Posterior sequestrectomy/nucleotomy for a lumbar disc herniation
patient's date of birth
patient's ID number
planned date of procedure/operation
In order to be able to make a decision, you should receive sufficient information about your condition, proposed treatment, alternatives, and related risk. Your physician will explain the necessary surgical treatment and the way in which it will be performed. The purpose of this information sheet is to help you prepare for the conversation with your physician and to document the most important points.
ANATOMY OF THE SPINE
The human spine is formed by individual vertebrae and connective tissue discs in between. The vertebrae form the spinal canal. There are seven cervical, twelve thoracic, and five lumbar vertebrae. The intervertebral discs are the link between the individual vertebral bodies.
Normal anatomy of the spine. Longitudinal section and cross sections through the cervical, thoracic and lumbar spine.
The little joints that link the vertebrae together are known as facet joints. They help to stabilize the spine and, together with the intervertebral discs, allow a certain degree of mobility of the spinal cord. The spinal canal should be wide enough to allow nerve roots to float freely in cerebrospinal fluid.
The front border of the spinal canal is built by the vertebral bodies and intervertebral discs, the side by the intervertebral joints (facets) and back by the ligamentum flavum (yellow band) and vertebral arches. Discs consist of an outer fibrous ring (annulus fibrosus), which surrounds an inner gel-like center (nucleus pulposus).
The spinal cord and nerve roots lie within the spinal canal. The spinal cord extends downwards approx. to the 1st lumbar vertebra. Below, only nerve roots are present in the spinal canal. At the level of the intervertebral disc the nerve roots pass through the neural root foramina to exit the spinal canal. The spinal cord and nerve roots conduct electric-like signals from the skin and joints to the brain, and process of movement is initiated from the brain to the muscles.
Disc herniation is a disease of the intervertebral discs - the connecting element between the individual vertebral bodies. The intervertebral disc consists of a coarse hard shell (fibrous ring) and a soft cloth inside. Together with small intervertebral joints and other connective tissue connections, the intervertebral discs provide the mobility of the spine and serve as shock absorbers to soften the impact of body movements.
Lumbar disc herniation
When the hard shell of the disc (the fibrous ring) breaks, the soft interior comes out of it and enters the spinal canal or the nerve root canals. At this time, any incoming material in the intervertebral disc can press the nerve roots or the spinal cord.
In most cases, the exact cause of disc herniation cannot be determined. Disc herniation is most often the result of aging. Factors increasing the risk of disc herniation are: 1) injury, 2) occupations requiring lifting, pushing and twisting and 3) hereditary.
CAUSE OF SYMPTOMS
Acute compression of a lumbar nerve root in the spinal canal
Acute compression of all nerve roots in the lumbar spinal canal
SYMPTOMS AND SIGNS
Tingling, numbness, pain or weakness in one leg. This pain usually starts at the lower back.
Numbness, severe pain and weakness in both legs, loss of bladder/bowel control, numbness of the genitals and loss of sexual function (Cauda syndrome)
THE DIAGNOSIS IS BASED ON
Medical historyClinical exam
and at least one of the following tests:
Magnetic resonance imaging (MRI)Computer tomographyMyelography
additionally you may have to do:
RadiographsFunctional (dynamic) radiographs
Diagnostic nerve root block
Facet joints block
Lumbar intervertebral disc herniations are treated either conservatively (non-surgical) or surgically. Most patients (80-90%) with acute pain only improve without surgery within 6 weeks.
Non-surgical treatment may include
Nonsteroidal anti-inflammatory drugsCorticosteroidsPhysiotherapy
Immobilization with belt
Strengthening the back muscles
Treatment with heat (Fango)
Therapeutic nerve root block
WHEN SHOULD AN OPERATION BE PERFORMED?
Elective surgery should be considered when a significant muscle weakness (>72 hours) is present or the symptoms (e.g. pain) impair the patient’s quality of life and conservative treatment fails to achieve significant improvement within 6-8 weeks.
Emergency operation should be performed if acute (<72 hours) paralysis, numbness in the genitals and loss of bowel/bladder control due to nerve root compression occurs. In these cases, the best results are achieved if surgery is performed within 12 hours of the onset of symptoms
Emergency surgery should be performed if аcute (<72 hours) loss of strength in a single muscle group due to nerve root compression are present. In this case, it is advisable to perform the surgery within 72 hours of symptoms onset.
WHAT IS THE GOAL OF SURGERY?
