carried out by specialist spinal surgeons who are able to offer patients a range of surgical treatment options.

Artificial Disc Replacement

Disc replacement is an operation that is meant to preserve movement. Each patient must be carefully evaluated pre-operatively as many patients are not suitable for the procedure.

In the lumbar spine it is sometimes offered for severe back pain that has not improved despite trying treatments that are usually effective. A CT scan is often done to exclude arthritis of the small facet joints of the spine, as if there is arthritis in these joints the operation is not likely to be helpful. Disc replacement in the lumbar spine is not as popular as it was 10 years ago. After surgery, the initial results seem to be excellent, however, the long term results do not appear to be much different to a spinal fusion for back pain. The operation is either performed on the front of the spine though the abdomen, or through the side of the abdomen.

In the cervical spine, as in the lumbar spine, the goal is to mimic the form and function of the original disc. The surgery, which is performed from the front of the neck, requires the diseased disc to be removed and an artificial disc placed in the space.