To release the compressed nerve roots and/or spinal cord
To preserve the protective function of the spine
To improve symptoms (e.g. pain reduction)
To stop the worsening of the symptoms
HOW IS SURGERY PERFORMED?
Foraminotomy/Laminotomy in lumbar spine
The procedure is performed in the prone position under x-ray visualization. The length of the skin incision depends on the number of spinal segments undergoing surgery. After positioning on the operation table an x-ray is taken order to determine the exact location of the diseased spinal segment. After the skin incision, the superficial muscle fascia is opened. Thereafter, the back muscles are detached from the spinous processes to expose the vertebral arches over a short distance.
A small part of the vertebral arch and/or intervertebral yellow ligament have to be removed to access the spinal canal. If necessary the nerve root is freed by opening the root canal.
Alternatively, the access might be directed trough the back muscles.
Pain at the operation site
After surgery pain at the operation site can be unpleasant, but usually responds well to medication.
Two to three days after surgery, symptoms similar to those that were present before can recur (e.g. pain or numbness). The underlying cause is most often a postoperative swelling. In most cases, these symptoms improve spontaneously without the need for a specific treatment.
In the first 24 hours after surgery, difficulty voiding may be present. Then it may be necessary to use a disposable urethral catheter to empty the bladder. Extreme flatulence can also occur and necessitate rectoscopic relief.
Progressive paralysis or numbness
If new onset or worsening paralysis or numbness in the buttocks and/or anal area occur a doctor must be notified immediately.
Orthostatic hypotension after surgery
When getting up after surgery orthostatic hypotension may lead to seizure (syncope). Before you get up for the first time inform the staff of your intention.
Shooting and/or burning pain 3-6 weeks after surgery
3-6 weeks after surgery, shooting and/or burning pain may occur in one or both legs. This pain is usually due to formation of adhesions after the surgery and resolve spontaneusly after several months.
Days, months or even years after the operation similar symptoms as before the operation (eg, numbness, pain, paralysis), or even a deterioration may occur. The reason may be a recurrence of the operated disc herniation, scar tissue or a new disc herniation at a different segment of the spine. Recurrent disc herniations occur in 5-10% of all patients.
Postoperative spinal instability
A late-onset (several weeks after surgery) of persistent back pain, could be a sign of spinal instability (loosening of the joints of the spine).
Common risks and complications (more than 5%) include:
After surgery an infection of the wound can occur. Superficial infections usually heal after treatment with antibiotics and local wound care. In rare cases, a re-operation might be necessary. Rarely, some infections may affect the intervertebral disc tissue or the vertebrae themselves. Several weeks of treatment with antibiotics and bed rest may be necessary. Only rarely, removal of the inflamed tissue and a stabilizing operation is required. In rare cases, the infection may pass into the bloodstream (sepsis) or the meninges infested (meningitis), which can lead to irreversible damage to the nervous system;
In rare cases, vertebrae may not fuse together following the surgery. This is called pseudarthrosis. In smokers or after implant failure, there is a lower rate of successful spine fusion. In such cases, the implants must be removed and placed again.
Appearance of preoperative symptoms 2-3 days after surgery
Two to three days after surgery, some symptoms (e.g. pain) may reoccur. Usually it is due to postoperative edema. These symptoms usualy resolve spontaneously after a few days.
Мonths/years after surgery similar preoperative symptoms may occur (paraesthesia, pain, paresis). The reason for this is most often a recurrence. Usually this requires re-operation.
Occasionally, injuries to the meninges (dura mater) may occur. This may cause the connections between subarachnoid space to fill with cerebrospinal fluid and body surface area (CSF fistula). In these cases, a re-operation to seal the dura mater hole is required. Leakage of cerebrospinal fluid may cause headache mainly located in the forehead and in extreme cases, due to a tear of a blood vessel, bleeding in the head or in the spinal canal;
Rarely, bleeding (hematoma) along the operation site may occur. In patients taking blood-thinning medications (Aspirin, Plavix, Warfarin etc.) or coagulation disorders, the risk is slightly higher. If the hematoma (bruise) is in the spinal canal, temporary or permanent neurological deficiencies (numbness, paralysis up to paraplegia) may occur. Very rarely, it may be necessary to evacuate the hematoma using open surgery.
Uncommon risks and complications (1-5%) include:
Hypertrophic scars and keloids, thickened scars due to excessive synthesis of collagen may occur after surgery. An additional treatment or a re-operation might be required.
Long recovery period
In some patients, the recovery period is long. Neck and shoulder pain may last up to 6 months.
Very rarely pain (incl. neuropathic pain), numbness, paresthesia and/or paralysis due to intraoperative injury or transection of nerves, nerve roots or ganglia may occur.
In the occurrence of newly emerging paresis (weakness), numbness in the genitals or loss of bowel/bladder control, you should immediately inform your physician.
Peripheral nerve lesions
despite padding on the operation table, pressure-induced damage to the skin, soft tissues, and eyes may occur. It is possible to encounter peripheral nerves damage by pressure or by traction. In individual cases, the resulting symptoms (e.g. pain, numbness, paresthesia and/or paralysis) may be permanent.
Pneumonia, urogenital infections, etc.
Surgery poses a physical burden to the whole organism which may lead to pneumonia or a urinary tract infection. These infections usually are treated successfully with antibiotics.
Prolonged wound healing
Wound healing can be delayed by factors like infection, maceration, necrosis,trauma, and edema.
The spine is a flexible system. The interaction of the vertebral bodies, intervertebral discs and ligaments allow a limited degree of movements. After surgery on the spine, however, a pathological hypermobility (instability) in some segments of the spine may occur. This condition must then be treated with painkillers, muscle strengthening or ultimately with fusion surgery (stabilization);
Before, during, or after surgery, blood clots may form (thrombosis), spread and obliterate a blood vessel in the lungs (pulmonary embolism). In rare cases, thrombosis may also lead to stroke. Medications affecting blood clotting (thrombosis prophylaxis) may lead to an increased intraor postoperative bleeding.
In approximately 15% of all spinal surgeries, results are unsatisfactory. One reason for this is that some of the complaints are provoked by other illnesses.
Rare risks and complications (less than1%) include:
Rarely, transient flushing with a feeling of warmth ('hot flashes') for several days or a disturbance of the menstrual cycle can occur after application of cortisone.
Rarely, application of iodine-containing contrast agents together with Metformin containing drugs may lead to organ failure (e.g. kidney).
Rarely, application of iodine-containing contrast agents may cause hyperthyroidism. In some cases this can lead to a life-threatening complication, thyrotoxic crisis.
In rare cases, local allergies to implants, disinfectants, tape, suture material, or topical preparations have been reported. Systemic reactions, which are more serious, may occur due to drugs used during surgery and narcotics. Allergies manifest themselves as skin redness, swelling, itching, nausea or other symptoms. Severe allergic reactions leading to respiratory problems, circulatory arrest or seizures are very rare. They may require additional treatment and can leave serious permanent damage.
Ulcer of the stomach and duodenum
Rarely, stress-related gastric/duodenal ulcers may occur.
Injury to adjacent tissues or organs
Very rarely when removing the intervertebral disc, injury to adjacent tissues or organs (e.g. large vessels, intestine, ureter) may occur. Such injuries are extremely rare, but can lead to permanent damage. In such cases, surgery is likely to be extended. Injury to major blood vessels can lead to severe hemorrhage requiring blood transfusion.
Infections due to blood transfusion
Excessive bleeding during or after surgery may require transfusion of blood or blood components. Very rarely, infectious agents such as Hepatitis viruses (hepatitis), HIV (AIDS) or other pathogens as well as yet unknown pathogens may be transferred. In very rare cases, temporary or permanent vision problems including blindness may occur following the transfusion.
Temporary or permanent neurological disfunction
Decline in ability to move arms and/or legs or a complete paralysis or impaired function of the bladder and anal sphincter. Very rare conditions such as impotence or loss of sensitivity in the genital area may occur as well. Further investigation (e.g. MRI study of the spinal canal) is required to determine the cause of these symptoms. Under certain circumstances, a re-operation might be necessary. Extremely rarely, these failures can be permanent;
Permanent damage, coma or death
Any operation can lead to permanent damage, coma or death. This, however, is extremely rare.
During the conversation with Dr. _________________ I was informed about the planned intervention and any unforeseen additional procedures/treatment that may become necessary. I was offered the opportunity to ask all questions I consider important about the nature and the purpose of the operation, its risks, and associated complications. I was informed about any additional treatment that may become necessary and its associated risks. I have no further questions and feel that the information provided is sufficient. Therefore, after adequate time for consideration, I, herewith, consent to the proposed surgical operation. I further consent to any unforeseen extensive procedures/treatment that may become necessary, including transfusion of blood and blood components, if this becomes necessary for medical reasons.
I agree with the anonymous use of collected tissue and intraoperative photographs for scientific purposes.
Place, date, time: __________________
Patient's signature: __________________
Physician's signature: __________________
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